1) Keeping up and Answering Questions

In a 2004 BMJ special edition about evidence-based medicine (EBM), an article provided a conceptual framework created by the authors to evaluate the “learner types” that would serve as goals medical school curricula on EBM. These learner types were doers (those who produce evidence-based materials like critical appraisals), users (those who seek out critical appraisals and other evidence-based sources of information), and replicators (those who model their practice after others who practice in an evidence-based manner).

In Take 3, Mark and I have tried to fulfill the doer role as faithfully as we could. And his original goal (as well as mine when I joined) was to support and encourage users of our synopses of the evidence. But we also attached our comments on the articles we summarized, often reflecting on our own practices, to help those who chose instead to replicate the practice we described.

As we close this chapter of Take 3, we feel an important obligation to provide some other resources that readers can use to base their practices on evidence. We hope that reading Take 3 has provided growth in using these sources…or at least will help readers have some healthy skepticism for and discipline in integrating the fire hose of new research information with their current practices.

Keeping up resources:

• The American Family Physician journal has had a long-standing commitment to making their content more evidence based. The SORT (Strength of Recommendation Taxonomy) table is important to readers to understand the basis for many of the recommendations in AFP review articles. In addition, many of the regular “departments” of the journal (Cochrane for Clinicians, STEPS, Clinical Inquiries) are the best products of the doers in Family Medicine.  In addition, for AAFP members, there is an abundance of free CME by taking the monthly quiz.
• InfoPOEMS/Essential Evidence Plus emails are daily summaries of curated and reviewed studies relevant to primary care. This subscription service has been around for decades, founded by the first family physician educators to widely popularize the EBM concepts in family medicine.
• Podcasts – three that Mark and I have been listening to (available on all major platforms):
  • Primary Care Update – this one is closest to critical appraisal of recent articles. Not the slickest audio production, but good, quick summaries of four articles and some geeky humor.
  • Curbsiders – a popular internal medicine podcast. Lots of good evidence-based medicine, but also lots of expert opinion thrown in. Very entertaining mix of outpatient and inpatient adult medicine.
  • AFP Podcast – presented by residents with faculty supervision, this is best characterized as a podcast-based summary of the AFP journal with some other fun items thrown in. An entertaining way to keep up with the AFP journal.

Question answering resources:

• DynaMed – This has long been my “electronic textbook” (over UpToDate) for its rigorous commitment to evidence-based medicine. The ability to drill down and link to the evidence behind its recommendations is the essence of EBM, in my opinion.
• The Cochrane Library – Huge database of systematic reviews with a goal of answering focused questions with a valid, reproducible systematic review methodology from the Cochrane Collaboration.
• TripDatabase.com – A long-standing “meta-search” engine that searches many places and organizes the information by evidence grade. The founder is committed to helping find the best answers as quickly as possible. Recently experimenting with incorporating artificial intelligence summaries and critical appraisal. The free version is good, the pro version gets you more access to information.
• OpenEvidenceAI – This is an exciting one. Produced by the Cleveland Clinic, Mayo Clinic and Harvard, it provides AI summaries of articles that can answer your query. It violates EBM rules by not explaining how it found the sources it does but provides reasonable summaries as well as citations of articles relevant to your questions. I have not found any “hallucinations” yet, but please keep a healthy skepticism about its answers.
• WikiGuidelines – A new resource on the block. The focus is to produce “humble” evidence-based guidelines that do not substitute expert opinion for strong recommendations. They prioritize a primary care audience as well as primary care participation on the guideline committee. They have notably published several of their initial guidelines on the JAMA Network. Largely internal medicine focused. Worth keeping an eye on.

John’s Comments:

This obviously is not a complete list, and not all of these are free. A piece of wisdom I have found very useful is: If you’re going to use a shortcut (someone else’s summary of the literature), at least use a product that itself doesn’t take shortcuts. As you are looking for other ways to keep up, review how the service produces its recommendations before buying/using those recommendations. Thank you for letting us talk evidence with you on Fridays…it’s been a great ride. Caveat lector!

References:

Straus SE, Green ML, Bell DS, et al. Evaluating the teaching of evidence based medicine: conceptual framework. BMJ. 2004;329(7473):1029-1032. Link

From the Literature and the Greater Good Science Center

2)  The Science of Gratitude

Gratitude infuses our religious, cultural, and scholarly traditions. It has been conceptualized as an emotion, a virtue, a moral sentiment, a motive, a coping response, a skill, and an attitude.  Most people have an instinctive understanding of what gratitude is, but it can be surprisingly difficult to define, as it can mean different things to different people in different contexts. 

Research suggests that gratitude is not simply a cultural construct. It has deep roots that are embedded in our evolutionary history, our brain structure and function, and in our family and social development.  Some researchers suggest that gratitude may have evolved as a mechanism to drive reciprocal altruism, thereby turning strangers into friends and allies who are more likely to help one another. Studies from neuroscience have identified brain areas that are likely involved in experiencing and expressing gratitude, providing further evidence for the idea that gratitude is an intrinsic component of human experience.

There are a variety of factors that have been linked to one’s likelihood of experiencing gratitude or having a grateful disposition, including personality, cognitive factors, and gender.  Research also suggests that social factors—including religion, cultural influences, and parenting styles—may influence a person’s tendency to experience gratitude.  Additionally, it appears that gratitude may be associated with many benefits for individuals, including better physical and psychological health, increased happiness and life satisfaction, and decreased materialism. 

Gratitude is also important to forming and maintaining social relationships.  Research suggests that gratitude inspires people to be more generous, kind, and helpful (or “prosocial”) and strengthens relationships, including romantic relationships and is associated with decreased loneliness.  Though there has not been a great deal of research explicitly focused on gratitude in the workplace, a handful of studies suggest that gratitude may help employees perform their jobs more effectively, feel more satisfied at work, and act more helpfully and respectfully toward their coworkers.

A growing number of studies have tested the efficacy of various practices (“interventions”) designed to boost gratitude, such as explicitly noting one’s blessings ("Three Good Things" exercise or gratitude journaling) and writing gratitude letters or even texts of gratitude to people whom one has never properly thanked.  A series of meta-analyses have attempted to determine the efficacy of gratitude interventions, and most have concluded that gratitude interventions do appear to significantly increase happiness, well-being, and positive mood.

Mark’s Comments:

The season of Thanksgiving always provides a wonderful backdrop for reflection on the place of gratitude in our lives.  Studies show that the feeling of gratitude is an important ingredient for overall well-being and will increase with regular practice (it’s a skill!).  Research on the science of gratitude is relatively new, and thus there are still many open questions left to explore.  If you want to get a sense of your present “gratitude aptitude” here’s a link to a gratitude quiz from Rick Hanson, PhD - Gratitude Quiz.

Reference:

Hittner J and Windholm G.  Meta-analysis of the association between gratitude and loneliness.  Applied Psychology: Health and Well-being. November 2024. 16(4): 2520-2535.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Celebrating Our “Angels” this Thanks-Giving

“Sometimes our light goes out but is blown again into instant flame by an encounter with another human being.  Each of us owes the deepest thanks to those who have rekindled this inner light.”   Albert Schweitzer, MD, Humanitarian and Nobel Peace Prize Recipient

There is a drawer where I keep cards, letters, and pictures that have been given to me over the years from patients, students, residents and colleagues, and when I’m feeling the need to be reminded of why I do this incredible but also demanding and emotionally draining work, I go through that drawer and pick out a few.  This ritual allows me to reflect on the many people who have spoken into my professional life and in doing so, helped make me “better than I am.”  Though I don’t remember someone ever advising me to save these items, I’ve learned over the years that many other colleagues have such a memento collection as well.   

Recently, after a particularly challenging day in clinic, including having to share some very sobering news about a likely terminal diagnosis with one patient and having another patient and her son expressing their anger to me regarding something that I had no control over, I was feeling in need of an uplift.  In response, I opened that drawer and allowed some of the notes and pictures to speak love and encouragement to me from across the miles and years.      

One of notes was from a dear friend and colleague, Elizabeth Vogel, PhD, with whom I worked from 2006-2009 as we created the Carilion Office of Professional Development and whose life ended very suddenly, and senselessly.  Elizabeth was one of those people whose inner light shone brightly, and her encouragement inspired the foundation for much of the work I am doing today.  The quote above was one of her favorites, and we often spoke of those people, whom she called her “Angels,” who had positively impacted our lives with their ability to see something in us that we couldn’t yet see in ourselves.  Though I didn’t tell her often enough, she was such a person for me. 

One of Elizabeth’s legacies was the inspiration she helped provide for what is now the PeerRxMed process.  She and I spoke often of the challenges of working in healthcare and of how very isolating it can be, both by choice and by design.  She often stated what has now become the obvious for me – that it is “crazy” for anyone try and navigate this professional journey on their own.  In doing so, she helped plant the seeds for the PeerRx vision that “No one should care alone.”   

All of which has left me thinking about other “Angels” in my life, past and present, and wondering about yours as well.  When was the last time we’ve thanked them for how they have positively impacted our lives?  In this season of Thanks-giving, perhaps we can all take a moment to express our gratitude to and for them – by texting, calling, or writing them, or for those no longer with us, pausing to express a prayer of gratitude.  For me, that would include my PeerRxMed partners, who weekly fan the flames of my life with their presence and their encouragement. 

Now more than ever we all need to show up as the “better versions” of ourselves, and there’s no way that’s going to happen on our own.  Fortunately, we all have “Angels” in our midst.  That’s something worth celebrating with Thanks-Giving every day ….

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  Guidelines for the Management of Focal Liver Lesions (FLL)

We are all familiar with how this goes…We order CT of the abdomen, and it comes back with a liver finding, most often when we were not suspecting the liver. The ACG has put together a helpful guideline trying to address the management of the spectrum of the common focal liver lesions (FLLs). A big problem with this guideline is that there is VERY little good evidence. The guideline committee used the GRADE methodology, which is a good standard for quickly communicating the evidence-base of the recommendation as well as the actual recommendation. Unfortunately, this guideline has only one of nineteen evidence-based recommendations that is graded above Low or Very Low strength of evidence. Despite that, there are some strong recommendations made by the committee based on the options available and their assessment of the likelihood of patients making that particular choice. There is a table (larger than the evidence-based recommendation table) in the report called “Key Concepts” – which is a list of recommendations (largely derived from “best practice” and “committee consensus”) that purport to fill in the gaps in the evidence.

I will list the primary-care focused, evidence-based recommendations below first. Strength of recommendations are graded strong (S), and conditional (C). Evidence ratings are noted as high (H), moderate (M), low (L), very low (VL).

The guideline details management of six major types of FLL. There is an overall recommendation that evaluation of any focal liver lesion include multi-phase contrast imaging with either CT or MRI. [S, L]

Hepatic adenomas: These are usually due to exogenous hormone use (oral contraceptives, hormonal IUDs). MRI is the preferred imaging modality to assess them. [C, VL] If < 5 cm, these can be followed, after discontinuing hormones [S, L] and working on weight loss [C, VL], with contrast imaging every 6 months for at least 2 years, then annually.[C, L]

Focal nodular hyperplasia: MRI is also recommended if these are suspected, with hepatobiliary-specific contrast. [C, L] There is no need to discontinue hormones for this condition. [C, VL]

Hemangioma: If there is cirrhosis or chronic hepatitis B who otherwise need hepatic carcinoma surveillance, these should be imaged every 3 to 6 months for one year. [S, L]

Simple hepatic cysts: If simple and asymptomatic, no follow up is needed. [S, L] If there are high-risk features (septation, fenestration, calcification, thickening, nodularity, etc.) seen on ultrasound then CT or MRI is warranted. [S, L] If symptomatic, there are procedures to drain the cysts.

Polycystic liver disease: Discontinue exogenous estrogen. [C, VL] If there are too many cysts to deal with procedurally, consider treatment with somatostatin analogs. [S, M]

Hydatid/echinococcal cysts: Surgical management is preferred [C, VL] over percutaneous treatment followed by anthelminthics, which may be necessary if surgery is not appropriate. [C, L]

Highlights of the key concepts include:

• Use history, physical and basic labs to assess the patient’s risk status. Most low-risk people will have benign causes for their FLLs.
• Biopsy is still indicated if there is an atypical or concerning appearance to any of these lesions.
• Hepatic adenomas in men should be resected. Hepatic adenomas > 5 cm in either sex can be observed for 6-12 months with risk factor modification, followed by resection if persistently large.
• Focal nodular hyperplasia is generally benign and does not need to be followed if confirmed by advanced imaging.

John’s Comments:

Many of these recommendations are common sense, but it is really surprising to see how little good evidence there is to guide our decisions in this area. There are other, less common, FLLs discussed in the Key Concepts section, and some nice flowcharts that detail the recommended workups, both of which make this guideline useful as a reference to consult when needed.

Reference:

·         Frenette C, Mendiratta-Lala M, Salgia R, Wong RJ, Sauer BG, Pillai A. ACG Clinical Guideline: Focal Liver Lesions. Official journal of the American College of Gastroenterology | ACG. 2024;119(7):1235. Link

From the “Guidance” and the AASLD 

2)  Steatotic Liver Disease 2024

The prevalence of NAFLD in adults is estimated to be 25%–30% in the general population and varies with the clinical setting, race/ethnicity, and geographic region studied but often remains undiagnosed.  NAFLD is closely linked to and often precedes the development of metabolic abnormalities (insulin resistance, dyslipidemia, central obesity, and hypertension).  The presence and severity of obesity are associated with NAFLD and disease progression.  Visceral fat, which is more metabolically active and inflammatory than subcutaneous fat, mediates the majority of this risk.  As adipose tissue becomes more metabolically stressed, dysfunctional, and inflamed, insulin signaling is progressively impaired, promoting the inappropriate release of fatty acids leading to intrahepatic lipid accumulation and inflammation.

In 2023, the American Association for the Study of Liver Diseases (AASLD) released updated guidance (differing from a “guideline”) on the clinical assessment and management of nonalcoholic fatty liver disease (NAFLD).  According to the AASLD, a “Guidance” differs from a “Guideline” in that it is not bound by the Grading of Recommendations, Assessment Development and Evaluation (GRADE) system. Thus, actionable statements rather than formal recommendations were provided. The highest available level of evidence was used to develop these statements, and, where high-level evidence was not available, expert opinion was used to develop guidance statements to inform clinical practice.

The guidance created an algorithm for management of the patient with clinical suspicion of steatotic liver disease.  This would include patients with steatosis noted on imaging or for whom there is a clinical suspicion of NAFLD, such as those with metabolic risk factors or unexplained elevation in liver chemistries.  The algorithm leans heavily on the calculation of a fibrosis-4 index (FIB-4) and further management based on this.  That further management includes an outline for a multidisciplinary approach to care, including advanced lipid management, weight management, and aggressive lifestyle interventions. 

This guidance is complemented by the American Association for Clinical Endocrinology’s 2022 guideline on the diagnosis and management of NAFLD, and in particular, their guidance regarding weight management across the spectrum of disease.  This guidance emphasizes that once someone has evidence of NAFLD, even if it is “mild”, they should be treated aggressively to prevent advancement of the hepatic damage.

In 2024, the major organizations in the US and Europe came up with a new classification system for this group of liver disorders.  The overarching term of steatotic liver disease (SLD) was chosen to classify individuals with hepatic steatosis due to various etiologies. The panel recommended the term steatosis in lieu of the term fatty because the latter was considered to be stigmatizing.  The new terminologies included the use metabolic dysfunction-associated steatotic liver disease (MASLD) in place of NAFLD and metabolic-dysfunction associated steatohepatitis (MASH) instead of nonalcoholic steatohepatitis (NASH), respectively.  A new overlap category was also introduced in the new terminology that includes individuals with cardiometabolic risk factors (CMRFs) and a spectrum of alcohol consumption (metabolic dysfunction and alcohol-associated steatotic liver disease, MetALD), while continuing to recognize other causes of hepatic steatosis including alcohol-associated liver disease (ALD) with or without metabolic risk factors, drug-induced liver injury, monogenic diseases, and other etiologies.

Mark’s Comments:

While changes in terminology can be confusing, what I took away most from my reviews was that it is easy for we who practice primary care medicine to get lulled into thinking that hepatic steatosis in its many forms is just one more manifestation of obesity rather than appreciating it’s significance as a gateway to many forms of hepatic damage and the subsequent systemic impacts of this.  As we take these changes more seriously, perhaps our patients will begin to be convinced to do so as well. 

References:

• Rinella M, et al.  AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology 77(5):1797-1835, May 2023. Link
• Kanwal F, et al.  Metabolic dysfunction–associated steatotic liver disease: Update and impact of new nomenclature on the American Association for the Study of Liver Diseases practice guidance on nonalcoholic fatty liver disease. Hepatology 79(5): 1212-1219, May 2024. Link
• Cusi K, et al.  American Association of Clinical Endocrinology Clinical Practice Guideline for the Diagnosis and Management of Nonalcoholic Fatty Liver Disease in Primary Care and Endocrinology Clinical Settings.  Endocrine Practice, May 2022: 28 (5): 528 – 562.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Breaking Free from the FOPO (Fear of People’s Opinions)

"Care about people’s approval, and you will be their prisoner." — Lao Tzu

We’ve all certainly experienced it.  Remember stepping into the exam room, or the conference room, your heart racing and mind buzzing with thoughts of what the patient or your colleagues might think?  The professional pressure to be flawless – feeling the need to continually live up to the expectations of others, can feel suffocating.  This mental burden has a name: the Fear of People’s Opinions or FOPO.  

I remember vividly a time early in my career when I was struck by what I now understand to be FOPO.  It was the first grand rounds I gave as a resident, and I was presenting a complex and potentially contentious ethical case, surrounded by peers and seasoned faculty whose opinions I highly valued.   Though well-prepared, as I spoke, I became tentative and unfocused, and a sense of uncertainty overwhelmed me.  All I could think about was whether they would agree with my conclusions.  Would they judge me for taking a then quite controversial position?  Would they think I was negligent, or naïve, or even incompetent? 

Psychologist Michael Gervais, who coined the acronym FOPO and works with some of the highest performing athletes and leaders in the world, suggests that feeling trapped in a cycle of self-doubt and overreliance on external validation is one of the greatest obstacles to reaching our full potential, particularly in high-stakes fields like medicine.  Research shows that when we’re preoccupied with what others might think, we’re less likely to take risks, make decisions confidently, or speak up with new ideas. This is particularly damaging in healthcare, where appropriate confidence and timely action is essential.     

Reflecting on that meeting years ago, and many since, I now recognize my fear wasn’t really about the presentation; it was about seeking approval.  Certainly, it is normal to want to feel validated, but when that desire leads to fear and even emotional paralysis, we can no longer show up as our best selves.  Gervais’s teachings have helped me realize that during that meeting I was giving away my power by depending on others’ opinions rather than being open to them while staying true to myself.  He indicates that the antidote is to shift our focus from primarily what others think to aligning our actions with our core values.  When we focus on what truly matters to us, we gain greater freedom to act authentically, even in high-pressure situations, and in doing so, become more effective, resilient, and fulfilled in our work – and less attached to the fear. 

This week, let’s challenge ourselves and each other to identify one area of our professional (or personal) lives where FOPO might have a grip, and to take one step toward letting go of that fear.  Sure, we can still value other’s opinions, but do not have to be dependent on them.  Instead, consider speaking up in a meeting when moved to do so, proposing a new idea you are excited about, or sharing something about yourself that is important to you, but that you may be withholding out of FOPO.  You might just find that this opens a deeper level of connection with colleagues, loved ones, and even yourself.

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  Some Useful Resources for the Med Management of T2D

Request:  Could you please provide some of your favorite resources for guiding the medical management of Type 2 Diabetes (T2D)?

Answer:  Two organizations have historically provided the most practical and accessible summaries for T2D management for those practicing primary care medicine – the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE).  Below is one from each of the two organizations on their approach to initial medical management.  Links to additional algorithms (including insulin initiation and dosing) are below as well.  These would be worth keeping close by as a link.  Unfortunately, unless you have a color printer, they are harder to read when printed out.

It should be noted that both algorithms emphasize comorbidities when choosing medications for patients with T2D.  One difference is that the ADA guideline (1^st below) doesn’t account well for medication expenses, which are a significant issue for many of our patients.  Also, the AACE better emphasizes that metformin is still the first agent we should consider for most patients (think of it as “basal metformin”!).

Link:  ADA Medications for T2D

Link:  AACE Medications for T2D

Additional Links:

• AACE Algorithm for adding/intensifying insulin:  Link
• AACE Profiles of antihyperglycemic medications:  Link

Mark’s Comments:

I love these “one pagers” that provide a helpful overview/review of a common and often changing aspect of our practice.

References:

• Comprehensive Type 2 Diabetes Management Algorithm – 2023 Update.  Endocrine Practice 29(5) Volume 29, Issue 5p305-340May 202329(5)29 (2023) 305e340.  Link
• American Diabetes Association Primary Care Advisory Group.  Introduction: Standards of Care in Diabetes—2024 Abridged for Primary Care Professionals.  Clin Diabetes 2024;42(2):181-222.  Link

From the Literature

2)  Bright Light Therapy for Any Depression

Light therapy is a well-recognized treatment for seasonal affective disorders; and, certainly, as we slide into the winter months and prepare to fall back into standard time, we all start craving the light a little more. Bright light therapy (BLT) is defined as using a fluorescent light box that produces white light for at least 30 minutes, the commonly used range is 10,000 lux. But does BLT have the same benefits for non-seasonal depression that it does for seasonal mood disorder?

Researchers published in JAMA Psychiatry set out to review the literature on this question. They used the Cochrane Handbook and PRISMA guidelines to conduct and report their review and, thereby, covered all the major quality criteria.

They found 11 studies (with 858 patients) that compared “BLT alone or BLT plus antidepressant with placebo, antidepressant monotherapy, or dim red light.” They only included studies after the year 2000.

The studies all used common depression scales to measure effect. BLT improved depression remission rates in the BLT group (40.7% vs 23.5%; odds ratio (OR), 2.42; 95% confidence interval (CI), 1.50-3.91; P <.001; I² (heterogeneity) = 21%, NNT ~ 5.8). Response rates ("response” was, unfortunately, left undefined) after 4 weeks were higher in the BLT group (63.0% vs 44.9%; OR, 1.79; 95% CI, 1.01-3.17; P = .04; I² = 32%, NNT ~ 5.5; they were higher in the less than 4-week time frame also). The researchers note a low risk of bias in the studies, and a low risk of publication bias across the studies. The authors note that this is the first review that could offer a consistent recommendation for BLT, but they suggest that it is probably best used as an adjunct to pharmacologic treatment of depression.

John’s Comments:

Lamps that deliver 10,000 lux BLT run from $19 to ~$150 on Amazon.com, making them reasonably accessible to a large segment of the population. Sunlight delivers 10,000 to 20,000 lux in 20-30 minutes on a partly cloudy day. BLT lamps frequently block the UV light, and do not depend on latitude or weather, making their dose delivery that much more reliable.

Reference:

• Menegaz De Almeida A, Aquino De Moraes FC, Cavalcanti Souza ME, et al. Bright Light Therapy for Nonseasonal Depressive Disorders: A Systematic Review and Meta-Analysis. JAMA Psychiatry. Published online October 2, 2024. Link

From PeerRxMed ( www.PeerRxMed.org )

3) Can We Start Over?  Re-connection Powered by Apology 

“Apologizing … means you value your relationship more than your ego.”  Mark Matthews, author

It was one of those mornings when, for whatever reason, the universe seemed to be conspiring against me and I was primed for frustration.  I had forgotten about a deadline and had an overflowing patient schedule.  When I arrived at work, logging onto the network seemed to take forever.  As I started clinic, the N95 mask I decided to wear that morning (due to a recent COVID “mini-surge”) was once again making communication with some of my hard-of-hearing patients particularly challenging.  Then, of course, everyone I had seen so far that morning, in addition to their lengthy “list,” had saved the significant “by the way” until my hand was on the door to leave the room.  Likely you can relate.

Now running behind, I had taken on a bit of an “attitude” as I prepared to enter the room of a patient I had never seen before who in reviewing his chart had terminal cancer and was experiencing a sore throat and intractable vomiting.  “Why didn’t the front desk direct him to the ED?!” I asked my nurse.  “The family insisted on bringing him here,” was her reply.  I sighed and may have rolled my eyes ….

So I put on my mask, knocked, and opened the door.  There in the small exam room were 4 people, including the patient, who was already lying on the exam table and obviously not well.  The tension in the air was palpable.  After brief introductions, I asked, “How can I help you today?”, my mask hiding my scowl, but perhaps not my scowling eyes and tone.  “Dad can’t stop vomiting,” was the reply from one of the daughters.  “I see you were in contact with your oncologist yesterday and they recommended going to the emergency department.  What prevented you from doing that?”  My impatience and frustration were already showing. 

And then two very unexpected things happened.  The patient started to cry and said, “I thought you’d be able to help me.  I’m just so scared …” and I also became tearful, could feel my demeanor softening, and these words came out of my mouth from somewhere deep inside me: “I’m sorry.  I came into this room carrying much of the emotion from my morning, which has been challenging for me.  That’s not fair to you.  Can we start over?”

We did.  And in that transition, my presence, rather than being toxic, became salve for 4 hurting and scared souls.  Somehow miraculously my “pity party for Mark” turned into a celebration of a life that, unbeknownst to us at the time, was to end 5 days later.  Tension was replaced by Holy tears as the family shared important and incredibly loving sentiments that had been withheld due to a fear of giving the impression that they had “lost hope.”  And it all happened because a lost connection was found again, powered by an apology …

Where are those reconnections waiting to happen in your life …?

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1) Measuring Important Things Well – Blood Pressure

As we know, hypertension is an underlying cause for lots of disease in the US – strokes, heart attacks, kidney failure, etc. Using the 2017 ACC/AHA guideline thresholds of 130/80 to define the line of high blood pressure (BP) – approximately 50% of patients have hypertension, but only ¼ of that group are actually controlled. The measurement of office BPs is fraught with variability: recent smoking, a long walk from the parking lot, chattiness, or fidgetiness all wreak havoc on our attempts to measure what is meant to be a “resting” BP.

There are many aspects of patient preparation that are recommended to produce the best office-based BP readings: emptying the bladder, proper cuff size, uncrossed legs, feet on the floor, no talking, and the cuff on a bare arm. Researchers from Johns Hopkins have studied the position of the measured arm during BP measurement, citing variability in what is done in the real world of busy ambulatory clinics.

The researchers studied three groups of patients – each underwent three BP measurements in each of three positions (which were randomized for each patient): arm supported on a desk with mid-cuff at heart level (“desk”), arm resting on the patient’s lap (“lap”), and arm unsupported hanging at the side (“side”). The desk position is the recommended positioning in major blood pressure guidelines. Each patient had their BP taken (in triplicate) using the desk position at the end of the randomized measurements as a fourth reading to account for variability of BP over time. The average of the three BPs taken in each position was used for the analysis. Subjects were adults, non-pregnant, and had normal cognition. They recruited people from grocery stores, through mailings, and in hypertension clinics. The analysis looked at the differences between average blood pressures in each position. The study was overall carefully done except for relying on Microsoft Excel for statistics – the researchers found out in the middle of the study that it couldn’t randomize the groups well enough, so they had to straighten all that out in the analysis.

133 patients were randomized, most were above age 60, 77% were black, 41% were obese. BP measurements using lap and side techniques were compared with the desk measurements as reference. Lap measurements of systolic BP were 3.9 (95% CI, 2.5−5.2) mmHg higher than desk, and side measurements were 6.5 (95% CI, 5.1−7.9) mmHg higher. Lap measurements of diastolic BP were 4.0 (95% CI, 3.1−4.9) mmHg higher and side measurements were 4.4 (95% CI, 3.4−5.4) mmHg higher. There were no important subgroup differences, and the randomization problems did not have any important effect on the results in a sensitivity analysis.

The authors conclude that ensuring the arm-supported-on-desk positioning can lead to clinically meaningful differences in BP and recommend taking BPs using this method.

John’s Comments:

Taking blood pressures is one of the first clinical skills we learn, and maybe because it’s so fundamental and common, we overlook the need for reliable quality. It’s worth heeding this study and paying attention to the other BP measurement guidance from the Million Hearts Campaign (example: Proper BP monitoring)

References:

·       Liu H, Zhao D, Sabit A, et al. Arm Position and Blood Pressure Readings: The ARMS Crossover Randomized Clinical Trial. JAMA Internal Medicine. Published online October 7, 2024. Link

From the Literature and Question From a Colleague

2)  Perioperative Management of Oral Anticoagulation

Question: “What are the latest recommendations regarding perioperative anticoagulation?  I don’t think you’ve covered this for a while.”

Answer:  In 2022 the American College of Chest Physicians updated their 2012 guideline addressing this challenging, important, and often confusing aspect of clinical care.  The guideline defines procedure risk in terms of potential morbidity from blood loss as follows: 

Minimal-bleed-risk procedures include:

• Minor dermatologic procedures (excision of basal and squamous cell skin cancers, actinic keratoses, and premalignant or cancerous skin nevi)
• Ophthalmologic (cataract) procedures
• Minor dental procedures (dental extractions, restorations, prosthetics, endodontics), dental cleanings, fillings
• Pacemaker or cardioverter-defibrillator device implantation

Low to moderate risk procedures include:

• Arthroscopy
• Cutaneous/lymph node biopsies
• Foot/hand surgery
• Coronary angiography
• GI endoscopy biopsy
• Colonoscopy biopsy
• Abdominal hysterectomy
• Laparoscopic cholecystectomy
• Abdominal hernia repair
• Hemorrhoidal surgery
• Bronchoscopy biopsy

In reviewing this extensive guideline, the three figures below from the guideline provide a wonderful and practical visual for the management of these patients.  

1.  For the perioperative management of vitamin K antagonists (warfarin) (LMWH = low-molecular-weight heparin):

2.  For the perioperative management of direct oral anticoagulants (DOACs):

3.  For the perioperative management of antiplatelet drugs (ASA = aspirin):

Mark’s Comments:

I’ve found these tables quite helpful, particularly for common dental and ophthalmologic procedures for which we’re asked regularly to provide “clearance.”  The stakes are high.  Keep them handy.

Reference:

Douketis J, et al.  Perioperative Management of Antithrombotic Therapy: 
An American College of Chest Physicians Clinical Practice Guideline. Chest, 2022;162(5):e207-e243. Link  Executive Summary:  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Embracing Our Imperfections:  Lessons from a Funhouse Mirror

"To be yourself in a world that is constantly trying to make you something else is the greatest accomplishment." – Ralph Waldo Emerson

As clinicians, we often hold ourselves to impossibly high standards, scrutinizing every aspect of our clinical performance.  This has been socialized into us since the beginning of our medical training and for most of us, many years prior to that.  While these standards exist for a good reason, this can result in a self-critical mindset that often spills over into our personal life and leads to feelings of inadequacy and self-doubt.  For many, this includes our personal appearance as well. 

Pause for a moment and consider things about your appearance that you don’t like.  We all have them.  What if we could reimagine our perceived flaws and see them through a different lens?

Recently while spending some time with friends on our patio, we noticed that a mirror there caused distortions of our reflections like those of a funhouse mirror.  We laughed hysterically at the absurdity of elongated necks, bulbous heads, enormous ears, and body builder biceps.  Later, as I reflected as to how easy it was to find these exaggerated distortions humorous, the thought struck me – what if I could apply this same light-hearted perspective to my real-life "flaws"?  How might I learn to laugh at my imperfections instead of letting them too often weigh me down?

Indeed, it is quite easy, particularly in our social media saturated world, to lose sight of our inner beauty and sense of self-worth and instead fixate on anything we view as “wrong” with us.  Just as the funhouse mirror's distortions are not a true representation of reality, neither are our self-critical thoughts.  By acknowledging that our perceptions are often distorted – whether by a funhouse mirror or our internal critic – we can begin to view ourselves with greater self-compassion.  Through this lens, we can start to challenge and reframe these negative perceptions, allowing for a more balanced and forgiving self-view.

Yes, we can be our own harshest critics.  Next time you catch yourself fixating on a flaw or mistake, try to imagine it reflected in a funhouse mirror.  Laugh at the distortion, recognize its exaggeration, and remind yourself that imperfections are a natural part of being human.  Embrace the unique qualities that make you who you are and remember that your worth is not defined by your perceived flaws.  Consider sharing some of these challenging thoughts with your PeerRx partner and laugh together at these silly but quite real perceptions.  By catching your negative self-talk early and practicing this more playful perspective of humor and acceptance, you will add the spirit of the funhouse mirror to your well-being toolbox.  It has sure helped me laugh at my “Dumbo” ears, which, I smile and remind myself, are not.  

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  Shoulder Injury Related to Vaccine Administration (SIRVA)  

Vaccines, both as a public health measure and as a clinical prevention intervention are very safe, but all interventions have the risk of adverse effects.  A relatively newly recognized vaccine adverse event in adults due to vaccination technique is shoulder injury related to vaccine administration (SIRVA).  More than just deltoid muscle soreness, this is a prolonged inflammation of the subacromial-subdeltoid bursa (SASDB) resulting in shoulder dysfunction including pain, limited range of motion, and perceived weakness related to vaccine administration.   There has been an increase in reported cases of SIRVA within the literature, particularly in adults, and is likely related to the mass vaccination programs associated with COVID-19 and influenza.

The pathophysiology is not certain, but placement of the vaccination in the subdeltoid bursa or other pericapsular tissue has been suggested to result in an inflammatory capsular process.   In 2010, a review of 13 cases of shoulder injury collected from the Vaccine Injury Compensation Program (VICP) was published that documented the predominant clinical factors of the condition the authors named SIRVA: absence of a history of shoulder dysfunction prior to vaccination, restricted range of motion, an absence of neurological symptoms or muscle weakness.  Only a minority of patients in this report resolved completely – the rest had persistent symptoms and dysfunction.  The authors quoted earlier work suggesting that in adults, the SASDB extended 3-6 cm beyond the edge of the acromion, and the presumed etiology of SIRVA was thought to be vaccine injection “too high” on the shoulder and into the SASDB.

In 2017, SIRVA was added to the VICP “Table” of known adverse events from vaccination, and a study was commissioned to review the VICP claims from 2010-2016, as they were seen to be increasing, especially related to influenza vaccination. 

That review was published in 2020 and noted the following:

• Most cases were in adult women (~82%)Most cases occurred in pharmacies (35%) and physicians’ offices (31%)
• Most cases occurred with inactivated influenza (84%) and TdaP (12%) vaccines
• The most common presenting symptoms were shoulder pain (94%) and limited range of motion (31%).  Most petitioners to the VICP have noted that they thought the injection had been “too high” on the shoulder or was “particularly painful.”
• MRI findings frequently show rotator cuff tendon tears and ruptures as well as shoulder arthritis, but these are common in adults and are not necessarily considered indicative of SIRVA.  Instead, other common findings – bursitis and tendinopathy – are more consistent with the presumed mechanism of the injury.
• The most common treatments for SIRVA include physical therapy, NSAIDs and corticosteroid injection into the bursa.  There is a list of surgical treatments in this article, but most of them are appropriate for the arthritic and mechanical rotator cuff issues that confound the interpretation of these cases.

The articles recommend the following to prevent SIRVA:

• Appropriate selection of needle length for age and weight.
• Full exposure of shoulder so all anatomical landmarks are visible (not pulling shirt down over shoulder)
• Appropriate selection of injection site – mid-deltoid, 2-3 finger breadths below the acromion.
• Appropriate angle for intramuscular injection – 90 degrees to skin.

Mark’s Comments:

I recently saw a patient in follow-up who likely had bilateral SIRVA after receiving injections in both arms at the same clinic.  In this case, my history indicated that she (in this case) pulled up her sleeves for the vaccination due to modesty, likely making identification of key landmarks more difficult.  Having cared for some patients who likely were experiencing SIRVA, the morbidity from it can be quite substantial and healing slow.

Anyone who administers deltoid injections should watch the two-minute video (2^nd reference) and care teams should review together. 

References:

• CDC guidance on vaccine administration and a video:  Guidance     Video   
• Video on preventing SIRVA (with soundtrack!):   Video
• Hesse EM, et al. Risk for Subdeltoid Bursitis After Influenza Vaccination: A Population-Based Cohort Study. Ann Intern Med. 2020 Jun 23;M19-3176. Link
• Wiesel B and Keeling L.  Shoulder Injury Related to Vaccine Administration.  J Am Acad Orthop Surg,  2021 Sep 1;29(17):732-739.  Abstract

From the Literature

2)  Reducing Sedatives for Sleep in the Elderly

Most of us have encountered the elderly patient who has been on benzodiazepines for sleep for a long time and is very reluctant to change. We know these medications can lead to or worsen cognitive impairment, mood disorder, and fall risk, but changing minds can be challenging. Investigators in Nova Scotia sought to implement a community intervention to reduce benzodiazepine receptor antagonist (BZRA, both benzodiazepines and “z-drugs”) use amongst the elderly in the province. Of note, the article states that approximately 20% of the elderly in Nova Scotia used BZRAs regularly, which seems a very high number, indeed.

The investigators recruited subjects using advertising outreach and random digit phone dialing. The subjects were randomized to one of three groups: Group 1 received a “knowledge mobilization intervention” (booklets and a website from “mySleepwell.ca”) that guided patients through cognitive behavioral therapy for insomnia (CBTi), Group 2 received educational booklets used in the EMPOWER study that showed a decrease in BZRA use, and group 3 got usual care for 6 months, followed by the Sleepwell intervention. Subjects were not blinded but there were independent outcome assessors used. Follow up rates were very good. Decrease in BZRA use was the primary outcome, but the investigators were careful to not count patients who were switched to another sedative, including “trazodone, quetiapine, tricyclic antidepressants, mirtazapine, gabapentin, centrally acting antihistamine, melatonin, or new use of cannabis or cannabinoids” – which is a challenging, yet very useful restriction in the study. Secondary outcomes included sleep and anxiety scales, quality of life, switching to other sedatives, and intervention fidelity measures.

There were 580 subjects were randomized - mean age of 72.1 (SD 5.7) years, 64.1% were female, 35.9% were male, and 88.5% were driving weekly or more. 26.2% of subjects discontinued BZRAs with the Sleepwell intervention, 20.3% with The EMPOWER intervention and only 7.5% with usual care (NNT* for Sleepwell vs. usual care ~ 5.3, NNT for EMPOWER vs. usual care ~ 7.8, there was no significant difference between the two active interventions). The Sleepwell intervention also led to a >=25% reduction in BZRA use over usual care, but the EMPOWER intervention did not. Starting other sedatives (both BZRA and not) was more common in the EMPOWER group, but there was no difference in alcohol consumption. Sleep measure differences were mixed, but not importantly different overall. Quality of life was not different between groups. Subjects stopping their BZRAs had withdrawal symptoms 33% of the time, but mostly insomnia, and none of the symptoms required emergency department visit or hospitalization.

The authors note that the Sleepwell intervention was tailored carefully – it advised against sedative substitution, it had a flexible recommended BZRA tapering schedule, it was more encouraging of education about CBTi, and the booklets had more pictures of people than the EMPOWER intervention. The authors note that the study was limited by lack of blinding and self-reported outcomes.

John’s Comments:

Despite a few quality considerations, this is a pretty remarkable trial result. The investigators had relatively little interaction with patients beyond the mailing and yet were pretty successful. I can imagine doing this at a practice level for patients. You can see some of the material in the Sleepwell intervention at their website.

*In the article, the authors actually used “number needed to mail” (NNM) - meaning the number of intervention packages with booklets and a cover letter that should be mailed to produce an additional outcome. This is technically the more precise measure, but I think it’s easy to get carried away with terminology…

Reference:

·         Gardner DM, Turner JP, Magalhaes S, Rajda M, Murphy AL. Patient Self-Guided Interventions to Reduce Sedative Use and Improve Sleep: The YAWNS NB Randomized Clinical Trial. JAMA Psychiatry. Published online September 18, 2024. Link

From PeerRxMed ( www.PeerRxMed.org )

3) Getting to “Yes, I’d Love Your Help”

“Having a need and needing help is not a sign that you’re weak; it’s a sign that you’re human.” — Kate Northrup, MD

As clinicians, we’re conditioned to be helpers—the ones who provide support, solutions, and care. Rarely do we voluntarily allow ourselves to be on the receiving end. Our training and professional culture often lead us to believe that seeking help is a sign of weakness or incompetence. What if instead of avoiding assistance, we embraced it as an opportunity for growth, connection, and resilience? What if we saw accepting an offer of help and asking for help as strengths rather than shortcomings?

A few years ago, while recovering from a debilitating back injury I was given the opportunity to rethink my beliefs about being helped.  During my healing journey, I engaged in a conversation with a colleague and PeerRx participant that completely shifted my perspective. When I shared my being-helped challenges with her, she smiled knowingly and provided some words of wisdom: “I’ve learned that whenever someone offers to help me, regardless of what it is, I always find a way to say yes, even when I could do it myself. It allows them to feel useful, and it gives us a chance to connect in a way we might otherwise miss.”

Reflecting on her words, I realized how often I had declined help, even when I really needed it, and how well-rehearsed my “having it all together” act had become.  This included seeking help for obvious things such as moving a heavy object (even after my injury!), and professionally for seeking a second opinion or assistance with a procedure.  I used to see these requests as either an inconvenience for the other person or as something that threatened my independence or ego.  But now, thanks to this reframe, I began to view them as opportunities to build relationships and to strengthen bonds with those around me.

This perspective continues to inspire how I approach being helped – both in terms of accepting it when offered and asking for it more often. In addition, it has changed how I help others.  Rather than accepting a “no thanks” or “I’ve got this” response to my offer of help, I find myself saying “let me help you” and just doing it while engaging the other person in a conversation that will enhance our connection.  By doing this, I’ve gained valuable insights and often we’ve ended up talking about things of great importance.  What I once saw as a sign of dependency or even incompetence has instead become a way to enrich both my professional and personal relationships!

So, this week, I challenge you to say “yes” the next time someone offers you help—no matter how small or trivial the offer may seem.  Notice how doing so lightens your day and deepens your connection. Once you get comfortable with this, take a further step and ask for help yourself, even if it feels unnecessary. The goal is to break the habit of mindless isolation and to embrace the connections that can be built through shared support. After all, isn’t that what PeerRx is all about?  And it all can start with the simple act of saying, “Yes, I’d love your help.”

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  Use of Muscle Relaxants for Chronic Pain

Chronic pain is commonly defined as pain that lasts > 3 months and/or extends past normal tissue healing time and has a prevalence for US adults of >20%.  Guidelines such as the Centers for Disease Control and Prevention’s 2022 Clinical Practice Guideline for Prescribing Opioids for Pain emphasizes a multimodal approach to pain management, incorporating nonpharmacologic and nonopioid pharmacologic treatment options, but leaving considerable latitude as to recommended treatment.  In 2017, the American College of Physicians published a Clinical Practice Guideline (which was endorsed by the American Academy of Family Physicians) on the treatments for acute, subacute, and chronic low back pain, emphasizing non-opioid treatment including

nonsteroidal anti-inflammatories (NSAIDs) and muscle relaxant medications for acute low back pain. 

However, with the emphasis in guidelines (and the evidence) to avoid the prescribing of opioid medication for chronic low back pain, there has been an increase in the use of skeletal muscle relaxants (SMRs) for chronic pain.  The centrally acting SMRs are a pharmacologically diverse category of medications that include antispasticity and antispasmodic medications, such as baclofen, carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine, and tizanidine. They are indicated for acute musculoskeletal conditions including spasms and low back pain but are commonly used off-label for numerous other pain and non-pain conditions.  This includes approximately one-third of patients being prescribed SMRs who do not have a preceding musculoskeletal disorder diagnosis.

A recently published systematic review investigated the long-term use of SMRs for chronic pain, focusing on their efficacy and safety. The study reviewed 44 clinical trials and cohort studies and found that SMRs may be beneficial in treating certain painful chronic conditions such as trigeminal neuralgia, painful cramps, and neck pain but were not significantly more effective than placebo for fibromyalgia, low back pain, or other chronic pain syndromes.

This indicates that the benefits of SMRs are condition specific. Side-effects are quite common and include sedation and dry mouth. Given these findings, the authors recommend that clinicians consider deprescribing SMRs if pain relief goals are not met, especially due to the potential for central nervous system side effects. Additionally, the guidelines referenced above have shown that non-pharmacological approaches, such as exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, biofeedback, low-level laser therapy, cognitive behavioral therapy, or spinal manipulation are all modalities that should be considered as part of a customized, comprehensive approach for most patients who have chronic low back pain rather than relying on pharmacologic therapy alone.   

Mark’s Comments:

For we in primary care, the review underscores the importance of individualized treatment strategies and the careful monitoring of SMRs' effectiveness and side effects, remembering that there are many modalities that can help these patients, and pills of any sort are only one of them.  Without the incorporation of some of these non-pharmaceutical modalities, optimal control of this pain for most patients will likely not occur.  From the perspective of caring for our elderly patients, this review appears to call us to even greater vigilance when using this medication class.  Note that the American Geriatrics Society 2023 updated Beers Criteria® for potentially inappropriate medication use in older adults lists this class of medications as “Avoid” with a strong strength of recommendation. 

Reference:

Oldfield B et al.  Long-Term Use of Muscle Relaxant Medications for Chronic Pain: A Systematic Review.  JAMA Netw Open. 2024;7(9):e2434835.  Link

 

From the Literature

2)  Antibiotic Duration for Respiratory Infections

There has been a move to shorter durations of antibiotic therapy for many infections over the last 20 years or so. These changes are inherently hard to get used to for clinicians trained with the longer durations (or maybe it just seems so to me), so knowing that the recommendations are based on solid evidence is important. The authors of a recent “umbrella” systematic review sought to lay out the evidence for shorter antibiotic durations for the following infections: community-acquired pneumonia (CAP), acute exacerbation of chronic obstructive pulmonary disease (AECOPD), hospital-acquired pneumonia (HAP), acute sinusitis, and streptococcal pharyngitis/tonsillitis.

The researchers performed a good search, had explicit questions to answer, and graded the quality of the systematic reviews they found. They made use of an interesting artificial-intelligence-based approach that sounded overall reasonable as there were multiple human checkpoints used by the researchers. They limited their search for evidence to adults only but included both inpatient and outpatient settings of treatment. They found a total of 40 systematic reviews, but unfortunately graded them as low or very low quality. They could not combine most of the data by meta-analysis, so had to present the results narratively.

·         CAP: 14 reviews were found. They defined short course antibiotics as 1 to 8 days, and longer course as 3 to 14 days. The included reviews varied as to whether they excluded studies with azithromycin (which has long had a shorter recommended course). Some did, some just analyzed azithromycin data separately. Overall, the reviews favored short course therapy for delivering a higher proportion of clinical cures, settling on an average of five days of therapy as the most effective. Shorter antibiotic courses also had similar microbiologic cure rates, and fewer adverse events.

·         ACOPD: 8 reviews were found. Clinical and microbiological cure rates were similar between short and long courses, but adverse events were fewer in the short course groups. Again, five days seemed to be the optimum duration of therapy for these infections.

·         HAP: 3 reviews were found, but there was so much variation between reviews (mainly ventilator-associated pneumonias vs. not) that no useful conclusions could be reached.

·         Sinusitis: 4 reviews were found, but only two provided useful data. Short course antibiotics produced similar clinical and microbiologic cure rates as longer courses. Adverse events were similar also, but when a sub-analysis specifying 5 days of treatment compared with 10 days of treatment was performed, the 5 day course led to fewer events.

·         Pharyngotonsillitis: Eight reviews were found, all of which required microbiologic confirmation of the infection, but still assessed clinical cure outcomes. Interestingly, shorter courses of cephalosporin antibiotics were better than longer course penicillin. Short courses of penicillins were not effective compared to longer courses.

In addition to the concerns about the quality of the evidence, the authors note that these findings should not be applied to immunocompromised patients.

John’s Comments:

Remember when 10 days of antibiotics was the rule for almost all infections? Simpler times…but antibiotic overuse is a known threat. The quality of evidence leaves a lot to be desired here, but there does seem to be consistency in the findings. For CAP, AECOPD, and sinusitis, a five-day course seems like a reasonable routine choice, but extending therapy to 10 days also seems very reasonable for a patient who is not responding well. For pharyngotonsillitis, confine short courses to cephalosporins, while penicillins still need a 10-day course.

Reference:

Kuijpers SME, Buis DTP, Ziesemer KA, et al. The evidence base for the optimal antibiotic treatment duration of upper and lower respiratory tract infections: an umbrella review. The Lancet Infectious Diseases. Published online September 2024:S1473309924004560. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Trust Me, I’m a Doctor:  The Anatomy of Trust

“The best way to find out if you can trust somebody is to trust them.”  ― Ernest Hemingway

Consider for a moment the qualities of someone you would say you “trust fully,” and someone whom you “don’t trust.”  How did you establish these judgments?  Though we don’t talk about it often, trust is certainly foundational in our work; trust in ourselves, our care team, our colleagues, the systems we work in, the medications we prescribe, and the equipment we use.  And trust in healthcare is fragile these days. 

The establishment of trust is also necessary in our relationships with patients.  As a Family Medicine resident, I was often struck by the trust patients placed in me, even when making life-or-death decisions.  Despite being a trainee, my opinion was sometimes valued even more than my attending’s or a consultant.   This prompted me to become a “student” of trust. 

During my research, I came across a “trust equation” that has continued to resonate:

Trust = Connection x Competence

           Risk

In this equation, “connection” is built through empathy and caring (“I sense you care about me”), while “competence” speaks to demonstrated skill and knowledge (“you appear to know what you’re doing”).  The “risk” factor underscores that trust isn’t absolute but varies depending on the perceived vulnerability involved.  When someone feels exposed or dependent on another’s judgment, the stakes—and the importance of trust—are higher. 

How can we strengthen these pillars in our daily work?  Consider starting with small, actionable steps.  For example, spend an extra minute explaining the rationale behind a treatment plan or decision.  Listen without interrupting when someone shares their concerns.  Acknowledge uncertainties openly, showing that you’re committed to working through them together.  These actions help build the “relationship” side of the equation, while our regularly honing fundamental skills fortifies the “competence” component.                                        

Ultimately, trust requires more than credentials, clinical skills, or a title; it demands a willingness to engage, communicate, and make oneself vulnerable.  Rebuilding trust in healthcare isn’t a quick fix but an ongoing commitment.   Continuously revisiting these fundamentals, not just as a theoretical exercise but as a practical approach to our interactions, will help us together find our way forward with our patients and with each other.  Let’s give it a try.  Trust me, I’m a doctor …

Feel free to forward Take 3 to your colleagues.  Glad to add them to the distribution list.

Mark and John

Carilion Clinic Department of Family and Community Medicine

1)  How to Best Screen for Alcohol Use Disorder

Screening for risky alcohol drinking, and brief counseling intervention if positive, has been recommended by the US Preventive Services Task Force (USPSTF) consistently since 1996. In medical school, most of us learned the CAGE questions (Have your tried to cut down drinking? Are you annoyed by people asking about your drinking? Have you felt guilty about your drinking? Do you ever drink alcohol as an eye-opener?), but these ask mainly about alcoholism, or more severe alcohol use disorder (AUD). But the concept of “unhealthy alcohol use” is broader, encompassing binge drinking and chronic drinking (“risky drinking”) above recommended levels in addition to alcoholism.

The USPSTF recommends using a broader approach to screening to prevent morbidity and mortality from the whole range of unhealthy alcohol use. The recommended brief screening methods included the Alcohol Use Disorder Identification Test – Consumption (AUDIT-C) and the Single Alcohol Use Question (SASQ). A recent entry in the Rational Clinical Examination Series looked at the diagnostic/screening utility of these questionnaires recently.

The authors completed a systematic review that searched comprehensively for diagnostic questions that detected both heavier than normal use as well as alcohol use disorder by DSM5 criteria. They found 35 studies which were generally of high quality. Most used the AUDIT or AUDIT-C, the National Institute of Alcohol Abuse and Alcoholism single item tool (which is basically the SASQ), and a few others screening tools. Diagnostic test characteristics for detecting alcohol use disorder (mild and greater) are presented below as likelihood ratios (LR) for positive (+) and negative (-) tests. As a reminder, LR+s are categorized as >10 (excellent), 5-10 (good), 2-5 (fair) and 1-2 (poor). LR-s are categorized as <0.1 (excellent), 0.1-0.2 (good), 0.2-0.5 (fair) and 0.5-1 (poor).

The NIAAA screener in adults works well for AUD in adults (LR+ 10, 95% confidence interval (CI) 6.7-16, LR- 0.09, 95%CI 0.03-0.26). The AUDIT-C has slightly less helpful characteristics (LR+ 1.9, 95%CI 1.7-2.2, LR- 0.37, 95%CI 0.32-0.43). Remember, the AUDIT-C looks mainly at amount of consumption of alcohol and is designed to screen for risky drinking also.  The full AUDIT is a better at AUD diagnosis (LR+6.5, 95%CI 3.9-11, LR- 0.33, 95%CI 0.03-0.52), and is a necessary follow-on screening after a positive AUDIT-C to distinguish alcoholism from risky drinking. The T-ACE (tolerance, annoyed, cut-down, eye opener) worked very well in pregnancy, but not a lot better than the AUDIT.

John’s Comments: 

It is sometimes hard to keep straight in the face of evidence like this that the full AUDIT and other measures like CAGE and T-ACE are used to diagnosed alcoholism/alcohol use disorder, whereas the “consumption”-related screeners like NIAAA/SASQ and AUDIT-C are meant to pick up any risky drinking to sort out later. In our recent research project on screening and managing unhealthy alcohol use, just getting clinicians to screen for risky drinking at all was an accomplishment. This important preventive screening commonly gets lost in all the other competing demands, but it’s a relatively easy, important screening, and patients do get better with our brief counseling. Try out the AUDIT-C or SASQ in your practice – it was surprising to our participants how big a problem this was for our patients.

Reference:

·         Wood E, Pan J, Cui Z, et al. Does This Patient Have Alcohol Use Disorder?: The Rational Clinical Examination Systematic Review. JAMA. 2024;331(14):1215. Link

From the Literature

2)  Opportunistic Salpingectomy for Ovarian Cancer Prevention

High-grade serous ovarian cancer (HGSOC) is the most common and most fatal form of ovarian cancer, affecting 1 in 70 females.  No effective screening test is available for HGSOC, and patients often present in an advanced stage of disease.  Around 70%–80% of deaths from ovarian cancer are caused by HGSOC.  Research has shown that HGSOC originates in the fallopian tubes.  As such, the practice of opportunistic salpingectomy (OS), which is the surgical removal of the fallopian tubes during benign gynecologic surgery (hysterectomy or instead of tubal ligation) while leaving the ovaries intact, has gained traction as a key strategy in reducing ovarian cancer risk.  

First described in 2010, a growing body of evidence supports the practice of OS.  Studies have highlighted the potential for OS to reduce ovarian cancer risk.  A population-based cohort has shown OS can lower the risk of HGSOC in the general population by 65%.  Studies have also shown no increase in surgical complications.  Specifically, no significant increase has been found in operative time, blood transfusions, postoperative recover, readmissions, postoperative complications, infections, or fever compared with hysterectomy or tubal ligation. 

Although OS offers the opportunity to significantly decrease the risk of ovarian cancer, it does not eliminate the risk entirely.  Counseling women who are undergoing routine pelvic surgery about the risks and benefits of salpingectomy should include an informed consent discussion about the role of oophorectomy and bilateral salpingo-oophorectomy.  Bilateral salpingo-oophorectomy that causes surgical menopause also reduces the risk of ovarian cancer but may increase the risk of cardiovascular disease, cancer other than ovarian cancer, osteoporosis, cognitive impairment, and all-cause mortality.  Additionally, ovarian function does not appear to be affected by salpingectomy at the time of hysterectomy based on surrogate serum markers.

A 2019 Committee Opinion from the American College of Obstetrics and Gynecology emphasized that the risks and benefits of salpingectomy should be discussed with patients who desire permanent sterilization.  It noted that plans to perform an opportunistic salpingectomy should not alter the intended route of hysterectomy and surgeons should continue to observe and practice minimally invasive techniques.  

While OS shows promise, some challenges remain. Counseling patients effectively on the risks and benefits of salpingectomy requires a nuanced understanding of individual cancer risk, family planning desires, and surgical candidacy. Additionally, concerns about long-term ovarian function after salpingectomy have been raised, although current data suggest that the impact on ovarian reserve and hormonal function is minimal.

Mark’s Comments: 

I had not heard of this until listening to a recent podcast.  OS certainly seems a reasonable approach to help minimize risk for ovarian cancer, especially considering the potential benefits (including preservation of ovarian function) versus the low risk of additional complications.  However, careful patient education and counseling is still important, including the fact that, unlike a tubal ligation, OS is not reversable.

References:

·         ACOG Committee Opinion No. 774: Opportunistic Salpingectomy as a Strategy for Epithelial Ovarian Cancer Prevention. Obstet Gynecol April 2019;133(4):p e279-e284.  Link

·         Werger M et al.  Opportunistic salpingectomy to decrease the risk of ovarian cancer.  CMAJ June 10, 2024 196 (22) E765.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Tolerations 2:  Breaking Free from Them Before They Break You

"Your life does not get better by chance, it gets better by change." – Jim Rohn

Tolerations, the subtle annoyances we live with every day, are more than just minor inconveniences. These seemingly small stressors slowly chip away at our mental energy and focus. While acknowledging them is a start, the next step is learning how to systematically identify and resolve them. This follow-up to a recent blog will explore strategies for recognizing these energy drains and offer a practical solution for addressing them. 

As previously shared, resolving a decade long toleration has led to an overwhelming sense of relief.  But as I relished the clarity that came with addressing this, other things I’ve been tolerating have come into finer focus – the computer keys that regularly stick, the unread “I’ll get to later” e-mail, the passport that has needed to be renewed since January, and numerous others.  This led to the realization that what I need is a system – a practical and sustainable approach to dealing with these recurring energy drains.

Indeed, as minor as they might seem, tolerations have a measurable impact on our mental well-being.  In fact, research shows unfulfilled goals, unresolved stressors, or unaddressed conflicts, no matter how “small,” remain active in our subconscious, creating a cognitive load that drains mental resources.  In healthcare, where quick thinking and mental clarity are paramount, these ongoing distractions can add unnecessary mental clutter, potentially leading to diminished job performance.  The good news is that even addressing the smallest tolerations can improve both mental clarity and emotional resilience.  In fact, achieving these small goals causes a release of dopamine (our brain’s "feel-good" chemical), which reinforces positive behavior and makes tackling bigger issues more manageable as well.

To begin the process of naming and eliminating these tolerations, consider performing regular “toleration audits.”  This simple but highly effective strategy begins with systematically identifying all the small irritations, frustrations, or inefficiencies in your life and writing them down.  Consider separating them into different areas of your life (work, home, relationships, finances, etc.) and make it your goal to list as many as you can (for fun, aim for 30 or more – trust me, they’re there).  Once you have your list, prioritize each item and start with the smallest, easiest ones.  The goal is to build momentum as well as increased awareness of places and patterns in your life where you are “settling” for less than what you desire. 

Remember, the process of identifying and addressing tolerations is an ongoing journey, not a one-time fix.  The good news is that even small actions can lead to big shifts in how we feel and function.  This week, I challenge you to conduct your own “Toleration Audit.”  Then, share what you’ve learned and your intentions for change with your PeerRx partner.  Take time to laugh at some of the ridiculous things you’ve been tolerating and be sure to celebrate each small victory.  By consistently addressing these energy drains, you’ll find greater focus, a heightened sense of accomplishment, and greater peace of mind.  And we could all sure use more of that …. 

Feel free to forward Take 3 to your colleagues.  Glad to add them to the distribution list.

 Mark and John

 Carilion Clinic Department of Family and Community Medicine

1)  When It Comes to Blood Pressure (BP) Cuffs, Size Matters

Clinical practice guidelines recommend selecting an appropriately sized blood pressure cuff based on mid-arm circumference prior to measuring BP.  Appropriate cuff size is determined by arm circumference, which is measured by identifying the midpoint of the upper arm (typically in the middle of the bicep) and measuring with the arm relaxed.  According to the American Heart Association, properly sized cuffs correspond to the following arm circumferences: 

The negative impact of the use of inappropriately sized cuffs (“miscuffing”) has been shown for both manual and automated BP devices.  The degree of variation from the appropriate size will determine the amount of error.  An undersized cuff will overestimate systolic blood pressure by approximately 5-10 mmHg and diastolic blood pressure by 2-6 mmHg even more if the mismatch is more than one cuff size.  An oversized cuff will underestimate systolic blood pressure (SBP) by approximately 5-10 mmHg and diastolic blood pressure (DBP) by 1-5 mmHg.  According to recent data from the National Health and Nutrition Examination Survey (NHANES), about half of US adults require a large or extra-large cuff size.  Therefore, the majority of errors are in using a cuff size that is too small, thus overestimating the actual blood pressure.  Additional studies have highlighted how improper cuff size could contribute to misdiagnosis, inappropriate treatment, and adverse health outcomes. 

Given the increased emphasis on home blood pressure readings, a recent study examined the availability of appropriate cuff sizes for the most popular home BP devices from Amazon.  Of the 10 devices reviewed, 9 offered cuff sizes covering arm circumferences from 22 to 42 cm (1 device with 2 cuff sizes) and 1 from 22 to 40 cm. Based on data from the NHANES survey 2015 to 2020, 6.7% of US adults (corresponding to 17.3 million adults based on the 2023 US census) could not use these devices as is since their arm circumferences were <22 cm (0.3% [0.8 million], including 32.3% with hypertension) or >42 cm (6.4% [16.5 million], including 67.3% with hypertension). The proportion of adults not covered by these devices was higher in Black adults (11.8%) than in other racial/ethnic groups (White adults [6.6%], Hispanic adults [5.2%], and Asian adults [1.8%]; P <0.001).  The authors concluded that ideally,  consumers should be able to select their appropriate cuff size without any additional cost. Furthermore, clinicians should instruct patients about how to measure arm circumference and the importance of selecting an appropriate cuff size when purchasing a home BP device.  They also expressed concern regarding the hidden racial disparity when it comes to access to home BP cuffs.

Mark’s Comments:

I continue to be amazed at all the potential confounding variables that must be considered to be able to measure blood pressure “correctly” (29 in one review – see 3^rd reference below).  Given the potential negative impact of inaccurate readings for patients and that BP measurement is on most ACO scorecards, finding ways to measure accurately becomes even more imperative.   

At the least, we should be educating patients (and each other) of the importance of proper cuff size, and perhaps should be listing this on the patients “Problem List” under the “overview” section of the Hypertension diagnosis. 

References:

• Ishigami J et al.  Effects of cuff size on the accuracy of blood pressure readings: the Cuff(SZ) randomized crossover trial. JAMA Intern Med. 2023;183:1061–1068. Link
• Kaur E et al.  Arm Size Coverage of Popular Over-the-Counter Blood Pressure Devices and Implications in US Adults. Hypertension. October 2024;.81:e125–e127.. Link
• Kallioinen K, et al.  Sources of inaccuracy in the measurement of adult patients’ resting blood pressure in clinical settings: a systematic review.  J Hypertens. 2017 Mar; 35(3): 421–441. Link

From the Literature

2)  A New Option for Menopausal Vasomotor Symptoms

Vasomotor symptoms (VMS - flushing, hot flashes, sweating) are very common for women in perimenopause, and are very disruptive – to relationships, sleep, and overall quality of life. Our options have been limited to hormones, selective serotonin reuptake inhibitors, blood pressure medications like clonidine – all of which have significant adverse effects or don’t work very well. Yes, gabapentin has also been tried, naturally, with similar results.

In May 2023, the FDA approved a new medication, a neurokinase 3 receptor antagonist called fezolinetant (trade name Veozah, which is no more memorable or easy-to-say). A systematic review of the available literature on fezolinetant has been recently published. The authors searched seven literature databases for randomized controlled trials of the medication vs. placebo. They appraised the studies using the Cochrane Risk of Bias tool, assessed the studies for heterogeneity and pooled the results via meta-analysis. The primary outcome was change in frequency of VMS. Secondary outcomes included quality of life scores, other measures of VMS frequency, and safety data – namely transaminase elevations, sleep disturbances, and other adverse events.

The researchers found 330 possibly relevant studies and ultimately selected five studies with six reports (containing data for 2080 patients). The included subjects had an average of 7-8 VMS episodes per day, and the trials studied a range of fezolinetant doses - 45, 60, or 90 mg per day. The included studies were of low risk of bias, four lasted 12 weeks and one lasted a year. Fezolinetant was associated with a mean difference of 2.62 fewer episodes per day than placebo at 12 weeks (95% confidence interval (CI), 1.84–3.41). Quality of life was not significantly different between the groups. More women achieved an over 75% reduction in symptoms with fezolinetant than with placebo (Odds ratio (OR) 3.07 (95% CI, 2.20–4.30), NNT~5) and sleep improved in the treatment group (OR 2.39 (95% CI, 1.60–3.58), NNT~ 11). The only significant adverse event found was an increase in alanine aminotransferase (ALT) levels over three times the upper limit of normal (OR 2.38 (95%CI, 1.04–5.41), NNT~83). Heterogeneity in the analyses was overall low to moderate.

John’s Comments:

Well, this drug seems to help…somewhat. The authors found it curious, and I agree, that the quality-of-life measure used did not show any significant differences with the intervention despite a reduction in symptom frequency, improved sleep, and no major side effects.   Some other neurokinase inhibitors have been studied but were abandoned due to hepatotoxicity, so the ALT elevation is something that bears close watching. Even though the drug was tested at multiple doses, the FDA-approved dose is only 45 mg. This drug may be worth trying, but price may be prohibitive (Goodrx.com lists it in the mid-$500 range), and I can’t even find it on several commercial formularies.

Referencs:

• Bonga KN, Mishra A, Maiti R, Padhy BM, Meher BR, Srinivasan A. Efficacy and Safety of Fezolinetant for the Treatment of Menopause-Associated Vasomotor Symptoms: A Meta-analysis. Obstet Gynecol. 2024;143(3):393-402. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  How Will You “Fall Forward” in the Coming Months?

"Life starts all over again when it gets crisp in the fall." — F. Scott Fitzgerald

As the fall colors begin to settle in and the last traces of summer slip away, we’re offered a beautiful opportunity for transition and reflection. There's something undeniably special about the shift from the long, warm days of summer to the shorter, crisper days of autumn. It feels like nature is inviting us to slow down, refocus, and prepare ourselves for the months ahead.

Autumn provides a different kind of energy—one that encourages us to ground ourselves, take stock of the year so far, and make any necessary adjustments as we enter the final stretch of the calendar. It’s a season rich with symbolism, from the shedding of leaves to the harvest of crops, and it can serve as a powerful reminder for us to do some shedding and harvesting of our own.

Remember that the PeerRxMed process involves those valuable PRx90 quarterly check-ins— “up to 90 minutes every 90 days” to touch base with yourself and your PeerRx partner. These conversations help to pause and recalibrate both personal and professional growth. It’s time to schedule that meeting again. To spark your discussion, here are some questions to ground and focus your reflections:

• What have you learned about yourself in the past 90 days?
• What goals or priorities will you focus on in the next quarter? Which will leave you disappointed if unaccomplished by the time we check in next?
• Do you have a break or vacation planned? What can you do this season that will bring you joy or peace?

In the spirit of fall, here are some additional questions to guide your personal reflection and dialogue, inspired by the themes of harvesting and shedding:

Fall Harvest: Fall is the season of reaping what we’ve sown. Take a moment to reflect on the seeds you planted earlier in the year. What projects or goals are coming to fruition? Which areas of your life are yielding the most growth and satisfaction? As you gather your personal and professional harvest, celebrate your wins, big and small. Then, think about what still needs attention. Is there something you’ve been nurturing that is now ripe for the picking?

Fall Shedding: Just as trees shed their leaves in preparation for winter, fall can be a time to let go of things that are no longer serving you. What have you been holding onto that you need to release? This could be a mindset, a habit, or even a project that’s run its course. Consider lightening your load to make room for fresh energy and new opportunities. As you let go, you create space for clarity and focus.

Don’t miss this perfect chance to “fall forward” by embracing the natural shift of the season. Take time for introspection, realignment, and meaningful conversations with your PeerRx partner. Three months from now, as winter begins, you’ll be glad you made the most of this autumnal pause, ensuring you’re well-positioned for whatever comes next.

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  Creating a 5 STARRS Practice “Culture By Design”

How would you describe your “practice culture?”  It may be a question you’ve never really considered.  And yet, all organizations and practices have a culture.  In the book, “Inside the Magic Kingdom” about the Disney culture, author Tom Connellan contends that all cultures are either by design or by default – and if you don’t know which yours is, then it is a culture by default.  A culture by default is not necessarily a toxic or dysfunctional culture.  It may be a highly functioning one.  The challenge is that without creating such culture deliberately and proactively, teams have no idea how to replicate it, sustain it, or adapt it if things aren’t going well.

The practice of medicine and the provision of health care is a challenging and often energy-draining one.  Statistics would indicate that as those working in health care, we are constantly at risk for burnout (emotional exhaustion, depersonalization, meaninglessness), compassion fatigue (find it difficult to care), and moral distress (deviate from core values).  The busyness and intensity of our work can also quickly place us in “survival mode,” where we end up focusing on just getting through the day rather than being present to those who are seeking our care and to our teammates providing that care throughout the day.

In the spirit of “practicing prevention,” what might a high functioning practice “culture by design” look like?   Let’s go one step further.  What would it look like to live out, on a day-to-day basis, the Vision below for your practice?”

“We are a thriving ‘Culture by Design’ medical practice characterized by exceptional care and heart-felt caring where we enjoy being together and doing our work.”

I’ve created an acronym to help guide such an inquiry.  The inquiry has 2 parts:  The first is individual reflection examining the impact (positive or negative) you might be having on your team, and the second is doing the same reflection with your teammates. 

STARRS:

·         Service – What is our philosophy for both patient care and “customer service” and are we implementing this consistently?  Additionally, how are we serving each other in the process of serving our patients?  There should be a consistent feedback mechanism in place to measure performance and a process in place to improve it.

·         Teamwork – Is there a common and explicit understanding of everyone’s role and are they trained and empowered to be able to perform this role effectively?  We commonly think of teamwork in the context of care delivery, or what we do together for our patients. Teamwork also refers to how we connect with each other as coworkers and team­mates. It requires presence and awareness, not only knowing each other by our titles and roles but also knowing about each other.

·         Attitude – Is everyone “choosing” and “owning” their attitude moment by moment, and is there a process in place for teammates to check in with each other and encourage each other during the course of our high pace, high pressure days?

·         Reflection – Is there a regular time put aside to dialogue about not only the “business” of the practice, but also to reflect on the challenges and joys of taking care of those who are often experiencing significant suffering and distress?

·         Renewal – Is time set aside for everyone to reenergize during the course of work?  How are having fun and celebrating successes part of the culture?

·         Self-Care – How do we emphasize self-care? Is holistic health and well-being encouraged and supported for each team member, including physical, emotional, mental, spiritual, and relational health?

Mark’s Comments:

Effective relationships are the foundation of the good work that we do.  We speak often and appropriately of the importance of our relationships with our patients.  Equally if not more essential to both our clinical effectiveness and the sustainability of our work are our relationships with our colleagues and care team.  I encourage each of you to use the tools in the referenced article (or you can reach out to me) to help facilitate your reflection; one focused on you (Being a 5 STARR Person) and one focused on your team (Being a 5 STARR Team).  I also encourage you to have each of your team members complete the Team survey and to use this for discussion as to the “State of the CommUnity” at your next practice team meeting.  Then make a plan to take action on those areas that have not achieved 5 STARRS! 

Reference:

·         Greenawald MH. How to create a culture of well-being in your practice. Fam Pract Manag. 2018;25(4):11-15.  Link

·         American Academy of Family Physicians: Practice and Career. Clinic Practice Culture:  Moving from Surviving to Thriving.  Link

From the Literature

2)  A Primary Care Response to Postpartum Morbidity

There has been extensive documentation of the problem of postpartum morbidity and mortality – a phenomenon that doesn’t have a high overall incidence but reveals highly impactful disparities related to social and structural determinants of health. A report from an Expert Panel (disclosure: I served on this panel) called for high-quality research focused on patients through their life course and entailing creative systems innovation to address the problems of postpartum health. Sounds a lot like a job for primary care to me.

A recent article in JAMA Network Open tested an intervention based on behavioral economics – a default choice intervention – to automatically arrange a primary care visit for post-partum women. The thinking behind this intervention was: 1) 30% of postpartum women have some chronic disease (e.g., hypertension, obesity, diabetes) and 11-22% have a mood disorder and 2) a defaulted primary care visit helps patients avoid the administrative burden associated with the healthcare system.

Pregnant or very recently postpartum patients with obesity, hypertension, diabetes, depression or anxiety were randomized to the default appointment intervention (notification of which was achieved by several patient-focused text messages) vs. usual care (a single text reminder to schedule an appointment in primary care). The primary outcome was a successful primary care appointment within 4 months of delivery, and secondary outcomes measured various aspects of the content of these visits.

There was an 19% absolute risk increase (+18.7%, 95% confidence interval 9.1% to 28.2%) of a successful primary care appointment in the intervention group. There was also a nearly 4% absolute risk reduction (−3.9%, 95% CI −7.8% to −0.1%) in postpartum readmission. There were a greater number of interventions directed at the postpartum conditions (e.g., weight loss plans, blood pressure assessment, diabetes assessment, mood screening) in the intervention group than in the control.

The authors emphasize that the point of such interventions is “to make it easier for people to make choices they already want to undertake but do not.” The study is limited by testing a bundled intervention (instead of the component parts individually) and by limiting the sample to those who already had primary care clinicians.

John’s Comments:

Our research group at Carilion Clinic has studied healthcare-associated administrative burdens (we call them “sludge”) and found that patients are dispirited by sludge, with the result that they don’t get the care they need. The problems associated with postpartum morbidity and mortality aren’t rare new diseases, but inadequate management of common conditions (e.g., hypertension, diabetes, depression) – due to complex structural determinants of health such as poor access and sludge. To improve the health of the populations we care for, we cannot continue to expect people to show up at our doors to seek care for what amount to risk factors and subclinical disease – we have to devise creative ways to ensure that these risks are managed before they turn into bad outcomes. “Default choice” interventions have the advantage of making the healthy choice easy while still preserving the patient’s right to opt out.

References:

·         Clapp MA, Ray A, Liang P, James KE, Ganguli I, Cohen JL. Postpartum Primary Care Engagement Using Default Scheduling and Tailored Messaging. JAMA Netw Open. 2024;7(7):e2422500. Link

·         Davidson KW, Terry MB, Braveman P, Reis PJ, Timmermans S, Epling JW. Maternal Mortality: A National Institutes of Health Pathways to Prevention Panel Report. Obstetrics & Gynecology. 2024;143(3):e78. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Tolerations: The Silent Energy Drainers in Our Lives

We all have things in our lives that we “tolerate” – a cluttered office, a squeaky door, a physical symptom, a messy inbox, or unresolved tension with a colleague,.  They’re the small, nagging things we “put up with” because, in the grand scheme of life, they don’t seem like a big deal.  But these tolerations can come at a cost.  They quietly drain our energy, steal our focus, and add to the overall stress we carry.

Recently, I had a tooth filled.  While that in itself may not seem like a big deal (or perhaps it does!), it was a minor procedure I had put off for years.  The reasons for this are many, but one day something finally “snapped” for me when the water flosser I had become dependent on for symptom relief was not working and I realized how much of my daily life was being impacted (no pun intended) by this small gap in my teeth.  In retrospect, that chip in my tooth became symbolic of all the things in my life that bother me, but not enough to do something about them.   That inaction slowly chips away at my mental and emotional bandwidth, eroding any sense of control over my environment and causing unneeded frustration in my life. 

Research confirms that these unresolved stressors, such as clutter, inefficiency, and unresolved conflict, no matter how minor, can cause cumulative distress and ultimately become chronic energy drains.  In healthcare, where we’re already juggling high-stakes decisions and overflowing schedules, these tolerations add an unnecessary layer of mental and even emotional fatigue that can impact not only our ability to perform at our best, but also diminish our quality of life. 

That chipped tooth wasn’t the only thing I was tolerating.  Like many of you, I also had a backlog of unread emails, a colleague I needed to have a tough conversation with, and a growing sense of weariness from managing so many unresolved stressors.  In the past few weeks when I finally started addressing some of them, beginning with having that tooth fixed, I’ve noticed an immediate sense of relief.  Suddenly, I felt more in control, “lighter,” and more focused on the things that truly mattered to me.  When I reflect back on the cumulative amount of emotional energy that was invested in that tooth, it is stunning – even embarrassing.

The truth is, when we allow tolerations to pile up, we unknowingly create an environment where stress thrives.  By proactively identifying and eliminating these energy drains, we free up mental space and emotional energy for a more meaningful life.  So what things are you tolerating?  Take a moment today to reflect on the small things you’ve been putting up with, whether at work or at home.  Make a list and identify one you could easily address in the next week – and repeat weekly.  Ask your PeerRx partner to help hold you accountable by naming your intentions in advance.  Then celebrate each small “victory.”  Notice how much lighter you feel and be reminded, sometimes it’s the smallest shifts that make the biggest difference. 

Oh, and in case you’re wondering, after a decade, I haven’t had to use the water flosser since my procedure.   So many tolerations, so little time …

Feel free to forward Take 3 to your colleagues.  Glad to add them to the distribution list.

 Mark and John

Carilion Clinic Department of Family and Community Medicine

1)  Primary Care Recognition of Cardiac Amyloidosis

There are certain things that we learned in medical school that will always feel rare to me. Amyloidosis is one of them. There are lots of different amyloidoses, but cardiac amyloidosis has gained some recent notoriety because one type is recognized a lot more than people thought. How much more? Well, it’s hard to find specific numbers, and there is nothing as useful as a rate we can expect to see in primary care, but we can start with what we know from a recent American College of Cardiology/American Heart Association (ACC/AHA) 

ACC/AHA “Expert Consensus Decision Pathway” (so, unfortunately, not an evidence-based clinical guideline).

There are two types of cardiac amyloidosis – light-chain (AL) and transthyretin (ATTR). AL remains pretty rare – incidence is estimated at 1 in 75,000-100,000 thousand people. ATTR is “more common than we thought” – 16% of people having valve replacements for aortic stenosis, 13% of people diagnosed with heart failure with preserved ejection fraction (HFpEF).

The diagnostic algorithm for the cardiac amyloidoses is a little complicated. First, try to think of amyloid when your patients have left ventricular (LV) hypertrophy or increased LV mass – especially if they also have a low-voltage ECG despite the increased LV mass - or if they have atrial fibrillation or other conduction disorders.

Then look for extracardiac clues:

• In both AL and ATTR: polyneuropathy and autonomic dysfunction
• In AL only: macroglossia, periorbital purpura, easy bruising, proteinuria
• In ATTR only: carpal tunnel, biceps tendon rupture, trigger finger, spinal stenosis

An echo might show the increased LV mass, but cardiac magnetic resonance imaging (MRI) can differentiate amyloid from other causes but MUST be accompanied by testing for an AL-associated monoclonal protein – serum kappa/lambda free light chains and serum and urine immunofixation electrophoresis (IFE).

Then the algorithm splits:

• If there is a monoclonal protein detected – consult hematology for AL-cardiomyopathy (AL-CM). This has a relatively poor prognosis.
• If there is no monoclonal protein, then scintigraphy can evaluate for ATTR-CM.
  • Treatment for ATTR-CM is available (tafamidis, an extremely expensive oral medication that can stabilize the amyloid deposits)
  • Even if tafamidis is not an option, treatment of the heart failure associated with ATTR-CM should account for the frequent intolerance of much of the guideline-directed medical therapy recommended for other heart failure.

John’s Comments:

It behooves primary care clinicians to be aware of this disorder – especially of the extra-cardiac manifestations – since we would be in the best position to see the diagnostic forest for the trees. For heart failure diagnosis and management in primary care, it is becoming more important for us to think through etiologies and presentations, form an accurate diagnosis, and appropriately tailor therapy. I think if we are more careful about pursuing the definitive diagnoses for the usual heart failure causes, less common ones like cardiac amyloidosis will stand out.

References:

• Kittleson MM, Ruberg FL, Ambardekar AV, et al. 2023 ACC Expert Consensus Decision Pathway on Comprehensive Multidisciplinary Care for the Patient With Cardiac Amyloidosis. Journal of the American College of Cardiology. 2023;81(11):1076-1126. Link
• When Heart Failure Is Actually Cardiac Amyloidosis. Medscape. Accessed September 6, 2024. Link

From the Literature

2)  Tirzepatide and Obstructive Sleep Apnea (OSA)

Obstructive sleep apnea (OSA) has an estimated prevalence in the US of 15-30% in males and 10-15% in females when OSA is defined broadly as an apnea-hypopnea index (AHI) >5 events per hour of sleep.  When more stringent definitions are used (eg, AHI ≥5 events per hour plus symptoms or AHI ≥15 events per hour/“moderate OSA”), the estimated prevalence is approximately 15% in males and 5% in females. Evidence confirms that advancing age, male sex, and higher body-mass index (BMI) increase OSA prevalence with higher BMI being the strongest factor for both risk and severity.   

More than 2 decades ago, prospective observational studies reported that a 10% weight gain over 4 years is associated with a 32% increase in the apnea–hypopnea index (AHI) and, conversely, a 10% weight loss predicts a 26% decrease in AHI.  More recently, randomized controlled trials (RCTs) with up to 4-year follow-up indicated that weight loss is associated with decreased OSA severity with an average change in AHI of 0.78 events/h for every kilogram of weight lost, and that a small proportion of patients can achieve remission of OSA (AHI < 5 events/h).

A recently published paper of two phase-3, double-blind, randomized, controlled trials involving 269 adults with moderate-to-severe obstructive sleep apnea and obesity looked to see the impact of a maximally tolerated dose of tirzepatide, a dual glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptor agonistGLP-1 agonist, vs. placebo for 52 weeks on their OSA.   Participants were assigned to trial 1 or trail 2 based on whether or not they were receiving CPAP.  The primary end point was the change in the AHI from baseline.  There were multiple secondary end points, including weight loss and sleep-related patient-reported symptoms.

At baseline, the mean AHI was 51.5 events per hour in trial 1 and 49.5 events per hour in trial 2, and the mean body-mass index (BMI) was 39.1 and 38.7, respectively.  The authors found that in trial 1, the mean change in AHI at week 52 was −25.3 events per hour (95% confidence interval [CI], −29.3 to −21.2) with tirzepatide and −5.3 events per hour (95% CI, −9.4 to −1.1) with placebo, for an estimated treatment difference of −20.0 events per hour (P<0.001).  In trial 2, the mean change in AHI at week 52 was −29.3 events per hour (95% CI, −33.2 to −25.4) with tirzepatide and −5.5 events per hour (95% CI, −9.9 to −1.2) with placebo, for an estimated treatment difference of −23.8 events per hour (P<0.001).  Averaging the two groups, the percent change in body weight was 18.7% (21.7 kg) in the tirzepatide group vs. 1.5% (1.7 kg) in the placebo group.

The authors concluded that for persons with moderate-to-severe obstructive sleep apnea and obesity, tirzepatide significantly reduced AHI, body weight, and short-term (1 week) sleep-related outcomes (as well as some other secondary outcomes) over 1 year of intervention as compared with placebo.

Mark’s Comments:

Essentially, what the authors found was that weight loss with tirzepatide improved OSA in a predictable way, just like previous studies have found for other modalities that promote weight loss, which, while exciting, is not ground-breaking.  What was notable about this study from my perspective is that it was published in the NEJM, funded by Lilly (makers of tirzepatide), and the lead author is a paid consultant for Lilly.  While I respect the fact that getting FDA approval for new indications requires research, I’m not clear why this study was New England Journal of Medicine-worthy.  Learning that a drug that has been shown to be effective for weight loss can also improve the symptoms of OSA is really not news.  I’m not paranoid, but it does make me wonder ….

In an accompanying editorial, the author was also diplomatically skeptical, writing, “Whether tirzepatide improves patient-centered outcomes in obstructive sleep apnea remains unclear because a change in the AHI has not been validated as a surrogate marker of clinically relevant end points …. Additional analyses of the effects of tirzepatide on a broader range of patient-reported outcome measures by the SURMOUNT-OSA team will be eagerly awaited to evaluate the potential utility of tirzepatide as a sole treatment for obstructive sleep apnea.”

Reference:

• Malholtra A, et al.  Tirzepatide for the Treatment of Obstructive Sleep Apnea and Obesity.  NEJM.  Published ahead of print 21 June 2024.  Link  

From PeerRxMed ( www.PeerRxMed.org )

3)  No One Should Struggle Alone

“We need to be better at helping each other.”  Physician colleague who came within minutes of committing suicide.

We know the work we do as physicians and other healthcare clinicians is challenging and can be incredibly emotionally taxing.  Each year at this time I’m reminded of the many conversations I’ve had over the years with colleagues who reached out for support due to their feeling that they were at their emotional “wits end”.  One that continues to stand out for me is a colleague who 7 years ago came within minutes of choosing to take her life through suicide.  Since then she has shared details with me of that painful time and her healing journey.    

When we last spoke, she was far enough away from that intensely dark and emotionally raw time to have gained deeper insight.  One of the things she told me (and has given me permission to share) speaks directly to why it is so essential to have a buddy (or buddies) who understands what it is like to travel this professional journey called healthcare:  “I’m not the kind of person who would ever consider something like suicide – so I thought.  But I broke, and the level of emotional pain I was feeling is difficult to describe.  It had to be quite obvious to others that something was wrong.  I believe they wanted to help, but none of them seemed comfortable in reaching out to me and when they did, it was easy to push them away.”  She concluded, “We need to be better at helping each other.” 

National Physician Suicide Awareness Day will be on Tuesday, September 17^th this year.  Started in 2018, the vision for this initiative is that this day will serve as a call to action for all of us to re-commit to breaking down stigma, opening the conversation, decreasing the fear of consequences, recognizing warning signs and learning to approach our colleagues who may be at risk for suicide or struggling emotionally.  Of course, it is a tragedy to think that we even need a day to raise awareness of physician suicide, but the statistics indicate that on average, one of our physician colleagues choses to take their life every day, and these statistics do not account for our NP, PA, PhD, PharmD, Allied health, and nursing teammates, all of whom, as we know, are struggling mightily as well.  Additionally, the 2023 Medscape Physician Suicide Report indicates 1 in 10 physicians have had thoughts of suicide, yet 40% told no one.    

According to Psychiatrist Michael Meyers, MD, author of the book The Physician as Patient, when a colleague shares that they are having suicidal thoughts, or even that they’re struggling emotionally, the first step is to thank them for sharing the information; “I’m sure that wasn’t easy, but I appreciate that you respect me enough to share with me.   Let’s talk more.”  Then ask what you can do to help.  If, on the other hand, you note that someone isn’t doing well, reach out and compassionately let them know of your concern and that you’d like to help, and don’t hesitate to ask directly if they’ve considered suicide. 

The pressures we face with the work we do are extraordinary.  Given this, the entire purpose of the PeerRxMed process is to ensure that “no one cares alone.”  It is vital that every one of us has someone we are certain we can reach out to in good times and bad and we know they will be there for us.  This is a person who knows us well enough that they would recognize when were weren’t doing well and would feel very comfortable and even insistent in ensuring we received the help we needed.   The stakes are too high to do otherwise.   Let’s all commit to becoming better at helping each other.  If you’re not signed up for PeerRx, get a buddy and do so (if you’re not sure how, e-mail me).  If you are, encourage others to sign up as well.  This is too important to leave to chance.  The life that we save could be someone close to us, or even our own.

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1) Updated Guidelines on Atopic Dermatitis (Eczema)

Eczema is one of those conditions that can become almost routine in primary care – often a diagnosis of “convenience” if the etiology of a rash is not immediately apparent. The American Academy (and College) of Allergy, Asthma, and Immunology (AAAI&ACAI) have updated their 2012 guidelines on the treatment of eczema with a major focus on creating trustworthy and equitable guidelines. They used an evidence-based practice center to perform network meta-analyses with systematic reviews on their a priori choice of five major topics: topical treatments, elimination diets, dilute bleach baths, allergen immunotherapy and phototherapy. The guideline committee had a broad multidisciplinary membership – including several primary care representatives as well as patient representatives. They used the GRADE guideline development process and had a focus on equity, especially the presentation of eczema across different skin tones and health disparities in treatment.

The recommendations are summarized as follows:

Basics:

• Ensure an accurate diagnosis and identify any complicating diagnoses
• Provide disease education and an action plan
• Advise avoiding triggers
• Ensure proper medication use and adherence
• Ensure “bland” moisturizer use at least once per day

Topical Treatments:

• Avoid prescription moisturizers in favor of bland (unscented), over-the-counter moisturizers
• Topical steroids (TS) are the mainstay of therapy – avoid high-potency (potency class 1 and 2) for longer than 4 weeks or on sensitive areas (face, skin folds, groin). TS are good for gaining initial control of flares, and for intermittent treatment of minor flares.
• Topical calcineurin inhibitors (TCI, pimecrolimus or tacrolimus) are recommended for flares not controlled by moisturizers also and may also be used for intermittent treatment. Used in recommended doses, they confer no increased risk of cancer.
• For both TS and TCIs, once a day dosing is recommended with slight preference over twice a day, though twice a day is acceptable.

Dilute Bleach Baths:

• Handout with instructions from the National Eczema Organization
• 0.005% (sodium hypochlorite) in lukewarm/tepid water for 10 minutes per bath and done twice per week
• Reduced eczema symptoms by 50% with number needed to treat (NNT) of ~10
• Best reserved for moderate or severe eczema resistant to moisturizers – there are many safety concerns.

Elimination Diets:

• Even though many with eczema also have food allergies, a meta-analysis showed minimal to no benefit of elimination diets for eczema control.

Allergen Immunotherapy:

•  In addition to treatment with moisturizers and either TS or TCIs, allergen immunotherapy (against house dust mites or specific allergens) reduced the severity of eczema by about 50%. Patients had a 10% risk of serious adverse reaction to injection immunotherapy but <1% reaction to sublingual therapy. Immunotherapy could help those with allergic rhinitis symptoms also, so a risk-benefit discussion is important for this choice.

Systemic Therapy

•  Mostly for moderate-severe eczema despite the above therapies.
• Biologics – dupilumab (6 years and older) and trolukinamab (12 years and older0 are recommended with strong evidence.
•  “Small molecules”
  • - the oral JAK inhibitors – abrocitinib (100-200 mg/day), baricitinib (2-4 mg/day), and upadacitinib (15-30 mg/day) – are conditionally recommended with low certainty evidence
  • Cyclosporine is conditionally recommended with low certainty evidence
• UV light therapy – small-band UV-B therapy can help in addition to the topical treatments.

Treatments to avoid:

• Baricitinib, methotrexate, mycophenolate
• Systemic corticosteroids

John’s Comments: 

These are well-done guidelines worthy of our attention in primary care. There is a very nice infographic that summarizes the recommendations in the full text of the guideline. The recommendations to stick with generic, “bland” moisturizers and TS as mainstays of therapy was refreshing. The safety data about TCIs was particularly appreciated, and I will feel better about using them for mild eczema. I will reserve bleach baths for carefully selected patients with moderate-severe eczema and will continue to refer patients to allergy/dermatology for treatments who need interventions beyond those.

Reference:

• Chu DK, Schneider L, Asiniwasis RN, et al. Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE– and Institute of Medicine–based recommendations. Annals of Allergy, Asthma & Immunology. 2024;132(3):274-312. Link

From the Literature and the American Heart Association (AHA)

2)  Life’s Essential 8 (LE8) and Cardiorespiratory Fitness (CVF)

In 2010, the American Heart Association (AHA) published a “Presidential Advisory” on defining optimal cardiovascular health (CVH) in adults called “Life’s Simple 7”.  These were seven metrics which had been shown to improve CVH and promote CV disease  prevention.  Extensive subsequent evidence provided insights into strengths and limitations of the original approach to defining and quantifying CVH. In response, the AHA convened a writing group to recommend enhancements and updates, which it published in 2022 as “Life’s Essential 8.”

The components of Life’s Essential 8 include:

• Diet:  Encourages the DASH diet components for population measure and the Mediterranean Eating Pattern for Americans (MEPA) for individuals. 
• Physical activity (PA):  The optimal level is >150 minutes (2.5 hours) of moderate physical activity or > 75 minutes of vigorous-intensity physical activity per week.
• Nicotine exposure: Includes use of inhaled nicotine-delivery systems, which includes e-cigarettes or vaping devices, and exposure to second-hand smoke.
• Sleep health:  Measured by average hours of sleep per night, with the ideal target level of 7-9 hours daily for adults.
• Body mass index (BMI):  BMI continues as a "reasonable" gauge to assess weight categories that may lead to health problems, though acknowledged as being imperfect.  BMI of 18.5–24.9 is associated with the highest levels of CV health.
• Blood lipids:  Encourages use of non-HDL cholesterol (Total cholesterol minus HDL cholesterol) as the preferred number to monitor.  Target is < 130.
• Blood glucose:  Use of fasting blood sugar (FBS) or A1C.  Target is  < 100 or < 5.7.
• Blood pressure:  Target measure is < 120/80.

For overall CVH, the writing group endorsed a composite, aggregate score for measuring, monitoring, and assessing change in CV health. The aggregate score is scaled from 0 to 100 points, calculated as the unweighted average of all 8 component metric scores.  The group also recommended categorical assessment of overall CVH, with scores of 80-100 be considered high CVH; 50 to 79 as moderate CVH; and 0 to 49 points, low CVH.

A companion paper in 2022 using utilizing the National Health and Nutrition Examination Surveys (NHANES) data for 2013-2018 assessed CVH scores for US adults and found that the overall mean CVH score was 64.7 with mean scores being lowest for diet, PA, and BMI metrics.  Overall, only 0.45% of adults had a perfect score of 100; 20% had high CV health (score of 80+), 63% moderate (score of 50 to 79), and 18% had low CV health (score of less than 50).  Since that time other studies of the Life’s Essential 8 metrics have shown a direct correlation to CRP measurements and coronary calcification scores. 

A recently published study compared CVH scores with cardiorespiratory fitness (CRF).

Akin to the CVH score, CRF is an integrative measure of CVH status that powerfully predicts CVD outcomes and CV and non-CV death across populations and underlying disease states.  CRF can be quantified directly using cardiopulmonary exercise testing (CPET) for assessment of peak oxygen uptake (V̇O₂).

Using a cohort of Framingham Heart Study (FHS) participants, the authors related an LE8 CVH score with CRF (peak V̇O₂) and complementary exercise response patterns in a large (N=1838) community‐based sample, hypothesizing that a greater LE8 score and improvement in LE8 score over time would be associated with greater CRF across age, sex, and underlying CVD status, thereby providing a potential intermediate biomarker for measuring the effects of interventions to promote CVH.

They related total LE8 score, score components, and change in LE8 score over 8 years with peak V̇O₂ (log‐transformed) and complementary CRF measures.  With a baseline mean LE8 score of 76±12, they found a higher LE8 score was associated favorably with peak V̇O₂, ventilatory efficiency, resting heart rate, and blood pressure response to exercise (all P<0.0001).  Also, a clinically meaningful 5‐point higher LE8 score was associated with a 6.0% greater peak V̇O₂.  Over an ≈8‐year interval, a 5‐unit increase in LE8 score was associated with a 3.7% higher peak V̇O₂ (P<0.0001).  They concluded that higher LE8 score and improvement in LE8 variables over time was associated with greater CRF, highlighting the importance of the LE8 factors in maintaining CRF.

Mark’s Comments:

It was good to see this LE8 score correlate with V̇O₂ peak (max).  While V̇O₂ max has become a sought-after measurement for fitness, this is a more challenging measurement to obtain in the general population so having possible surrogate measures is desirable.  I encourage you to take a few minutes to calculate your personal LE8 score.  See the 2^nd reference. No perfect sore for me, so I have some opportunities for some focused attention.  How about you?

References:

• Ravichandran S, et al.  Life's Essential 8 Cardiovascular Health Score and Cardiorespiratory Fitness in the Community.  JAHA May 2024;13(9).  Link
• American Heart Association “My Life Check” Cardiovascular Health Assessment (Register for Free):  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Sowing Kindness by Showing Kindness

“ … all kindness begins with the sown seed.”  Mary Oliver from her poem, “What I Have Learned So Far.”

In last week’s PeerRx blog, I encouraged our community to accept the 21-day “Kindness Challenge” by doing an intentional act of kindness daily for 21 days.  My own experience thus far has been quite eye-opening.  Though I did some things I may have done anyway, I was much more present and aware than normal, and perhaps because of this, it seemed my kindness showed up differently;

• For the man at the gym who hadn’t been there for a while, so I inquired about his absence and learned he’d had an MI (minimal risk factors) and had been rehabbing.  That day was the first back at the gym in 2 months for him.
• For the elder who was having trouble navigating some stairs and for whom I stopped and helped.
• For the woman whose dog had broken from the leash and needed help getting her leashed again.
• For my friend who needed some support and encouragement from me as he prepared for an important meeting that had some “behind the scenes dynamics.”

We all could likely create such lists if we stopped to think about it.  What has stood out for me so far is the deeper understanding that ultimately, kindness is an action, not simply an intention.  And it is that action that integrates the abstract concept of “being kind” with “doing kindnesses.”   

One of my favorite poets, Mary Oliver, appears to have internalized this “lesson” in the poem below.  As you continue (or start) your own 21-day “Kindness Challenge,” perhaps her words will provide a different perspective as to how you might approach it.  This week, may you too be “ignited” as you spread the light of kindness. 

What I Have Learned So Far

Meditation is old and honorable, so why should I
not sit, every morning of my life, on the hillside,
looking into the shining world? Because, properly
attended to, delight, as well as havoc, is suggestion.
Can one be passionate about the just, the
ideal, the sublime, and the holy, and yet commit
to no labor in its cause? I don't think so.

All summations have a beginning, all effect has a
story, all kindness begins with the sown seed.
Thought buds toward radiance. The gospel of
light is the crossroads - of indolence, or action.

Be ignited, or be gone.

Mary Oliver

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  2024-2025 COVID Vaccine Recommendations

The CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended the updated 2024-2025 COVID-19 vaccine for all people age >= 6 months, regardless of prior vaccination status. The CDC stresses the following important points in this recommendation:

• The specific products available for this recommendation are:
  • Moderna COVID-19 vaccine for ages 6 months and older
  • Novavax COVID-19 vaccine for ages 12 years and older
  • Pfizer-BioNTech COVID-19 vaccine for ages 6 months and older
• The updated 2024-2025 COVID-19 vaccine can be given as soon as it is available.
• The COVID-19 virus continues to evolve rapidly, and previously effective vaccine doses are rendered less effective by the virus’ mutations and time.
• The vaccine is intended to prevent serious outcomes of COVID-19 (death and hospitalization), including long COVID.

A summary of the evidence presented to the ACIP, and their subsequent deliberation is summarized on their website in the Evidence-to-Recommendation framework slides.

The highlights are:

• The risk of death from COVID-19 in the January 2024 wave was overwhelmingly among the >= 75 year age group followed by the 65-74 year age group. The only other group with significant mortality was the <= 6 months age group, for whom the vaccine is not recommended.
• COVID-19 has the highest hospital admission rate amongst the vaccine preventable diseases in children 6 months to 17 years.
• There are persistent racial/ethnic disparities in COVID-19 hospitalizations that primarily disadvantage American Indian/Alaskan Native populations followed closely by Black, non-Hispanic populations.
• Vaccine effectiveness in studies of the 2023-4 vaccines was in the mid-40% range for medically attended COVID and hospitalization, and ~23% for COVID death. As a reminder, vaccine effectiveness is the percent fewer people who will get the outcome if exposed to the virus (similar to a relative risk reduction).
• Safety data from the 2023-4 vaccines continues to be reassuring overall:
  • Myocarditis is a small risk, predominately in adolescent/young adult males, and seems to resolve quickly. There is a very small risk of persistent features on cardiac magnetic resonance imaging, the clinical relevance of which is poorly understood.
  • A stroke signal that was previously seen in reporting data did not bear out in Vaccine Safety Datalink studies.
  • Guillain-Barré syndrome occurrence rates in ages 65 years or greater are similar to other vaccines.
• Statistical modeling was used to assess the risk-benefit of a high-risk vaccination strategy (only those with comorbidities and/or age > 65 years) vs. a universal strategy. A universal strategy prevents approximately 30,000 hospitalizations per year. In addition, most of the adults in the United States have a factor that renders them high risk, which limits the ability to see differences in the strategies.
• There were a number of additional sociological, cost-effectiveness, and feasibility concerns researched, most of which supported or were neutral to a universal vaccination strategy.

John’s Comments:

The ACIP does quite a lot of study about the balance of benefits and harms and important contextual factors using its Evidence-to-Recommendations framework. Unfortunately, the data is always going to lag too long to help decision making when it is needed, so there are a lot of assumptions that must be made. These decisions are explicitly made and published, which is what is most important.

It's clear that even though we are “getting used to” COVID-19, it is still responsible for significant death, hospitalization and illness in the country, so routine vaccination is still a good strategy. We should reassure our patients that the safety monitoring of these vaccines is robust and ongoing.

References:

• CDC Newsroom. CDC Recommends Updated 2024-2025 COVID-19 and Flu Vaccines for Fall/Winter Virus Season. CDC. June 27, 2024. Accessed August 28, 2024. Link
• Panagiotakopoulos, Lakshmi. Evidence to Recommendations Framework: 2024-2025 COVID 19 Vaccines in Persons ≥6 Months of Age. Presented at: ACIP June 26-28, 2024 Meeting. Accessed August 28, 2024. Link

From the Literature

2)  Toward a Better Understanding of Long COVID

According to the World Health Organization (WHO), as of August 11, 2024 there have been more than 775 million confirmed cases of SARS-CoV-2 infection worldwide, and the actual number of those who have had the infection is likely quite higher, including many who have had multiple infections.  More than 4 years after the COVID-19 pandemic began, millions of people continue to suffer long-term sequelae of SARS-CoV-2 infection.  Many clinicians remain unsure of how to evaluate and manage individuals with post-COVID-19 syndrome, commonly known as long COVID. 

A recently published review article has attempted to provide updated information on this evolving syndrome.  The authors sought to bring together multiple streams of literature on the epidemiology, pathophysiology (including the hypothesized mechanisms of organ damage), lived experience and clinical manifestations, and clinical investigation and management of long COVID.  Although current approaches to long COVID care are largely designed to alleviate symptoms and optimize function, recent advances in clinical phenotyping, deep molecular profiling, and biomarker identification might herald a more mechanism-informed and personally tailored approach to clinical care in the near future.

Estimates of the incidence of long COVID after acute infection range from 50–85% for unvaccinated people who were hospitalized, 10–35% for unvaccinated people who were not hospitalized, and 8–12% for vaccinated individuals.  One challenge that accounts for these wide estimates is that there is still not a universally accepted definition of long COVID.  The US Department of Health and Human Services defines it as “signs, symptoms, and conditions that continue to develop after initial COVID-19 infection and last more than 4 weeks.”  However, even this definition does not include a minimum level of symptom severity or functional impairment, and other current definitions still diverge on symptom duration (4 weeks, 6 weeks, 12 weeks, 3 months, 6 months, or a year since the acute infection).  Additionally there are presently no biomarkers that can help guide the diagnosis. 

Long COVID can occur in all ages, genders, ethnic and racial groups, in people who were previously healthy and fully vaccinated, and in individuals whose acute illness was mild or even asymptomatic.  Manifestations are heterogeneous, multisystemic (the condition can affect any and all organ systems) and can change over time.  But patterns that are both diagnostically and prognostically important can usually be discerned through a careful history-taking process.  Many but not all people with long COVID have pre-existing chronic conditions (including asthma, allergies, attention deficit hyperactivity disorder, musculoskeletal pain, diabetes, poor mental health, insomnia, headaches, chronic fatigue, and frailty), which can exacerbate—and be exacerbated by—it.

Additionally, many long COVID symptoms are non-specific or overlap with those of conditions that commonly coexist (or might be confused) with long COVID, such as chronic musculoskeletal or rheumatological conditions, chronic respiratory conditions, type 2 diabetes, or thyroid disorders.  More challenging still, it is thought that long COVID is frequently misdiagnosed, most commonly as menopause, common migraine, depression, anxiety, or deconditioning.

Clinical investigation and management depend on the duration, nature, severity, and trajectory of symptoms. In people in the first 6 months after acute infection and with more than minimal symptoms, there is some evidence to support a multidisciplinary approach to rehabilitation.  Rehabilitation would normally include pacing strategies (avoiding post-exertional crashes by taking into account the patient’s symptoms on a given day), physiotherapy (and especially breathing exercises), psychological support, cognitive and speech rehabilitation, attention to lifeworld context (such as reasonable adjustments and a phased return to the workplace), olfactory training for anosmia, and dietary advice.  Although exercise has traditionally been a core element of rehabilitation, there is new evidence that unmoderated exercise in long COVID can exacerbate inflammatory and other pathological processes, leading to a worsening of symptoms and delayed recovery. 

Present recommendations for work-up including performing blood tests as appropriate to exclude anemia, renal or thyroid disease, vitamin deficiency (eg, vitamins D and B12), acute phase reactants (eg, C-reactive protein); exclude other causes of fatigue, including sleep disorders and neurological conditions; monitor symptom severity and frequency and pattern of relapses; and keep a patient activity diary to record triggers.  Additional work-up should focus on specific symptoms or signs of body system or organ dysfunction. 

The authors conclude that although there is extensive evidence to support multiple interacting biological mechanisms in the pathogenesis of long COVID, most current clinical management is not derived from these biological mechanisms.  Accelerating the study and implementation of specific treatments targeting these biological mechanisms will be the next area of breakthrough for treatment of those suffering from long COVID.

Mark’s Comments:

I was drawn to this review both because of the topic and also the lead author, who is someone I’ve held in high esteem since I was a resident.  Given the potential numbers of patients who have long COVID, it is imperative that we who practice primary care medicine (and medicine period) continue to both better understand this syndrome and  those who are afflicted with it.   There are many who are claiming “success” with various treatments (including longer term Paxlovid, the vaccine, and various anti-inflammatories and immune modulators).   Unfortunately, it appears that some of these clinicians are taking advantage of this vulnerable population and profiting over their relative desperation to “try anything.”  We owe it to those patients to continue to find ways to support them even when we don’t know the most effective way to treat them.    

Reference:

• Greenhalgh T et al.  Long Covid: a Clinical Update.  Lancet. 17 August 2024: 404(10453):707-724.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Elevating Your Kindness Quotient: Take the KQ Challenge

"Kindness is more important than wisdom, and the recognition of this is the beginning of wisdom." — Theodore Isaac Rubin, MD, psychiatrist and author

The gesture was so simple.  It came by text from a colleague:  “Hey Mark, Thank you for these weekly PeerRx nudges and blogs.  They have helped my buddy and I stay connected for the past 4 years.  Just wanted to say thanks.”   That was it – 30 words that likely took less than 15 seconds to compose, and it tenderized my heart for the entire day.

In last week's blog, I shared a story of how a patient calling me “kind” had left me wondering, “What if kindness was one of the most immediately impactful therapies I could provide to those I care for?”  Yes kindness, the powerful force that not only uplifts others but also nourishes our own well-being.  I concluded my blog by encouraging our PeerRx community to take a "KQ Quiz" to gauge your baseline “Kindness Quotient” and promised this week to share some ideas as to how one can increase their KQ.  And now with that recent text, I’m now left wondering, “What if expressing kindness was one of the most important actions I could take every day, within or outside of my work?”

Self-kindness is really the foundation for raising your KQ.  It is crucial for your own well-being, and it is from a place of self-kindness that you will express it to others.  This includes self-forgiveness and compassionate self-talk.  It’s easy to be hard on yourself, especially when things don’t go as planned. But consciously prioritizing and practicing self-kindness will allow you to experience a shift in to a “kindness mindset” over time.    

Once you have established a foundation of self-kindness, other kindness practices flow more naturally.  Giving someone your undivided attention through active listening with the intention of seeking to understand them is sadly, a too rare gift.  Offering a kind word, genuine compliment, or expression of gratitude can quickly lift someone’s spirit.  Performing intentional acts of kindness can be an instant “joy-spreader”, often inspiring others to pay it forward.  Being patient and forgiving when tempted to do otherwise can create a ripple effect of grace and harmony.  Making time for another, even briefly, can be one of the kindest things you can do.  It might mean making a phone call to check in on someone, offering to help with a task, or simply sitting with them. 

So as you can see, increasing our KQ doesn’t require sweeping changes or elaborate plans.  It starts with small, intentional actions that when repeated daily, can lead to a profound shift in how we experience the world and how others experience us.  As the ancient Greek storyteller Aesop reminds us, "No act of kindness, no matter how small, is ever wasted."  So consider accepting my 21-day “Kindness Challenge” by choosing to perform at least one intentional act of kindness every day for the next 3 weeks and noticing the impact on you and others.  Then share what you experience with your PeerRx partner or another colleague.  In doing so, you may find that kindness starts to become not just something you do, but who you are.  And that might just change your life – for the even better.    

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1) A New Treatment for Osteoarthritis?

A frustrating but common condition in primary care is osteoarthritis. Our medical options for treating this are limited: acetaminophen is frequently regarded by patients as ineffective, non-steroidal anti-inflammatory drugs (NSAIDs) can be toxic (especially at high doses for long treatment durations), and chronic opioid therapy for this condition is almost never a good option. Corticosteroid injections are frequently short-lived and often ineffective, and surgery is put off until the patient is both of older age and significantly disabled.

A familiar, but newly applied medical therapy has been tested for knee osteoarthritis (OA) – methotrexate (MTX). Usually used for rheumatologic conditions, methotrexate was subjected to a randomized, placebo-controlled trial for pain reduction in knee OA. From 15 clinical sites in the United Kingdom (UK), patients were solicited from both primary care and specialty care when their therapy for knee OA (acetaminophen, NSAIDs, or opioids) was deemed ineffective. Knee OA was diagnosed clinically using a locally read x-ray, and patients who had had steroid or hyaluronic acid injections or who had taken oral steroids recently were excluded. Patients were screened for rheumatologic disease using laboratory testing, and, if positive, were excluded.

Patients were randomized to oral MTX (dose escalating from 10 mg to 25 mg over six weeks) or placebo. Both groups of patients were given oral folic acid supplements. The patients were followed for 13 months, and a “rescue” intraarticular steroid injection was offered at six months if the pain was intolerable on medications. Pain was measured as a primary outcome at 6 months (and at baseline) by “average severity of pain out of 10 over the past week.” There were a slew of additional surveys and pain assessments administered as secondary outcomes.

One hundred fifty-five patients were randomized to MTX or placebo. Follow up percentage gradually declined over the 12 months to 78% - usually from quitting the study or from adverse events, but the loss was equal between groups. Both groups’ results on the pain rating scale decreased at 6 months, but the MTX group decreased by 0.8 points more (95% confidence interval (CI) 0.08 to 1.51; P < 0.030, which translates to a standard effect size of 0.34 or moderate). The benefit did not last until 12 months, and the authors postulate that the reduction in average MTX dose over the last six months of the trial (due to adverse events) could have caused the lack of benefit. There were scattered other significant differences amongst the scales used and the quarterly time points measured. There were no differences in analgesic use or radiologic changes. The authors made a point of stating that the main limitation was the choice not to allow subcutaneous injections of MTX to those that could not tolerate oral. This study was funded by “Versus Arthritis” – a UK charity organization for arthritis sufferers that sponsored arthritis research, but did not have a role in design, writing, or decision to publish the funded research.

John’s Comments:

Reading the abstract of this study, one gets the impression that MTX is a viable new therapy, and, while the study did achieve its primary outcome, the difference is rather small, and inconsistent across study time periods and scales. It could be that MTX finds a niche in non-rheumatologic arthritis, but for now, I would resist the urge to use this for OA pending more data.

Reference:

•  Kingsbury SR, Tharmanathan P, Keding A, et al. Pain Reduction With Oral Methotrexate in Knee Osteoarthritis: A Randomized, Placebo-Controlled Clinical Trial. Ann Intern Med. Published online July 30, 2024:M24-0303. Link

From the Literature (sort of) and a Question From a Colleague

2)  Resuable Water Bottle Hygiene

Question:

“Thank you for your recent Pointer on the health concerns regarding microplastics and nanoplastics.  It was quite timely.  I’m still left wondering about the safety of reusable water bottles.  Not so much the metal from them as their cleanliness.  Is there any information on that?”

Answer:

The reusable water bottle market reached approximately $2 billion in the US in 2023.  They are a popular choice for health- and eco-conscious consumers, and based on our recent Pointer, would seem to be a safer choice than plastic disposable water bottles.  However, their cleanliness is a concern if they are not properly maintained. Several studies have shown that reusable water bottles can harbor a variety of bacteria (including E. coli, Staphylococcus aureus, and Pseudomonas spp.), mold, and other microorganisms if they are not regularly cleaned. The primary sources of contamination are the user's mouth, hands, and environmental exposure.  Bottles with spout-top and screw-top lids, narrow necks, and/or straws create the greatest risk for microbe contamination. 

The International Association for Food Protection recommends washing bottles once a day with hot, soapy water, which surveys indicate is done by less than half of water bottle users.  It is recommended to use a clean sponge or bottle brush to scrub the inside of the bottle, making sure to get deep into the crevices.  Cleaning should occur more often if one drinks from it while eating or fills it with things other than water, like coffee or juice.  Having a bottle with a filter does not appear to make a difference in terms of bottle contamination. 

Some fun facts according to data from the website WaterFilterGuru.com:

• On average, a reusable water bottle has 40,000 times the bacteria of a toilet seat, 14x the bacteria of a pet water bowl, 5x the bacteria of a computer mouse, and 2x the bacteria of a kitchen seat.
• A straw-top water bottle has 14x the bacteria of a pet bowl
•  A spout-top water bottle has 3x the bacteria of a kitchen sink.
• Gen Zers clean their bottles the least often, with 16% cleaning theirs only a few times a month.
•  

Mark’s Comments:

While this is perhaps not the most “evidence-based” Pointer we’ve done, given that more than half of all adults in the US own a reusable water bottle (and growing), the topic is certainly a relevant one.  Once a day cleaning of these bottles seems a wise habit in general, remembering, of course, that just because bacteria grow from these bottles does not mean they are pathogens. 

Preparing this Pointer also provided me pause as I considered how often I wash the cup I use in our bathroom, or my toothbrush.  Let’s just say it will happen more often going forward.

References:

• Sun X, et al.  The Cleanliness of Reusable Water Bottles: How Contamination Levels are Affected by Bottle Usage and Cleaning Behaviors of Bottle Owners. Food Protection Trends, Nov/Dec 2017: 37(6):392–402.  Link
• WaterFilterGuru.com.  2022.  Swabbing Water Bottles: How Clean Is the Water You Drink?.  Link

From PeerRxMed ( www.PeerRxMed.org )

3) Leaving Them Better Than You Found Them – Just Be Kind

"Be kind whenever possible. It is always possible".  The Dalai Lama

As he stood up to leave, he tearfully said, “You are so incredibly kind” and gave me a hug.  We had just talked about a very sensitive health subject which had invoked for him both fear and shame and he was feeling the weight of the consequences of his actions.  For my part, I listened, and both clarified some misinformation and offered some words of comfort and encouragement.  I thought I had been an astute, thorough, insightful, caring, and even wise physician for him.  “Kindness” was not on my radar.  Yet there it was – “You are so … kind.”

It was intriguing to me that my initial internal reaction to his words was a surprising one.  While I have no objection to being seen as kind, I don’t identify with it as one of my core professional attributes and realized in that moment that I’ve still not gotten past my professional (and perhaps gender) programming equating kindness with softness or weakness.  But then I reconsidered as I recalled how many of my patient visits end with some tears, a “thank you,” and even a hug. 

Now I was wondering, “What if kindness was one of the most immediately impactful therapies I could provide to those I care for?”  After all, it can easily be expressed within the flow of patient care, transcends age, condition, and circumstance, and even in small “doses,” has the power to help not only hurting bodies, but emotional hurts as well.  This "medicine" has the potential to reduce pain, alleviate anxiety, improve adherence, and promote a sense of well-being.  And it can have positive therapeutic effects on the “prescriber” as well. 

Indeed, there is evidence that kindness can change our physiology.  Receiving kindness can decrease blood pressure and cortisol levels.  Being kind has the potential to boost serotonin and dopamine, neurotransmitters that increase feelings of satisfaction and well-being.  Brain imaging shows that expressing kindness can actually “light up” our pleasure/reward centers.  Perhaps most importantly, kindness can stimulate the release of oxytocin, promoting a sense of bonding for both the giver and recipient. 

Reflecting on my experience with that patient, I realize that the few minutes I spent connecting with him likely did more for his well-being than any prescription I could have given.  This isn’t just a feel-good story, but a “help them feel better” story as well.  When we engage meaningfully with others—patients, colleagues, or strangers—we contribute to a cycle of positivity.  Next week, I’ll share some ideas as to how you can increase your KQ (“Kindness Quotient”), but in the meantime, consider taking this "KQ Quiz" to see what your baseline is.  With this particular patient, I still think I was astute, thorough, insightful, caring, and even wise.  But apparently I was also kind.  And that, it appears,  made all the difference. 

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  A Review of Testing for Respiratory Viruses

As we wind up summer, get ready for flu shot season, and finish battling a new wave of COVID-19 infections, it may be useful to review our testing practices for viral respiratory viruses. As the severity of the COVID infections has decreased and isolation procedures have relaxed for non-healthcare personnel, practices may have defaulted to less stringent policies for COVID testing. Those who continue to use PCR testing in offices may have begun using these expensive tests for rapid diagnosis of other respiratory pathogens like influenza and respiratory syncytial virus (RSV).

Below is a summary of information from the IDSA guidelines on COVID-19 testing and the CDC’s guidance for non-hospitalized patients with acute upper respiratory infection.

Nucleic acid amplification testing (NAAT) using polymerase chain reaction (PCR):

• Considered to be the reference standard for testing – assumed to be 100% sensitive and specific for clinical use.\
• Can be used to rule out infections in patients for whom the likelihood of further transmission is important, like healthcare workers, or patients living in group facilities.
• Can be used for testing both symptomatic patients and, in certain cases, asymptomatic patients with known exposures.
• COVID-19 testing using NAAT is covered by insurances, and desktop test processing machines are available for primary care practices.
• Influenza and RSV testing using NAAT is indicated for hospitalized patients or patients who may be returning to a nursing facility or similar living situation – mainly to facilitate any necessary isolation. It is not needed for most outpatients.
• The inclusion of NAAT testing for influenza and RSV can increase COVID NAAT testing costs by 4-6x. (e.g., ~$150 per test to ~$700-1000)
• The point-of-care desktop machines take usually less than 1 hour for a result.

COVID-19 antigen testing

• Sensitivity – between 81 and 89% - higher sensitivities are seen in patients who have been symptomatic for < five days. After five days, the sensitivity falls to 54%.
• Specificity – high, 97-99% - positive tests do not need reconfirmation.
• Sensitivity in asymptomatic patients is only 64%.
• One-time antigen testing cannot RULE OUT infection, especially in symptomatic patients.
  • CDC guidance suggests that antigen testing may be used in series (2 or 3 tests, each separated by 48 hours) for a known exposure and/or in high-risk individuals.
  • Healthcare workers cannot be returned to work with only a single negative antigen test and NAAT testing is recommended (required in many places).

 Influenza antigen testing

• Antigen tests are considered to have low-moderate sensitivity and high specificity.
  • Their ability to rule out disease depends on prevalence; when influenza is circulating, a negative test is less helpful.
• The best use of antigen testing is when it would change management.
  • A high-risk patient with typical influenza symptoms when influenza is circulating does not really need testing, and a negative test should not deter antiviral use.
  • A low-risk patient for whom antivirals would not be recommended generally does not need testing.
  • A high-risk patient with intermediate likelihood of flu is a good candidate for testing.
    • Patients at high-risk for influenza complications include: < 5 years (especially < 2 years), over age 64, pregnancy or immediate post-partum, chronic neurologic or other medical disease.

One potential use of outpatient viral testing is to reduce antibiotic use for viral upper respiratory illness. There have been few studies, and the evidence is mixed at best, so viral testing for this reason cannot yet be recommended.

John’s Comments:

• Unfortunately, a strategy of “universal” testing of symptomatic patients for flu and COVID without consideration of risk, employment, living situations, etc. can both lead to waste as well as cause errors in clinical decision-making for high-risk patients.
• The tried-and-true question, “Will this test change your management?” is still the best guide to appropriate testing. We just have to think a little more broadly about our “management” (patient living situations, return to work guidelines, etc.)
• CDC’s FluView and the corresponding state databases can be used to monitor influenza activity to help guide decisions.
• At Carilion Clinic, acutely symptomatic employees are not considered COVID negative without a NAAT (PCR) test.

References:

• Hayden MK, Hanson KE, Englund JA, et al. The Infectious Diseases Society of America Guidelines on the Diagnosis of COVID-19: Antigen Testing (January 2023). Clinical Infectious Diseases. 2024;78(7):e350-e384. Link
• Hayden MK, Hanson KE, Englund JA, et al. The Infectious Diseases Society of America Guidelines on the Diagnosis of COVID-19: Molecular Diagnostic Testing (December 2023). Clinical Infectious Diseases. 2024;78(7):e385-e415. Link
• Clinical Guidance for Patients with Acute Respiratory Illness Not Being Hospitalized When SARS-CoV-2 and Influenza Viruses are Co-Circulating | CDC. July 16, 2024. Accessed August 14, 2024. Link
• Uyeki TM, Bernstein HH, Bradley JS, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenzaa. Clinical Infectious Diseases. 2019;68(6):e1-e47. Link

From the Literature

2)  Lipedema – Are You Missing This Diagnosis?

Lipedema (adiposis dolorosa, or painful fat syndrome) is a subcutaneous lipodystrophy found exclusively in females characterized by increased palpable nodular and fibrotic adipose tissue deposits most commonly the buttocks, hips, and lower extremities while sparing the feet (“cuff sign”) and out of proportion to the rest of the body.  Its prevalence is unclear due to likely significant underdiagnosis and widely varying estimates.   

The etiology and pathophysiology of lipedema are not well understood, but it is thought to be triggered by hormonal changes during puberty, childbirth, or menopause.  Estrogen is theorized to play a role, as it regulates lipid and glucose metabolism and female-associated adipocyte distribution.  A cross-sectional study found the prevalence of lipedema increased with weight and body mass index, and obesity is believed to be an aggravating factor for lymphatic harm and edema leading to lymphatic overload.

Classic symptoms of lipedema include an aching discomfort at rest, limb pain on palpation, and a feeling of heaviness of the legs.  Signs include easy bruising and prominent malleolar fat pads in the presence of normal feet. 

There are two common conditions that are often confused with lipedema – obesity and lymphedema.  While both obesity and lipedema can have a similar appearance, early on in those with lipedema the upper portion of the body is not affected.   

The majority of lymphedema is due to a known injury to the lymphatic system (secondary lymphedema).  Risk factors are commonly present and include; cancer treatment (radiation therapy and lymphatic resection for cancer of the breast, head, or neck and other malignancies); soft-tissue infection (and cellulitis); chronic venous insufficiency; injury; trauma; and surgery; and obesity.  Unlike lipedema, there is not usually tenderness or pain with lymphedema in the absence of infection, there is foot involvement, and there is usually an absence of increased fatty tissue unless the patient has obesity as well. 

The 3 conditions can co-exist as lipedema with superimposed obesity-induced lymphedema.  If the diagnosis is in doubt, a lymphoscintigram can be obtained and dual-energy x-ray absorptiometry (DEXA) can be useful in assessing fat mass and lean body mass.  There are no blood tests that are diagnostic for lipedema,

Treatment for lipedema can be challenging.  Patient education is essential, recognizing that conservative treatment, including aggressive weight management, regular physical activity, and compressive therapies for edema management when indicated may help relieve symptoms but will have minor effects on the appearance of the extremities (<10% volume reduction).  More aggressive and definitive treatment can include surgical weight loss and liposuction.  Referral to a physician who has expertise in management is essential. 

Mark’s Comments:

A few months ago a patient asked me what I knew about lipedema as she suspected she may have it, and at the time my answer was “next to nothing” (I even spelled it incorrectly – lipidema, in my initial search).  Since then I’ve diagnosed it in two patients, including with one of our residents this week.  I reached out to Matthew Joy, MD, a colleague in our Section of Plastic and Reconstructive Surgery and Director of Lymphatic and Reconstructive Microsurgery to get his insights.  It turns out this is an area for which he has great clinical interest and has developed expertise.  He replied, “Ideally these patients should also be optimized medically and with compressive therapies prior to considering surgery.  That usually includes addressing obesity if this is a significant issue as well as working with PT/OT and possible lymphedema therapies depending on the clinical picture.”   Some of my additional reading also indicated that earlier treatment can lead to more favorable outcomes, so keeping this on your radar as a clinical possibility is important.  The first reference below has a wonderful Table (1) that outlines the distinctions between lipedema, lymphedema, and obesity and has a memorable picture of the “cuff sign.”

 

References:

• Daniels L, et al.  Lymphedema vs lipedema: Similar but different.  Cleve Clin J Med.  July 2024; 91(7): 425-436.  Link
• Lipedema Foundation:  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Becoming More Human – Thanks for the Reminder, COVID

Medical culture is steeped in a tradition of stoicism, where showing vulnerability is often misconstrued as weakness."  Danielle Ofri, MD, author of "What Doctors Feel: How Emotions Affect the Practice of Medicine

“It’s positive.”  More than 1,500 days after COVID-19 was declared a public health emergency in the US, and having likely been exposed thousands of times without getting ill, the virus had caught up to me, and I joined the hundreds of millions of others around the world who have been infected.  While this seemed inevitable and I was fortunate to experience a relatively mild infection, what struck me most was how quickly my professional programming kicked into gear.

At first, there was denial when the symptoms appeared.  I thought, “It’s probably just a summer cold or allergies.”  Then came the immediate heroic stance: “I’ll heal in no time” and “Let’s pivot to virtual.” I felt a sense of indispensability—“I don’t have time for this,” and “They need me at that meeting.”  There was also the predictable feeling of weakness for getting sick at all: “What have I been doing that has depressed my superhuman immune system?”  And, of course, I found myself humorously trying to trace where I might have been exposed—patient care, the obvious answer, only came to mind after several other possibilities.

What didn’t surface initially, though, was any sense of grace for myself and my body, despite my decades of work advancing clinician and care team well-being.  I realized that I was once again living out the socialization ingrained in us during medical training, which instills a sense of duty, responsibility, and self-sacrifice.  We’re implicitly, if not explicitly, encouraged to downplay our own health concerns.  It’s second nature in a culture that insists “the patient always comes first” and views “illness as weakness,” even as we treat the ill daily.

This mindset is often beneficial, even necessary, in high-pressure situations, allowing us to perform at our best. However, it can create blind spots when recognizing and addressing our own health issues. For many healthcare professionals, admitting illness can feel like admitting defeat. There’s an unspoken stigma attached to being sick—a sense that we should be invulnerable to the very ailments we treat. This feeling is especially pronounced in the context of COVID-19, where clinicians were initially hailed as “heroes.”

As I’ve recovered, those initial feelings of vulnerability and even embarrassment have lessened.  I recognize how fortunate I was to have had only a “moderate cold” and inconvenience.  Being transparent about my experience has prompted many colleagues to share their own “COVID stories” and even some who have opened up about other illnesses or injuries they’ve been struggling with.  This openness has been particularly true among my PeerRx partners.  The time in isolation has allowed me to refresh my priorities, approach my health differently, and strengthen my “self-compassion muscle.”  In doing so, I’ve somehow become more human.  And that, to me, is a good thing.  So thanks for the reminder COVID.  Now, if you would only go away ….

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  Blood Pressure Lowering – How Much and For Whom?

Ever since the SPRINT trial, we’ve been litigating the value of ever lower goals for hypertension therapy. SPRINT did show a reduction in major adverse cardiac events and overall mortality for elderly patients at high risk for heart disease, but unfortunately, the major US guidelines (from the American Heart Association (AHA)/American College of Cardiology (ACC)) on hypertension used that information to lower blood pressure goals for everyone. The American College of Physicians and the American Academy of Family Physicians disagreed and still recommended 140/90 goals for adults < 60 years and a 150/90 goal for adults 60 years and older (though the AAFP has recently reduced the goal to below 140/90 for all).

In the Lancet, a new study from China has been published – an open-label, but blinded outcome trial of intensive vs. less intensive treatment of systolic blood pressure (SBP). Patient in the intensive group were treated to less than 120 mg Hg SBP and the less intensive group was treated to less than 140 mm Hg. Importantly for generalizability reasons, the patients had “high cardiovascular risk” – defined as a diagnosis of cardiovascular disease (coronary artery disease, stroke, etc.) or two major cardiovascular risk factors (>=60 years for men, >=65 years for women, diabetes, hyperlipidemia, or current smoking). The study was done well overall in terms of validity criteria (except for being open label), and they overcame some limitations due to the COVID-19 pandemic. The median follow up was 3.4 years. The primary outcome was a composite outcome (major vascular events) – i.e., myocardial infarction, revascularization, hospitalization or emergency department visit for heart failure, stroke, or death from cardiovascular causes. The authors also examined side effects such as hypotension and advancement of chronic kidney disease.

There were 11,255 subjects with a mean age of 64.6 years, 41.3% were women and 38.7% had diabetes, 28.9% had coronary heart disease, and 26.9% had stroke. At randomization, both groups had SBP in the mid-140s, and both groups met their target SBPs on average in the trial. The intensive group needed 2.7 medications on average, versus 2 medications in the less-intensive group. The primary (composite) outcome occurred in 547 (9.7%) of participants in the intensive group and 623 (11.1%) in the less intensive group (hazard ratio (HR) 0.88; 95% confidence interval (CI) 0.78 to 0.99; p=0.028). This results in an approximate number needed to treat (NNT) of 71. One of the limitations of composite outcomes is that it is possible that the least severe outcome ends up accounting for all the effect. Not in this case. Cardiovascular death was significantly less likely in the intensive group (HR 0.61; 95% CI 0.44 to 0.84, NNT ~ 167). The risk of death from any cause was also significantly reduced (HR 0.79; 95% CI 0.64 to 0.97). None of the other outcome differences were individually significant.

For adverse events, the composite kidney outcome (end stage renal disease, glomerular filtration rate (GFR) decline) occurred in 3.0% of the intensive participants and in 1.8% of the less intensive group (HR 1.70; 95% CI 1.33 to 2.17, number needed to harm (NNH) ~83). The overall rate of serious adverse events was equal between groups, but syncope (sometimes resulting in hospitalization or fractures) was more frequent in the intensive group (HR 3.0; 95% CI 1.35 to 6.68, NNH~333).

John’s Comments:

I think the point is made about treating patients at high cardiovascular risk to lower SBP goals. However, it takes an additional medication (3 vs. 2), on average, to get people to these goals. For those of you watching (or being measured on) HEDIS metrics, you’ll note that they don’t really capture the subtlety of high vs. average risk when defining SBP goals – instead, I think they’re aiming in the middle, as recommended by the ACC/AHA guidelines. Control of hypertension is clearly an important clinical goal, but we face multiple barriers – inadequately specific metrics, therapeutic inertia on the part of clinicians, cost to patients, etc.

Reference:

·       Liu J, Li Y, Ge J, et al. Lowering systolic blood pressure to less than 120 mm Hg versus less than 140 mm Hg in patients with high cardiovascular risk with and without diabetes or previous stroke: an open-label, blinded-outcome, randomised trial. The Lancet. 2024;404(10449):245-255. Link

From the Environmental Working Group (EWG)

2)  The Fresh Produce “Dirty Dozen” and “Clean Fifteen” 2024

The Environmental Working Group (EWG) is a nonprofit organization focused on human health and the environment.  Since 2004, EWG researchers have published an annual report regarding pesticide content in fruits and vegetables called the “Dirty Dozen” and the “Clean 15,” creating the rankings based on laboratory tests done by the FDA and the U.S. Department of Agriculture's Pesticide Testing Program.

The 2024 guide includes data from 47,510 samples of 46 fruits and vegetables. The USDA peels or scrubs and washes produce samples before testing, whereas the FDA only removes dirt before testing its samples. Even after these steps, the tests still found traces of 209 different pesticides.  Some of the USDA’s tests show traces of pesticides long since banned by the Environmental Protection Agency.  Non-organic produce is loaded with fungicides that may harm human hormone systems – four of the five most frequently detected chemicals are fungicides.   

The 2024 “Dirty Dozen” list, in descending order:  1. Strawberries; 2. Spinach; 3. Kale, Collard, and Mustard Greens ; 4. Grapes; 5. Peaches; 6. Pears; 7. Nectarines; 8. Apples; 9. Bell and Hot Peppers; 10. Cherries; 11. Blueberries; 12. Green Beans.

Over 50 different pesticides were detected on every type of crop on the list, except cherries.  More than 90% of samples of strawberries, apples, cherries, spinach, nectarines and grapes tested positive for residues of two or more pesticides.  Kale, collard and mustard greens, as well as hot peppers and bell peppers, had the most pesticides detected of any crop — 100 pesticides in total.  The neurotoxic organophosphate insecticide acephate, prohibited from use on green beans in 2011, was detected on six percent of green bean samples.

The 2024 "Clean 15'' is a list of the produce least likely to contain pesticide residue. The list, in descending order:  1. Avocados; 2. Sweet corn; 3. Pineapples; 4. Onions; 5. Papayas; 6. Sweet Peas; 7. Asparagus; 8. Honeydew Melons; 9. Kiwis; 10. Cabbages; 11; Watermelon, 12; Mushrooms; 13. Mangos; 14.  Sweet Potatoes; 15. Carrots.

Almost 65 percent of the Clean 15 samples had no detectable pesticide residues.  Avocados and sweet corn were the cleanest produce – less than 2% of samples showed any detectable pesticides. Just over 10% of Clean 15 samples had residues of two or more pesticides.  No sample from the first six Clean 15 items tested positive for more than three pesticides.

Mark’s Comments:

It is difficult to estimate the extent of the health hazard from this, as there are many variables (amount of exposure, type of toxin, etc.).  Unfortunately, there are no cleaning processes that can effectively eliminate toxins but washing with water has been shown to be beneficial in at least removing some of the pesticide residue.

Critics not involved in the report say they worry the list will discourage people from eating fruits and vegetables.  Certainly, minimizing exposure as much as possible would seem to be prudent, which may mean avoiding or buying organic for the “dirty dozen.”  However, the EWG does recommend eating produce even from the Dirty Dozen rather than foods or snacks that are less healthy, such as processed foods laden with fat, sugar, salt, or additives.

Note that the government labels as “organic” food grown without synthetic chemicals or fertilizers, genetic engineering, radiation, and sewage sludge.  Unfortunately, in general organic food is more expensive and not accessible to many. 

References:

• Environmental Working Group.  EWG’s 2024 Shopper’s Guide to Pesticides in Produce™.  March 20, 2024.   Link
• Frequently Asked Questions about Produce and Pesticides:  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  “Hatching” New Insights through Nested Meditations – I’m “All In”

After more than 4 ½ years, the SARS-CoV-2 virus finally caught up to me this week.  Being in isolation has provided a lot of reflection time, so I didn’t consider it at all a coincidence when I received a text from one of my faculty colleagues with a picture of a poem I had written and shared with some or our residents in June of 2022 as part of our R&R (“Reflection & Renewal”) resident support group, which I co-facilitated.   As you might recall, it was around that same time we were really looking to “open up” due to a relative decline in COVID activity, and there was much uncertainty, disagreement and various levels of comfort around doing so, even within the medical community.

In writing the poem, I was inspired to use a particular structure called a “nested meditation,” which was originally introduced to me through the work of psychologist Kevin Anderson, PhD.  A nested meditation is a brief, accessibly written meditation that begins with a single line, then repeats, adding one additional line at a time.  As each line is added, the meaning of the piece shifts and when read slowly with a pause after each stanza, important insights or “Aha’s” often emerge.

The poem “All In” attempted to help sort out some of my own thoughts and emotions during that time (and now!).  Though when I wrote it I had no idea where it would finally “land,” I was pleased where it did.  As you read it, stop after each stanza to see what bubbles up for you and then consider trying to write one yourself (would start with 4 stanzas).  You might be quite surprised as to what surfaces for you.  Then take the time to share some insights (and perhaps your newly written nested meditation) with your PeerRx partner, a colleague, a friend, or even me.   I’m all in!  How about you?

 All In

We’re all in!

We’re all in

this together ...

We’re all in

this!  Together

we will find the way out! 

We’re all in

this.  Together,

we will find the way out

of our collective disconnection.  

We’re all in

this ….  Together

we will find, the way out

of our collective disconnection 

is to honestly share our joys and sorrows with others. 

We’re all in

this together.

We will find, the way out

of our collective disconnection 

is two; –  honestly share our joys and sorrows with others

and – lovingly hear theirs in return. 

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  Another Option for HIV Prevention?

The US Preventive Services Task Force has recommended pre-exposure prophylaxis (PrEP) for HIV prevention since 2019. The wording of the recommendation included the term “effective antiretroviral therapy,” to allow for newer medications that would be produced after the recommendation (rather than specify the Emtricitabine / Tenofovir Disoproxil Fumarate (F/TDF) combination (Truvada) on which the initial recommendation was based). Adherence issues associated with the daily oral F/TDF regimen were a major focus of the recommendation, as efficacy dropped off dramatically under 70% adherence. Emtricitabine/tenofovir alafenamide fumarate (F/TAF) (Descovy) was deemed effective soon after the recommendation, and more recently a bimonthly injection of cabotegravir was approved.

A new study of twice-yearly injectable Lenacapavir has just been published. The study compared the newer lenacapavir with F/TAF with the active control (F/TDF). They also compared the rate of new infections on these medications with the “background rate of infections” in the population of adolescents and young women in South Africa and Uganda. The study was thoughtful and overall well-done. It was funded by the makers of Truvada and Descovy. Part of the backstory here was that the initial Descovy trials did not include cis gender women as participants, and Gilead received some criticism for that. This new study is an attempt to recover that ground by studying both lenacapavir and F/TAF compared to F/TDF in cis gender women specifically.

There were 5345 participants randomized and 5338 analyzed. Over the year of treatment, the background (no prophylaxis) rate of HIV was 2.41 per 100 person-years, the per 100 person-year rates for F/TDF, F/TAF, and lenacapavir were 1.69, 2.02 and zero. That’s right, zero infections in the study for lenacapavir. Also, importantly, rates for the F/TAF group were not meaningfully different than the background rate of infection. Other STI rates were high and similar between groups. Post-hoc analysis revealed lower rates of HIV incidence with higher rates of adherence with F/TAF and F/TDF- confirming the lesson from the first F/TDF trials. There were more injection site reactions with lenacapavir than with the other drugs, but few withdrawals due to those and gastrointestinal and renal side effects were less than the oral medications.

John’s Comments:

HIV prevention is important but is also complex and changes frequently as evidence accumulates. I would recommend the CDC HIV PrEP guidelines as the most up to date source to ensure that you’re thinking of all the right things (e.g., when to start PrEP, how to monitor treatment, other testing to consider, etc.). Lenacapavir has not yet made it into these guidelines.

Remember, the best way to ask about risk in a patient for whom you’re considering PrEP is to ask about specific risky behaviors – “How many sexual partners have you had in the last year?”, or “Do you have anal receptive intercourse?” This enables you to learn about true risk factors without getting lost in not-specific-enough labels associated with identity (gay, straight, etc.)

Reference:

• Bekker LG, Das M, Karim QA, et al. Twice-Yearly Lenacapavir or Daily F/TAF for HIV Prevention in Cisgender Women. New England Journal of Medicine. 0(0). Link

From the Literature and the American Cancer Society

2)  Modifiable Risk Factors for Cancer Prevention

Cancer prevention and early detection are central to the mission of both primary care medicine and public health.  Large reductions in smoking and improvements in earlier cancer detection have contributed to steady declines in cancer mortality since the early 1990s, averting an estimated 3.8 million cancer deaths.  In 2014, an estimated 42% of cancer cases and 45% of cancer deaths in the US could be attributed to modifiable risk factors.  Furthermore, cancer screening tests can prevent thousands of additional cancer cases and deaths through identification and removal of premalignant abnormalities (colorectal and cervical) and detection of cancers at an early stage when treatment is more effective.

A recently published paper updated these estimates based on the proportion and number of invasive cancer cases (excluding nonmelanoma skin cancers) and deaths, overall and for 30 cancer types among adults who were aged > 30 in 2019 in the US, that were attributable to potentially modifiable risk factors.  The researchers used an accepted formula to estimate the population-attributable fraction (PAF; i.e., the proportion of cancer attributable to risk factors in the population) for each risk factor and associated cancer in each stratum of sex and age group. 

Risk factors included cigarette smoking; second-hand smoke; excess body weight; alcohol consumption; consumption of red and processed meat; low consumption of fruits and vegetables, dietary fiber, and dietary calcium; physical inactivity; ultraviolet radiation; and seven carcinogenic infections. Numbers of cancer cases and deaths were obtained from data sources with complete national coverage, risk factor prevalence estimates from national surveys, and associated relative risks of cancer from published large-scale pooled or meta-analyses.

They found that in 2019, an estimated 40% of all incident cancers (excluding nonmelanoma skin cancers) and 44% of all cancer deaths were attributable to the evaluated risk factors.  Cigarette smoking was the leading risk factor contributing to cancer cases and deaths overall (19.3% and 28.5%, respectively), followed by excess body weight (7.6% and 7.3%, respectively), and alcohol consumption (5.4% and 4.1%, respectively). For 19 of 30 evaluated cancer types, more than one half of the cancer cases and deaths were attributable to the potentially modifiable risk factors considered in this study.  Lung cancer had the highest number of attributed cancer cases and deaths, followed by female breast cancer, skin melanoma, and colorectal cancer for attributed cases and by colorectal, liver, and esophageal cancer for attributable deaths.

The authors concluded these findings reinforce that the morbidity and premature mortality from cancer in the US can be substantially reduced through broad and equitable implementation of known preventive initiatives, such as excise taxes on cigarettes to reduce smoking, screening for and treating HCV infection, and vaccination against HPV infection.  They note that further implementation research is needed for broad application of known interventions, particularly for excess body weight, unhealthy diet, alcohol consumption, and physical inactivity.   

Mark’s Comments:

It is encouraging to see how attention to risk factor reduction can have a profound impact on modifying these risk factors.  For example, current smoking has declined from 20.9% in 2005 to 11.5% in 2021.  Cervical cancer is estimated to be 100% preventable based on this study.  The authors note that further research is also needed on the association between potentially modifiable risk factors and cancers for which the current evidence for causality in humans is limited; on common cancers with few established modifiable risk factors (e.g., prostate cancer and non-Hodgkin lymphoma); on other potentially modifiable exposures, such as occupational carcinogens, air pollution, and other environmental risk factors; on associations of exposures throughout the lifetime; and on interactions between risk factors. 

These are exciting times here at Carilion Clinic as we prepare to break ground on a new cancer center.  At the same time, I am also hoping that some of our efforts (and resources) can also be devoted to finding and more effectively implementing ways to prevent those cancers in the first place.  There appears to be plenty of opportunities.

References:

• Islami F, et al.  Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States, 2019.  CA Cancer J Clin. Published ahead of Print July 1, 2024. 1–28.  Link
• American Cancer Society:  Cancer Prevention and Early Detection – Facts and Figures 2023-2024.  December 2023.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Asking Powerful Questions to Build Professional Intimacy

"Intimacy is the willingness to be vulnerable." – Brené Brown

Who is a colleague who knows you well?  As I reflect on my professional friendships where others “know me best,” at some point we have explored together the questions that matter most to each of us.  While initially our conversations were limited to work-related topics and casual banter, over time we began to share aspects of ourselves we hadn’t previously revealed, including our struggles, our fears, our hopes, our dreams, and the “bigger” questions of life for us, particularly those regarding purpose and meaning.   

However, in our fast-paced and perpetually demanding world of healthcare, forming deep, meaningful friendships can be challenging, even as we know these connections are vital for our emotional support and professional well-being.  “I don’t have time” is the most common reason for not having such bonds, but if it were simply a matter of time, we would likely feel closely connected with those we’ve worked alongside for countless hours, often over many years.  What then is the often-missing ingredient for developing such relationships?   

Psychologist Arthur Aron’s research on intimacy-building highlights the importance of asking (and answering) the right questions to foster these bonds.  While the word “intimacy” may initially seem off-putting (“I’m not seeking intimacy with my colleagues!”), it is important to remember that the Latin origins of the word intimacy (intimis/intimatus) mean “inmost” and “to make known” – or what I have come to understand as “into-me-see.” 

In this particular study, randomly paired participants were given a series of 36 progressively intimate questions to both ask and answer over 45 minutes.  The questions were designed to encourage mutual self-disclosure and ranged from light-hearted  (“When did you last sing to yourself?”) to more deeply personal (“What’s your most treasured memory?” and “When did you last cry in front of another person?”).  Results demonstrated that by using this more intentional process, interpersonal connections were consistently deepened compared to those who engaged in small talk. 

Building our professional friendships requires more than just shared experiences; it demands intentionality and vulnerability.  Dr. Aron’s intimacy-building questions offer a practical tool for fostering these connections.  I challenge you to integrate some of his questions into your conversations with your PeerRx partner or another colleague and experience how the dialogue helps transform your interactions – and your relationship.  Here's a structured process that might be useful and includes the 36 questions, though I would encourage you to savor these questions and answer them together over many weeks rather than all at once.  By embracing the art of asking and answering good questions, you can build stronger, more intimate friendships that enrich your professional (and personal) life.  That sounds like a wonderful reason to reconsider “professional intimacy.”

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  ADHD Treatment and Major Outcomes

For many drugs, data about their long-term use and important outcomes such as mortality is often not available from the narrow, randomized controlled trials done to win US Food and Drug Administration (FDA) approval. We must rely instead on large and long duration observational studies (prospective or retrospective) for long-term outcomes. However, while cohort studies may be overall less expensive and easier to do, they are subject to biases that are sometimes difficult to control.

Cases in point, two articles in my “Take 3” inbox this week – both on the effects of Attention Deficit Hyperactivity Disorder (ADHD) pharmacotherapy on outcomes. The first study used European ADHD registry data to compare prior pharmacotherapy users with <1 dose/day users and >=1 dose/day users. They looked at the outcomes of acute coronary syndromes, stroke, heart failure, and a composite outcome of all three both during the 10 years of follow up. Adjustments were made for a variety of medical diagnoses (mental and physical comorbidities) and prescription medications.

Ultimately, the researchers found an association between increasing daily doses of ADHD medication and stroke and heart failure. Comparing highest dose users and prior users there was a relative risk of stroke of 1.2 (95% confidence interval (CI) 1.0 to 1.5; number needed to harm (NNH) 258), heart failure (RR 1.7; 95% CI: 1.3 to 2.2; number NNH 204), and the composite outcome (relative risk: 1.3; 95% CI: 1.1 to 1.5; NNH 116), but not for acute coronary syndromes (relative risk: 1.1; 95% CI: 0.8 to 1.4). There were only non-significant associations for <1 dose/day users. However, there were potential confounding variables not accounted for in the analyses: lifestyle, weight, smoking and exercise being the big ones. In addition, there were also increases in non-steroidal anti-inflammatory drugs (NSAIDs) correlated with increases in ADHD medications that were not apparently accounted for and could have increased the likelihood of CV outcomes.

Contrast that with a dataset study of ADHD medications in a teenager/young adult European cohort that examined all-cause mortality. Starting ADHD medications for recently diagnosed teenagers and adults decreased all-cause mortality at 2 years by 8.9 deaths per 10,000, 95%CI –17.3 to –0.6 (hazard ratio (HR) 0.79, 95%CI 0.70 to 0.88). Most of the reduction in death was in the category of unnatural causes (accidents, injuries, poisoning, suicide): 7.4 fewer deaths per 10,000, 95%CI –14.2 to –0.5 (HR 0.75, 95%CI 0.66 to 0.86). In this cohort, males had reduced overall death from unnatural causes only, while women had a reduction in death from natural causes only. The authors are careful to note that the observed reduction may not be due to medication per se, but possibly other factors associated with the decision to treat (counseling, support, etc.).

John’s Comments:

At a Virginia Academy of Family Physicians meeting last year, I heard a compelling presentation on ADHD treatment that emphasized the higher mortality of young adults with ADHD – primarily from accidents and injuries – and exhorted the audience to consider this in treatment decisions. The data above add to that argument. We should work to reduce cardiovascular risk factors in all our patients but perhaps provide additional encouragement for adults who require ADHD medication in the long term.

References:

·         Holt A, Strange JE, Rasmussen PV, et al. Long-Term Cardiovascular Risk Associated With Treatment of Attention-Deficit/Hyperactivity Disorder in Adults. J Am Coll Cardiol. 2024;83(19):1870-1882. Link

·         Li L, Zhu N, Zhang L, et al. ADHD Pharmacotherapy and Mortality in Individuals With ADHD. JAMA. 2024;331(10):850-860. Link

From The Literature

2)  Health Impacts of Micro-nano Plastics (MNPs)

Microplastics (MPs) and nanoplastics (NPs) are small plastic particles which originate from the degradation of plastic or from industrial processes. These particles are typically less than 5 millimeters for microplastics and less than 100 nanometers for nanoplastics.  They are ubiquitous in water, air, and soil, and very high quantities have been detected even in ecosystems as remote as Arctic Sea ice and deep-sea sediments. 

Humans can be exposed to these substances through various routes, including ingestion, inhalation, and dermal contact in both indoor and outdoor environments.  Within humans, they have been detected in breast milk, the placenta, myocardial tissue, liver, kidneys, testicles, and most recently in penile tissue.  Indeed, a recently published study found micro-nano plastic (MNP) particle concentrations per liter of three popular brands of bottled water to be between 110,000 – 370,000 rather than the previously reported 300. 

The toxicological impact of MNPs at the cellular level is an area of active research.  NPs, due to their high surface area to volume ratio, are particularly concerning.  They can generate reactive oxygen particles, leading to oxidative stress and damage to cellular components, including lipids, proteins, and DNA.  This oxidative stress can trigger inflammatory pathways and disrupt cellular homeostasis.  Additionally, MNPs can act as carriers for other toxic substances, such as persistent organic pollutants (POPs) and heavy metals, enhancing their potential toxicity.

Despite these findings, there is a paucity of research as to the impact these microplastics have on human health.  What is known is that the chemicals often found in plastics are known to cause multiple health problems, including cancers, metabolic disorders, attention deficit/hyperactivity disorder, and fertility issues, thought to be due to oxidative stress, inflammation, and endocrine disruption.    

The most widely known of these chemicals are the phenols, and in particular bisphenol A (BPA – an endocrine disruptor with estrogen-like activity), and its metabolites.  BPA has been used by manufacturers to make plastics hard and clear since the 1950s, including in water bottles, baby bottles, and in the lining of food cans.  In 2012, the FDA banned the use of BPAs in the production of baby bottles, sippy cups, and infant formula packaging but has taken no further action on a larger scale. 

Another commonly used chemical class of concern are phthalates, which are used to make soft, flexible plastics such as PVC (“vinyl”) products and food packaging.  They are also used to make fragrances found in beauty and skin care products.

A recently published prospective, multicenter, observational study has added to our understanding of the potential health impacts of MNPs.  The authors studied excised carotid plaque specimens from patients who underwent carotid endarterectomy for asymptomatic carotid artery disease to look for evidence of MNPs.  The specimens were analyzed with the use of pyrolysis–gas chromatography–mass spectrometry, stable isotope analysis, and electron microscopy.  Inflammatory biomarkers were assessed with enzyme-linked immunosorbent assay and immunohistochemical assay. The primary end point was a composite of myocardial infarction, stroke, or death from any cause among patients who had evidence of MNPs in plaque as compared with patients with plaque that showed no evidence of MNPs.

A total of 304 patients were enrolled in the study, and 257 completed a mean follow-up of 34 months.  Polyethylene was detected in the plaque of 58% of patients, and 12% also had measurable amounts of polyvinyl chloride.  Electron microscopy revealed visible, jagged-edged foreign particles among plaque macrophages and scattered in the external debris.  Patients in whom MNPs were detected within the atheroma were at higher risk for a primary end-point event than those in whom these substances were not detected (hazard ratio, 4.53; 95% confidence interval, 2.00 to 10.27; P<0.001).

Mark’s Comments:

As I synthesized my reading on this topic, it would have been quite easy to conclude, “Dude, we’re screwed.”  However, there are some simple steps anyone can take to try and minimize MNP exposure.  These include not microwaving or otherwise heating food and drinks in polycarbonate plastic (particularly recycle numbers 7 and 3 plastics), handwashing polycarbonate containers rather than putting them in the dishwasher, minimizing canned food consumption, using nonplastic storage materials for food and beverages (eg, glass or stainless steel – particularly for warm food), and, as noted above, not regularly drinking liquids that have been stored in plastic bottles.  I have begun taking frozen foods out of their plastic containers prior to heating them and avoid drinking liquids stored in plastic bottles entirely.  Afterall, I still want to believe that every little nano-bit makes a difference.

References:

·         Marfella R, et al.  Microplastics and Nanoplastics in Atheromas and Cardiovascular Events.  N Engl J Med 2024;390:900-910.  Link

·         Woodruff T.  Health Effects of Fossil Fuel–Derived Endocrine Disruptors.  N Engl J Med 2024;390(1):922-933.  Link

From PeerRxMed ( www.PeerRxMed.org )

3) Learning to Love My “Manyme’s” 

"I contain multitudes." - Walt Whitman, from the poem “Song of Myself, 51”

Many years ago, one of my mentors shared with me that the practice of medicine is, to a certain degree, a “performance art” as we continually adapt ourselves to our patients, their context, and the dynamic environment we work within.  He went on to share that as we rapidly shift from compassionate caregiver to decisive leader to so many other identities, our many physician "me's" are ever-changing.  This fluidity can be both empowering and exhausting, and it is part of what makes our work profoundly human, deeply impactful, and perpetually challenging. 

This week I received a touching reminder of the importance of regulating my many ”me’s” and how, when “the performance” is done well, the result can be life changing for those I care for.  At the end of a visit with a very medically challenged young adult patient and his care-giver mother, she handed me an envelope and simply said, “Please read this later” and they both gave me a hug.   

That evening, when I wasn’t distracted, I opened the one-page typed letter.  It started, “I want to take the time to let you know how grateful I am that you are my son’s physician.”  The letter went on to describe her challenges in caring for her special needs son as a single mother, and the impact my care and that of others had on him.  Near the end, she wrote, “My son adores you and always looks forward to seeing you, which is quite unusual for him…,” and closed, “There is a special place in Heaven for doctors such as you.”  Yes, the tears flowed.

What touched me most as I reflected on this letter was how, of the many “me’s” who regularly show up when I am caring for patients, this is who he, and she, experienced.  They saw the good listener, the comforter, the jokester, the teacher.  They experienced patient me, calm me, smiling me, and the “never-in-a-hurry” me.  What they miraculously did not experience were the many other not so lovely “me’s” – the tired me, the “mad-at-the-computer” me, the “frustrated-with-stupid-paperwork” me, even the “I-really-don’t-have-time-for-a-student-today” me, just to name a few.  Somehow for this family, our time together translated into the letter now sitting before me, and into the “there’s-a-special-place-in-Heaven-for-doctors-such-as-you” me.  Wow …

This week, I invite you to reflect on your own “manyme's" and how they show up for you at work (and outside of work).  Consider taking some time to share what you observe with your PeerRx partner.  Even for those aspects that you perhaps find “unlovely” or “inconvenient,” recognize that they are part of who you are and someone got you to this point.  Sure, I don’t want “grumpy” me, “distant” me or even “efficient” me to be the predominant me to who shows up at work or anywhere else.  Yet, even they are showing up for a reason.  And somehow, at least according to my patient and his mother, there’s a place in “Heaven” for them too.   

PS:  For an adorable short Sesame Street segment about our many “me’s” (circa 1991), click here:  Link

Feel free to forward Take 3 to your colleagues.  Glad to add them to the distribution list.

 Mark and John

Carilion Clinic Department of Family and Community Medicine

1)  How Much Difference Can SGLT-2 Inhibitors Make?

These days, as soon as we’ve had our fill of discussing glucagon-like-peptide-1 (GLP-1) agonists, we turn around and get hit with sodium–glucose co-transporter-2 inhibitors (SGLT-2i).  We’ve covered the rapid ascendancy of SGLT-2s in both diabetes and congestive heart failure (CHF, Take 3 #534 and #537). Most of the studies that are provided as evidence of their benefit include “composite outcomes” – usually Major Adverse Cardiac Events (or MACE) – which include any one of: myocardial infarction (MI), admission for CHF, revascularization or cardiovascular death.  One of the problems with using composite outcomes is that unless the outcomes included in the composite are all relatively equal in severity, the most common (and frequently less serious) outcome is usually the one that accounts for most of the benefit, which can produce a false impression of the drug’s effectiveness.  In addition, there is now enough accumulated evidence on these agents to look for patterns of effectiveness in patients with multiple conditions – CHF, atherosclerotic cardiovascular disease (ASCVD), history of diabetes (DM), or chronic kidney disease (CKD) – rather than the limited range conditions in any one primary study.

The authors of a recent Lancet systematic review wanted to analyze the largest studies of SGLT-2is to see if their effect on important individual outcomes held up across patient populations with a range of comorbidities. They looked for studies with > 1000 patients that had any one of: type 2 DM, CHF, CKD, and ASCVD, took an SGLT-2i or placebo, and who were evaluated for: “[1] a composite of first hospitalization for heart failure or cardiovascular death, [2] first hospitalization for heart failure, [3] total (i.e. first and recurrent) hospitalization for  heart failure, [4] cardiovascular death, and [5] all-cause mortality.” (I know…they used some smaller composite outcomes even in this study…).  The authors searched multiple databases, appraised each study for risk of bias, and assessed for heterogeneity across the data – all good quality points.

There was data from 15 separate studies (57 publications, including re-analyses) included in the analysis. Overall, the meta-analysis showed SGLT-2 inhibitors were associated with significant reductions in each of the five outcomes:  composite hospitalization or heart failure or cardiovascular death (HR 0·78 [95% CI 0·75–0·82]), first hospitalization for heart failure (HR 0·71 [0·67–0·75], cardiovascular death (HR 0·87 [0·83–0·92]), total hospitalization for heart failure (RR 0·70 [95% CI 0·66–0·75]), and all-cause mortality (HR 0·89 [95% CI 0·84–0·94]). Across a range of demographics, the effect of SGLT-2i therapy was consistent, except for a greater reduction in total hospitalization for heart failure in those of Asian race, and geographic location in Asia.

The effect of SGLT-2i therapy was also consistent across patients in patients with pre-existing CHF, DM, and ASCVD and various combinations of those conditions – although the effect was generally stronger for the hospitalization outcomes than for the mortality outcomes. In patients with a recent myocardial infarction, there was no significant effect on cardiovascular death (both alone, and in the composite outcome with first hospitalization for CHF). The authors found relatively low amounts of heterogeneity in the meta-analyses. They assessed all the studies to be of low risk of bias. There was possible publication bias in the hospitalization outcomes, but not for cardiovascular death (this could have been because the authors intentionally excluded small studies, which may have shown less effect).

John’s Comments:

While these types of studies aren’t themselves groundbreaking, they are helpful to reassure us that real world use of these agents (in patients with a variety of demographics and comorbidities) will produce results consistent with the individual trials. One important addition this study achieves is a better sense of overall reduction in cardiovascular mortality, since none of the trials were independently powered to examine this. Of note, there were no safety or tolerability outcomes included in this analysis, which is unfortunate.

Reference:

• Usman MS, Bhatt DL, Hameed I, et al. Effect of SGLT2 inhibitors on heart failure outcomes and cardiovascular death across the cardiometabolic disease spectrum: a systematic review and meta-analysis. The Lancet Diabetes & Endocrinology. 2024;12(7):447-461. Link

From the American Headache Society

2)  First Line Treatment for the Prevention of Migraine

It is estimated that migraine headaches (migraine) impacts about 12% of the US adult population, effecting 17% of women and 6% of men.  Those with migraine often experience reduced quality of life due to pain, nausea, sensitivity to light and sound, and other symptoms. These can severely impact daily activities, work, and social interactions.  Migraine is also often associated with other health conditions such as depression, anxiety, sleep disorders, and cardiovascular diseases.

Preventive therapy is a core goal in the treatment of migraine.  Preventive treatment is defined as an intervention to reduce migraine attack frequency, intensity, duration, and disability.  Successful preventive therapy should also improve responsiveness to acute treatments, reduce overall costs attributed to migraine and its treatment, and improve quality of life. Preventive therapy is indicated in ~40% of patients with migraine, although only a minority of such patients are using such treatments, in part because of limitations with efficacy and tolerability for more longstanding, established therapies.

The available evidence indicates traditional first-line treatments, particularly orally administered medications, may not be consistently effective, have concerns with tolerability and safety, and lack clear predictors of treatment response that guide clinical decisions about which to try first.  As these medications were all developed for indications other than migraine, the choice of which of these preventive treatments to implement is often based upon comorbidities, such as hypertension, insomnia, depression, and obesity, that may make a given treatment either indicated or contraindicated.  Multiple studies show that long-term adherence to these therapies is poor, based in part on unsatisfactory tolerability, and, in part, on lack of efficacy.

In 2021 the American Headache Society (AHS) published a consensus statement on migraine prevention and recommended, based on the available evidence at the time, that an individual try at least two classes of previous first-line migraine medications for ≥8 weeks before being considered for CGRP-targeting therapy.  In the case of chronic migraine, the recommendation was that a trial of onabotulinumtoxinA/Botox could be an alternative to a trial of two classes of medications.

Since the time of that statement, new evidence has been published regarding the efficacy, safety, and tolerability of calcitonin gene-related peptide (CGRP)-targeting therapies include the monoclonal antibodies (mAbs – erenumab/Aimovig, fremanezumab/Ajovy, galcanezumab/Emgality, and eptinezumab/Vyepti), and the small-molecule CGRP receptor antagonists (gepants – rimegepant/Nurtec and atogepant/Qulipta).  Given this new information, the AHS recently published an updated position statement for migraine preventive therapy specifically indicating that initiation of these newer therapies should not require trial and failure of non-specific migraine preventive medication approaches but rather should be considered first-line therapy.

Updated recommendations for treatments to consider include:

• For of episodic migraine with or without aura (4–14 monthly migraine days/MMDs) based upon International Classification of Headache Disorders (ICHD-3) with at least moderate disability ((Migraine Disability Assessment/MIDAS score ≥11 or Headache Impact Test/HIT-6 score >50)

OR

• For chronic migraine with or without aura (≥15 monthly headache days/MHDs) based upon ICHD-3. 
  • Topiramate
  • Divalproex sodium/valproate sodium
  • Beta-blocker: metoprolol, propranolol, timolol, atenolol, nadolol
  • Candesartan
  • Tricyclic antidepressant: amitriptyline, nortriptyline
  • Serotonin-norepinephrine reuptake inhibitor: venlafaxine, duloxetine
  • Other Level A or B treatments (established efficacy or probably effective) according to AAN scheme for classification of evidence
  • Monoclonal antibodies targeting CGRP or its receptor including erenumab, fremenezumab, galcanezumab, or eptinezumab
  • Small-molecules targeting the CGRP receptor (“gepants”) including atogepant and rimegepant

For chronic migraine, considerations can also include OnabotulinumtoxinA

Mark’s Comments:

Although it appears the older and newer preventive medications have similar efficacies, the CGRP-targeted therapies often have better tolerability and fewer side effects than the antidepressants, antihypertensives, and antiseizure medications but cost significantly more.  This is the trade-off we’ll need to balance as we determine where these medications “fit” into our treatment options.  As with other newer medications, this will unfortunately often come down to insurance coverage.  For example, the GoodRx price for a month of fremenezumab/Ajovy is $720 and for atogepant/Qulipta is $1,069.  The good news is, we have options.  Lots of them, so work with your patients to find the one that works for them.

Reference:

• Charles A, et al.  Calcitonin gene-related peptide-targeting therapies are a first-line option for the prevention of migraine: An American Headache Society position statement update.  Headache. April 2024.  64(4): 333-341.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Being Positively Deviant (and inviting others along for the ride)

"The reasonable man [sic] adapts himself to the world: the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man." — George Bernard Shaw

In my work helping to lead clinician well-being efforts, it has become a regular habit of mine to ask colleagues who are successfully navigating and even thriving in the midst of our demanding work, or what we might call “positive deviants,” if they have any “secrets” to their approach.  These are the colleagues who obviously love what they do and experience joy doing it while others struggle mightily.  They’re doing similar work, often in the same organization, but with a widely different outcome. 

Indeed, this question is quite relevant given the data regarding physician distress, where studies consistently (and persistently) indicate the majority of us continue to be “failing to thrive.”  Positive deviance encourages the adoption of often unconventional yet successful practices by those who, despite facing similar challenges, find ways to achieve more desirable outcomes.  These often simple practices deviate from what we have come to accept as the norm and can often include innovative approaches to time management, administrative efficiency, psychological reframing, prioritizing self-care, and fostering supportive professional relationships. 

While their answers vary based on context and personality, there are a few common themes that have emerged over the years of my inquiry and are supported by research.  The first is that almost without exception these positive professional deviants assign meaning to their work that elevates it beyond transaction to a sense of calling.  In doing so, they know their work matters and makes a difference, even in the midst of potential tedium and hassle.  They also are willing to try new things when their present process is not working, and are never content with the “status quo” when it is not achieving desired outcomes.  Additionally, they have all developed the habit of being able (and willing) to reframe situations to tap into “possibility thinking” even as I would not consider any of them to be “excessively” optimistic.

While some organizational cultures are threatened by such qualities (labeling them “Mavericks” or even “disruptive”), positive deviance can benefit healthcare organizations by creating a culture of collaborative experimentation and improvement. This can foster a more supportive and resilient healthcare environment even in the midst of organizational entropy.  

But perhaps the most telling insight from my query of my “positive deviant” network was how many of them shared with me that, “No one has ever asked me this before!”  It’s time that we do so more often.  By seeking out and learning from those who have found ways to maintain their well-being, we can adopt new strategies that enhance our own lives.  Take a moment this week to observe your colleagues and identify someone who seems to be thriving despite the challenges of our work. Initiate a conversation with them about their strategies for maintaining well-being and consider how you might incorporate some of their practices into your own life.  Share your findings with a peer and encourage them to do the same.  By fostering a culture of positive deviance, we can collectively improve our well-being and continue to provide the best care for our patients.  Now that does sound positively deviant!

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  New RSV (RSV) Vaccine Indications for Adults

At it's June meeting, the ACIP reviewed new evidence to tailor respiratory syncytial virus (RSV) vaccine recommendations for adults 60 years and older. The new recommendations are:

• Adults 75 years of age and older should receive a single dose of RSV vaccine

• Adults 60–74 years of age and older who are at increased risk of severe RSV disease receive a single dose of RSV vaccine.
  • The list of risk factors is NOT yet finalized, but the possibilities mentioned include: asthma, chronic kidney disease, chronic obstructive pulmonary disease, coronary artery disease, current smoker, diabetes, stroke, obesity, heart failure, immune compromise, and living in a nursing facility.

• Patients who got an RSV vaccine last year do not need another. It is best given in late summer or early fall.
• The ACIP includes in this recommendation three vaccines: the protein subunit-based Pfizer vaccine (Abrysvo) and GSK vaccine (Arexvy) and Moderna’s new mRNA vaccine (mResvia).

The ACIP based this recommendation on as-yet-unpublished data presented to the CDC that showed that the following factors increased the risk of RSV-associated hospitalization:

• Number of chronic conditions:
  • One condition - relative risk (RR) 2.1 vs. none, and
  • Two conditions - RR 7.3 vs. none
• Age group:
  • 60-74 years – RR 1.9 vs. 50-59 years
  • 75 and older – RR 6.0 vs. 50-59 years

In the older populations, RSV illness is similar to strains of COVID-19 or influenza in terms of severity, is associated with a higher-than-expected rate of acute cardiac events, and usually results in prolonged convalescence needs, including skilled nursing facility.

In the Evidence-to-Recommendations presentation at the ACIP meeting, the evidence supporting these recommendations was reviewed as moderate to high for the protein subunit-based RSV vaccines preventing “medically attended RSV” (outpatient, emergency department or inpatient) and low for preventing hospitalization. For harms, RSV protein subunit vaccines cause no increase in Serious Adverse Events (moderate evidence) but may increase the risk of inflammatory neurological outcomes (e.g., Guillain-Barre syndrome) slightly (low evidence). The Moderna mRNA vaccine, in a single phase 2/3 study, had a vaccine effectiveness of 39% for prevention of medically attended RSV, and 80% for prevention of hospitalization. The evidence was graded low to very low for these outcomes. The harms from the mRNA vaccine were mostly an increased risk of severe reactogenicity (i.e., fever, local reaction; RR 1.54, 95%CI 1.40-1.68)

John’s Comments:

Note the conspicuous absence of any “shared decision making” recommendations in this update. CDC heard loud and clear from clinicians that SDM in this context was infeasible. In addition, it sounds like they realized that pharmacies were actively marketing the vaccine without worrying about the SDM. So, they gave up on it, but tightened the recommendations a bit, which I think is a better idea. In my opinion, the evidence for the mRNA vaccine is notably weaker than that for the protein subunit vaccines (largely because it’s newer), despite the equal recommendations. It may be that the ACIP wanted to provide an option for those concerned about “inflammatory neurological adverse events.” The mRNA vaccine must be stored deep frozen (-40 to -15 degrees Celsius) and can be thawed only for 30 days – all of which will limit its usefulness in practices. However, because this vaccine will be paid for only through Medicare Part D and not part B, it will be given primarily in pharmacies anyway.

References:

• CDC Newsroom. CDC Updates RSV Vaccination Recommendation for Adults. CDC. Published January 1, 2016. Accessed June 27, 2024.Link
• CDC. ACIP Vaccine Recommendations and Schedules | CDC - Recent Meeting Recommendations. Published June 28, 2024. Accessed July 1, 2024. Link
• Britton A, Melgar M, Roper L. Evidence to Recommendations Framework (EtR): RSV Vaccination in Adults Aged 50–59 years, 60–74 years, and 75 years and older. Presented at: Advisory Committee on Immunization Practices; June 26, 2024; Atlanta, GA. Accessed July 1, 2024. Link

From the Literature, the Surgeon General, and the Blogosphere

2)  The Negative Impacts of Social Media on Youth

It is estimated that more than 95% of adolescents utilize social media as an integral aspect of their lives.  With the social medial platform Facebook (now 20 years old) having over 3 billion active users, Instagram having an estimated 2 billion and TikTok 1.5 billion, the constant exposure to these platform algorithms has in many ways become a social experiment on a scale never before experienced in human history.

Yet, the potential negative mental health impacts of these platforms for youth and adults has been raised as a concern for years.  Studies published as early as 2014 began to show the increased risk for anxiety, depression, poor self-image, loneliness, self-harm, and suicidal ideation.  Additional studies showed that the structures and algorithms used on these social media sites strongly impacted the dopamine reward systems of the brain, raising concerns of their potential “addictive” properties.  

Smartphones did not initially raise major developmental concerns for children.  As social psychologist Jonathan Haidt and his colleague Zach Rausch have noted in their research, the problems started around 2010 when the smartphone platform was combined with other factors to form a perfect psychological storm, including social media apps, high-speed internet, extensive wireless networks, a backward-facing camera (encouraging selfies), addictive games, easily accessible pornography, and free apps that maximize profit by cultivating addiction and social contagion.

They write this toxic technological mix allowed smartphones to take over children’s lives. Usage rates averaging seven hours a day gradually but profoundly rewired their maturing brains. Haidt postulates this rewiring gave rise to four “foundational concerns”:

1. Social deprivation: a smartphone as an “experience blocker”, taking up hours a day that would otherwise be spent in physical play or in-person conversations with friends and family.
2. Sleep deprivation: too many teenagers stay on their smartphones late at night when they need rest.
3. Attention fragmentation: alerts and messages continually drag teenagers away from the present moment and tasks requiring concentration.
4. Addiction: apps and social media are deliberately designed to hack vulnerabilities in teenagers’ psychologies, leading to a dopaminergic-driven challenge to enjoy anything else.  

They note their research showed that girls proved more vulnerable to the damaging effects of social media, while boys retreated into online gaming and pornography.

All of this culminated in May of 2023, when the US Surgeon General issued an Advisory on Social Media and Youth Mental Health in which he made a call to action for policy makers, social media companies, researchers, parents, and youth and the American Psychological Association (APA) issued a Health Advisory on Social Media Use in Adolescence, making a series of recommendations based on the scientific evidence at to that point.  The Surgeon General followed in June of this year with an op-ed in the New York Times and calling on the US Congress to place a warning label on social media apps.  In July of 2024, the Governor of Virginia issued an executive order banning cell phone use in public schools as of January 1, 2025.

Dr. Haidt summarized his work in the 2024 book The Anxious Generation, where he  indicated that the path forward is one of collective action by implementing “new norms.”  These include; no smartphones before high school; no social media before 16; phone-free schools; and more independence, free play, and responsibility in the real world.

Mark’s Comments:

In their "Free the Anxious Generation" initiative, Haidt and colleagues write, “We state an ambitious goal: to begin the end of the phone-based childhood by the end of 2025.”  With movement toward that goal at the local, state and national level, it may not be long until we finally reach the “tipping point” and begin to turn the tide by becoming more intentional as to how this new technology is used in order to maximize its strengths while neutralizing its limitations, for children AND adults.  And perhaps we will carry some of these lessons into how we choose to utilize AI.  But that’s a big “perhaps.” 

References:

See embedded links in the Pointer

From PeerRxMed ( www.PeerRxMed.org )

3)  Do You Speak Appreciationese?

“Each of us wants to know that what we do matters …. and that we matter.”  Gary Chapman, PhD and Paul White, PhD, co-authors of the book The 5 Languages of Appreciation in the Workplace

Do you like to feel appreciated?  Hopefully your answer to that question is “Duh!”  I sure do, and most others do as well.  Yet, in the midst of our incredibly challenging work, “not feeling appreciated” is cited in surveys as an all-too-common theme among not only physicians but all members of the care team.  If we’re not feeling appreciated, we’re likely not expressing it to others either, and that leaves an incredible vacuum for “negative emotional contagion” to run rampant across our organizations and communities (and families).  So, the real question is not if, but rather how do you (and others) like to be appreciated? 

Perhaps you didn’t realize that not everyone likes to receive appreciation in the same way, and that your attempts to show appreciation to others may be missing the mark.  Psychologists Gary Chapman and Paul White have devoted a significant portion of their careers to sharing the positive impact we can have on each other when we connect in a way that is resonant.  Dr. Chapman originally called this type of connection as speaking our “Love Languages,” and the two together brought a similar understanding to the workplace using the “Languages of Appreciation.”  

They observed that we are most deeply fulfilled when we receive appreciation in our preferred language/s and that unless we express our appreciation in another’s, we “miss the mark” and fail to meet their deepest needs to feel appreciated. This can mean  even our best of intentions can fall far short of their potential positive impact and leave others feeling unsupported and not valued – often described as “not feeling the love.”

Chapman and White have identified 5 primary “languages” of appreciation, including Words of Affirmation, Quality Time, Acts of Service, Tangible Gifts, and Physical Touch, and found that most people have a preferred primary and secondary language.   Incorporating awareness of these different “languages” in relationships can help to create stronger connections among coworkers and a more positive workplace environment.  That has certainly been my experience over many years as preferences for how we feel most appreciated are shared and explored.   

Having a culture of appreciation at work will not only help us get through challenging times but will enable us to feel more connected and deepen our relationships.  This week, perhaps you can learn more about (or be reminded of) the preferred language of yourself and others, and then practice learning some new languages to make sure you are “contagious” with appreciation.  And if you want to be contagious with me, a “You da man” with a smile and fist bump will work just fine. 😎

To learn more about your “language” (or for a “refresher”), see the resources below:

• 5 Love Languages Quiz: https://www.5lovelanguages.com/quizzes/  (Free)
• Motivating by Appreciation (MBA) at Work Inventory:  https://mbainventory.com/take-online-personality-assessment-inventory/  (NOTE there is a cost for this of $15 for the basic inventory, $25 for a “Medical” version)

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

Johns’ Comments:  In my piece about vitamin D supplementation last week, I inadvertently wrote mcg (micrograms) instead of IU (international units) for the usual recommended supplementation doses.  I’m usually very careful about that…because both IU and mcg are used routinely in drug references, but most clinical recommendations are written in IU. The recommendation sentence should have read: “For supplementation, the society recommends daily, low-dose vitamin D (400-800 IU/day)…“  For reference, 400 IU of vitamin D3 is 10 mcg.

My apologies, and thanks to the alert reader that questioned it. Please feel free send us a note if something we say doesn’t make sense; we’re always happy to clarify…or correct.

From the Literature

1)  Very Brief Advice for Smoking Cessation

For years, the standard model for smoking cessation (as well as cessation of other addicting substances) has been SBIRT – Screening, Brief Intervention, and Referral to Treatment. Although this method was meant to standardize and somewhat streamline substance abuse counseling, primary care clinicians can rarely accomplish all the steps in clinical practice. The Brief Intervention part alone comprises models like the “Five As”: Ask, Advise, Assess, Assist, and Arrange follow up. When coupled with the necessary Screening activities and Referral for Treatment discussions, these are challenging to fit into practice.  Very Brief Advice (VBA, models such as “AAR” - Ask, Advise, Refer or “ABC” - Ask about smoking, give Brief advice and offer Cessation therapy as needed) were invented to make these techniques more usable.

A multi-national research group conducted a systematic review of VBA’s effectiveness for smoking cessation compared to no advice/usual care. Studies were selected that were controlled trials of VBA (<3 minutes of intervention per patient) vs. control, and outcomes included continuous smoking cessation after 6 months (by self-report or biochemical confirmation). There was a comprehensive search performed and very specific selection criteria were applied. The studies were assessed for risk of bias using the Cochrane tool, and heterogeneity was assessed in a couple of ways.

Thirteen studies were found that met inclusion criteria. The studies were of overall moderate risk of bias, mostly due to issues of blinding, attrition bias, and outcome reporting. The crude relative risk (RR) of self-reported smoking cessation with VBA was 1.28 (95% confidence interval (CI) 1.10–1.49; NNT ~ 66). After non-pre-specified analysis that corrected for some publication bias, VBA still resulted in more cessation at 6 months: RR 1.17, 95% CI 1.07–1.27; NNT ~ 73. There were five studies that measured biochemically validated abstinence; the meta-analysis of these revealed a bigger relative risk of 1.53, but it was not statistically significant (95% CI 0.98–2.40; NNT ~ 256).

John’s Comments:

While neither the strength of evidence nor the results of VBA interventions are especially impressive, they may be worth trying if the full SBIRT is not practical. It’s certainly easier to remember. We need to keep studying brief interventions for behavioral change like this to incorporate into our busy primary care practices. VBA has been shown to work with alcohol overuse, so maybe we’ll get better evidence for it for smoking eventually.

Reference:

•  Cheng CCW, He WJA, Gouda H, et al. Effectiveness of Very Brief Advice on Tobacco Cessation: A Systematic Review and Meta-Analysis. J GEN INTERN MED. Published online May 2, 2024. Link

From the USPSTF

2)  Interventions for High BMI in Children and Adolescents

Approximately 20% of children and adolescents aged 2-19 in the US have a body mass index (BMI) at or above the 95th percentile for age and sex, based on Centers for Disease Control and Prevention (CDC) growth charts from 2000.  Though the use of BMI has received criticism, its use is the currently accepted clinical standard measure of excess fat in the US, and childhood and adolescent weight status is usually obtained by calculating BMI.  Traditionally, children and adolescents are categorized as having “obesity” when their BMI is at or above the 95th percentile on CDC growth charts.  

The USPSTF recently updated its 2017 recommendation for screening for obesity in this age group.  In the updated recommendation, the USPSTF used the general term “high BMI” when referring to youth with a body weight status ≥95th percentile for age and sex according to CDC standards.  The Task Force acknowledges that BMI is an imperfect measure of adiposity and is not an equivalent measure of adiposity across all racial and ethnic populations.  However, they note that most children with a BMI-for-age at or above the 95th percentile have high adiposity, while few children with a BMI-for-age below the 85th percentile have high adiposity.

The USPSTF now recommends that clinicians provide or refer children and adolescents 6 years or older with a high body mass index (≥95th percentile for age and sex) to comprehensive, intensive behavioral interventions. (B recommendation).  They note that to achieve benefit, it is important that this group receive intensive (26 or more contact hours) behavioral interventions based on present data.

The data indicates that comprehensive, intensive behavioral interventions that include supervised physical activity sessions for up to 1 year result in weight loss in children and adolescents.  Effective, high-intensity (≥26 contact hours) behavioral interventions result in greater weight loss than less intense interventions and result in some improvements in cardiometabolic risk factors.  While there was variation, many of the studied interventions included sessions targeting both the parent and child (separately, together, or both); offered group sessions in addition to individual or single-family sessions; provided information about healthy eating, safe exercising, and reading food labels; and incorporated behavior change techniques such as problem solving, monitoring diet and physical activity behaviors, and goal setting.  These types of interventions are often delivered by multidisciplinary teams, including clinicians, exercise physiologists or physical therapists, dietitians or diet assistants, psychologists or social workers, or other behavioral specialists.

The USPSTF recognizes the challenges that the families of children and adolescents encounter in accessing effective, intensive behavioral interventions for high BMI. Identifying high BMI and how to address it are important steps in helping children and adolescents and their families obtain the support they need. The USPSTF also understands that stigma associated with high BMI can be harmful to children and adolescents.  However, there was no evidence that behavioral interventions resulted in additional stigma.  Also, none of the trials found a decrease in self-esteem or body satisfaction, or an increase in disordered eating, associated with behavioral interventions.

The Task Force notes that while several medications demonstrated greater weight loss than placebo, the totality of the evidence was found to be inadequate. An important limitation of the pharmacotherapy studies was that there was only a single trial for each effective medication (ie, phentermine/topiramate, semaglutide, and liraglutide) that lasted longer than 2 months.  The limited evidence on weight maintenance after pharmacotherapy discontinuation suggests that weight rebound starts soon after discontinuation, implying that long-term use will be needed to maintain weight loss.  However, there is no evidence on the harms of long-term medication use.  Therefore, the USPSTF encourages clinicians to promote behavioral interventions as the primary effective intervention for weight loss in children and adolescents.

Mark’s Comments:

Similar to the 2023 American Academy of Pediatrics (AAP) 2023 practice guideline for the evaluation and management of children and adolescents with obesity which was highlighted in the January 14, 2023 Take 3, the USPSTF emphasizes that active, comprehensive, and intensive intervention and not simply “watchful waiting” is the approach that will lead to more desirable outcomes for this population.  This is certainly desirable given the potential long-term individual and population impacts of high BMI.  This Algorithm from the American Academy of Pediatrics 2023 practice guideline, which generally is in alignment with the USPStF, provides a useful 1-page overview of the AAP recommendations. 

References:

• USPSTF.  Interventions for High Body Mass Index in Children and Adolescents: US Preventive Services Task Force Recommendation Statement.   JAMA. Published online June 18, 2024. doi:10.1001/jama.2024.11146.  Link
• Hampl SE, et al.  Executive Summary: Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity.  Pediatrics.  January 9, 2023; DOI: 10.1542/peds.2022-060640.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  It’s Halftime

“It’s halftime for 2024!” said July 1st   

Part of the inspiration for the PeerRxMed process was the recognition that the work we do in healthcare will regularly create the conditions that can put us “off-course” and potentially “drain” us regarding any and all aspects of our personal and professional well-being.  Under such circumstances, we risk becoming distanced from meaning, identity, priorities, perspective, and from each other.   That is why it is essential to schedule regular time for recovery and recalibration and also why we need others in our lives who can help provide input, encouragement, and accountability .

A vital component of the PeerRx process is what I call PRx90, the quarterly “up to 90 minutes every 90 days” check-in with your PeerRx partner or other colleague intended to provide a deliberate space for and deeper reflection and connection.  Here’s a reminder of that process.

When you schedule time to connect, here are some questions to consider for dialogue together: 

• What would you say are your present top 2 personal and professional priorities and how are you incorporating them deliberately into your life?
• What have you learned about yourself over the past 3 months?
• What are your personal/professional goals over the next three months?  What is one that will cause disappointment if you have not accomplished it when we meet again in 3 months?
• What are your dreams both personally and professionally?  How are you taking action to move toward them?
• When’s your next vacation / adventure / break?  What will you do that will be fun for you?

Taking time regularly for reflection, recovery, and recalibration is not selfish, but rather sanity and ultimately good stewardship of your life energy.   Sadly, it is often neglected by those who are always “on the go” and/or perpetually “needed by others.”  So don’t skip 2024 halftime!  Schedule some personal time in the next 2 weeks for a “life check-up” to ensure you’re on target for living the life you want to be living using the questions above as a guide.   That time should include writing down your answers to the questions above.  In addition, schedule some face-to-face time (live or via video) to allow you and your PeerRx partner to provide mutual support and encouragement.  It will help make for an even better “Second Half” for you as well as for all those people in your life who are impacted by you.  That sounds like a wise investment to me!

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  (More) Guidelines on Vitamin Supplementation and Testing

The US Preventive Services Task Force (USPSTF) does not recommend screening for vitamin D levels routinely (Insufficient evidence). For fracture prevention, the USPTSF recommends against supplementing Vitamin D with less than 400 mcg per day and has no recommendation (insufficient evidence) for any other supplementation. The Institute of Medicine (now National Academy of Medicine) in 2007 similarly found no evidence for routine screening for Vitamin D, and instead suggested age-based routine supplementation for everyone.

Vitamin D has held a bright spot on stage for over 20 years. In 2000, only 0.3% of people used vitamin D supplements; in 2014, it was almost 20%. This surge has been due to a combination of expert opinion recommendations and lots of research revealing associations between vitamin D and several disease states. Randomized trials have mostly failed to demonstrate benefits from screening or supplementation. The Endocrine Society – one of three endocrinology specialty societies – has recently produced their own guideline on Vitamin D supplementation and testing attempting to summarize this trial data. The goal of this Guideline Development Panel was to establish clinical guidelines for the use of vitamin D to lower the risk of disease in individuals without established indications for vitamin D treatment or 25(OH)D testing.

This guideline used the GRADE system for appraising and grading evidence. Patients and general internists were represented on the guideline group, but not other primary care physicians. The Mayo clinic evidence-based practice center performed the systematic review for the guideline group’s questions. The guideline was posted for peer and public review before final publication.

The authors looked at specific outcomes for pediatric (1-18), young adult, older adult and elderly population. They regarded the question of vitamin D supplementation for infants (through formula or supplementation for breast-fed infants) as a settled question (recommended).

A quick summary of their recommendations:

The society recommends against routine screening for vit D, even in populations such as: those with “dark complexions” and those who are obese (all weak recs, very low evid).

For supplementation, the society recommends daily, low-dose vitamin D (400-800 mcg/day) over the non-daily, high-dose forms (e.g., 50,000 units weekly) when needed for people ages 50 years and higher. (weak rec, low evid).

John’s Comments:

I was primed to react strongly to this guideline, given the pro-vitamin D stances of the other endocrinology organizations in the past (yes, this is known as “bias”), but this group had a robust, transparent guideline process. When they exercised judgement to make recommendations based on, at most, moderate evidence, they at least labelled the recommendations appropriately as “weak.” These recommendations are pretty close to the IOM’s recommendations from 2007, so it’s nice to see that when there is a robust evidence-based process for guidelines, we can get consistent recommendations across groups.

References:

• Demay MB, Pittas AG, Bikle DD, et al. Vitamin D for the Prevention of Disease: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. Published online June 3, 2024: dgae290.  Link
• Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium; Ross AC, Taylor CL, Yaktine AL, et al., editors. Dietary Reference Intakes for Calcium and Vitamin D. Washington (DC): National Academies Press (US); 2011. Link

From the Literature and the CDC

2)  STI Prevention After Unprotected Sex

The incidence of sexually transmitted infections (STIs) caused by Neisseria gonorrhoeae, Chlamydia trachomatis, and Treponema pallidum has continued to increase in the US, with certain populations disproportionately affected.  Postexposure prophylaxis (PEP) involves taking a medication to prevent an infection after a possible exposure and is a common strategy for prevention of HIV and other infections. PEP is distinct from pre-exposure prophylaxis (PrEP), which involves taking a medication before exposure occurs.  

Doxycycline is used as PrEP or PEP to prevent infections such as malaria and Lyme disease but, until recently, has not been used to prevent STIs.  The CDC recently published a recommendation for the use of doxycycline postexposure prophylaxis (doxy PEP) as a way to prevent some bacterial STIs in certain higher-risk populations.  The CDC specifically recommends that clinicians should counsel all gay, bisexual, and other men who have sex with men (MSM) and transgender women (TGW) who have a history of at least one bacterial sexually transmitted infection (STI) (specifically, syphilis, chlamydia or gonorrhea) during the past 12 months about the benefits and harms of using doxycycline (any formulation) 200 mg once within 72 hours (not to exceed 200 mg per 24 hours) of oral, vaginal, or anal sex (not to exceed one dose/24 hours).  This should be offered through a shared decision-making process.

In three large randomized controlled trials, 200 mg of doxycycline taken within 72 hours after sex has been shown to reduce syphilis and chlamydia infections by >70% and gonococcal infections by approximately 50% in higher risk groups including gay, bisexual, and other men who have sex with men and transgender women.  

Doxy PEP, when offered, should be implemented in the context of a comprehensive sexual health approach, including risk reduction counseling, STI screening and treatment, recommended vaccination and linkage to HIV PrEP, HIV care, or other services as appropriate.  Persons who are prescribed doxy PEP for self-administration should undergo bacterial STI testing at anatomic sites of exposure at baseline and every 3–6 months thereafter.  Ongoing need for doxy PEP should be assessed every 3–6 months as well. HIV screening should be performed for HIV-negative MSM and TGW according to current recommendations. 

The recommendation notes that although not directly assessed in the trials included in these guidelines, doxy PEP could be discussed with MSM and TGW who have not had a bacterial STI diagnosed during the previous year but will be participating in sexual activities that are known to increase likelihood of exposure to STIs.

The CDC noted that no recommendation can be given at this time on the use of doxy PEP for cisgender women, cisgender heterosexual men, transgender men, and other queer and nonbinary persons as the evidence is insufficient to assess the balance of benefits and harms in these groups. 

Mark’s Comments:

I’ve already had a patient from one of these high-risk groups ask about this, so thought it important to get the word out.  Don’t be surprised if you have patients asking about Doxy PEP who are not in one of these high-risk groups, “but will be participating in sexual activities that are known to increase likelihood of exposure to STIs.”  Should you decide to prescribe it to them (which may be quite reasonable under certain circumstances), be sure to follow the guidance above regarding testing, education, counseling (including contraception counseling), screening, and follow-up.

Reference:

US Centers for Disease Control and Prevention.  CDC Clinical Guidelines on the Use of Doxycycline Postexposure Prophylaxis for Bacterial Sexually Transmitted Infection Prevention, United States, 2024.  Morbidity and Mortality Weekly Report. June 6, 2024.  Vol. 73, No. 2.  Link

From PeerRxMed ( www.PeerRxMed.org )

3) Let’s Be Out to “Get” Each Other

“You know what everybody needs?… Everybody needs to be understood.”   Sherwin Nuland, MD, surgeon, author, bioethicist

When my children were younger, we used to regularly play a game in which I would say to them in a scary voice “I’m out to get you!” and then a chase would ensue, usually starting with screams and ending with us in a pile on the floor laughing.   At a recent gathering, those now grown children were recalling with fondness how much they loved that game.  Which has left me wondering what the adult version of being “out to get you” looks like (certainly without the scary voice) given our very human desire to be better understood, or “gotten.” 

Over the 4+ years since the PeerRx process was started, I’ve heard from numerous colleagues as to the power of regular peer connection, and the importance of having established an increased level of familiarity and comfort with each other.  Here are two stories that have been shared that clearly demonstrate the importance of our creating space to understand and be understood.  I suspect each of these stories will resonate with something similar to what you have experienced.     

The first colleague shared a story about the power of creating a space to allow another to feel heard: “I really didn’t want to check in even though I know it doesn’t have to take long.  There was just too much going on in my week.  If it hadn’t been for your ‘nudge’ e-mail, I wouldn’t have done it.  When I texted my PeerRx buddy and asked, ‘How are you?,’ they texted back that they were so glad I reached out – that they really needed to talk with someone about a struggle they were having, and they didn’t know who else to talk with about it.  What resulted was an important phone call where they opened-up about something quite serious they had been grappling with and we talked through it together.  I don’t think any of that would have happened had I not reached out.  It felt really good to be able to help them.”   And I suspect it felt even better to be the colleague who was helped. 

The second story was equally powerful about our need to feel understood.  “I had a close friend who had unexpectedly died recently, and I was feeling quite sad about it.  When I checked in with my buddy (FaceTime), they asked how I was doing.  I initially said that I was ‘fine,’ and then realized I was falling into a default pattern for me around stuffing ‘negative emotions.’  In the spirit of your encouragement to ‘feel what you feel,’ I interrupted that default mode and shared that I was actually not doing fine and was feeling profound sadness over the recent loss of someone whom I loved dearly.  What followed was an incredible sharing about how death had impacted each of our lives, and we both found ourselves crying, which I rarely do and never in front of a colleague.  We only talked for 20 minutes, but at the end I felt both comforted and so much more deeply connected with them.”  Wow ….

Yes, the need to feel understood is an essential part of who we are.  There is incredible power when we connect around those things that most deeply matter to us.  This week, when someone asks, “How are you?”, allow yourself to be “gotten” a little more by sharing something from your sacred “this is really important to me” space, and take a moment to appreciate the gift of having someone in your life who cares enough to be “out to get you.”  The chasing, screaming, and scary voice are, of course, optional …

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  Reducing Pain From Childhood Vaccinations

Anticipated pain from vaccinations can be a barrier to successful immunization not only for the cognizant children themselves, but for the needle-fearing parent. A 2010 systematic review recommended the following techniques for reducing pain from childhood vaccinations: breastfeeding, sugar solution, choosing the least painful brand of vaccine if available, and topical anesthesia all work best (A recommendations). Injecting rapidly without aspiration for intramuscular vaccinations, injecting the most painful vaccine last, rubbing the skin at the planned injection site with moderate intensity in a child over 4 years, clinician or parent led distracting techniques, child-led distracting techniques (age over 3 years), deep breathing or blowing (age over 3 years), and using combined psychological interventions (behavioral and cognitive) in children over 3 years were all also effective (B recommendations). There was good evidence to AVOID placing the child supine for vaccination or telling the child “It won’t hurt.”

A new study looks at the effect of a cold, vibrating instrument placed 0.5 cm superior to the injection site for 1 minute prior to vaccination and 15 seconds after vaccination in six-month-olds. Eighty infants were randomized to the instrument or to no intervention. Pain was assessed by the researchers using observation (the Modified Pain Behavior Scale, MBPS) and crying duration. The children were placed on a vaccination bed in a quiet room with their parent (presumably in a supine position, since they were all injected in the vastus lateralis muscle), were vaccinated by the same person and with the same vaccine.

Pain intensity (by MPBS) was less in the intervention group (6.1 ± 1.8 vs. 7.0 ± 2.1, p = 0.032, effect size 0.48, on a 10-point scale). Crying duration was much less in the intervention group (18.6 seconds less, p = 0.0001, effect size 0.86). As a reminder, effect sizes are generic measures of magnitude; for this effect size, 0.2 is small, 0.5 is moderate, and 0.8 is a large effect.

John’s Comments: 

Pain during vaccinations can really cause an issue in our clinics by tying up nurses attempting to give a vaccine to a reluctant, scared child. So, an intervention like this would be a welcome routine addition. This study would have been more convincing with an active placebo – maybe one that made noise and looked similar but didn’t vibrate and was room temperature. However, there are several studies on this technique with different age groups that are finding consistent results. It doesn’t appear to be harmful at all, so it may be worth a try. A commercial form of this device is available online under the brand “Buzzy.” You can see Buzzy in action. Caveat emptor.

References:

• Taddio A, Appleton M, Bortolussi R, et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline (summary). CMAJ. 2010;182(18):1989-1995. Link
• Unesi Z, Amouzeshi Z, Jamavar J, Mahmoudzadeh Zarandi F. The Effect of a Combination of Vibration and External Cold on Pain Caused during Vaccine Injection in Infants: A Randomized Clinical Trial. Int J Clin Pract. 2024;2024:7170927. Link

From the USPSTF

2)  Preventing Falls In Older Adults – PS

In our April 5 Take 3, we shared that falls are among the most common and preventable causes of morbidity and mortality for older adults and increase substantially after age 65.   In 2018, 28% of community-dwelling adults > 65 reported at least 1 fall in the past year and 10% reported a fall-related injury.  Most fall-related deaths occur in adults 85 years or older; this group also has the fastest-growing rate of death from falls.  This data provides a sense of urgency to identify those at greatest risk and implement effective methods to prevent falls in this age group.   

The US Preventive Services Task Force (USPSTF) recently updated their 2018 recommendations for fall prevention for community dwelling adults > 65 who are at increased risk.  Recommendations include:

• recommends exercise interventions to prevent falls (Grade B) and
• recommends that clinicians individualize the decision to offer multifactorial interventions to prevent falls, recognizing the existing evidence for the net benefit of routinely offering multifactorial interventions to prevent falls is small.  When determining whether this service is appropriate for an individual, patients and clinicians should consider the balance of benefits and harms based on the circumstances of prior falls, presence of comorbid conditions, and the patient’s values and preferences (Grade C).

The review noted that effective exercise interventions include supervised individual physical therapy and group exercise classes and that it is difficult to identify specific components of exercise that are particularly effective. The most commonly studied exercise components were gait, balance, and functional training, followed by strength and resistance training, flexibility, and endurance training. The most common frequency and duration for exercise interventions was 2 to 3 sessions per week for 12 months, although duration of exercise interventions ranged from 2 to 30 months.

Multifactorial interventions include an initial assessment of modifiable risk factors for falls and subsequent customized interventions for each patient based on issues identified in the initial assessment.  The initial assessment could include a multidisciplinary comprehensive geriatric assessment or an assessment using a combination of various components, such as balance, gait, vision, postural blood pressure, medication, environment, cognition, and psychological health.  Intervention components vary based on the initial assessment and could include group or individual exercise, psychological interventions (eg, cognitive behavioral therapy), nutrition therapy, education, medication management, urinary incontinence management, environmental modification, physical or occupational therapy, social or community services, and referral to specialists (eg, ophthalmologist, neurologist, or cardiologist).

The following interventions were reviewed by the USPSTF but lack sufficient evidence to assess their benefits and harms in preventing falls in community-dwelling older adults when offered alone and not in the context of a multifactorial intervention: environmental modification, medication management, psychological interventions, education interventions, and combination interventions (exercise plus environment interventions or exercise plus education interventions).

Mark’s Comments:

An accompanying editorial to the Task Force recommendation noted that in general,  functional exercises that focus on movements performed in daily activities and balance appear to be more effective for fall prevention than walking or resistance training alone.  However, we know that counseling a patient to exercise more is rarely enough to change behavior.  Less than half of community-dwelling adults > 65 meet physical activity guidelines.  Therefore, although evidence suggests it is important for primary care clinicians to recommend exercise, the major challenge is transforming this recommendation into action.  Encouraging participation in community-funded exercise programs adds the element of socialization and accountability, which is preferred when possible.  And remember to take advantage of your time during Medicare Annual Wellness visits to screen, counsel and educate your patients to minimize their fall risk.  The algorithm at the last reference below might be helpful in this regard.

References:

•  Nicholson WK, et al.  Interventions to Prevent Falls in Community-Dwelling Older Adults.  US Preventive Task Force Recommendation Statement.  JAMA 2024.  Published online June 4.  Link
• Reuben D and Gantz D.  Editorial - Preventing Falls in Older Persons:  Steps in the Right Direction.  JAMA 2024.  Published online June 4.  Link
• CDC STEADI (Stopping Elderly Accidents, Death, and Injuries) Older Adult Fall Prevention Resources:  Link
• CDC STEADI Falls Prevention Algorithm:  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  We Need to Take More Call

“You just call on me …. when you need a hand.  We all need somebody to lean on.”  Bill Withers, Rock and Roll Hall of Fame inductee, from the song “Lean on Me”

Asking for help is not something that comes naturally or easily for me, nor for many others.  And yet, I’m always glad to help when a colleague reaches out to me, and touched when someone connects “just to check in.”  While there was a time in my career when I may have been bothered and perhaps even felt a bit defensive by such an outreach (professional posturing = “I’m fine!”), those days are past for me.  The emotional load we carry is simply too great for any of us to try to process it alone. 

At the same time, I’m a lot more likely to both reach out for help and look forward to those “check-ins” when a trusting relationship exists.  How is that trust developed?  Through regular brief connections (“touches”) by text or e-mail and also pre-scheduled times to meet in order to share life together.  Unlike ongoing friendships from our youth, our “adult relationships” take regular and intentional action in order for them to effectively form, be sustained, and grow, because at this stage in our careers and lives we don’t usually have a lot of “hang out together” time.  Yet these newer relationships are essential, as these are often the people who know us best now, not simply as an older version of a person they knew from the past.         

So it was a true gift this past week to have the opportunity to check in via video with a  valued colleague I’ve known for the past 8 years who lives elsewhere, and with whom I hadn’t spoken for 3 months.  While our original intention when we scheduled the meeting weeks ago was to “catch up and look ahead,” we ended up talking about a decision I was struggling with that he had a unique perspective on.  Had we not had this regular time scheduled, I likely would not have reached out to him to serve as a sounding board.       

While it would be my desire that colleagues would feel comfortable calling on me when they need a hand (or an ear) and that I would be totally comfortable doing the same with them, we know that familiarity and shared experience make such an outreach much more likely.  This happens by our being intentional about connecting not only when we need support or encouragement, but also when we simply want to communicate “I’ve been thinking about you and wondering how you are, so let’s connect soon” and scheduling that time without feeling like we are imposing or bothering each other. 

That’s the entire purpose of PeerRx – to both regularly remind us of the importance of sharing the journey together, and then help encourage and equip us to do so.  For that reason, I’m glad to take more “call.”  That kind of call is never an imposition.  Rather, it is life-giving for all involved.  As Bill Withers reminds us “… it won't be long till I'm gonna need somebody to lean on …,” so let’s be sure to prepare by proactively and regularly scheduling time with our inner circle of trusted colleagues, including our PeerRx partner.  And as a bonus, there will be no post-call brain fog …. 

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  Blood Testing for Colorectal Cancer (CRC)

The benefits of colorectal cancer screening are well known. The US Preventive Services Task Force (USPSTF) gives it an A rating for ages 50-74, a B rating for ages 45-49, and a C rating from ages 75-85. The USPSTF recommends any of the approved testing technologies to achieve this screening – high-sensitivity guaiac-based stool testing, fecal immunochemical testing (FIT), FIT + DNA testing, CT colonography, flexible sigmoidoscopy and colonoscopy. Each of these is statistically modeled to predict, in a population, the number of colon cancers detected, the number of life years gained, and the number of colonoscopies required (with their attendant harms) to achieve those gains. Perhaps not surprisingly, FIT and colonoscopy have the most acceptable benefit risk ratios according to that modeling.

Enter, now, Guardant Health’s Shield test, a blood test “…intended to detect colorectal

cancer derived alterations in cell-free DNA from blood,” which achieved Food and Drug Administration approval in May. This test provides a result of “signal detected” or “not detected”, and if “detected,” the patient is advised to have a colonoscopy to look for colorectal cancer. This test was studied in a single study (whose results are not published) and was found (according to the FDA report) to have a sensitivity of 83.1% for colorectal cancer, a sensitivity of 13.2% for advanced adenoma, and a specificity of 89.6% for advanced neoplasia.

Quotations from a Medscape article about this approval include: “it’s a good test for late-stage colon cancer, but not for early stages or advanced adenomas,” and “is not designed as a preventative strategy.” The FDA report states that the committee discussed whether repeat testing may overcome the low sensitivity for advanced adenomas but could not reach a conclusion in the absence of evidence.

John’s Comments:

Readers that follow preventive services recommendations may recognize some of the quotations as similar to criticisms of stool-based colon cancer screening. Proponents of a primary colonoscopy-based screening program often tout the ability of colonoscopy not only to find colorectal cancer but also to find and remove advanced adenomas – a “double-whammy” of prevention that stool tests cannot match, since they only detect lesions that bleed, i.e., mostly cancers. Stool tests, and now blood tests, have low sensitivities for advanced adenomas. Stool tests make up for this defect through close-interval re-testing, thereby increasing their sensitivity over time. It is not yet known whether this strategy can work for blood testing. The FDA committee discussed that this blood test might be able to recruit patients to screening who have refused other screening tests due to discomfort or other barriers. We have a few years until the USPSTF updates its recommendation, and we have not yet seen the company’s study used for approval. So, if insurances decide to cover it, I would try to restrict its use to those that refuse other screening methods and only as long as they would consent to a colonoscopy if the test is positive.

References:

·         Blood Test for Colon Cancer Screening Secures FDA Panel’s Blessing. Published May 24, 2024. Accessed May 25, 2024. Link

·         Molecular and Clinical Genetics Panel of the Medical Devices Advisory Committee. Brief Summary of the Molecular and Clinical Genetics Panel of the Medical Devices Advisory Committee. US Food and Drug Administration; 2024. Accessed June 3, 2024. Link

From the Literature and “Nudge” From a Colleague

2)  Using the DICE Model in Dementia to Help Support Caregivers

Currently, there are more than 6 million persons living with dementia (PLWD) in the US and 11 million family caregivers providing unpaid care for those individuals.  Most persons living with dementia will exhibit at least one behavioral or psychological symptom of dementia (BPSD), such as wandering, aggression, and hallucinations, over the course of their illness.  Adverse consequences of BPSD include unplanned hospitalizations and nursing home placement.  When this occurs, caregivers are more likely to experience caregiver burden, including stress and depression.

A patient-centered approach is required to address specific behavioral concerns and underlying factors.  While non-pharmacological approaches are the recommended first-line treatment for managing BPSD, psychotropic medications are commonly used, despite minimal evidence of benefit and substantial risks.  It is postulated that a major reason for this is the absence of training for front-line clinicians, resulting in discomfort addressing BPSD themselves, and in turn, being ill-equipped to educate caregivers.

The DICE model is a structured approach designed to evaluate and manage BPSD.  Developed by a team of dementia care experts, DICE stands for Describe, Investigate, Create, and Evaluate. This model provides a systematic method for clinicians and caregivers to understand and address the complex and often distressing behaviors exhibited by individuals with dementia.  It emphasizes a person-centered approach, aiming to improve the quality of life for both patients and caregivers by identifying and addressing the underlying causes of BPSD.

The first step, "Describe," involves a detailed characterization of the behaviors, including their frequency, duration, and context.  Caregivers and healthcare providers gather comprehensive information about the behavior, noting any patterns or triggers. This descriptive phase is crucial as it sets the foundation for understanding the behaviors in the context of the individual's life and environment.  It encourages a thorough observation and documentation process, which is essential for next steps. 

In the "Investigate" phase, attention is directed to identifying possible causes of the behaviors.  This involves examining medical, psychological, and environmental factors that could be contributing to the BPSD.  Clinicians review the patient's medical history, current medications, and overall physical health, as well as psychosocial factors such as recent changes in routine or environment.  The goal is to uncover any reversible factors or unmet needs that could be addressed to mitigate the problematic behaviors.

The "Create" step focuses on developing and implementing a comprehensive care plan tailored to the individual's needs. This plan may include non-pharmacological interventions, such as environmental modifications, behavioral strategies, and support for caregivers.  When necessary, pharmacological treatments might also be considered, but the emphasis is on personalized, non-drug approaches first.

Finally, the "Evaluate" phase involves monitoring the effectiveness of interventions and making adjustments as needed.  This ongoing assessment ensures that the care plan remains effective and responsive to the changing needs of the individual with dementia.

Mark’s Comments:

With appreciation to Brian Unwin, MD, who is the Section Chief of Geriatrics at Carilion Clinic, for his “nudge” to share this model more broadly.  Brian shares, “The DICE model for BPSD isn’t new, but it is very helpful in trying to understand why an individual with dementia is having behavioral/emotional change.  It helps us do better than "let's just check a urine.  I find that we often fall short in the investigation piece, especially the environmental and caregiver issues.”

There is now a free training in the DICE model that provides case-based skills building and resources for both clinicians and family caregivers and is intended to improve family and formal caregivers’ confidence and knowledge of individualized dementia care.  Additionally this Worksheet provides a nice summary of the model and the process for evaluation as well as an extensive list of helpful non-pharmacological interventions to consider.

References:

·         Kales H, et al. Moving Evidence-Informed Assessment and Management of Behavioral and Psychological Symptoms of Dementia into the Real World: Training Family and Staff Caregivers in the DICE Approach.  Am J Psych 28(12):December 2020: 1248-1255.  Link

·         DICE Approach – Free Training. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Being Admitted by a Colleague to the “I See You …”

 “The ultimate touchstone of friendship … is witness.”   David Whyte; poet, author, philosopher

Recently I have become aware of more than a handful of colleagues who are facing significant personal health concerns.  Some have been very forthcoming regarding these challenges, and others have remained quite private, often for very extended periods of time.   

As I spoke with some of them about their journey and then reflected on some of my own past and present health challenges, I noted a common thread for those times when they (and I) felt most supported.  It was when a friend created a safe space for them to feel seen and heard – when that friend was actively and unconditionally present.   It is that space that I have come to understand as the place of “witness.” 

In his essay on “Friendship” from the book “Consolations: The Solace, Nourishment, and Underlying Meaning of Everyday Words,” David Whyte writes the following about this type of friendship:  “A friend knows our difficulties and shadows and remains in sight, a companion to our vulnerabilities more than our triumphs, when we are under the strange illusion we do not need them.” 

But need them we do, and after providing caution regarding how overwork and too much emphasis on a professional identity can cause us to lose perspective on the importance of these relationships, he concludes by highlighting the healing power of witness in friendship:  “ … the ultimate touchstone of friendship … is witness, the privilege of having been seen by someone and the equal privilege of being granted the sight of the essence of another, to have walked with them and to have believed in them, and sometimes just to have accompanied them for however brief a span, on a journey impossible to accomplish alone”

Yet, despite our “knowing better,” we are too often tempted to try and travel portions of this professional journey alone, and these are often the times that we need witness the most.   So as you connect with your PeerRx partner in the coming weeks for your weekly check-ins, take advantage of this time to reciprocally serve not only as an encourager, but also as a supportive witness to each other’s healing – a mutual practice of allowing yourselves to be admitted to the “I See You.”  There is no more powerful of a gift that you could give to each other.

NOTE:  Here is a recording of David Whyte reading and reflecting upon the entire “Friendship” essay (5 minutes):  Friendship - David Whyte

Feel free to forward Take 3 to your colleagues.  Glad to add them to the distribution list.

 Mark and John

Carilion Clinic Department of Family and Community Medicine

1)  All the New Hepatitis Recommendations …

There have been a lot of recent changes to prevention (screening and vaccination) recommendations for viral hepatitis over the past few years. Our electronic health records, optimized for the most current Advisory Committee on Immunization Practices (ACIP) and US Preventive Services Task Force (USPSTF) recommendations, may show a lot more care gaps for these than we are prepared for. The table below summarizes the current recommendations.

Insurance coverage varies with these vaccinations also.

·         Hepatitis A vaccine:

o   Commercial insurers should cover routine childhood vaccination.

o   Insurers should cover vaccine for high-risk indications. Attach the relevant ICD-10 code (in addition to the Z23 vaccination code), and document indication in your progress note. Insurers usually do not cover adult vaccination solely for international travel.

·         Hepatitis B vaccine:

o   Medicare will cover in-office vaccination through part B for high-risk indications only (attach high-risk ICD-10 code and document indication in progress note.

o   Part D plans should cover all vaccines recommended by ACIP including routine adult vaccination (but not all eligible patients have Part D).

o   Commercial insurers should cover all vaccines recommended by ACIP.

Be careful with the combination Hepatitis A/Hepatitis B vaccine (Twinrix). This is a three-dose vaccination (it follows the Hepatitis B recombinant vaccine schedule) and will only be covered by insurance if both vaccines are indicated. It will not be covered by Medicare Part B.

John’s Comments: 

There’s a lot going on in hepatitis prevention these days, so the table above helped me organize things a bit. For full information about the indications for screening and vaccination, see the relevant recommendation documents from the USPSTF (links above) or ACIP recommendations (below).

I reached out to Mariana Gomez, MD, Assistant Professor of Medicine at Virginia Tech Carilion School of Medicine and an Infectious Disease Attending at Carilion Clinic. She emphasized: For high-risk patients getting hepatitis B vaccination, a post-vaccination series antibody test 1-2 months after the final dose is recommended. In hepatitis C, antibodies remain positive for life, and they do not confer immunity. Active HCV infection is diagnosed with a positive antibody that reflexes to an elevated RNA test.

References:

• Nelson NP. Prevention of Hepatitis A Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices, 2020. MMWR Recomm Rep. 2020;69. Link
• Schillie S. Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2018;67. Link
• Weng MK. Universal Hepatitis B Vaccination in Adults Aged 19–59 Years: Updated Recommendations of the Advisory Committee on Immunization Practices — United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;71. Link
• Billing & Reimbursement Archives. Immunize.org. Published October 26, 2022. Accessed May 28, 2024. Link

From the Literature and the Guidelines

2)  Newer Pharmacologic Treatments for Type 2 Diabetes (T2D) 

The age-adjusted prevalence of type 2 diabetes in adults is 14.8% in the United States and the age-adjusted incidence is 5.8 per 1000 persons; however, an estimated 23% of the U.S. adults with T2D are undiagnosed.  Despite multiple treatment options, 16% of adults with type 2 diabetes have inadequate glycemic control, with HbA_1c levels of 9% or higher. Inadequate glycemic control is more prevalent among Black (24%) and Hispanic (29%) adults than among White adults (9%) with T2D.

Since the American College of Physicians (ACP) published its last guideline in 2017 on the pharmacological treatment for T2D, newer pharmacologic treatments have been introduced, including glucagon-like peptide-1 (GLP-1) agonists (dulaglutide, exenatide, liraglutide, lixisenatide, and semaglutide), a GLP-1 agonist and glucose-dependent insulinotropic polypeptide agonist (tirzepatide), sodium–glucose cotransporter-2 (SGLT-2) inhibitors (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, and bexagliflozin), dipeptidyl peptidase-4 (DPP-4) inhibitors (alogliptin, linagliptin, saxagliptin, and sitagliptin), and long-acting insulins (insulin glargine and insulin degludec).

In these updated guidelines, the ACP recommends for nonpregnant adults with T2D:

Recommendation 1:  Add a sodium–glucose cotransporter-2 (SGLT-2) inhibitor or glucagon-like peptide-1 (GLP-1) agonist to metformin and lifestyle modifications in adults with type 2 diabetes and inadequate glycemic control (strong recommendation; high-certainty evidence).

• Use an SGLT-2 inhibitor to reduce the risk for all-cause mortality, major adverse cardiovascular events, progression of chronic kidney disease, and hospitalization due to congestive heart failure.
• Use a GLP-1 agonist to reduce the risk for all-cause mortality, major adverse cardiovascular events, and stroke.

Recommendation 2:  Do not add a dipeptidyl peptidase-4 (DPP-4) inhibitor to metformin and lifestyle modifications in adults with type 2 diabetes and inadequate glycemic control to reduce morbidity and all-cause mortality (strong recommendation; high-certainty evidence).

Interventions With No Recommendations

Evidence was inconclusive to develop recommendations for both add-on tirzepatide and add-on long-acting insulins to metformin and lifestyle modifications.

These recommendations are consistent with the more detailed and nuanced recommendations from the American Diabetes Association (ADA) 2024 Diabetes Standards of Care, which are summarized in this Figure:  Link

Mark’s Comments:    

Expense has been a substantial barrier for both the SGLT-2i and GLP-1 medications.  Fortunately, with the approval of bexagliflozin in late 2023 and retailing for approximately $50 - $60 for a 30-day supply, there is now an affordable SGLT-2i available.  Regrettably, this is not yet the case for any GLP-1 medication, the least expensive of which is exenatide, retailing for > $900/month. 

References: 

• Qaseem A, et al.  Newer Pharmacologic Treatments in Adults With Type 2 Diabetes: A Clinical Guideline From the American College of Physicians.  Ann Int Med Published Online 19 April 2024.  Volume 177, Number 5.   Link
• American Diabetes Association Professional Practice Committee.  Approaches to Glycemic Treatment: Standards of Care in Diabetes—2024.  Diabetes Care 2024;47(Supplement_1):S158–S178.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Recognizing Our Need to Belong 

"Belonging is being accepted for you. Fitting in is being accepted for being like everyone else." – Anonymous

Recently I’ve been thinking a lot about the power and importance of “belonging,” and when I have and have not experienced it.   This was catalyzed by the closing plenary at the recent  American Academy of Family Physicians (AAFP) Physician Well-being conference.  During her talk, former AAFP President Ada Stewart, MD, building on a quote by Verna Myers, made this memorable distinction:  “Diversity is being invited to the dance; Inclusion is being asked to dance; Belonging is being able to dance like no one is watching.” 

When Abraham Maslow, PhD, first published his "hierarchy of needs", he recognized that the human need for interpersonal connection and acceptance was so important that he placed “love and belonging” just after the needs for food, clothing, shelter, and physical safety and before those of self-esteem and self-actualization.  He understood that true belonging is not the same as inheriting (“I belong to my family”), joining (“I belong to my professional society”), being selected (“I belong to this honor society”) or fitting in, selling out, or pretending (“I belong to this social group”).  It is not about adaptation, but rather acceptance.     

Creating the conditions for belongingness requires an approach that fosters inclusivity, respect, and deeper understanding.  Encouraging open communication where every voice is sought and valued is crucial.  Raising awareness and educating about biases and stereotypes can be eye-opening.  Establishing mentorship or buddy systems (such as PeerRx) can facilitate connections and provide support.  Recognizing and celebrating individual and collective achievements regardless of background or identity reinforces a sense of belonging.  Additionally, creating opportunities for shared group experiences can strengthen bonds.  By prioritizing a culture where everyone feels respected, supported, valued, and needed, any group can cultivate belongingness.  

Indeed, what has been most impactful for me about the many times I have experienced belonging was both the level of acceptance I experienced from others and the space I felt to learn how to better accept myself.  During those times, we encouraged each other to share the hidden parts of ourselves, to take interpersonal risks, and while doing so, to show grace for and laugh with each other.  They were opportunities to "bring the best of me, and the rest of me."  In the process, “the rest of me” slowly began to transform, to heal, to soften, to grow. 

Given the amount of “life energy” we spend at work, I believe it is imperative that we are able to find a sense of belonging there and to create one for each other.  It shouldn’t surprise me that as I have allowed “the rest of me” to show up more in my present job by sharing more of the essential parts of myself, including my love of writing and passion for coaching, I’ve experienced a greater sense of belonging … and deeper meaning.  That is certainly something I’d wish for all of us.  No one should care alone. 

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  HCC Coding and Succeeding in Value-Based Care

The Centers for Medicare and Medicaid Services (CMS) has as its strategic plan to have “all Medicare…and the vast majority of Medicaid beneficiaries…in a care relationship with accountability for quality and total cost of care by 2030.” Most of the care delivery models that CMS has been experimenting with for Medicare (like Next Generation Accountable Care Organization (NG-ACO), Medicare Shared Savings Program (MSSP), etc.) to prepare the health care system for this transition are models of capitated funding where the financial resources available to deliver care over a year are allocated per patient. Because patients with more chronic disease require more healthcare resources, in a fair system, the capitated payments should be adjusted based on the overall risk of healthcare spending for a patient.

Enter Hierarchical Condition Category (HCC) coding, also called Risk-Adjustment Factor (RAF) coding. For CMS to allocate an appropriately risk-adjusted amount of funding to care for a patient, they must have some idea of how much care that patient will need based on their medical problems. The way we let CMS know about our patients’ medical problems is by submitting diagnosis codes on healthcare claims. The financial reckoning happens at the end of each year, and the system resets (or “forgets”) each year, requiring that each of the applicable diagnosis codes be entered at least once per year. HCC codes are a specific list of ICD-10 codes that have been deemed by CMS to predict significant healthcare cost, so, if a patient has one of these diagnoses, it is important to use this specific HCC code on a claim each year.

Our success in value-based care, then, depends on a shift in thinking from precisely describing the work we do (the basis for the detailed Evaluation and Management-based coding under which we have lived for years) to precisely describing our patients’ active diagnoses every year. Most healthcare organizations that do well in value-based care have set up a system to ensure that our patients’ diagnoses are appropriately coded each year:

• A reminder system to submit an HCC code in the current year that has been coded in a previous year. (called “reconfirmation” coding)
• A system to look for diagnoses that are appropriate for a patient, but haven’t yet been coded (e.g., an obesity code for a patient with an elevated body mass index, called “suspected condition” coding)
• For both reconfirmation and suspect coding, the system should help clinicians code to the highest specificity to accurately describe the patient’s condition and maximize reimbursement for their care. (e.g., avoiding “unspecified” codes and symptom codes where a more specific code is possible).
• An emphasis on yearly health maintenance visits (especially the Medicare Annual Wellness visit), where there is an opportunity to code any active conditions that have not yet been documented that year.
•  A way to ensure proper documentation to support a code on a claim. We cannot simply list diagnoses, we must document an effort to monitor, evaluate, assess and/or treat (“MEAT”) the coded condition. For conditions we treat in primary care, this is usually straightforward, but for conditions that are treated by specialists, engaging the patient in a brief discussion about progress, symptoms and plans for returning to the specialist and documenting these items is usually sufficient.
• Working in partnership with coding compliance staff to ensure that we are accurately coding and documenting.

John’s Comments:

Family Medicine organizations have long advocated for a way to “get off the RVU treadmill” – a system that is engineered to reward procedures and frequent visits over thoughtful primary care. In a sense, we have gotten what was requested, but change in a massive bureaucratic system that affects our financial well-being is always going to be difficult. Simply put, rather than worrying about the number of review-of-systems and physical exam bullet points we document to meet an E&M code, we must begin to shift our focus to diagnoses and documentation of our assessment and plan thinking. It is incumbent upon healthcare organizations to recognize the difficulty of this transition for clinicians and create systems that minimize the burden of change.

References:

• Dera JD. How to Succeed in Value-Based Care. Fam Pract Manag. 2021;28(6):25-31. Link
• Magoon V, Domdera J. What Family Physicians Need to Know About the Wave of 2024 HCC Changes. Fam Pract Manag. 2023;30(6):6-12. Link

Question/Reminder From a Colleague

2)  The Effectiveness of UPF Clothing for Sun Protection

Question:  “Thanks for your annual Take 3 sunscreen review last week.  What about SPF clothing?  Is it effective and worth the cost?”   

Answer:  There is actually no such thing as SPF clothing. Clothing/fabrics are tested using a UPF (Ultraviolet Protection Factor) rating system.  The UPF rating indicates how much UV radiation (UV-R) will pass through the fabric – the higher the rating the greater the protection.  A UPF 25 means 1/25 (4%) of UV-R will pass. UPF 50 means 1/50 (2%) will be able to penetrate the fabrics.  The highest UPF protective level is 50+, which means less than 2% of the UV-R may be penetrating the clothes. There is no “official” UPF higher than 50+. 

Currently, manufacturers follow voluntary testing guidelines and use private labs to determine a fabric’s UPF rating.  The most common standard used in the US to “rate” UPF clothing is ASTM (formerly the American Society for Testing and Materials).  Some manufacturers also use the AS/NZS (Australia/New Zealand Standard). They are similar in terms of the measurement process used.  In general, advanced textiles and fabrics score better for UPF ratings.  Polyester & Nylon are best for UV reflection. Wool and silk are moderately effective. Cotton, rayon, flax and hemp are the least effective.   

The Federal Trade Commission monitors UPF advertising claims. If a manufacturer adds a tag with a UPF 15-50+ rating to any product, it must adhere to the testing standards outlined above. No clothing item with an Ultraviolet Protection of less than 15 can be labeled “sun-protective”. 

Interestingly, Consumer Reports did a study in 2015 comparing the UPF of three white shirts, only one of which had a UPF claim.  The UPF 50+ rated rash guard, which was a blend of 84 percent polyester and 16 percent spandex embedded with titanium dioxide, delivered a UPF of 174.  A cotton long-sleeve T-shirt which was thicker than a regular T-shirt had a UPF of 115 and a non-rated long-sleeve compression crew made of the same polyester/spandex blend as the UPF 50+ rash guard had a UPF of 392.  When wet, the 50+ UPF shirt’s UPF actually increased to 211, the blend decreased to 304, and the cotton T-shirt decreased to a UPF of 39.

Mark’s Comments:

Clothing can offer excellent sun protection without having a UPF label. For example, it is estimated that jeans have a UPF of approximately 1700!  However, a normal-thickness white t-shirt has a UPF of 5.  Note there is great price variation of UPF products, but one can be purchased for under $20.  My favorite long sleeve shirt for paddle-boarding cost me $19.  Even at a higher price, a sun-shirt that will last years (and that you don’t have to worry about “reapplying” 2 hours after swimming or after sweating like sunscreen) begins to look like a good bargain indeed. 

There is a distinction between a shirt made of UPF material and a “rash guard” UPF shirt.  Rash guards are made to fit snugly (think 2^nd skin) and can be used during swimming.  Both are effective, though with rash guards, stretch points (like shoulders) can decrease UPF effectiveness.  Note as well that the most popular “sun hat,” the baseball cap, protects the head and forehead well, but not much else.  That’s why I’m a big fan of the broad-brimmed sunhat, even if I get some good-natured teasing about it.  Sure beats MOH’s surgery!

Reference:

• American Academy of Dermatology:  What to wear to protect your skin from the sun:  Link. Infographic:  Link
• Consumer Reports Sun Protection Clothing:  Report

From PeerRxMed ( www.PeerRxMed.org )

3)  Practicing the Art of Intentional Living

“Intentional living is the art of making our own choices before others’ choices make us.”   Richie Norton, author and podcaster

Consider for a moment how you started this day.  Literally, what are the first things you thought and did?  If you are like many, your day started with some type of alarm going off, and then your thoughts immediately started planning for the day while you reached to check your mobile device.  

What might it look like if you started your day more intentionally, from a place I call “by design”?  This is something I started doing a few years ago and it has completely changed my life for the better.   Even before my feet hit the floor each morning, I pause and ask myself, “Who and how will I show up this day?”  In other words, what will be the “experience of myself” for my family, friends, colleagues, patients, care team, neighbors, and strangers throughout the many opportunities, challenges, frustrations, and “surprises” that await.  In doing this, I am recognizing there are many “Marks” who have the potential to appear and there is a window of opportunity before the sun rises to consciously “choose” before some of the more assertive “selves” or the busyness of the day try to take charge.  

The Sanskrit name for this approach to “whole life” intention-setting is sankalpa.  A sankalpa is an intention formed by the heart and mind – it is a is a vow and commitment made to support one’s highest truth and best self, and is something lived into in the present, not some time off in the future.  Doing so is what makes it more powerful than a goal.  Think of it as “a promise to your Soul.” 

As my day progresses, I keep some words in my “toolbox” that serve as a reminder of my intention.  These include “remember” “choose,” “pause” and “A-Game” that I repeat silently to myself when thoughts or circumstances are causing me to potentially “veer” from my stated desire as to how I want to be in that moment.  For you, this reminder could be a word, phrase, symbol, or even picture.  Not surprisingly, research has found that such regular intention setting can actually “rewire” our brain, alter our psyche, and even change our physiology.

How about you?  What “Soul promise” are you embracing each day to help provide focus as you connect with others?  If you’re not doing so by intention, you’re doing so by default, and likely, as the quote above indicates, the “world” is making many of “your” choices for you.  Why not consider starting each morning for the next 7 days by consciously answering the question “Who and how will I show up this day?” and notice what happens.  Better yet, why not agree with your PeerRx buddy to both do it, and then provide encouragement and support as you share the experience.  Either way, a better version of you will likely guide your way to a much better day.  You can thank me later …

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  New Breast Cancer Screening Recommendations

Breast cancer screening remains an area where conflicting recommendations between specialty groups persist. Breast cancer is the second most common cancer and second most common cause of cancer death among women. While the incidence is higher in white women, black women die more frequently from breast cancer, despite having greater self-reported screening rates. Finally, the incidence of breast cancer in women aged 40-49 rose two percent per year in the period between 2015 and 2019.

The USPSTF noted that the foundational data on the effectiveness of screening has not changed and relied preliminarily on statistical modeling using data from six different breast cancer registries to analyze questions of starting and stopping ages and screening intervals.

The USPSTF recommendation grading scheme reports on both certainty of evidence and net benefit (benefits minus harms). A ‘B” recommendation is for moderate evidence of a moderate net benefit and a “C” recommendation is for moderate evidence of a small net benefit.

2024 USPSTF Recommendations:

• Screening recommended every 2 years in women 40-74 years (B recommendation)

o   Clinical considerations section states conventional mammography or digital breast tomosynthesis (DBT, “3D mammography) are both effective.

• Insufficient evidence (I statement) for:

o   Screening in ages 75 and above

o   Breast ultrasound or MRI for dense breast tissue

It is worth noting that this new recommendation is similar to their recommendation in 2002, but with more decisiveness about the recommended 2-year interval, which is based on modeling evidence showing this interval best balances the benefits of screening and harms associated with screening (false positives and negatives, overdiagnosis, and radiation exposure).

Historical USPSTF Mammography Recommendations:

• 1996 – Every 1-2 years in ages 50-69 (B recommendation), C recommendation for 40-49 years and C recommendation for 70 and over.
• 2002 – Every 1-2 years, ages 40 and older
• 2009 – Every 2 years, 50-74 years (B recommendation), C recommendation for every 2 years in ages 40-49 years.
• 2016 – Same as 2009. Insufficient evidence on Digital Breast Tomosynthesis (“3D mammography”, I statement).

There are heterogeneous recommendations for breast cancer screening from the interested guideline societies that complicate the public health message, although the USPSTF’s new recommendation does reduce the differences somewhat.

American College of Obstetricians and Gynecologists:

• Offer breast cancer screening between 40 and 49 years.
• Recommend screening between 50 and “at least” 75 years.
• Every 1-2 years.

American Cancer Society

• Ages 40-44 – Offer the option to start yearly screening.
• Ages 45-55 – Recommend yearly screening routinely.
• > 55 years – Recommend screening every 1–2-year screening until life expectancy is limited to under 10 years.

American College of Radiology

• Recommend yearly screening starting age 40 for average risk women.
• Assess breast cancer risk beginning as early as age 25 for high-risk populations (lifetime risk > 20%) and consider implementing both MRI surveillance and yearly mammograms.

As noted, the USPSTF has now quietly included digital breast tomosynthesis (DBT, “3D mammography”) as an adjunct to conventional mammography in its recommended screening methods, noting that, while there is a slight increase in positive predictive value with DBT, no trials have shown a difference in outcomes with its use.

John’s Comments: 

It appears that the USPSTF extended a firmer recommendation for screening down to age 40 because it was reacting to the significantly increased rate of cancer incidence (2% per year) in women aged 40-49 over the 2015-2019 period. When addressing the question of how to decrease breast cancer mortality in a population, extending the screening age range is not always the best answer. Ensuring adequate screening rates in the recommended age groups is another way. Current rates hover around 50% for Medicaid patients, and 70% for Medicare and commercially insured patients, and extending the age range will likely just reinforce those disparities. Finally, addressing racial disparities in breast cancer mortality are unlikely to be improved by extending screening ages, but instead by exploring and overcoming differences in the receptor status of breast cancers (black women have more triple-negative cancers which have a worse prognosis) and reducing barriers to treatment.

Reference:

• US Preventive Services Task Force. Screening for Breast Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. Published online April 30, 2024. Link

From Consumer Reports, the AAD, and in Preparation for Summer

2)  Sunscreen 2024:  Let the User Beware, But Do Use Something

According to the American Academy of Dermatology (AAD), it is estimated that one in five Americans will develop skin cancer in their lifetime.  Sun protection is the most effective way to prevent skin cancer.  For sunscreen, the sun protection factor (SPF) is a relative measure of how long a sunscreen will protect from UVB rays, which are the chief cause of sunburn and a contributor to skin cancer.  Usually the number is explained as the amount of time it takes an individual’s skin to burn when it’s covered in sunscreen compared with when it’s not. For example, assuming you apply—and reapply—the sunscreen correctly (recommended every 2 hours), if you’d normally burn after 20 minutes it would take 10 hours with the application of SPF 30 sunscreen.

SPF calculations do not apply to UVA rays, which can tan and age skin and cause skin cancer. That’s why it is necessary to use a broad-spectrum sunscreen that provides protection against both types of UV rays.  However, no sunscreen blocks 100 percent of UVA or UVB rays. The breakdown: SPF 30 blocks 97 percent of UVB rays, SPF 50 blocks 98 percent, and SPF 100 blocks 99 percent.  The AAD recommends everyone use water resistant sunscreen that offers broad-spectrum protection against UVA and UVB rays at a SPF 30 or higher.

It is also important to note that sun protection may be required indoors if much time is spent sitting near a sunny window. Glass blocks UVB rays, but it can let through some  UVA rays.  Automobile windshields do a good job for both UVA and UVB light (particularly newer models), but automobile side windows don’t provide as effective protection for UVA light. 

The Consumer Reports company has recently published its 2024 sunscreen ratings, testing 96 products this year.  In the past few years, the company has consistently noted that many tested products perform at less than half their labeled SPF number and many are inconsistent in their protection across product batches and various products from the same company.  They’ve also found that cost and brand name do not necessarily correlate with quality.  Since the AAD recommends using a product with an SPF of 30 or higher, this means that in many cases, users are not adequately protected, even with listed SPF ratings of 50.  This also means that most products with an SPF rating of 30 are not sufficient.  All products listed below have a tested SPF of > 30.

Additionally, testing has consistently found that so-called natural or mineral sunscreens (those that contain only titanium dioxide, zinc oxide, or both as active ingredients) have tended to perform less well.  This does not include products labeled sunblock, such as higher concentration zinc oxide products (think white noses on lifeguards).

According to the FDA, there are no chemical sunscreens that are generally regarded as safe and effective (GRASE) because additional data is needed.  Note, this does not mean they are unsafe (comparable to an “I” recommendation from the USPSTF).

The Top Rated/Recommended Sunscreens per Consumer Reports for 2024:

·         Lotion:     - Coppertone Water Babies Lotion SPF 50 (Score of 100/100)

              - La Roche-Posay Anthelios Kids Lotion SPF 50 (Score 90) (expensive)

                               - Every Day Humans Oh My Bod! Lotion SPF 50 (Score 83)

                              - Eucerin Advanced Hydration Lotion SFP 30 (Score 75)

    - La Roche-Posay Anthelios Melt-in Milk Lotion SPF 60 (Score 73)    

      (expensive)

   - Alba Botanica Hawaiian Lotion SPF 30 Aloe Vera (Score 70)

                                      - Equate (Walmart) Ultra Lotion SPF 50 (Score 68)

·         Spray:     - Eucerin Advanced Hydration Spray SPF 50 (Score 88)

           - Black Girl Sunscreen Kids Spray & Play SPF 50 (Score 77)

          - Trader Joe’s SPF Spray 50+ (Score 74)

          - Neutrogena Beach Defense Water + Sun SPF 50 (Score 71)

          - Black Girl Make it Glow Spray SPF 30 (Score 68)

- Sun Bum Premium Spray SPF 50 (Score 67)

    Other Notable sprays for affordability:

- Equate (Walmart) Sport Spray SFP 50 (Score 65) (< $5)

- Up and Up (Target) Sport Spray SPF 50 (Score 64) (< $5)

Some additional tips regarding sunscreen from Consumer Reports include:

•  Check the expiration date (formulated to remain effective for 3 years)
• Shake the product well before applying
• Apply generously at least 15 minutes before going into the sunlight or water
• Don’t forget commonly missed spots, including lips, backs of hands, tops of feet, back of the neck, scalp, and ears.
• Reapply every 2 hours and immediately after swimming or sweati
• Use spray screens appropriately by holding the nozzle 4 to 6 inches away from the  skin, spraying until the skin glistens, then rubbing it in, even if it is labeled “no rub.”

Mark’s Comments: 

What makes the Consumer Reports evaluation compelling is that the same process was used on all products under the same conditions (less potential bias than a company testing their own product).  They also buy the product off the shelf.  The Eucerin products are a new addition to the testing this year and scored well for both their lotion and spray products listed.  My experience has been that people gravitate toward spray over lotion, so in terms of actual usage, the sprays may be the better choice.  However, I also note that often the spray is used incorrectly, so the benefit of “use” may not translate into better protection.  And don’t forget to wear a sun protection hat.  Baseball caps may be fashionable but they’re not particularly effective for comprehensive protection from the neck up.

References:

• Consumer Reports Sunscreen Ratings:  April 2024 (by subscription):  Link
• American Academy of Dermatology Sunscreen FAQs:  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Back to the Fundamentals: We’re In This Together

“Don’t worry!  I got your back.”  — Anchoring phrase at the 2024 AAFP Physician Well-being Conference

At the recently held American Academy of Family Physicians (AAFP) Physician Well-being Conference, we started our time by considering the conference as our Hero's journey, and together created a group story, facilitated by our incredibly talented colleague and conference faculty member, Belinda Fu, MD. 

As we ended the session and set out on our conference “journey,” Belinda encouraged the participants to connect with those sitting near them and with a half-hug, share the phrase, “Don’t worry, I got you back.”   The positive energy in the room was palpable and that exercise set the tone for the Spirit of the conference, which became a wonderful space for support and encouragement. 

The phrase “I got your back” likely originated from fighter airplane pilots during World War 1 and has lived on through the now popular term “wingman.”  However, the importance of having a “buddy” has extended well beyond the military, including the Scouting and YMCA swimming programs.  Indeed, it was through my own experience in the YMCA swimming programs and their buddy system that the PeerRxMed program was inspired.

As it became used more commonly and outside of the military, the phrase signified a commitment to watching out for someone's safety and well-being, especially in challenging or even dangerous circumstances, and sends an explicit message of support and solidarity.  As used during the conference, the phrase took on a meaning less of being “defended” as of being looked after with care and protection as we allowed ourselves to explore vulnerable parts of our emotional lives.  This was demonstrated through heart-felt listening and the gift of “being together,” sending the message that “I’m here for you, I’m with you, I am on your side, we’re in this together.”

The purpose of the PeerRx process is well-captured in the phrase, “I got your back.”   Given the challenging circumstances of our work, it would seem that having a colleague who is intentionally supporting us and watching out for our safety and well-being would be mandatory (at least “sanity”) for all of us.  Tragically, too many of us continue to “go it alone” even in the face of often overwhelming (yes, even “dangerous”) circumstances.  By participating in the PeerRx process, you’ve made a wise decision to not give in to this temptation.  Let’s encourage others to “buddy up” as well.   Everyone deserves to have buddy who has their back.   Remember, when it comes to our “professional Hero’s journey,” we’re in this together.

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

After reading my recent Pointer on diagnosing ADHD, our residency program’s lead Behavioral Scientist, Laura Kurdila, PhD, worried that my sentence, “Thoughtful use of readily available tools in primary care is frequently all that is needed” might mislead readers. She emphasizes that the tools reviewed are starting points for a clinical assessment of medical and behavioral history, family and social context and clinical examination – all of which can be done, of course, in primary care. Simply relying on the tool itself for diagnosis is inadequate. And, if there is uncertainty about the diagnosis or the response to treatment, a referral to a behavioral health specialist for a comprehensive evaluation is certainly indicated.

From the JAMA Rational Clinical Examination Series

1)  Newborn Hip Exams Work

Developmental dysplasia of the hip (DDH) is rare (0.4-2.3% prevalence) but catching it before three months of age is essential to enabling a simpler treatment plan of bracing and avoiding surgery and prolonged rehabilitation. The most recent installment in the JAMA Rational Clinical Examination (RCE) series is a systematic review of basic clinical examination methods for DDH, including physical examination techniques. RCE articles apply all the systematic review methods to the evidence on physical examination techniques. The review covered the following tests: Galeazzi (looking for difference in femur length when flexed and adducted), limited hip abduction of one side on active ROM testing, “clicking” of either hip on range of motion, Barlow (downward pressure on the flexed abducted hip causing posterior dislocation) and Ortolani (anterior relocation of a dislocated hip upon abduction of the flexed hip). The Barlow and Ortolani tests are meant to be performed together. Ultrasound using the standard Graf grading method was used as the reference standard for diagnosis.

Results:

LR pos: likelihood ratio for a positive test, 1-2 poor, 2-5 fair, 5-10 good, >10 excellent.

LR neg: likelihood ratio for a negative test, .5-1 poor, .2-.5 fair, .1-.2 good, <.1 excellent

The authors note that out of 1000 hips (not children) screened with Barlow and Ortolani maneuvers 4 (95% CI, 2-6) dislocations will be picked up. There will be 9 (95% CI, 1-30) unnecessary ultrasounds, but also still 5 (95% CI, 3-8) missed diagnoses. In higher prevalence locations (Austria, Norway) or with a family history, screening with ultrasound may be a better choice.

John’s Comments:

Our training on the Barlow and Ortolani tests can be somewhat variable in quality. This article has nice diagrams to describe the test techniques, and the authors point out that periodic retraining would benefit clinicians. It’s a rare case where thoughtful physical examination is proven to be a useful screening technique (despite its limitations), so this is one we should be good at.

Reference:

• Singh A, Wade RG, Metcalfe D, Perry DC. Does This Infant Have a Dislocated Hip?: The Rational Clinical Examination Systematic Review. JAMA. Published online April 15, 2024. Link

From the Literature and “Healthy Skeptic School”

2)  Honing Your Critical Thinking Skills:  Avoiding Fallacies of Logic

In the April 26 Take 3, we highlighted the importance of recognizing and managing common cognitive biases in order to prevent diagnostic error, and cautioned how prevalent these biases are in clinical care.

This week we continue our theme of sharpening our critical thinking skills by examining the phenomenon of logical fallacies.  Note that cognitive biases and logical fallacies are different.  Cognitive biases are rooted in the way the brain actually works whereas logical fallacies are errors in reasoning that occur in the moment.  Individuals can be trained to avoid logical fallacies, but as noted last week, cognitive biases, because they work as part of our cognitive “operating system,” must be consciously managed.  

Fallacies of logic confuse correlation, coincidence, and causation, otherwise known as “False Cause.”  In deductive logic (and hence in deductive arguments), fallacies are errors in the structure of the argument such that the conclusion does not necessarily follow from the premises. In inductive logic, fallacies are unjustified claims that the arguer tries to use to support an inference between evidence and a conclusion.

With This, Therefore Because of This (Cum Hoc Ergo Propter Hoc)

When two things seem to happen in correlation or at the same time with each other, many will mistakenly think that one thing caused the other when no such causal relationship has been established.  For example: “Many people who have strokes are on blood pressure medications.  Those blood pressure pills must be causing strokes."

Post Hoc Fallacy (Post Hoc Ergo Propter Hoc)

A precedes B, therefore A caused B. It is subtly different from the previous fallacy because in this case, the ordering of the events is key and appears to be integral to the causality.  The fallacy lies in coming to a conclusion based solely on the order of events, rather than taking into account other factors that might rule out the connection.  For example: "I get these symptoms at the same time every year and antibiotics are the only thing that works.”

Appeal to Authority (Argumentum ad Verecundiam)

None of us can know everything.  We rely on those with in-depth experience to help provide additional necessary context, particularly when it comes to the recognition and management of rare or serious manifestations of disease and the use of new medications, diagnostic tests, or procedures.  But specialists and generalists are two different kinds of experts that have two different ways of knowing things.  Neither of them should be looked at as authority, but as complementary approaches to the applied science of medicine.  Unfortunately, specialists are often treated as authorities on decisions that may better use a generalist approach – interpreting diagnostic tests in a primary care population, evaluating the right management course in a patient with multi-morbidity, and weighing available treatments in the context of the patient’s values and circumstances.  Our “healthy skeptic antennae” should be active when we hear appeals such as: “In my experience…”, “Dr. X, the world-renowned cardiologist always uses this with her patients…”, “This is the way we do it a Z Medical University …”  This doesn’t make the conclusion necessarily wrong, just that it should be consciously scrutinized.

The Bandwagon Effect (Argumentum ad Populum)

Also known as the “appeal to popularity,” this is a variation of the appeal to authority. In this case the "authority" is popularity or “the masses.”  There is a subtle “peer pressure” effect that occurs with this appeal.  We are often quick to jump on the bandwagon when we are afraid of looking as though we're not as up-to­ date as our colleagues.  The use of GLP-1 agonists (for everything?!) would be a present example of this.  As with other fallacies, the conclusion is not necessarily false, but the conclusion’s premise is wrong.

The Slippery Slope

The arguer tries to convince others that one action will lead to a series of events that will eventually lead to an ultimate, usually unwanted, consequence.  This is fallacious if it is unlikely that each intermediate step will necessarily follow the preceding one.  This argument is used regularly in political debate and ethical arguments in healthcare. 

The Appeal to Nature

This is perhaps the most prevalent fallacy used in the health and wellness industry.  It occurs when something is claimed to be good because it’s perceived as natural, or bad because it’s perceived as unnatural and is the basis for claims such as “all-natural ingredients” and “free from chemicals.” 

Mark’s Comments:

These fallacies occur regularly in the course of clinical care and are used quite commonly in medical advertising.  The first step in honing one’s critical thinking skills is acknowledging that we are susceptible to such fallacies of logic and regularly listening for them in the course of our daily work.  For those interested in learning more about the many fallacies (there are many more), this Link to "Skeptical Medicine" provides a good overview and some wonderful video clips. 

References:

• Shaughnessy AF, et al.  Separating the Wheat from the Chaff: Identifying Fallacies in Pharmaceutical Promotion.  J GIM 1994. 9 (10): 563–568. Link
• Tiller N.  The Skeptic’s Guide to Sports Science:  Ten Health and Wellness Fallacies Every Skeptic Should Know.  September 23, 2022. Link

From PeerRxMed ( www.PeerRxMed.org )

3) Time for a “Retirement Party” From Competitive Suffering?

“Saying someone shouldn’t feel sad because someone else may have it worse is like saying someone can't be happy because someone else may have it better.”                                                                                                                                                  Unknown 

 

If you’re like many who work in healthcare, as you care for people who are facing significant health challenges, you’ve likely found yourself at times thinking, “Who am I to complain when there are so many who have it so much worse?”  There may even be a voice or voices from your past joining in that chorus.  The psychological literature has coined this common mindset as “comparative suffering.” 

Comparative suffering is when one feels the need to contrast one person’s suffering with the suffering of others.  Those of us in healthcare have generally been socialized to believe that our struggles and/or suffering are not legitimate or can wait because it is our job to care for the many others in distress.  We often even take it one step further and find ourselves participating in a process termed “competitive suffering,” in which we assign all suffering, both ours and that of others, a “legitimacy score” along some sort of self-created legitimacy scale.  And those of us in healthcare usually judge our own by much more stringent criteria – a phenomenon commonly known as minimizing ….       

Recently I found myself doing this very thing when I experienced some “twinges” similar to those of a serious and quite painful back injury I had three years ago for which I was unable to walk without assistance for a period of time.  While the symptoms in this case were fortunately transient (and likely unrelated), I found myself “joking” with a colleague “it’s just a little PTSD” (legitimacy scale) when the fact is there is rarely a day that goes by when I don’t think about that injury, usually when lifting something, and in the process, experience a “twinge” of both gratitude for my healing and fear of recurrence.  

Some might conclude that comparative suffering is a healthy pattern of thinking.  Afterall, isn’t “counting your blessings” encouraged throughout the well-being literature (and by me)?  And no one wants to be labeled a “whiner” or a “victim.”  But being grateful is not the same as pretending that you don’t have struggles, and one can express their struggles in constructive ways, such as sharing them with a trusted friend.  In fact, denying or suppressing your suffering rather than addressing it can actually cause greater suffering because the distress doesn’t magically go away, and we then also feel ALONE with it.  The consequence is a diminished ability to be compassionate, both with others and oneself.    

So remember, we can live our most authentic life by both keeping our struggles in perspective AND allowing ourselves and others to feel and express them in healthy ways.  Afterall, no one goes through life without them, so why not practice validating what you feel and then decide the story you will tell.  Perhaps you can even take it one step further, letting your PeerRx partner serve as your “becoming more human” practice partner as you officially announce your retirement from competitive suffering.  I’d welcome the opportunity to attend your “retirement party” … and would love for you to come to mine!

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  A Refresher on Pertussis

Pertussis has unfortunately been making an on-again-off-again resurgence over the last decade or so. As we know, it can cause a lingering “bronchitis” in adults and older children, but in infants it can be deadly. The CDC’s Advisory Committee on Immunization Practice (ACIP) has basically allowed repeat Tdap vaccination (rather than 1 dose in adulthood followed by Td vaccinations) and encouraged pregnancy vaccination and “cocoon vaccination” (vaccinating all the newborn infant’s close contacts) around expectant mothers – all with the goal of decreasing infant exposure and illness.  There is an outbreak currently in North Dakota and early reports of an outbreak in the New River Valley here in Virginia.

Given this, some clinical pointers from the CDC to remember:

·         Exposure to symptom onset is usually 4-10 (max 21) days.

·         Pertussis is a three-phase illness:

o   Coryza – 1-2 weeks – lots of congestion, mild cough. In infants – apnea.

o   Paroxysmal – 4-5 weeks – paroxysmal coughing, inspiratory “whoop”, oxygen desaturation, dehydration

o   Recovery – 2-3 weeks, symptoms slowly improve.

·         Antibiotic treatment is best in the first two weeks of illness prior to the onset of paroxysmal coughing in order to improve symptoms. After this point, there is less benefit to antibiotics. Azithromycin is the antibiotic of first choice. (clarithromycin, erythromycin, and trimethoprim/sulfamethoxazole (for age>2 years) are alternatives).

o   Azithromycin is given at a dose of 10 mg/kg/day for 5 days for children less than 6 months. Above six months, the child dose is 10 mg/kg on the first day, then 5 mg/kg/day for 4 more days (max 500 mg/dose). For adults, 500 mg at onset and 250 mg/day for 4 days is recommended.

o   For infants and pregnant women, treat up to 6 weeks after cough onset, but for everyone else, treat within 3 weeks of cough onset.

·         The trickiest part is differentiating URI symptoms from early pertussis. A history of contact with individuals with a severe or lingering cough, mild fever and lots of congestion are most consistent with early pertussis.

·         Testing is the preferred method to confirm diagnosis prior to treatment. Most available are nasopharyngeal swabs for pertussis PCR testing.

·         However, if you have clinical suspicion in an infant or other high-risk individual, it is recommended to start empiric azithromycin until the test has returned, given the benefits of early treatment.

·         Use “droplet precautions” in practice when evaluating suspected patients – wash hands before and after examination, use a mask and faceshield/goggles

·         Hospitalization may be required for anyone with pertussis (usually children) if their oxygenation is low, or if they are dehydrated.

·         Post-exposure prophylactic antibiotics should be limited to those at high-risk of complications from pertussis (mainly infants), but it is best to coordinate this with local public health or infection control officials.

·         Be sure to report positive pertussis tests to your local health department immediately. It is best that the clinician is involved in that report to provide necessary clinical details.

John’s Comments: 

While treating possible high-risk pertussis cases early is a goal, be careful not to fall into overusing antibiotics.  Look at the whole picture – likelihood of infection and risk from infection – to make your decision.  Outbreaks of pertussis represent a failure of population levels of immunization, so make sure to get people vaccinated with Tdap as indicated whenever possible.

Reference:

·         Pertussis (Whooping Cough) Clinical Information | CDC. Published August 25, 2022. Accessed April 23, 2024. Link

From the Agency for Healthcare Research and Quality (AHRQ)

2) Preventing Diagnostic Errors Through “Bias Management”

Though estimates vary, diagnostic errors in primary care are thought to be more common than we should be comfortable with.  One challenge is that unlike therapeutic errors, diagnostic errors are more difficult to determine/measure.  Adverse events related to misdiagnosis are more likely to be judged preventable than other types of adverse events such as medication errors.  It is thought that approximately 75% of diagnostic errors have a cognitive component. 

Cognitive biases are systematic cognitive dispositions or inclinations in thinking and reasoning that often do not comply with the tenets of logic, probability reasoning, and plausibility.   At least 188 of these biases have been described.  These intuitive and subconscious tendencies are foundational to human judgment, decision making, and the resulting behavior.  Psychological frameworks consider biases as resulting from the use of (inappropriate) cognitive heuristics (shortcuts) that people apply to deal with data-limitations, information processing limitations, or lack of expertise.  The two overarching cognitive components that are common within medical decision-making errors include:

·         the tendency to seek only as much information as necessary to form an initial clinical impression, and

·         the tendency to stick with the initial impression even as new information becomes available. 

These decision-making errors are expressed through the following biases: 

·         Confirmation Bias – The tendency to selectively seek information that supports initial impressions.

·         Overvalue Bias – The tendency to overvalue irrelevant information if it has been deliberately sought by the clinician. This bias compounds confirmation bias, because the clinician first seeks irrelevant information, then systematically overvalues this irrelevant information when it is obtained.

·         Anchoring Bias – The inadequate adjustment of probabilities as new disconfirming information becomes available. 

·         Status Quo Bias – The tendency to stick with initial impressions as the number of new possible alternative diagnoses increases.

·         Framing Effect – The tendency to be affected by how information is framed or presented.  For example, by being informed of someone else’s conclusions about the information.

·         Diagnostic Overshadowing Bias – The attribution of symptoms to an existing diagnosis rather than a potential co-morbid condition.  This occurs most commonly in patients with psychiatric conditions.

·         Implicit Bias – The unconscious attitudes, thoughts, and feelings about a particular people or group that can drive stereotypes and prejudices against that group.

·         Action Bias – The tendency to act when faced with a problem even when inaction would potentially be more effective, or to act when no evident problem exists. 

Given the prevalence of diagnostic errors, studies have explored interventions for prevention.  Some cognitive- and system-based interventions include:

·         Cognitive awareness – Includes efforts to teach trainees and clinicians about the diagnostic thinking process and methods to improve it through conscious awareness and questioning.  This may also be improved through teamwork and case discussions. While clinicians are limited in their ability to self-monitor their thought processes (“Blind Spot Bias”), their colleagues might be willing and able to do so.

·         System-based improvements – Structured diagnostic assessments for common clinical scenarios (e.g., chest pain, fever in an infant) can ensure that relevant findings are elicited, and common conditions considered.  These can be augmented by computer-assisted decision support systems that advise or provide guidance about a particular clinical decision at the point of care.

Mark’s Comment:

The potential for bias is quite real in the practice of medicine, and the denial of it does not make it go away. We often don’t appreciate the demanding mental discipline required for effective clinical practice, even for what might appear to be common and perhaps even “mundane” issues.  Adding negative emotion, either what we bring into the exam room and/or what is precipitated by our patients, only adds to the need for this discipline. Consider what biases you might be most susceptible to and strategies you are using/might use to overcome such biases.

References:

·         Etchells E.  Anchoring Bias With Critical Implications.  AHRQ Web M+M.  Published Online June 2015.   Link

·         Lazris A, Ross A.  Lown Right Care: Diagnostic Overshadowing:  When Cognitive Biases Can Harm Patients.  Am Fam Physician. 2023;108(3):292-294.  Link

·         Doherty T  and Carrol A.  Believing in Overcoming Cognitive Biases.  AMA J Ethics.  2020;22(9):E773-778.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  How Certain Are You Doctor?

“Medicine is a science of uncertainty and an art of probability.”  Sir William Osler

From my formative days in medical training, the principles captured in Williams Osler’s above quote were instilled in me regarding medicine being both a “science” and an “art” and therefore the importance of having the professional humility to acknowledge that much of what we do is filled with uncertainty.   Indeed, I have found myself understanding that the reverse of his quote is also true – when it comes to the practice of medicine, there is “science and art” to both uncertainty and to probability.  Yet applying both the art and science of uncertainty and probability to clinical practice is not as easy as this quote might make it appear.   

For example, recently I saw a woman in her 50s previously unknown to me who had been experiencing “chest pain” intermittently over the past several days.  While she had some cardiac risk factors, she also had many other risk factors for both musculoskeletal pain as well as GERD, and both the history and exam were consistent with a non-cardiac source.  Her EKG was normal, and a review of her chart indicated she had a negative “cardiac work-up” a year ago for similar symptoms.    

Feeling convinced that this her pain was non-cardiac and that empiric treatment and “tincture of reassurance” were the appropriate next steps, I discussed my findings and recommendations with her.  She listened carefully and then posed the question that whenever asked tends to pierce our clinical armor and leave us reflexively shifting into defensive mode by either going on a test-ordering spree or digging in emotionally to our position (or both):  “How certain are you doctor?” 

In that nanosecond of processing, somehow my mind found an alternative, wiser path, and rather than reactively feeling the need to answer her question, I responded with a question of my own.  “What has you most concerned?” I asked, expecting her to say that if I couldn’t be completely sure then more testing was necessary.  Instead, she answered, “I had a physician previously tell me when I had similar symptoms that if we couldn’t be absolutely sure, then we needed to do more tests.  I’d prefer not to do that as it caused both great discomfort and significant expense for me.”  I smiled and felt almost as if the spirit of William Osler was standing behind me, smiling as well.  “Yes,” I replied, “I can understand how that might have happened.  Let me tell you why I don’t think that’s necessary today.”  She left satisfied with our plan, and her symptoms subsequently resolved. 

We live on the edge of uncertainty and precipice of probability every day in our work.  We don’t, however, often talk about how best to navigate it and the psychological toll that it can take.  Because of that, it can weigh us down without our even being consciously aware of it.  How about you?  How do you navigate the art and science of uncertainty and probability in your clinical work?  This certainly seems like a challenge (and even burden) worth exploring and sharing with a colleague, perhaps starting with your PeerRx partner.  Afterall, in the world of professional uncertainty that we all navigate on a daily basis, no one should care alone.

Feel free to forward Take 3 to your colleagues.  Glad to add them to the distribution list.

 Mark and John

 Carilion Clinic Department of Family and Community Medicine

1)  “Proper” Technique For Use of Allergy Nasal Sprays?

Question:  
“Now that ‘allergy season’ is here, I’m wondering what the evidence is regarding the proper technique for the use of intranasal sprays.  I’ve read and been taught many different things.”

Answer:  

Allergic rhinitis is quite prevalent, affecting approximately 15% of the population based on clinician diagnosis and as high as 30% based on self-reported nasal symptoms.  Intranasal corticosteroids (INS) are considered first-line treatment for allergic rhinitis.  Given the pervasiveness of use, having an evidence-based standardized technique for INS application could be of great potential benefit for optimizing treatment effectiveness and decreasing side effects.  However, there is little published information about the appropriate technique(s) for optimally using these medications. 

The most comprehensive review of nasal spray technique was published in 2004.  Among their findings was a paucity of data regarding optimal technique with notable variation among the recommendations for proper use in the package inserts for the various available medications.  Significant differences included variations in head tilt, differences in the angle the spray should be directed, whether the opposite nostril should be pressed shut while spraying, whether to use the opposite hand when spraying in each respective nostril, and whether there should be any inhalation through the nose or sniff during or immediately after spraying. 

In their conclusions, the reviewers found: “The current available data on the effects of positioning, sniffing or inhaling, and blowing the nose prior to INS administration have not conclusively demonstrated clear differences in either the effectiveness or the safety of these agents. On the basis of evidence concerning the mechanics of existing INS deposition devices, the ease with which patients can use and understand them, and the likelihood that patients will comply with recommendations for their use, the panel has developed guidelines for the use of topical INS sprays.”

Based on their review, the 7-member expert panel recommended the following as a best practice:

1. Hold head in a neutral upright position.
2. Clear nose of any thick or excessive mucus, if present, by gently blowing the nose.
3. Insert spray nozzle into the nostril.
4. Direct the spray laterally or to the side, away from the middle of the nose (septum) and toward the outer portion of the eye or the top of the ear on that side. (If possible, use the right hand to spray the left nostril and left hand to spray the right nostril, to direct the spray away from the septum.)
5. Activate the device as recommended by the manufacturer and with the number of sprays recommended by the doctor.
6. Gently breathe in or sniff during the spraying.
7. Breathe out through the nose.

Mark’s Comments:

It should be noted that the clinical resource UpToDate provides instructions on proper technique to optimize the effects of and adherence with treatment, including a Figure on “How to use a nasal spray properly,” but provides no references for these recommendations.   

My bottom line based on my review as well as clinical and personal experience is that the guidance above seems reasonable, though I do not tell my patients to gently breathe in or sniff during spraying, as I find that this likely leads to more of the medication ending up in the nasopharynx.  As I tell my patients, “If you can taste the medication, you’re not doing it right.”  I also instruct them to not blow their nose for at least 10 minutes and preferably closer to 30 minutes to optimize medication absorption. 

Reference:

·         Benninger M, et al. Techniques of Intranasal Steroid Use.  Otolaryngol Head Neck Surg.  January 2004; 130(1): 5-24.  Link

From the Literature

2)  Diagnosing ADHD in Children and Adolescents

Attention deficit and hyperactivity disorder (ADHD) has a worldwide prevalence of between 5 and 10% in children. It is certainly common in primary care practices, and, given the shortage of child/adolescent mental health services in many areas, primary care clinicians generally must be responsible for the care of these patients. The medications used, while effective, can be dangerous in terms of both side effects and potential for misuse, and the outcomes at risk are the education and socialization of children. Correct diagnosis, then, is of utmost importance.

A systematic review was published last month in the journal Pediatrics evaluating all possible tools used in the diagnosis of ADHD: “parental ratings, teacher ratings, youth self-reports, clinician tools, neuropsychological tests, biospecimen, electroencephalography (EEG), and neuroimaging.” The authors performed a comprehensive search of multiple databases, had explicit inclusion criteria (patients <18 years, a reference standard of an examination by a licensed mental health provider using the Diagnostic and Statistical Manual, version 5 (DSM-V)), and critically appraised the studies.

The authors evaluated over 23,000 studies and selected the reports of 231 studies that met criteria. The strength of evidence was overall low-moderate and the supporting evidence for each set of diagnostic tools varied in its strength. For results, each category of assessment had associated ranges of sensitivity and specificity, but it is more expedient to report the “area under the curve” (AUC) for these tests. AUC is a commonly used statistic in diagnostic testing that reflects the best balance (therefore the most clinical utility) between sensitivity and specificity in a diagnostic test. The AUC ranges for each group (0.5 is useless, 1.0 is perfect) were:

• Parent rating:  0.55 to 0.95
  • Child behavior checklist (CBCL) only:  0.83 to 0.84
• Teaching rating:  0.65 to 0.84
• Combined rating (parents and teachers):  0.86
  • With machine learning (ML):  0.98
• Self-rating:  0.56 to 0.85
• Other testing (interview guides, activity trackers, etc.):  0.75 to 0.9996
• Neuropsychologic testing:  0.59 to 0.93
• Biospecimen:  0.68 to 1.00
• EEG:  0.63 to 1.00
• Neuroimaging (MRI, fMRI, aided by ML):  0.58 to over 0.99

The sensitivities of these tools varied widely by setting; they were lower in primary care compared with behavioral health settings. The specificities were much more consistent between settings. These tests were better at distinguishing ADHD from a “neurotypical” population than they were at distinguishing ADHD from other behavioral disorders. There was general inconsistency in parent vs. teacher rating scales, which could indicate either different behavior in each setting or poor instrument performance between settings. Neuropsychological testing, frequently assumed to be more “diagnostic,” performed no better than the rating scales.

John’s Comments: 

Examining the numbers in the AUC column above tells me that research in this area has not settled. The CBCL seems to be the most consistently good symptom checklist. Combining parent and teacher ratings is not necessarily better than parent rating alone but may be useful to get a full picture of behavior across settings. In addition, there doesn’t seem to be much benefit from routine use of neuropsychiatric testing, imaging, or other advanced testing over just symptom scores. Thoughtful use of readily available tools in primary care is frequently all that is needed.

In the introduction, the authors note that, based on rigid diagnostic criteria, the prevalence of ADHD is 5%, but based on clinical diagnosis, it reaches up to 10%. One explanation for this may be symptoms that are impairing but don’t reach the rigid thresholds for diagnosis. But another explanation has been shown to be cultural bias; ADHD is diagnosed more in boys, in poor families, and in whites. It is important to use standard diagnostic tools like rating scales and to work against this potential for bias when interpreting the ratings.

Reference:

·         Peterson BS, Trampush J, Brown M, et al. Tools for the Diagnosis of ADHD in Children and Adolescents: A Systematic Review. Pediatrics. Published online March 25, 2024:e2024065854. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Helping Each Other Carry the Weight of Our Professional Burdens

“Owning our story and loving ourselves through that process is perhaps the bravest thing we will ever do.”  Brené Brown

Imagine eleven physicians sitting in a circle, devoting an hour together to process their “collective stories” of professional challenges.  While for some that may be hard to imagine, that is exactly what I did with 10 other colleagues last week.  After a brief introduction, we each read a short, prepared vignette we had been given about a professional struggle that had been experienced by a colleague.  While none had been written by the group, each one read sounded eerily familiar.

“One of my colleagues appears completely burned out and I worry about them but am hesitant to say anything because I don’t want to make them defensive or appear to think that I know what’s best for them.  And I feeling pretty crispy myself!” read the first.  Then after a brief moment of silence and already some knowing nods, the next was read.  “By the time I get home after a day at work I am often so exhausted that I can’t even pretend I’m excited to see my partner and children.  And our sex life has tanked and sadly, I’m not sure I really care,” read the next with more nods and a few fleeting grimaces of recognition.  

And so we continued around the circle.  After some time for quiet reflection, we then shared what spoke to us, what we identified with, and how these stories related to our own experience and the professional burdens we carried.  Similar to the many other “Burdens and Blessings” workshops I have co-facilitated for medical students, residents, and practicing physicians across numerous specialties, our burdens were plentiful.  Likewise, with our sharing, we were also comforted in our realization that we were not alone in our experience of them. 

As often happens, one of the group reminded us that these challenges were part of “what we signed up for.”  Certainly our professional training and socialization would have us believe this.  If this is true, then where do our “human selves” go to share and begin to process all our stories of the tragedy, despair, powerlessness, woundedness, pain and loss we see daily in our work?  For too many of us, the answer is ”nowhere and with no one,” as most have had no modeling for doing so, and often no encouragement.  Instead, we carry these burdens by ourselves, concluding that since others appear to be adeptly handling these challenges, we must be weak or flawed because we are finding them overwhelming.  And so we struggle in silence and too often are left feeling isolated and alone.

The work we do is good and important work, and yes, we knew it would be hard, but that in no way justifies our allowing it to break us.  The PeerRxMed process was created to help dismantle the many barriers the culture of medicine has created which interfere with our fundamental human need to connect with and support each other on our professional journey.  With my PeerRx partners, I’ve found a safe space where we can share our stories – stories of grief, of burdens, of loss, and also of the many blessings of our work.  Please don’t keep the stories you carry bottled up inside.  We need to share our stories with each other.  No one should carry their professional burdens alone. 

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  Update on Cystatin C Use in Estimating Kidney Function

Back in Take 3 #527, we reviewed the use of cystatin C to better estimate kidney function. We concluded that it was not yet ready for prime-time use, but we were waiting for the promised 2023 update of guidelines from KDIGO, the international kidney quality improvement organization. Those guidelines have now been published.

The guidelines are based on a systematic review by the Johns Hopkins Evidence-Based Practice Center. The panel used a formal GRADE process for making recommendations and also included non-evidence-based “practice pointers” to “fill in evidence gaps.”

Using cystatin C to better estimate eGFR is recommended generally to assign kidney function stages if it is available (moderate certainty evidence) for patients who are at risk for kidney disease. The primary rationale is that the use of creatinine (in eGFR) varies by muscle mass and cystatin C can vary with certain wasting conditions, so using them together allows one to compensate for the weaknesses of the other. The eGFR calculation using cystatin C (eGFRcr-cys) is especially recommended over eGFRcr (creatinine alone) for the following conditions: eating disorders, extreme sports, above the knee amputations, spinal cord injury with paraplegia/quadriplegia, severe obesity, most weight-loss diets, malnutrition, cancer, heart failure, catabolic consuming disease (HIV, tuberculosis, etc.), muscle wasting disease, cirrhosis, steroid use, decreased tubular secretion, or use broad-spectrum antibiotics that decrease external elimination (e.g., vancomycin). Cystatin C is ordered from a serum sample.

Additional recommendations:

·         Use eGFRcr-cys (recommended with low certainty evidence) when eGFR is important for treatment decisions like drug dosing, kidney replacement therapy (dialysis), etc.

·         Use a validated estimating equation to calculate eGFR rather than relying on just creatinine or cystatin C levels alone (recommended with very low certainty evidence).

·         Use a validated kidney failure risk equation (such as the Kidney Failure Risk Equation, which uses commonly available lab values) to calculate the absolute risk of kidney failure to determine need for nephrology referral and more intensive therapy (recommended with high certainty evidence). A practice pointer suggests an absolute risk of 3-5% over 5 years as a threshold for referral to nephrology.

This guideline contains additional information about prevention and treatment that we will summarize in a future pointer.

John’s Comments:

The guideline includes an algorithm that is summarized as follows:

1.    Identify patients at risk for CKD (hypertension, diabetes, coronary artery disease, history of acute kidney injury (AKI))

2.    Test for CKD in patients at risk using eGFRcr or uACR (urine albumin/creatinine).

3.    If one of those is elevated, check the other one, and rule out AKI.

4.    If either one of these remains abnormal for three months, check an eGFRcr-cys to confirm and identify the correct stage of CKD.

On the one hand, this algorithm, comprised mostly of Practice Pointers and not evidence, seems reasonable to recommend eGFRcr-cys as a confirmatory test for CKD (not a screening test). On the other hand, much of the algorithm conflicts with the diabetes kidney health recommendations, which advocate for both eGFRcr and uACR yearly as screening for this high-risk population. The certainty of evidence is at best moderate for using eGFRcr-cys routinely, but if there are conditions that render eGFR less accurate (as listed above), and you are concerned about CKD, it may be useful to confirm the diagnosis and stage with eGFRcr-cys.  Popular calculators (like MDCalc) have already included an option for calculating eGFR using cystatin C. Our commercial lab already has a panel available, but there’s at least one warning about Medicare not covering it, so check with your own lab and watch for additional cost.

Reference:

·         Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney International. 2024;105(4):S117-S314.  Link

From the Literature and a Question From a Colleague

2)  The Potential Impact of Gabapentinoids on COPD Exacerbations

Question:

I read recently that gabapentin can cause COPD exacerbations. This was news to me.  What’s your take?

Answer:

In December of 2019, the US FDA published a safety communication warning that serious breathing difficulties may occur in patients using gabapentin (Neurontin, etc.) or pregabalin (Lyrica) who have respiratory risk factors, including those with conditions such as COPD that reduce lung function.  The FDA also warned that these drugs can behave in an additive way to potentiate central nervous system (CNS) and respiratory depression when co-prescribed with another CNS depressant, opioid, and if used should be initiated at the lowest effective dose and an alternative should be considered. 

A previous study found that approximately 85% of all patients with COPD have at least 1 pain-related diagnosis, including 27% with neuropathic pain, and 70% reported using at least 1 prescription pain medication.  Despite this, until recently no population-based studies had been done to investigate the potential respiratory adverse effects of gabapentinoids on patients with COPD.

A retrospective cohort study out of Canada published this year sought to address this gap.  Within an identified base cohort of patients with COPD between 1994 (when gabapentin was approved) and 2015, more than 13,000 patients who had initiated gabapentinoid therapy with an indication (epilepsy, neuropathic pain, or other chronic pain) were matched 1:1 with nonusers with COPD.  The primary outcome was severe COPD exacerbation requiring hospitalization.  Compared with nonuse, gabapentinoid use was associated with increased risk for severe COPD exacerbation regardless of the reason for the medication (Hazard Ratio/HR, 1.39 [Confidence Interval/CI, 1.29 to 1.50]).  The increased risk was similar with gabapentin and pregabalin.

The authors concluded that for patients with COPD, gabapentinoid use was associated with increased risk for severe exacerbation.  This study supports the warnings from the FDA and highlights the importance of considering this potential risk when prescribing gabapentin and pregabalin to patients with COPD.

Mark’s Comments:

The data is likely sobering regarding the number of patients with COPD who are on a gabapentinoid who likely have not been counseled about this caution.  As with many therapies for patients with multiple co-morbidities, we clinicians must help them weigh the risks and benefits, which in instances like this is a very imprecise science.  At the least, it would seem prudent to have taken the time to counsel your COPD patients who are on a gabapentinoid about this risk, and document that you did.

References:

·         Rahman AA, et al.  Gabapentinoids and risk for severe exacerbation in chronic obstructive pulmonary disease: a population-based cohort study.  Ann Intern Med 2024;17(2):144-154.  Link

·         US Food and Drug Administration Drug Safety Warning: FDA warns about serious breathing problems with seizure and nerve pain medicines gabapentin (Neurontin, Gralise, Horizant) and pregabalin (Lyrica, Lyrica CR).  12-19-2019. Link

From PeerRxMed ( www.PeerRxMed.org )

3) Saying “No” to Regain your JOMO

“The difference between successful people and really successful people is that really successful people say no to almost everything.”  ― Warren Buffet

How are you?  When I ask colleagues this question in the context of their professional lives, adjectives such as “overly busy,” ”surviving,” overwhelmed,” “running on fumes,” and even “at the end of my rope” are sadly used too often.  Indeed, for many, activities that had previously been joy-filled now lack any sense of fulfillment whatsoever.  Yet one of the biggest challenges for many of those same physicians is their inability to say “no.”   

Over the last decade, there is an acronym that has gained popularity which describes this phenomenon – JOMO or the Joy Of Missing Out.  JOMO is seen as an antidote to the more pervasive phenomenon of FOMO or Fear Of Missing Out, exemplified by our society’s obsession with social media.   During our “pandemic pause,” many found that instead of “missing out” on the things they weren’t able to do, they discovered their overfull lives were often causing them to miss out on many of the simple things in life (like “doing nothing,” engaging in hobbies, and spending time with loved ones) that actually brought them great joy.   The pandemic provided a “legitimate excuse” to say no to activities that many found they weren’t actually interested in but felt a professional and/or social obligation to say “yes” to.    

Yet our present circumstances would indicate many of us didn’t actually internalize any of our “pandemic lessons”!  So how can one learn to say “no” more effectively?  “Saying No Experts” have found certain techniques can be quite useful in helping you to both say no and not feel like you’re letting someone down and/or missing out on the “opportunity of a lifetime” in the process of doing so. 

The first step is to spend some time becoming clear about your priorities and therefore being better able to discern if opportunities are right for you.  The next step is to realize that there will be many more “good” opportunities that come your way than you can ever say “yes” to, so saying “no” is something that you should expect to happen regularly.  And then there is “how to say no” in a way that leaves you feeling less guilty about it.  Those same experts encourage that practicing the actual phrases ahead of time can allow them to become more natural for you.  In fact, one of them has provided "50 Ways to Nicely Say No" to help get you started.

If it’s reassuring for you, I’ve never had a colleague express regret about having better aligned their priorities with their time.  I have, however, had many express regrets when they didn’t.   The same goes for me.  So why not take some time this week to examine your schedule, and see where there might be opportunities to say no?  Perhaps you could discuss these with your PeerRx partner and even practice!  What may be waiting on the other side of your next “no, thank you” is the joy of missing out, and as you now know, that’s likely not really missing out at all.

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  Falls Prevention in Older Adults

Falls are among the most common and preventable causes of morbidity and mortality for older adults and increase substantially after age 65.  In a 2018 survey, 28% of community dwelling adults aged > 65 reported falling in the last year.  Other data indicates one of 5 falls among older adults leads to fractures or head injury.  Health care expenditures related to falls in the account for 4.4% of Medicare hospital expenditures, 5.7% of physician and other health professional expenditures, and 11.8% of spending for home health services, long-term care facilities, and durable medical equipment.

In a sample of community-dwelling adults > 60, fear of falling and fall-related activity restriction were highly prevalent (69% for fear of falling and 38% for fall-related activity restriction).  Both concerns are associated with sarcopenia and depression.

Clinicians across specialties and settings of care are likely to encounter patients at risk of falls. The cause of falls may be multi- factorial, requiring careful assessment and intervention across multiple domains.  A recently published review was written with the intention of summarizing current understanding of best practices for risk stratification, clinical assessment, and selection of risk reduction interventions for falls prevention.

Risk factors for falls can be intrinsic or extrinsic to the patient.   Major intrinsic risk factors for 2 or more falls over 6-12 months are generally related to neurologic diseases (eg, Parkinson disease, stroke) and major neurocognitive disorders such as dementia, which may not be modifiable.  Factors defining the frailty phenotype (unintentional weight loss, self-reported exhaustion, muscle weakness, slow walking speed, and low physical activity) are associated with falls in an additive manner.  Other moderate risk factors, including visual and hearing impairment, pain, and orthostatic hypotension, are potentially modifiable.

Medications are the most common modifiable extrinsic risk factor for falls, particularly psychoactive, anticholinergic, cardiovascular (particularly loop diuretics), and analgesic medications.  High-quality studies suggest an association between environmental hazards and recurrent falls, particularly when the hazard interferes with function (eg, low seats).  Poor lighting and tripping hazards (eg, rugs) are other common environmental risk factors.  Walking barefoot or in stockings markedly increases the risk of falls while athletic shoes (sneakers) are associated with a lower risk compared with other shoes.

Most clinical practice guidelines suggest risk stratification for adults > 65 using a combination of fall history (eg, “Have you fallen in last 12 months?”), subjective fear of falling, and a mobility screening test such as Timed Up and Go (TUG) test or gait speed measurement.  For those with prior falls, fear of falling, and/or abnormal TUG or gait screening test, guidelines recommend a targeted clinical assessment to identify modifiable factors.  Recommended physical examination includes assessments for sensory impairment (eg, hearing, vision, neuropathy), orthostasis, foot deformities, and gait abnormalities.  A more detailed gait and balance evaluation to guide need for assistive devices such as canes and walkers and/or rehabilitation services can be completed in primary care using the Short Physical Performance Battery (SPPB) (gait speed measurement, 3-stage balance test, and chair stand test), or by referral to a physical therapist.  

General categories of interventions tested for fall prevention include exercise programs to improve leg strength and balance, vision interventions, home environmental modification, deprescribing programs, podiatry interventions, multifactorial interventions (ie, systematic risk factor assessment followed by tailored intervention targeting multiple modifiable factors), and multicomponent interventions (ie, fixed combinations of interventions provided to all patients).  Gait and balance training by physical therapy is generally covered by Medicare.  Durable medical equipment such as canes, walkers, and commode chairs are covered under Medicare Part B for specific diagnoses with a 20% co-pay, and some Medicare Advantage plans also cover additional home safety equipment such as tub chairs and grab bars, although plans vary widely.  

Many older adults are able to access balance and functional exercise classes through community- funded programs or Silver Sneakers, a fitness program for adults > 65 that provides access to gyms, community exercise classes, and exercise videos, and is fully covered by most Medicare Advantage and some other insurance plans.  Home safety checklists are available for patients and families to use to identify environmental hazards, although their effectiveness is unclear. The CDC offers a clinician toolkit and patient education materials, and many state or area councils on aging curate lists of local fall prevention community resources.

In December of 2023 the USPSTF published draft updated recommendations for interventions for falls prevention in community-dwelling older adults > 65.  The draft recommends exercise interventions to prevent falls for those who are at increased risk (B) and recommends that clinicians individualize the decision to offer multifactorial interventions to prevent falls based on individual patient context (C). 

Mark’s Comments:

Advising our patients to move more while moving safely is certainly something that we should be advising for practically all of our elderly patients.  This resource on exercises for falls prevention from the National Council on Aging comes with video links for each recommendation and is one of many resources that can help guide your advice.  Encouraging participation in community-funded exercise programs adds the element of socialization, which is preferred when possible.  And remember to take advantage of your time during Medicare Annual Wellness visits to both counsel and educate your patients to minimize their risk of falling.

References:

• Colon-Emeric C, et al. Risk Assessment and Prevention of Falls in Older Community-Dwelling Adults: A Review. JAMA published online March 27, 2024.  doi:10.1001/jama.2023.2694.  Link
• USPSTF. Falls Prevention in Community-Dwelling Older Adults: Interventions.  Draft Recommendation Statement.  December 5, 2023.  Link

From the Literature

2)  Exercise for Depression

Exercise, or at least physical activity, has shown up in many guidelines about the management of depression in primary care. The MacArthur Foundation Initiative on Primary Care and Depression at the nearest turn of the century included exercise as one of its key depression self-management recommendations. And yet, the evidence behind exercise for depression has been scant, low-quality, and lacking in detail about dose or intensity. A recent systematic review has attempted to create the most recent summary of the evidence. The authors used network meta-analysis to deal with the effect of different modalities of exercise to avoid having to combine them to facilitate the usual analyses.

The investigators searched multiple databases, had specific and realistic inclusion criteria (major depression either clinically diagnosed, or by validated self-report scale), assessed the included studies for their validity (using Cochrane’s risk of bias tool), and assessed the body of evidence for excessive heterogeneity (aided by a newer method that uses “prediction intervals” which works better with network meta-analyses). They did not report a search for unpublished data.

Two hundred and forty-six reports of 218 studies, including 14,170 participants were included. Because most studies did not blind either the participants or research staff, they were judged as at least low and most often very low quality, which ultimately affects the certainty of the conclusions of this review. Large effects in depression reduction were found with dance. Moderate effects were found with walking/jogging, yoga, strength training, mixed aerobic exercise, and tai chi/qigong. Cognitive behavioral therapy was in the middle of the moderate effect group, the combination of exercise + SSRI followed behind that.  SSRI therapy alone was the least effective intervention studied, with only a small effect. However, all these comparisons are somewhat tentative – studies sometimes studied effects in only one sex, or under-reported factors like age. The best evidence was associated with walking/jogging (though still at a “low” rating). All other comparisons were at a “very low” evidence rating.

There was a clear and consistent dose-response curve to exercise – the higher the intensity, the more the effect. The best exercise for women and for younger patients was strength training. For men and older patients, it was yoga/qigong. There was statistically significant publication bias in the evidence, but not enough to alter the findings.

John’s Comments:

The evidence about exercise and depression still feels slightly “soft” in places and its magnitude of effect might change in the future, but the association is definitely there. I try to discuss several self-management recommendations with my patients with depression, and exercise is always included – mainly because it has so many other benefits – if we’re wrong about its effect on depression, it’s still beneficial in many other ways! The benefit of exercise appears to be greater than SSRIs in this study, which ought to give us some pause…

Reference:

·         Noetel M, Sanders T, Gallardo-Gómez D, et al. Effect of exercise for depression: systematic review and network meta-analysis of randomised controlled trials. BMJ. 2024;384:e075847. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  How Will You Spring Forward in the Coming Months?

"I have great faith in a seed.... Convince me that you have a seed there, and I am prepared to expect wonders." — Henry David Thoreau

I don’t know about you, but I’m quite grateful that spring has finally arrived.  This change of seasons provides a dramatic and symbolic contrast from the colder, dark and more monotone backdrop of winter to the warmer, lighter, burst-of-senses palette of spring, and with it, a chance to do some personal and professional reflection.

Recall that a vital component of the PeerRxMed process is the PRx90 quarterly check-in (“up to 90 minutes every 90 days”) intended to provide a deliberate space for reconnecting with yourself and your PeerRx partner.  Here’s a reminder of that Process.   It’s time to schedule that quarterly meeting once again.  To help guide your dialogue, consider these standard quarterly questions as well as a few others below:   

• What have you learned about yourself over the past 3 months?
• What are your top personal/professional goals and priorities over the next three months?  What is one that will cause disappointment if you have not accomplished it when we meet again in 3 months?
• When’s your next vacation / adventure / break?  What will you do that will be fun for you?

In the spirit of the season, here are some additional questions for personal reflection and sharing around two traditional activities of spring:

Spring Cleaning: 

Consider how some internal and external “spring cleaning” of your life might be useful as you begin to prepare for the next few months.  What needs to be cleaned up and what given or thrown away?  What habits or patterns have you accumulated that you no longer need or have outgrown?  What is “cluttering up” your life in terms of over-commitments or mindless activity?  What parts of you need some “sprucing up” through a change in pattern of diet, exercise, sleep, or even making an appointment for routine medical care?

Spring Planting: 

Consider what type of seeds you would like to plant in your personal and professional life that could lead to a bountiful harvest in the next 4-6 months.  Is there a specific “crop” you need to prioritize?   What tools and resources do you need to ensure your growth goes as planned?   What is your personal equivalent of water and sunlight that you will need?   How will you schedule regular “weeding”?

Don’t squander this incredible opportunity for spring cleaning and planting.  Schedule some personal reflection time as well as time with your PeerRx partner.  As you look back 3 months from now, you’ll be glad you did.

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  A “Polypill” for Cardiovascular (CV) Risk Reduction

The notion of a “polypill” traces back to an article in the BMJ in 2003 by two epidemiologists, who wrote it up as a thought experiment. Then some researchers in India decided to try it, and we were off to the races! After 700+ Medline citations and several large randomized controlled trials in the interim, it is now pretty serious business.

Researchers in Iran performed this recent polypill study. They designed a cluster randomized trial (randomizing 91 villages) in the entire southern district in Iran to deliver education about healthy lifestyle vs. lifestyle education plus a polypill for everyone aged 50 and over. The polypill contained hydrochlorothiazide 12.5 mg, aspirin 81 mg, atorvastatin 20 mg, and enalapril 5 mg (people who developed cough got a formulation with valsartan 40 mg instead of the enalapril). Blood pressures were measured at baseline, and anyone with hypertension were referred to primary care for treatment (in addition to their study condition treatment), and clinicians were asked to adjust doses of any other medications to account for the ingredients of the polypill. The primary outcome was first occurrence of a major adverse cardiovascular outcome (MACE): non-fatal myocardial infarction, unstable angina, fatal myocardial infarction, non-fatal and fatal stroke, sudden death, or heart failure.

They recruited 4,415 subjects to the trial, mean age 59.9 years, and 55% female. Over the 5 years of the trial, the risk of MACE was reduced from 8% in the control group to 4% in the intervention group (absolute risk reduction 4%, 95% confidence interval 2.5% to 5.3%, number needed to treat ~ 25,). The effect was the same in both primary (lower-risk) and secondary (higher-risk) prevention patients (which is unusual, most ). Most of the difference in MACE was due to a reduction in non-fatal cardiovascular disease events, and there were no differences in any of the mortality rates (of course, the study was not powered to show them if they were present). Blood pressure (both systolic and diastolic) decreased in the intervention group dramatically at year 2, but control BP decreased also until at the end of year 5, there was no difference in BP between groups. There were tolerability issues of dyspepsia, nausea, etc. with the polypill, but the rate of intracranial hemorrhage was similar in both groups and there were no gastrointestinal hemorrhages or renal failures in the polypill group.

John’s Comments:

I love the idea of a polypill – it’s like House, MD meets Bertie Botts’ Every Flavor jellybeans. My specific reasons:

• It helps to overcome the limitations of traditional clinical health systems in impacting cardiovascular disease in the population. There’s much less cholesterol-checking, co-pays, and sitting quietly for 5 minutes to retake your blood pressure for a fairly large benefit.
• It works for both primary and secondary prevention and is cheap and easy.
• It can be given, as this study shows, in addition to routine medical care. It may even help overcome the therapeutic inertia that is often seen in patients with borderline risk levels.
• It makes an important pharmacologic point about the relative effectiveness of the first doses of most medications; that small doses of multiple different drugs may be more effective than pushing the dose of a single medication.
• I don’t think the polypill will ever catch on in the US – it doesn’t match our desire for high-tech solutions and (overly-) personalized medicine. My one beef with polypills is that they are, sadly, just a roughly equivalent substitute for a Mediterranean diet and regular physical activity.

References:

• Malekzadeh F, Gandomkar A, Poustchi H, et al. Effectiveness of polypill for primary and secondary prevention of cardiovascular disease: a pragmatic cluster-randomised controlled trial (PolyPars). Heart. Published online March 14, 2024. Link
• Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ. 2003;326(7404):1419. Link

From the Literature

2)  The Health Impacts of Ultra-processed Foods

Ultra-processed foods, as defined using the Nova food classification system, encompass a broad range of ready to eat products, including packaged snacks, carbonated soft drinks, instant noodles, and ready-made meals.  These products are characterized as industrial formulations primarily composed of chemically modified substances extracted from foods, along with additives to enhance taste, texture, appearance, and durability, with minimal to no inclusion of whole foods.  Analyses of worldwide ultra-processed food sales data and consumption patterns indicate a shift towards an increasingly ultra-processed global diet.  In the US, the share of dietary energy derived from ultra-processed foods is estimated to be 58%, the highest in the world (compared to 10% in Italy and 42% in Australia).  Notably, over recent decades, the availability and variety of ultra-processed products sold has substantially and rapidly increased in countries across diverse economic development levels, but especially in many highly populated low- and middle-income nations.

The specific features of ultra-processed foods raise concerns about overall diet quality and the health of populations more broadly. For example, some characteristics of ultra-processed foods include alterations to food matrices and textures, potential contaminants from packaging material and processing, and the presence of food additives and other industrial ingredients, as well as nutrient poor profiles (for example, higher energy, salt, sugar, and saturated fat, with lower levels of dietary fiber, micronutrients, and vitamins).  Although mechanistic research is still in its infancy, emerging evidence suggests that such properties may pose synergistic or compounded consequences for chronic inflammatory diseases and may act through known or plausible physiological mechanisms including changes to the gut microbiome and increased inflammation.

No comprehensive umbrella review has offered a broad overview and assessment of the existing meta-analytic evidence on potential adverse health outcomes from ultra-processed food consumption.  To bridge this gap in evidence and contribute to the ongoing discussion on the role of ultra-processed food exposure in chronic diseases, a recent umbrella review was published. 

The review included 45 distinct pooled analyses, encompassing a total population of almost 10 million participants and spanning seven health parameters related to mortality, cancer, and mental, respiratory, cardiovascular, gastrointestinal, and metabolic health outcomes.  Across the pooled analyses, greater exposure to ultra-processed foods, whether measured as higher versus lower consumption, additional servings per day, or a 10% increment, was consistently associated with a higher risk of adverse health outcomes (71% of outcomes).

The authors found the strongest available evidence pertained to direct associations between greater exposure to ultra-processed foods and higher risks of all-cause mortality, cardiovascular disease related mortality, common mental disorder outcomes, overweight and obesity, and type 2 diabetes. Evidence for the associations of ultra-processed food exposure with asthma, gastrointestinal health, some cancers, and intermediate cardiometabolic risk factors was limited and the authors felt warranted further investigation.  They concluded that the findings provided a rationale to develop and evaluate the effectiveness of using population based and public health measures to target and reduce dietary exposure to ultra-processed foods for improved health.  They also call for urgent research on causative mechanisms. 

Mark’s Comments:

This data is sobering, and in particular for “Western” and “Westernizing” countries.  Ultra-processed foods, including breads, cookies, savory snacks, reconstituted meat products, milk-based drinks, breakfast cereals, juices and sodas, and frozen and ready-to-eat meals tend to be high in refined carbohydrates and added fats are highly rewarding, appealing, and when consumed compulsively, may be addictive.  There is an entire body of science behind the creation of these foods that is highlighting some of our evolutionary programming regarding our drive to eat.  Unless we are very conscious about countering this programming, these trends do not bode well for our future health as individuals and as a society. 

Reference:

Lane M, et al.  Ultra-processed food exposure and adverse health outcomes: umbrella review of epidemiological meta-analyses. BMJ 2024;384:e077310 (Published online 28  February 2024.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Say It Now!  Gratitude is for Sharing, Not Saving

“The deepest principle in human nature is the craving to be appreciated.”  William James, MD, considered to be the “Father of American Psychology”

His smile of surprised glee radiated as we put a “Birthday Prince” hat (with the two “s’s” crossed out) and golden cape on our friend and colleague and seated him at the head of the table.  The occasion was a “significant decade” birthday, and six of us had gathered to celebrate this time with him.

Our celebration, however, was going to be different than the typical birthday party.  Though there were silly hats and some singing (accompanied by a ukelele), we all had come ready to honor him very intentionally.  In preparation for the celebration, we each took time to reflect on what he had meant to us using the following guidance: 

• Remembering the first time we met him or a formative time early in our getting to know him
• A quality we admired in him
• Something about him that we found endearing or cracked us up
• A story about how he had positively impacted our life or something that he has taught us
• Our hopes for him for the next 5 years accompanied by a representative small gift of some sort (funny was preferred over serious, though meaningful symbols were encouraged as well)

And now, between appetizers and drinks, we were going around the table, one question at a time, and sharing our sentiments.  There was much laughter, meaningful heart-felt  stories, and a deep sense of admiration and love.  It was an incredible time and a forever memory for all who were there.

Our gathering was inspired by the "Say It Now" movement, which was launched in 2022 by founder Walter Green after he noted how often we wait to honor and share our deepest admiration and gratitude for others until the “end,” whether that “end” be in retirement, on their death beds, or most tragically, at their funerals.  His intention was to change how and when we express gratitude for the people who’ve meant so much in our lives – from too late to right now, by providing encouragement and simple tools to help facilitate our expressions of gratitude.  Whether expressed in writing, verbally, or as a group event, he believes that letting someone know how much you appreciate them can become a transformative experience – for their life and yours!  

I believe that as well, and experienced it once again during our recent celebration.   Which leaves me wondering, what important people in each of our lives don’t know how much they are appreciated – what they mean to us and how they’ve positively impacted our lives?  As Walter Green has said, “There is no benefit in waiting – this is the moment!”  Give them, and you, a wonderful gift.  Say it now …

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  Guideline for Diagnosis and Management of PTSD

The experience of a traumatic incident – serious accident, assault, war exposure, or disaster - is unfortunately pretty common among US adults, estimated at 70% of the population. Fortunately, only a fraction of those (in the non-military population) develops fully-diagnosed post-traumatic stress disorder (PTSD) – 4% in men, 8% in women.

The US Department of Defense (DoD) and the Veteran’s Administration (VA) have joined forces to produce some of the better evidence-based guidelines for a variety of common conditions since the early 2000s. The first iteration of this guideline on PTSD was published in 2017 and has now been updated.

DoD/VA guidelines generally follow the National Academy of Medicine’s recommendations for trustworthy guidelines closely. This guideline used precise clinical questions, a rigorous evidence search, and GRADE (a widely accepted evidence rating and recommendation system) to formulate their recommendations. In addition, there was a rigorous conflict of interest policy for the guideline members.

The primary care-relevant recommendations, with strength of recommendation in [ ] are:

·         Screen for PTSD using the Primary Care Screener for PTSD for DSM-5 [weak].

·         Formally diagnose PTSD and follow its course using a structured interview tool (CAPS-5 or PSSI for diagnosis, CAPS-5 or PTSD Checklist for DSM5 for monitoring) [weak].

·         For patients diagnosed with acute stress disorder (ASD) after trauma, cognitive behavioral therapy can prevent PTSD [weak]. No other intervention (including medications) has been shown to prevent it.

·         Psychotherapy is recommended over pharmacotherapy for treatment of PTSD generally [strong]:

o   Cognitive processing therapy, eye movement desensitization and reprocessing and prolonged exposure are [strong] recommendations.

o   Ehlers cognitive therapy, present centered therapy, or written exposure therapy are supported by [weak] evidence.

o   Telemedicine delivered versions of the above therapies are recommended if needed if that therapy has been validated for telemedicine [strong].

·         Pharmacotherapy, if needed:

o   Paroxetine, sertraline, or venlafaxine are recommended [strong].

o   Avoid benzodiazepines and cannabis [strong].

o   Avoid divalproex, guanfacine, ketamine, prazosin, risperidone, tiagabine, vortioxetine and any of the atypical antipsychotics [weak].

o   Prazosin can be useful for nightmares [weak].

·         Non-pharmacologic therapy:

o   Consider mindfulness-based stress reduction (MBSR) [weak].

o   Avoid electroconvulsive therapy and vagus nerve stimulation [weak].

·         Co-occurring substance use disorder or other behavioral disorders do not preclude the psychotherapies listed above [weak].

·         Many other treatments are listed in the guideline, but anything not mentioned here had insufficient evidence to recommend for or against.

John’s Comments:

For the screening and diagnosis tools mentioned, go to the VA’s PTSD site (some require registration). “Screening” for PTSD is not well explained here. It presumably does not mean universal screening, but initial testing when a history of trauma is present and there are suggestive symptoms. The preferred treatment is psychotherapy but, often, when we refer for counseling, we get the techniques the counselor is most familiar with and feels would work best. Still, it can’t hurt to ask for the specific techniques listed above. We can treat a lot of PTSD in primary care – most of the therapies are well within our scope if we have psychotherapy referral available (and I know that’s a big “if”).

Reference:

·         Schnurr PP, Hamblen JL, Wolf J, et al. The Management of Posttraumatic Stress Disorder and Acute Stress Disorder: Synopsis of the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline. Ann Intern Med. 2024;177(3):363-374. Link

From the Literature and the American College of Cardiology (ACC)

2)  Heart Failure with Reduced Ejection Fraction (HFrEF) 2024

In the US, approximately 115 million people have hypertension, 100 million have obesity, 92 million have prediabetes, 26 million have diabetes, and 125 million have atherosclerotic CVD.  These are known risk factors for development of HF, which places a large portion of the US population for at-risk or stage A HF.  It is estimated that presently almost 7 million US adults have HFrEF.

In 2022, three cardiology professional societies published a joint updated guideline on the management of HF.  The guideline was intended to provide patient-centric recommendations to prevent, diagnose, and manage patients with HF.  As follow-up to this, the American College of Cardiology (ACC) recently updated their 2021 expert consensus decision pathway (ECDP) for those with heart failure with reduced ejection fraction (HFrEF = left ventricular ejection fraction [LVEF] ≤40%) that is intended to provide more practical guidance on introducing the numerous evidence-based therapies, improving adherence, overcoming treatment barriers, acknowledging contraindications and situations for which little data exist, affording expensive therapies, treating special cohorts, and making the transition to palliative care.  The document focuses primarily on the management of patients with chronic HFrEF in the ambulatory setting and without symptoms or signs of clinical instability.

As a reminder, some notable highlights from the 2022 HF guideline include:

·         New classifications for HF include HF with preserved ejection fraction (HFpEF = EF >50%), HF with mildly reduced EF (HFmrEF = EF 41-49%), HF with reduced EF (HFrEF = EF <40%).  An additional category, HF with improved EF (HFimpEF) refers to patients with previous HFrEF who now have an LVEF >40%.

·         For suspected or new-onset HF, or those presenting with acute decompensated HF, a CXR and a transthoracic echocardiography (TTE) should be performed.

·         In patients presenting with dyspnea, measurement of B-type natriuretic peptide (BNP) or N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) is useful to support a diagnosis or exclusion of HF.  In patients with chronic HF, BNP or NT-proBNP levels are recommended for risk stratification. 

·         Guideline-directed medical therapy (GDMT) for HFrEF now includes 4 medication classes: a sodium-glucose cotransporter-2 inhibitors (SGLT2i), a beta-blocker, a mineralocorticoid receptor antagonist (MRA - spironolactone), and a renin-angiotensin system (RAS) inhibitor (ACEi, ARB, or ARNi - angiotensin receptor-neprilysin inhibitor: sacubitril/valsartan - Entresto). 

·         Patients with HFimpEF should continue their HFrEF treatment.

·         In patients with HF who have fluid retention, a loop diuretic is recommended to relieve congestion, improve symptoms, and prevent worsening HF.

The new 2024 decision pathway emphasizes that for the person with de novo HFrEF, therapies should be initiated with a goal of reaching target or maximally tolerated doses of the 4 key medication classes as soon as possible, and ideally no longer than 3 months.  Since there is no optimal order of initiation and/or titration, clinicians will need to individualize treatment based on the comprehensive clinical and social picture.  Table 1 in the document provides helpful guidance on the starting and target doses for medications in each drug class.  

The decision pathway also notes some guiding principles which can improve decision-making for and adherence to GDMT.  These include:

·         GDMT is the foundation of HF care

·         Start GDMT immediately and titrate during each encounter.

·         Target doses are associated with best outcomes.

·         Prioritize addressing clinical, social, and financial barriers to achieving GDMT.

·         Diligent management of volume status will reduce patient symptoms.

·         Tolerability and side effects depend, in part, on how and when GDMT is prescribed.

·         Focus on the patient’s symptoms, functional capacity, and cardiac function. 

·         The value of a therapy to a patient is the combination of benefits and burdens as they relate to that patient’s values, goals, and preferences. 

·         Team-based care is critical to optimizing GDMT and may include frequent follow-up visits, telehealth visits, and remote monitoring.

Mark’s Comments:

The decision pathway has some useful tables/algorithms for future reference and provides helpful guidance for med management.  My criticism is while it makes a point of discussing access to medications, it downplays just how challenging it is for many to be able to afford some of the medications for GDMT, and in particular any of the SGLT2-inhibitors as well as sacubitril/valsartan (Entresto).  

References:

·         Heidenreich P, et al.  2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report sof the ACC/AHA Joint Committee on Clinical Practice Guidelines.  J Am Coll Cardiol. Apr 01, 2022.  Full Guideline  Executive Summary

·         Maddox T et al.  2024 ACC Expert Consensus Decision Pathway for Treatment of Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight.   J Am Coll Cardiol. Mar 08, 2024  Link

From PeerRxMed ( www.PeerRxMed.org )

3)   The Secret of Living Well?  Let’s Wonder Together …

“Perhaps the secret of living well is not having all the answers, but in pursuing unanswerable questions in good company.”  Rachel Naomi Remen, MD

One of my favorite words is “wonder,” especially the interplay between two of its definitions – to marvel (“wow!”) and to question (“how?”).  When I pay attention to this combination of awe and curiosity, magical “surprises” regularly show up for me.  And when this happens, I predictably find myself wanting to share these experiences with others.

This is particularly true for my clinical work.  The complex workings of the human body and its many manifestations of health and disease overflows with wonder.   When I am present and attentive, there are numerous “wonder-filled” moments during my day.  This is likely true for you as well.  However, in the day-to-day busyness and isolated nature of work, it is easy to put our heads down and just plow through and in the process, not only miss these moments but also the opportunity to share them.  Which has left me pondering how I/we might transcend this pattern. 

Recently, while working with one of our 3^rd year medical students, I decided to very intentionally look for opportunities to embrace this sense of wonderment, and to invite him into that space with me.  During one clinical session, we cared for a 100-year old great-great grandmother who shared pictures and stories of her newborn great-great granddaughter, diagnosed hyperthyroidism in a 19-year old with a significantly enlarged thyroid who has likely had it for at least a year, heard the story of a man who had lost 50 pounds in the past 6 months by changing his diet, I&D’d an abscess to profuse thanks, and discussed two instances where cognitive “anchoring bias” had likely led to misdiagnoses.  By the end of our time he was wide-eyed with marveling and questioning.  It was an exhilarating time that left me reflecting just how different that same clinic would have been had we not shared these moments together.   

In her poem "Sometimes", Mary Oliver writes about how to bring more wonder into our days with 7 words of simple yet profound wisdom that she called “Instructions for living a life”:

Pay attention.

Be astonished.

Tell about it.

Each day we have the opportunity to both embrace our amazing professional journey and also to share it with those around us – not only students, but also colleagues, nurses, and even patients.  Too often, however, the nature of our work and the manner in which we carry it out leaves our sense of wonder neglected and dulled.  Over the next 3 weeks, consider setting an intention of sharing one wonder-full thing a day with someone – perhaps starting with your PeerRx partner.  Through pursuing meaningful connection to “marvel and question” together, perhaps the “secret” of living well will no longer be such a secret after all.    

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  Continuous Blood Glucose Monitoring

The indications for continuous glucose monitoring (CGM) have broadened from Type 1 diabetes only to now include Type 2 diabetes (T2DM). The evidence for improved glycemic control has been established for type 1 diabetes but has been inconsistent in Type 2. There are three types of CGM:

• real-time (rt) CGM, where users get continuous updates of their glucose levels,
• retrospective (or professional) CGM, where glucose levels are recorded continuously, but the patient does not see the readings until they are downloaded after a week or two (this review does not address these), and
• intermittent scan (is) CGM, where patients must manually wave a reader over the sensor to obtain data.

The authors of a new systematic review in the American Diabetes Association’s journal Diabetes Care wanted to summarize the available evidence for CGMs in T2DM. They performed a reasonably comprehensive search, had explicit inclusion criteria which included a requirement of at least 8 weeks of use of the CGM. Change in hemoglobin A1c (HgbA1c) was the primary outcome, and there were several other lab and clinical outcomes listed as secondary. Studies were evaluated with the Cochrane Risk of Bias tool and they appropriately assessed heterogeneity in the study data.

Twenty-nine articles were found about 26 studies. There were 17 trials of rtCGM and 9 trials of isCGM both vs. self-measured blood glucose (SMBG) readings by fingerstick. The articles were generally at low risk of bias. The range of baseline HgbA1c was 6.6 to 9.9% and the rest of the patients seemed appropriately diverse with respect to age and medications.

For rtCGM, there was a drop of -0.19% (95% confidence interval (CI) -0.34 to -0.04%) and for isCGM, there was a drop of -0.31% (95% CI -0.46 to -0.17%) both compared to usual care/SMBG. These results did not vary by time of treatment, treatment type, baseline A1c level or other factors. There were no changes in body weight or other clinical outcomes. Small groups of included studies showed some additional benefit for isCGM over rtCGM on “time in range” of blood glucoses. In terms of safety, both rtCGM and isCGM had more device and all-cause adverse events, but not glucose-related adverse events. Patients’ satisfaction scores were better than SMBG with isCGM and worse than SMBG with the rtCGM. The authors note the limitations of lack of standardization in outcomes across the included studies as well as the short duration of CGM use (8-34 weeks). All the authors have received funding from various device manufacturers and other industry sources, but state that the study design and reporting were not influenced by industry.

The ADA standards of care recommend CGM use (either type, but they rate the evidence better for rtCGM) for patients with type 2 diabetes who are on multiple daily insulin injections or a single basal insulin injection. They recommend, based on expert opinion only, CGM for youth with type 2 diabetes if they are capable of using it correctly.

John’s Comments:

The authors also note that this is a rapidly involving field of both technology and evidence, so conclusions like safety can change rapidly as the technology improves; do not interpret these findings as settled evidence. Noting the better results from isCGM than rtCGM reminds me a lesson we encounter repeatedly in medicine – that more information is not always better than just some information. It may be that the requirement to actively swipe the monitor in isCGM leads to more attention to blood sugar levels. For now, the evidence points most strongly to using isCGM in patients on insulin who are capable of using it correctly and safely.

References:

• Seidu S, Kunutsor SK, Ajjan RA, Choudhary P. Efficacy and Safety of Continuous Glucose Monitoring and Intermittently Scanned Continuous Glucose Monitoring in Patients With Type 2 Diabetes: A Systematic Review and Meta-analysis of Interventional Evidence. Diabetes Care. 2024;47(1):169-179. Link
• American Diabetes Association Professional Practice Committee. 7. Diabetes Technology: Standards of Care in Diabetes—2024. Diabetes Care. 2023;47(Supplement_1):S126-S144. Link

From the Literature and the American College of Rheumatology (ACR)

2)  Gout Refresher

Gout is the most common form of inflammatory arthritis, affecting more than 12 million adults in the US.   Acute gout is caused by accumulation of monosodium urate crystallization in the joints, typically due to chronic hyperuricemia, with serum urate levels exceeding the saturation point of approximately 6.8 mg/dL for monosodium urate crystallization in the body.  While the etiology of gout is well-understood and there are effective and inexpensive medications to treat it, gaps in quality of care persist.  A treat-to-target management strategy that includes urate lowering therapy (ULT) dose titration measurements to achieve and maintain a target serum urate (SU) level of <6mg/dl is strongly recommended by the American College of Rheumatology (ACR) for over 2 decades.  Despite this, there has been no increase in ULT utilization.  Adherence to ULT remains poor as well. 

How much does “treating to target” matter?  A recently published retrospective study using the UK Biobank data base assessed the associations of a single serum urate measurement with subsequent risk of acute gout flares among patients in the UK with a history of gout.  Among 3613 patients with gout (mean age, 60 years; 3104 [86%] men), over a mean follow-up of 8.3 years, 95% of gout flares occurred in people with baseline serum urate > 6 mg/dL and 98% got those with a baseline serum urate greater > 5.  Rates of acute gout flares per 1000 person-years were 10.6 for participants with urate levels < 6, 40.1 for levels of 6.0 to 6.9 mg/dL, 82.0 for levels of 7.0 to 7.9 mg/dL, 101.3 for levels of 8.0 to 8.9 mg/dL, and > 120 for urate levels > 9.  So it appears maintaining lower serum urate levels matters to prevent acute flares.

In 2020, the American College of Rheumatology (ACR) published updated guidelines for the treatment of gout.  Below are some pertinent reminders: 

• Initiating pharmacologic urate lowering therapy (ULT) is strongly recommended for gout patients with any of the following: ≥1 subcutaneous tophi; evidence of radiographic damage (any modality) attributable to gout; OR frequent gout flares, with frequent being defined as ≥ 2 annually and conditionally recommended for patients who have previously experienced >1 flare but have infrequent flares (<2/year).
• Initiating ULT is conditionally recommended for patients with experiencing their first flare when comorbid moderate-to-severe CKD (stage ≥3), SU concentration >9 mg/dl, or urolithiasis is present.
• Initiating ULT is conditionally recommended against in patients with asymptomatic hyperuricemia. (NNT – 24 to prevent 1 flare over 3 years)
• Treatment with the xanthene oxidase inhibitor allopurinol as the preferred first-line agent, over all other ULTs, is strongly recommended for all patients, including those with moderate-to-severe CKD (stage ≥3). 
• Starting treatment with low-dose allopurinol (≤100 mg/day and lower in patients with CKD [stage ≥3]) with subsequent dose titration is strongly recommended.
• Administering concomitant anti-inflammatory prophylaxis therapy (e.g., colchicine, nonsteroidal anti-inflammatory drugs, prednisone/prednisolone) over no anti-inflammatory prophylaxis therapy is strongly recommended.
• Continuing concomitant anti-inflammatory prophylaxis therapy for 3–6 months over <3 months, with ongoing evaluation and continued prophylaxis as needed if the patient continues to experience gout flares, is strongly recommended.
• Continuing ULT indefinitely over stopping ULT is conditionally recommended.
• Switching hydrochlorothiazide to an alternate antihypertensive when feasible is conditionally recommended for patients with gout, regardless of disease activity.
• Using NSAIDS, colchicine, or glucocorticoids (oral, intraarticular, or intramuscular) as appropriate first-line therapy for gout flares is strongly recommended.
• Given similar efficacy and a lower risk of adverse effects, low-dose colchicine (no more than 1.8 mg/day on day 1, then 0.6 mg qd/bid subsequently) over high-dose colchicine is strongly recommended when colchicine is the chosen agent.
• When the decision is made that ULT is indicated while the patient is experiencing a gout flare, starting ULT during the gout flare over starting ULT after the gout flare has resolved is conditionally recommended.

Mark’s Comments:

The ACR has been consistent in their guidance to treat to target with allopurinol for most patients who are candidates for gout treatment.  Though recommended for quite some time, my experience is that most patients who are started on medication are not followed-up for serum uric acid monitoring.  Reframing recurrent gout as a chronic disease may help us think differently about how we treat and monitor it.  A 1-month supply of allopurinol is presently < $10 and colchicine < $25 from GoodRx.

Note that if an NSAID is chosen for treatment, all prescription strength NSAIDs appear equally effective in optimum doses for treatment of acute gout and there are choices with a safer side-effect profile than indomethacin.  Note as well that “pushing colchicine to diarrhea,” which some may have learned during their training, is discouraged. 

Remember that when appropriate treatment is started within 24 hours of a flare, it will usually resolve in 2-3 days, whereas waiting will often result in the necessity of treating for a much longer period of time.  This means we need to be educating our patients with recurrent gout to not wait to contact/see us prior to starting treatment and to be sure they have their medications available. 

References:

• FitzGerald JD et al. 2020 American College of Rheumatology Guideline for the Management of Gout.  Arthritis & Rheumatology June 2020. 1-17.  Link
• McCormick N et al.  Serum Urate and Recurrent Gout.  JAMA. 2024;331(5):417-424. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Practicing What We Profess:  Haven’t Got Time?

“Why is it that giving myself a break feels like such a big deal!?”  Me

For multiple reasons, it’s been a rough few weeks physically and emotionally for me.  In the midst of that, I asked one of my PeerRx buddies, “Why is it that giving myself a break feels like such a big deal!?”

“Sounds like you need some self-compassion,” they replied with a smile.  “Perhaps you need to go back and read your previous blog on that.”   And then they challenged me, “Why don’t you just take a week off from writing a blog entry?”

While I couldn’t find a good reason, I did find a reason; “That’s just not what Mark does.” 

They laughed, and replied, “Is it too late for Mark to change?” 

My answer is contained in the poem below, written as a “message from my Soul” in response to my recent challenges.  Where might you need to give yourself a break?  If doing so seems like a “big deal,” consider the cost of not doing so.  That’s likely a way bigger deal.  It certainly has been for me.  Here’s to making some regular time for self-compassion, and then remembering ….

Haven’t Got Time

“I haven’t got time for the pain,” she sang

like the voice on the radio

 from long ago

though the music

     was all in my head …

and as she continued,

I told my pain

neither do I

but the pain

didn’t seem

     to care …

 nor did

the

 time.

“Suffering, was the only thing that

made me feel I was alive,”

   she persisted ….

Fortunately a Voice

of self-compassion

interrupted,

encouraging me

yet once again

to recognize that

this background music,

now the soundtrack of

my present suffering,

was simply residual

noise from my past

and was no longer

                                enlivening … if it ever was ….

So I turned down the volume,

hoping this time

 to remember,

until I next

forget

I really haven’t

got

time

.

.

.

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1) Respiratory Viruses – Prevention and Control

Given the recent recognition of the “triple threat” seasonal illnesses – COVID-19, influenza, and respiratory syncytial virus – the CDC has issued general guidance about respiratory virus prevention and control. None of this should seem particularly new to us, but the recommendations are an important reminder for use in our workplaces as well as the treatment of our patients.

It is important to remember that respiratory viruses, while we do not often acknowledge their prevalence and consequences, are responsible worldwide for 3 to 5 million cases of severe illness, and about 290,000 to 650,000 respiratory deaths (PAHO.org), especially in people with immune compromise and at extremes of age. The CDC offers some straightforward measures to prevent and control these illnesses:

1.    Immunization – A cheap, readily available intervention that can reduce community transmission and decrease complications and hospitalizations from respiratory viruses. (see new COVID-19 vaccine recommendation below).

2.    Hygiene – handwashing (also prevents rotavirus!), covering coughs and sneezes and cleaning surfaces.

3.    Ventilation – we know this lesson from tuberculosis, but it is good advice for respiratory viruses – air circulation, outside activities and air purification can all decrease person-to-person spread of pathogens.

4.    Stay home when you’re sick – We and our patients are conditioned to show up to work if only mildly ill. Advocate and model responsibility and protect your colleagues and patients – stay home when you are ill. The CDC recently reduced the isolation time required for COVID-19 to align more with the typical recommendations for influenza, but this does not apply for healthcare workers yet.

5.    Wear a mask when appropriate – if nothing else, the COVID-19 pandemic taught us how to wear masks. If your patient has a respiratory illness, there is no logical reason for either of you to go without a mask – especially in a crowded, small examination room. Societally, they seem to be more accepted generally now (at least from my trips to the grocery store), which is helpful.

6.    Physical (not social) distancing – Simple aerodynamics – staying away from crowds during times of high illness prevalence – will reduce the chance you get sneezed or coughed on.

7.    Testing – Testing is important for sentinel surveillance of what’s going around and can be useful for individual exposure considerations (COVID-19, flu, etc.). It is also helpful for high-risk patients that may benefit from specific antiviral treatments. Routine testing for everyone who is sick may not be all that helpful if it won’t change management.

The following patients are at high risk of complications from respiratory viral illness: Older age (>65 but especially > 75 years), young children (< 5 years, but especially under 6 months), people with immune system diseases or reduced immunity, people with disabilities, and pregnant people.

Speaking of immunizations, repeat COVID-19 (2023-24) vaccination, i.e., a second dose for this season, is now recommended for people over age 65, in addition to people with a history of immune compromise. This new second dose should be given at least 2 months after the previous dose.

John’s Comments:

Each of these illnesses can feel like “just a cold” to healthy people, but together they cause substantial morbidity, mortality, loss of work productivity and medical expenditure in our otherwise fairly advanced society. Why do we have such a “thing” about trying to reduce our exposure to these illnesses by doing the very simple interventions listed above? In my experience, the disease of “presenteeism” (showing up to work sick) is a major cause of healthcare associated viral spread. Let’s try to do and advocate for better.

References:

·         Coronavirus Disease 2019. Centers for Disease Control and Prevention. Published March 1, 2024. Accessed March 4, 2024. Link

·         Respiratory Virus Guidance. Published March 1, 2024. Accessed March 5, 2024. Link

From the Literature

2)  Pickleball Injury Primer   

Pickleball, a sport that combines elements of tennis, ping pong, and badminton, has in recent times rapidly gained popularity among all age groups, especially among middle-aged adults.  Surprisingly, the sport is actually almost 60 years old.  According to USA Pickleball, the sport was first invented in 1965 on a backyard badminton court. 

In March of 2023, the Association of Pickleball Professionals (APP) estimated that 48.3 million adults in the US (19% of the adult population) had played at least once in the previous 12 months, while in comparison, according the US Tennis Association (USTA), 23.6 million US adults played tennis in 2022.  Surprisingly, the APP’s latest research also reveals that the average age of avid pickleball players is 34.8 (down from 41% in 2021) and more than 70% of them are between age 18-44.

Given this rise in popularity, it is surprising there is scant medical literature published on pickleball injuries.   There are some who consider pickleball a “milder” sport in comparison to tennis and thus may not be viewed as a high injury-risk sport, because it is played on a smaller court with less running, uses a small paddle, and has lower ball strike velocities.  However, because of some of the demographic who have been drawn to the game as well as the potential surprising intensity of it, there has been a reported rise in game-related injuries. 

Common injuries include repetitive use injuries of the knee (meniscal pathology, patellar tendinopathy, medial collateral ligament strains, and osteoarthritis flares), shoulder conditions (rotator cuff tendinopathy), lateral epicondylitis, Achilles tendonitis, and plantar fasciitis.  Additionally, muscle strain and ligament sprains commonly affect the wrist and elbow, calf, ankle, and hamstring.  Facial trauma (including orbital trauma) and fractures of the wrist are increasing in frequency as the demographic of active players shifts to a younger age. 

These injuries are often a result of improper warm-up and cool-down, lack of flexibility, improper technique, overuse, and inadequate equipment. Reportedly, women have a higher incidence  of shoulder, foot, and wrist injuries, whereas lower-limb injuries (knee, ankle, thigh, calf) are more common in men.  Acute injuries tend to affect lower extremities, whereas chronic injuries usually involve the upper extremities.

Recommendations to prevent pickleball injuries include proper warm-ups, dynamic stretching and strengthening exercises, and cool-downs. Proper footwear with ankle support can reduce the risk of sprains, which includes court shoes rather than running shoes, and mastering correct playing techniques can help avoid overuse injuries. Players should gradually build up their playing intensity, especially if they are new or returning to physical activity after a break.

Mark’s Comments:

In full disclosure, though I played competitive tennis through college, for multiple reasons I’ve never played pickleball.  Having watched videos of recreational and competitive play, it is easy to see how one could believe it is “safer” from an injury standpoint than tennis.  However, there is quicker movement and bending than in tennis, thus increasing the risk of what has been described as Slip/Trip/Fall/Dive injury mechanisms.   Additionally, as pointed out above, many recreational players are not well-equipped for playing, including footwear that places them at risk for lateral movement injuries.  So while pickleball offers the potential for some wonderful physical and social benefits, awareness and preventive measures are essential to avoid injury and experience recreational enjoyment.

References:

·         K Vitale, S Liu. Pickleball: review and clinical recommendations for this fast-growing sport.  Curr Sports Med Rep, 19 (2020), pp. 406-413.  Link

·         Greiner N.  Pickleball:  Injury Considerations in an Increasingly Popular Sport.  Mo Med 2019 Nov-Dec 116(6): 488–491.  Link.

From PeerRxMed ( www.PeerRxMed.org )

3) Our Oath is to First Help, not to “Not Harm”

“Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm.”  Hippocrates, from what we know as “The Hippocratic Oath”

You’ve likely heard somewhere along your professional journey that we took an oath as physicians to “first do no harm” or its Latin equivalent, “primum non noncere.”  While the phrase is attributed to Hippocrates and even more specifically, the “Hippocratic Oath,” that is not its origin.  As noted in the quote above, it seemed quite important for Hippocrates to be clear that our role as physicians is to be helpers and healers, and while doing so, to minimize harm.  The phrase “first do no harm,” has been traced back to English physician Thomas Sydenham (as in Sydenham’s chorea) in the 1600s rather than to our Greek physician predecessor in 460 BC. 

Indeed, it would seem that our role as clinicians and as healers is always to “first help” while attempting to find balance in four pillars of contemporary medical ethics; beneficence (help), non-maleficence (don’t harm), autonomy, and justice.  One doesn’t have to spend too much time reflecting on clinical practice to recognize we are continually navigating the challenges and dynamic tension of these four pillars, particularly that of “help/don’t harm.”  Every surgeon knows they often cut through healthy tissue to get to the unhealthy, and all medications are prescribed recognizing the balance of potential benefits and harms.

But what does any of this have to do with helping to support each other on our professional journey?  My intention is not to provide a lesson on ancient medical history,  but perhaps a modern one instead.  The data over the past decade has been quite clear that there are many hurting colleagues in our midst, likely including some who are reading this blog.  If we are called to “first help,” it would seem such a professional obligation extends not only to our patients, but also to each other.   

 

I am concerned that the same misunderstanding of “first not harming” rather than “first helping” for our patient care also often prevents us from reaching out to colleagues who we know, or suspect, are struggling.  Instead, we may be tempted to anchor to beliefs such as “I don’t know what to say” or “What if I say the wrong thing and they push me away?” or even “Doing so is not part of my training” – all of which I would call “not harm” talk.  Certainly, we never learned skills for professional connection and support during our medical training.    

Fortunately, there are resources available to assist us in learning how to better help and support each other.  I consider the PeerRxMed process to be one such resource.  Additionally, physician colleague Simon Mittal provides a nice overview in this brief article, “How to Approach a Colleague Who May Be in Distress—Practical Guidance to Help,” which I would summarize as “reach out, tell them you care and want to help, and let them know they are not alone.”   As we continue to collectively work to create a more supportive and sustainable professional culture, let’s remind each other that we are called to “first help,” for our patients and for each other.  I suspect Hippocrates would agree that none of us should care alone, and that our attempting to do so would be … harmful.

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  Estimating the Benefit of All the New “CKM” Drugs

As we read in Take 3 # 528, cardio-kidney-metabolic (CKM) syndrome is advocated to be a new major sphere of concern in practice. Because of drugs like glucagon-like peptide (GLP)-1 agonists, sodium glucose cotransporter (SGLT)-2 inhibitors, and non-steroidal mineralocorticoid receptor antagonists (ns-MRAs), the American Heart Association (AHA) and American College of Cardiology (ACC) guidelines have begun to shift to a more holistic view of risk – encompassing heart, kidney, and metabolic disease as a product of intersecting and somewhat synergistic risk factors.

But how effective are these new drugs in actually taming risk in these patients? A new statistical modeling study makes some educated guesses. This study uses individual patient data (which is great) from 2 large SGLT-2 trials (CREDENCE and CANVAS), study level data (which is good) from eight studies of GLP-1 agonists, and study level data from 2 trials of finerenone (an ns-MRA). The authors combined this data to project the likelihood of MACE (major adverse cardiac events – cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke) when these drugs were used in various combinations (including all together) in patients with diabetes and albuminuria. The authors had to make a lot of assumptions to combine this data for analysis, but generally offered sound reasons for their methods or based them on previous studies in the field.

The absolute risk differences (which are more useful than relative statistics like hazard ratios) presented in this study were calculated over three years. For the combination of all three agents (plus renin-angiotensin system blockade with ACE inhibitors or ARBs) vs. “usual care” there was a decrease in the risk of MACE by 4.4% (95% confidence interval (CI) 3.0 to 5.7, number needed to treat 23). The authors also estimate an all-cause mortality reduction of 3.1% (NNT ~ 33).

There are lots of limitations to this kind of data analysis – using only select trial databases (even for logical reasons like they are from large, well-done studies, with individual patient data available) limits generalizability. The authors assumed that the effect of the medications would stay the same over time when that is not truly known. The authors did make adjustments for the difficulties with adherence that were seen in the trials. Finally, this study was not a test of these drugs actually tried together in patients – instead their predicted combination effects were assumed to be additive in the model, when this might not be true at all in real life.

John’s Comments:

There is a LOT of hype around these medications currently, and they seem to have a lot of promise, but an NNT of 23 over 3 years to prevent an additional MACE outcome, while good, is far from the miraculous effect we’d expect, given the hype. I mean, they used ALL the drugs and in a fairly high-risk population…I expected more. The difference in estimated life years gained with the combination of these medications in this artificial analysis is 3.2 years (from 17.9 to 21.1 years) – real life results may vary considerably. It will be difficult, but essential, for us to keep up with the actual study results from the trials of these drugs to avoid being swayed too far by all the enthusiasm.

References:

• Neuen BL, Heerspink HJL, Vart P, et al. Estimated Lifetime Cardiovascular, Kidney, and Mortality Benefits of Combination Treatment With SGLT2 Inhibitors, GLP-1 Receptor Agonists, and Nonsteroidal MRA Compared With Conventional Care in Patients With Type 2 Diabetes and Albuminuria. Circulation. 2024;149(6):450-462. Link

Question from a Colleague

2)  Therapies for Onychomycosis

Question:  Anything new for the treatment of onychomycosis?

Answer:  Onychomycosis occurs in 10% of the general population, 20% of persons older than 60 years, and 50% of those older than 70 years.  In addition to its unappealing appearance, it can cause nail disfigurement, pain, and may increase risk for soft tissue bacterial infections. Dermatophytes are the most common causes, but yeast (eg, C. albicans) and nondermatophyte molds are other common causes.  Confirming the diagnosis with a fungal culture can be helpful as the diagnosis can commonly be confused with nail discoloration from other causes, such as trauma, lichen planus, and psoriasis. However, while a culture can have high specificity, it is time-consuming (three to six weeks) and dependent on an appropriate medium, the temperature conditions, and the existence of viable fungus. Contamination by bacteria and other opportunistic fungi may compromise the correct diagnosis.

Treatment can be difficult because of high failure rates and high recurrence rates, so establishing expectations prior to treatment is important.  Approximately 20% of patients who have successful treatment will have recurrence within 2 years of treatment. For most patients, oral treatments will be preferred when taking into consideration cost and outcomes. Terbinafine is considered the first line treatment, particularly if multiple nails and/or nail beds are involved.  Initial treatment of 250 mg/day for 6 weeks for fingernails and for 12 weeks for toenails is considered the present “gold standard.”  Cost is generally quite low ($10/month) and monitoring minimal.  Recommendations are to check liver function tests at baseline and if normal, no further monitoring is needed unless the patient has underlying known liver disease. 

A recently published network meta-analysis looked at the relative efficacy of monotherapies for dermatophyte toenail onychomycosis.  The authors looked at 21 studies and used a statistical calculation method of surface under the cumulative ranking curve (SUCRA) which measures the likelihood that a regimen was more likely to be effective or to cause harm for each regimen.  Their findings confirm terbinafine as the overall standard but with some potential refinements.  Using the definition of “complete cure rate” as having attained both mycological and clinical cure, they found that terbinafine “booster therapy” with 250 mg daily for 12 weeks followed by 12 weeks off followed by 4 additional weeks was more effective in complete cure at 1 year (83% vs. 46%) and terbinafine given continuously for 24 and 16 weeks had better mycological cure rate at 1 year than other terbinafine regimens but not as good as the booster therapy for complete cure (59% for 24 week therapy and 51% for 16 week therapy). 

Mark’s Comments:

I found this most recent study to be helpful in terms of confirming terbinafine as our “gold standard” for treatment but also in terms of considering other potential regimens for patients.  Given their findings, I’ll likely consider the “booster option” with more patients after discussing the pros and cons.  Remind patients that good foot hygiene can be helpful to prevent recurrence, including keeping feet dry, wearing clean socks, keeping nails trimmed, avoiding going barefoot at the pool or in the locker room, and using an antifungal product for feet and shoes.   

Reference:

• Gupta A et al.  Relative impact of traditional vs. newer oral antifungals for dermatophyte toenail onychomycosis: a network meta-analysis study.  British Journal of Dermatology, Volume 189, Issue 1, July 2023, Pages 12–22. Link

From PeerRxMed ( www.PeerRxMed.org )

3) Perhaps It’s Time to Get Angry

“Anybody can become angry - that is easy, but to be angry with the right person,  to the right degree, at the right time, for the right purpose, and in the right way - that is not within everybody's power and is not easy.”   Aristotle

My outburst caught me completely off guard.  After a seemingly trivial episode in which I realized I had forgotten something at home while traveling to work, I screamed a series of expletives to no one in particular.  Afterwards I felt both surprised and strangely a little better, but at the same time disturbed by the force of my reaction when I am usually pretty even keeled.  I was left wondering where all of that emotion might have come from.  

Most of us who work in healthcare have been led to believe the experience of anger or frustration or a myriad of other strongly “negatively charged”  emotions is very “unprofessional.”  We therefore may find ourselves often denying or suppressing them.   This does not, of course,  make them go away, but rather more often has them leak or burst out at inopportune or inappropriate times or cause us internal “emotional corrosion.”   And while certainly the way one expresses their anger can be inappropriate and/or destructive, the experience of anger itself is quite natural and very understandable given the present challenges of practicing medicine and our past few years as a country.

Wondering what the professionals have to say about “anger management” these days,  I visited the website of our colleagues at Mental Health America (MHA) and was relieved to find that perhaps my private vocal outburst was not so inappropriate after all.  Some of their suggestions for outlets for emotions such as anger include consciously pausing and breathing, exercising, journaling, dancing, singing, going to a different room or outside, verbalizing the anger in an appropriate setting (aka “venting”), asking for help, and even screaming (in private).  They emphasized the importance of gaining a better understanding of the cause or causes of your anger for you and managing both yourself and that circumstance. 

Later that day I took a few minutes to process this episode with one of my PeerRxMed buddies.  In doing so, I was able to see how a stressor from a health-related issue may have been the real source of my outburst, with my forgetfulness being a catalyst for the anger that was apparently lurking just under the surface.  We also checked in with each other as to how we were processing our numerous present challenges and whether we were regularly accessing the outlets that we know are helpful for us.  Finally, we agreed that it would be wise for us to check in more frequently to specifically ask how each of us was doing emotionally, while not accepting “I’m fine” for an answer.

So, if you’ve experienced feelings of anger lately (or whatever you call your “anger-like emotions”), please know you’re not abnormal and you’re not alone.  Remember that your PeerRxMed partner is standing by to help support you, since I’m confident that you are no longer foolish enough to think you can or should manage your challenges and distress on your own.  Indeed, we all need to leave those days behind us.  After all, no one should care alone … ever. 

For more suggestions and details from Mental Health America, here are some links:

• Dealing with anger and frustration:  Link
• Healthy ways to release rage:  Link

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  Diagnosis and Management of Trigger Points

Myofascial trigger points are hypersensitive, hyperirritable  nodules that can occur in tight bands of skele­tal muscle.  They may cause motor, sensory, and autonomic pain symptoms locally and in a referred pattern, decreased range of motion, and musculoskeletal dysfunction.  They often accompany chronic musculoskeletal disorders and can arise from muscle overuse, injury, or stress.  These can be located anywhere skeletal muscle is found but are most often found in the muscles used to maintain body posture are affected, namely the muscles in the neck, shoulders, and pelvic girdle, including the upper trapezius, scalene, sternocleidomastoid, levator scapulae, and quadratus lumborum.

The first step in managing trigger points is their accurate identification. Diagnosis is primarily clinical, based on patient history and physical examination. Patients typically present with localized reproducible pain, tenderness, and sometimes referral pain patterns that mimic other conditions. Palpation of the affected muscle can reveal a taut band or nodule, and applying pressure can elicit a characteristic twitch response or referred pain locally or directed proximally or distally, but not in a dermatomal or nerve root distribution.  Tender points, by comparison, are associated with pain at the site of palpation only, are not associated with referred pain, and occur in the insertion zone of muscles, not in taut bands in the muscle belly.  Patients with fibromyalgia have tender points by definition. 

Treatment of myofascial trigger points aims to alleviate pain, restore function, and address any underlying causes.  Management strategies include both non-pharmacological and pharmacological approaches, tailored to the patient's specific needs and clinical presentation.  There is no accepted standardized treatment protocol for treatment due to lack of comprehensive comparative trials.  Presently accepted pharmacologic treatments include massage, osteopathic manual medicine, physical therapy, and the spray and stretch technique.  Oral nonsteroidal anti-inflammatory drugs, acetaminophen, and muscle relaxants can be used in conjunction with or instead of these.  More invasive  strategies include acupuncture, dry needling, and trigger point injections using pharmacologic agents.

A common modality used by primary care clinicians is trigger point injections.  These are distinguished from dry needling, which involves inserting needles into trigger points to elicit a local twitch response and can help relieve muscle tension and pain.  Trigger point injections involve injections of local anesthetics (sometimes combined with corticosteroids), into trigger points and can provide immediate relief of pain and muscle tension.  Some also use normal saline or sterile water as the injection agent.  No single pharmacologic agent or mixture of active drugs has been proven superior to another in the treatment of trigger points, nor has any agent been proven superior to placebo.

Complications of trigger point injection and dry needling are rare; however, injuries can occur, including pneumothorax, a vasovagal response, needle breakage and localized fat atrophy from the corticosteroid.  Because of the potential for patient harm and lack of evidence for superiority, less invasive meth­ods are recommended as first-line treatments.  If a trigger point injection is performed, a 1.5 inch 25- or 27-gauge needle is recommended with a volume of liquid typically ranging from 0.5 mL to 2 mL per trigger point.  The goal is to use the minimum effective volume that provides symptomatic relief.  If lidocaine is used it should be without epinephrine.  It is essential to be well-versed in the anatomy of the area being treated and the technique for injection to ensure efficacy and minimize complications.

Educating patients about trigger points and their management as well as is crucial.  Advising on ergonomic adjustments, stress management techniques, and regular physical activity can help prevent the development or exacerbation of trigger points.

Mark’s Comments:

The original impetus for this Pointer was a peer review case I was asked to review regarding a complication from a trigger point injection.  However, since that time, I have unfortunately had personal experience of the incredible pain these can cause and the vast array of neurological symptoms that can manifest.  I’ve also experienced the power of PT, osteopathic manipulation, massage, and dry needling to help them resolve.  This experience has left me wondering how many of these I’ve missed over the years by not doing a careful enough musculoskeletal exam. 

Note:  The 2^nd reference, which is available without membership, provides much better details of the actual trigger point injection procedure.

References:

• Shipton B, Sunkesula S, Mall J.  Trigger Point Injections.  Am Fam Phys February 2023;107 (2): 159-164.  Link
• Alvarez D and Rockwell P,  Trigger Points: Diagnosis and Management.  Am Fam Phys February 15, 2002;65(4):653-661. Link

From the Literature

2)  Using “Behavioral Economics” to Reduce Low Value Care

The term “low value care” refers to healthcare provided to patients that is of no benefit or causes harm. Low value care (LVC) was the target of the Choosing Wisely Campaign from the American Board of Internal Medicine but is a worldwide problem. Reducing LVC has been trickier to accomplish than encouraging high-value care, and we need better interventions to change practice.

Researchers from Michigan developed a practice-based study to reduce three low-value care measures based on the American Geriatric Society Choosing Wisely Recommendations: 1) in adults >65 years with diabetes and hemoglobin A1c<7.0%, avoid using medications other than metformin, 2) avoid using benzodiazepines or sedative-hypnotics as first line treatment for insomnia or anxiety in adults older than 65 years, and 3) avoid screening for prostate cancer in men > 75 years. Clinicians were enrolled in the study after watching a presentation about these recommendations. Four different interventions were applied: a) the clinicians signed a written commitment to these recommendations, b) photos of the committed clinicians were placed in waiting rooms and exam rooms with information about the recommendations they committed to, c) patients for whom these recommendations applied were mailed an information sheet about the recommendations prior to appointments with the committed clinicians, and d) the committed clinicians received weekly emails reminding them about the recommendations and describing strategies for implementing them in practice.

The researchers measured patient-months of LVC as the primary outcome since they wanted to evaluate whether ongoing LVC was discontinued or “de-intensified” (i.e., dose reductions in the diabetes and insomnia/anxiety patients) as well as whether new LVC was avoided. There were 81 clinicians from two health systems that participated. LVC was present in 20.5% of the control patient-months and 16.0% of intervention patient-months and the odds of LVC were 0.79 (95% confidence interval (CI) 0.65 to 0.97) in the intervention group compared to control. None of the cohorts (diabetes, insomnia/anxiety, or prostate cancer screening) showed statistically significant reduction independently. The reduction lessened over the time of the trial (mostly due to the insomnia/anxiety cohort) but remained significant in adjusted multivariable analysis. There was also more de-intensification during the intervention patient-months with the diabetes cohort (OR 1.85, 95% CI 1.06 to 3.24) than with the insomnia/anxiety cohort (OR 0.84, 95% CI 0.53 to 1.33).

John’s Comments:

Changing LVC practice in this study required not educating patients or physicians, but leveraging written commitments, social norms, and deliberative thinking. These techniques worked best with diabetes and screening for prostate cancer but didn’t work as well for the challenging clinical problems of insomnia and anxiety. Our education and best intentions frequently give way to patient pressure and lack of good alternatives. With opioid prescribing, we needed state laws and registries to change our behavior to make a meaningful difference, so I’m not clear how we make substantial progress in this area without the pressure of a public health problem. In the meantime, it is important to think creatively about achieving even small reductions in LVC.

References:

• Kullgren JT, Kim HM, Slowey M, et al. Using Behavioral Economics to Reduce Low-Value Care Among Older Adults: A Cluster Randomized Clinical Trial. JAMA Intern Med. Published online January 29, 2024. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  A Waken:  Happy 4^th Anniversary PeerRxMed!

“Courage starts with showing up and letting ourselves be seen …. Because true belonging only happens when we present our authentic, imperfect selves to the world.”  Brene Brown (The Gifts of Imperfection). 

This week marks the 4^th Anniversary of the launch of the PeerRxMed process and 14 years since the vision for PeerRx was first planted in me.   For each of the over 200 times I’ve shared a blog since then, I still feel that same vulnerability I felt when I first hit the “make public” button on the PeerRxMed website and the program was officially “out there.”

In that first blog, I wrote the following, “Those of you who know me well will likely be surprised as to how hard it was for me to do this.  The vulnerability I have been feeling at the prospect of sharing this dream more widely has at times been stifling … as I was allowing my fears that it wouldn’t be ‘perfect’ or some might think it was ‘soft’ or ‘trite’ and the potential criticism that may arise to prevent me from moving ahead.  It’s the same reason that in the past I have shared the poetry I write with so few people, even though I consider it to be a vital expression of who I am.” 

I went on to write; “It is my suspicion that many of us don’t allow wonderful, deeply important parts of ourselves to be “seen” due to our fear as to how those parts will be received.   And in the process, we don’t really bring our “authentic selves” to the world.  If that is true for you, what are some of those parts of you and what prevents you from sharing more?”

As I reflected this week on the incredible journey that the PeerRx process has taken since that time, I had a realization regarding that first blog.  Though I have shared the works of other poets on the blog, I have never shared any of my own poetry that I consider to be “a vital expression of who I am.”

So on the “4^th Anniversary” of PeerRxMed, I share with you (click below) a poem that in many ways has come to serve as an expression of my “essence.”  It is my hope that it might speak to you something “essential” in you as well. 

Feel free to forward Take 3 to your colleagues.  Glad to add them to the distribution list.

 Mark and John

 Carilion Clinic Department of Family and Community Medicine

1a)  Insulin Detemir (Levemir) Discontinuation

Question:  “I’m getting many questions from patients that they’ve been told they will no longer be able to get insulin detemir (Levemir).  What’s going on?”  

Answer:  According to Novo Nordisk, Levemir FlexPen, the injection pen version of insulin detemir, will likely face supply disruption starting in mid-January 2024, lasting up until the FlexPen’s discontinuation on April 1 of 2024. Levemir in vials will no longer be available after Dec. 31, 2024.  According to the company, this is due to global manufacturing constraints, formulary losses impacting patient access, and the availability of alternative options.

Levemir, which was originally approved in 2005, has been a staple as a long-acting insulin option along with insulin glargine U-100 (Lantus, Basalglar, Semglee), which was approved in 2000.  Levemir is also currently the only long-acting insulin approved for pregnancy in the US.

In 2015, a new longer-acting basal insulin manufactured by Novo Nordisk, Tresiba (insulin degludec), received regulatory approval as a once-daily option, as did Toujeo (insulin glargine U 300– Sanofi). 

For your patients presently on insulin detemir (Lantus), refill with a chosen alternative that the patient knows is covered or have the pharmacy notify of preferred alternatives if not covered by their insurance.  Conversions include:

•  For insulin detemir (Levemir) once daily doses can be converted 1:1 with insulin glargine U-100 (Lantus, Basaglar, Semglee), insulin degludec (Tresiba), and insulin glargine U-300 (Tresiba) 
• For insulin detemir (Levemir) twice daily doses, consideration should be given to a 10-20% decrease in total once-daily dose to avoid the potential for hypoglycemia  
• To switch from insulin detemir (Levemir) to long-acting NPH insulin, use the same daily dose but divide the total dose into twice-daily

Mark’s Comments:

Levemir represents a sizable portion of the basal insulin market (it generated $649 million in revenue in 2022 alone). As a commonly used basal insulin that people with diabetes rely on to manage their blood sugar, its discontinuation – particularly near the onset of a significant price cut – is likely to affect consumers, reducing access to medications for many.  We don’t usually include the pharmaceutical manufacturers in Take 3, but this dynamic is relevant in this setting.  There is some speculation that this change was also necessary in order to increase manufacturing capacity for semaglutide (Ozembic) due to demand/anticipated demand (ie: this was a business decision). 

For Carilion clinicians, our PharmD colleagues have ask that we NOT forward these patients to them to determine coverage.  Doing so will quickly overwhelm present resources and will result in a delay of care for your patient.

Reference:

Prescriber Insights (fka Prescriber’s Letter-by subscription only): January 2024.

2b)  Race and National Origin in Research Studies and Guidelines

Question:  “You recently did a Pointer in which parameters for BMI implications were different for those who were ‘Asian’ than other populations.  In this context, what groups does this distinction include?”

Answer:  When the term "Asian" is used in medical practice guidelines, it generally refers to individuals who are from or have ancestry linked to the continent of Asia.   According to the National Institutes of Health (NIH), the terms “Asian” and “Asian American” refer to any persons whose origins are in any of the original populations of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, Bangladesh, India, Japan, Korea, Malaysia, Pakistan, the Philippines, Thailand, and Vietnam.  The word “Oriental” is no longer used in this context.   The NIH encourages us of specific terms whenever possible and to not hyphenate Asian American or other dual-heritage terms.

AAPI, which stands for Asian Americans and Pacific Islanders, is an acronym widely used by people within these communities but may not be familiar to readers outside of them and the NIH does not recommend this acronym be used.

Mark’s Comments:

Remember that risk differentiation is an epidemiological construct which is thought to be based on genetic predisposition and not culture/subculture.  It's worth noting that the broad categorization of "Asian" in medical guidelines has been critiqued for potentially oversimplifying the diversity within Asian populations. There is a growing movement towards more nuanced and detailed classifications that better reflect the genetic, environmental, and social heterogeneity of these groups.

When specific guidelines refer to "Asian" populations, they should ideally clarify the context and the specific populations or subgroups they are referencing in order to avoid these generalizations and ensure the guidance is as relevant and useful as possible.  Remember this is a rapidly evolving area of understanding on a population scale with much personalization required in the context of individual patient care. 

Reference:

NIH Style Guide – Race and National Origin:  Link

From Academic Medicine

2)  Using Improvisation Principles in Clinical Teaching

Usually, teaching medical students or residents in the clinic affords many novel lessons for learners: common bread-and-butter diseases, rare diseases, atypical presentations of common disease, physical examination findings, etc. But sometimes, our students may actually see a patient with well-controlled hypertension who is up to date on everything…what to do then? We have our list of more formal teaching techniques – the One-Minute-Preceptor, mini-lectures, well-rehearsed teaching scripts, etc., but sometimes we haven’t thought well-enough ahead to have prepared even these, and we need to come up with something new...quick.

A review article in Academic Medicine recently discussed this dilemma and drew some principles from improvisational theater to spark creativity in teaching; what the authors call pseudo-improvised teaching. These techniques are content neutral and can be applied to follow up earlier educational points or to broach new themes in the discussion afterward. The authors define five categories of improvisational theory applied to clinical teaching with some examples:

1.    “Watch This!” Assigned Observation and Discussion – have the learner listen for specific elements of your interaction with the patient (empathy cues, jargon, etc.), or have the learner observe the patient walking into the room, or through a window, and gather all they can about their medical condition.

2.    “Everything is a Gift” Humanity rounds – These were clearly developed for a small team rather than 1:1 preceptor: student teaching but can still be applicable. Everyone on the team is encouraged to share:

1. gratitude - for something in their lives (patients can participate in this one.
2. vulnerability – each person shares something they don’t know well.
3. wellness – an interest or hobby from life outside medicine.
4. culture – music, art, food, etc. from each team member’s culture that they have recently enjoyed.

3.    “Make Your Scene Partner Look Good” Using Multidisciplinary Team Members as Teachers – Ask nurses, other clinical staff, or patients to share teaching pearls about the clinical topic with the learners. Or go around the room and have everyone share knowledge about the topic (without worrying about correctness until the summarizing at the end).

4.    “Mini chalk talks” When drawing a blank…draw a blank – Draw a stick figure and have learners label with symptoms and signs for a random (or recently seen) disease. Or completely deconstruct a lab test by writing all the components, and having learners present what they know about each.

5.    "What’s the Theme?": Longitudinal Themes –

1. Equity rounds – how would social and structural determinants have affected this patient’s diagnosis and treatment?
2. Brevity – distill patient information into a Haiku, tweet, or pager phrase.
3. Pager party – give a hypothetical on-call problem to a learner to solve to practice cross-covering.
4. Spaced learning – spread a mini-lecture into multiple chunks to be given between each patient.

John’s Comments:

While the authors refer to some literature, this is not a study, so reader beware. Techniques like this can be engaging for learners, certainly, but they also might mix it up in a healthy way for preceptors – working against burnout by injecting a little creativity and humor. In addition, some of these techniques can leverage the learners’ powers of observation in new contexts that might allow us new insight into our patients’ complaints.

Reference:

·         Jarrett ES, Allen KA, Marmet J, Klein M, Moerdler S, Pitt MB. “What’s My Line?”: Pseudo-Improvised Teaching When the Clinical Teaching Script Is Blank. Acad Med. 2023;98(12):1360-1365. Link

From PeerRxMed ( www.PeerRxMed.org )

3) Bouncing Back … and Then Some ….

"In the depth of winter, I finally learned that within me there lay an invincible summer." - Albert Camus, French Novelist and Nobel Prize Winner

We’ve all cared for them – patients who seemingly defy all odds to not only overcome their medical challenges but emerge “better” somehow amid them, or even because of them.  This, as we know, is not the norm.  Many others are left with physical and/or emotional wounds from which they never recover or at best find a “new normal” that is far less than before.   Yet there is a growing number for whom such events seem to propel them forward to a life more deeply meaningful and generative than they could have previously imagined.  This last group is experiencing what has come to be called post-traumatic growth (PTG). 

How about we clinicians?  Many of us experience traumatic clinical circumstances often, and personal ones as well.  PTG holds that people who endure psychological struggle following adversity can often experience a greater appreciation for life, improved personal relationships, increased personal strength, recognition of new possibilities, and a deeper spiritual sense of meaning and purpose.  How might we allow ourselves to process these events in a way that we could emerge from them not only healed, but perhaps under the right circumstances, even “better”? 

I think often of one such transformational time for me when a woman I cared for during her pregnancy developed disseminated intravascular coagulation (DIC) during her delivery and died despite all we did to help her.  Though I was emotionally devastated, I initially mistook my “cognitive resilience” (“We did all we could under the circumstances”) as emotional healing and dismissed any emotions that did not fit that narrative.  It wasn’t until more than a year later that I finally conceded how poorly I was really doing emotionally and sought the help of a therapist.  Growth came about for me by processing the many emotions, including these, that had been suppressed along my medical journey and developing new tools to understand and navigate the entirety of my emotional life.  As I integrated these lessons, I emerged healthier and more whole.   

While the concept of growing from adversity is inspiring and certainly appealing, it is essential to recognize the nuanced pathways and numerous challenges on the path of  recovery and not be seduced into believing that all adversity can be magically converted into a positively transformed life.  That’s what I initially tried to do after my patient’s death.  In reality, my growth required overcoming much emotional scripting and professional programming, and ultimately only happened because of the many people who provided support, encouragement, and expertise to me. 

Certainly, the possibility of post-traumatic growth is something that can be inspiring for us all, offering a hopeful perspective on recovery.   As healthcare professionals, let's strive to foster environments that support both the acknowledgment of pain and the possibility of growth; with our patients, with each other, and with ourselves.  In doing so, let’s approach post-traumatic growth as a “team sport” rather than an individual undertaking or accomplishment.  While we can’t “rush” our healing, with the help of others we can recognize that within the depths of any trauma, there lies the potential for an "invincible summer."  Remember, no one should try to heal alone, including you ….

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  Anticoagulation Duration for Pulmonary Embolism

Question:  “Can you please address the reasons for continuing treatment for pulmonary embolism (PE) for 6 months (rather than the standard 3 months) in Take 3? We all can determine who needs indefinite anticoagulation, but the decision to increase to 6 months duration seems murky.”

Answer:  Venous thromboembolism management has changed dramatically in the last 20 years and the accepted guideline for anticoagulation practice is a periodic issue of the journal Chest from the American Thoracic Society. For a PE that is provoked by surgery, a transient non-surgical risk factor (not cancer), or is unprovoked, 3 months of anticoagulation with a direct oral anticoagulant (DOAC) medication is recommended regardless of bleeding risk. Three months is preferred over six, twelve, and twenty-four months specifically. For patients with cancer, low molecular weight heparin (LMWH) is recommended for 3 months, followed by either continued LMWH or DOAC indefinitely.

The choice about “extended” anticoagulation therapy comes when the patient has had an unprovoked PE and has only a low-moderate bleeding risk (0-1 bleeding risk factors) or experiences a recurrence of PE. But “extended,” in this guideline, means “indefinite” or “no stop date.”  If extended therapy is being considered, at the 3-month mark stop the anticoagulants for 4 weeks and check a d-dimer (d-dimer is not reliable on anticoagulants). If the d-dimer is elevated, the patient has double the risk of VTE. If the patient is male, that increases the risk by 75% also.  There are no recommendations for 6 or 12 months of therapy. Studies used to make this recommendation showed that risk of recurrent VTE remained low while on the anticoagulant but rose back to the same baseline level regardless of how long anticoagulation lasted. Of note, these studies were done with vitamin K antagonists (warfarin), but the guideline noted that they have insufficient evidence to make separate recommendations for DOACs.

A systematic review from 2020 found only three studies with data that addressed the issue of length of anticoagulation with DOAC. It showed a benefit to longer anticoagulation (one year or more) in terms of both recurrence of VTE and mortality. The study pointed out an increased bleeding risk with the DOAC vs. placebo, but the absolute risk of bleeding in either group was fairly low. The results were heterogenous and dominated by a single study.

John’s Comments:

The decision to start or continue anticoagulation is about a risk-benefit discussion of bleeding vs. prevention of further clotting. The evidence for long-term anticoagulation with DOAC for PE is fairly scant, and the recommendations are based on evidence about VKA and a collection of evidence favoring DOACs (especially apixaban and rivaroxaban) for bleeding risk. The Chest guidelines advocate either 3 months of anticoagulation or indefinite anticoagulation for most VTE, depending on risk of further embolus and amount of bleeding risk. There are no current recommendations for any of the intermediate durations. Given that risk of recurrence upon discontinuation of anticoagulation is no different with 3, 6, 12 or 24 months of treatment, three months seems to be the best choice unless there is a reason to continue to suppress that risk indefinitely.

References:

• Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease. Chest. 2016;149(2):315-352. Link
• Ebraheem M, Alzahrani I, Crowther M, et al.  Extended DOAC therapy in patients with VTE and potential risk of recurrence: A systematic review and meta‐analysis. Journal of Thrombosis and Haemostasis. 2020;18(9):2308-2317. Link

From the CDC and the Guidelines

2)  Prescribing Opioids for Chronic Pain – A Guideline Reminder

Pain is one of the most common reasons adults seek medical care.  Approximately one in five U.S. adults had chronic pain (lasting > 3 months) in 2019 and approximately one in 14 adults experienced “high-impact” chronic pain, defined as having pain on most days or every day during the past 3 months that limited life or work activities.  

Opioids can be essential medications for the management of pain; however, they carry considerable potential risk.  In 2022 the CDC updated their 2016 guideline on the use of opioids to treat pain.  Based on some recent conversations, we thought a reminder was in order.  Evidence was categorized into the following types: type 1 (high strength), type 2 (moderate strength), type 3 (low strength), or type 4 (low strength with serious limitations). When no studies were available or the evidence was too limited to estimate effects, evidence was assessed as insufficient.  Recommendations were also assigned one of two categories (category A or B) based on multiple factors of overall quality of the recommendation.   Recommendations include:  

• Maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider opioid therapy for acute pain (B3) and subacute and chronic pain (A2) if benefits are anticipated to outweigh risks to the patient.
• Before prescribing opioid therapy for acute pain, discuss with patients the realistic benefits and known risks of opioid therapy (B3).
• Before prescribing opioid therapy for subacute and chronic pain, discuss with patients the realistic benefits and known risks, work with patients to establish treatment goals for pain and function, and consider how therapy will be discontinued if benefits do not outweigh risks (A2).
• When starting opioid therapy for acute, subacute, or chronic pain, prescribe immediate-release opioids exclusively (A4).
• When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, prescribe the lowest effective dosage. If opioids are continued for subacute or chronic pain, use caution, carefully evaluate individual benefits and risks when considering increasing dosage, and avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients (A3).
• For patients already receiving opioid therapy, carefully weigh benefits and risks and exercise care when changing opioid dosage. If benefits outweigh risks of continued therapy, work closely with patients to optimize nonopioid therapies.  If benefits do not outweigh risks of continued therapy, optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual circumstances of the patient, appropriately taper and discontinue. Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), opioid therapy should not be discontinued abruptly or rapidly reduced (B4). 
• When opioids are needed for acute pain, prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids (A4).
• Evaluate benefits and risks with patients within 1–4 weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation (A4).
• Before starting and periodically during continuation of opioid therapy, evaluate risk for opioid-related harms and discuss risk with patients.  Incorporate into the management plan strategies to mitigate risk, including offering naloxone (A4). 
• When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically thereafter, review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data (B4). 
• When prescribing opioids for subacute or chronic pain, consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances (B4). 
• Use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants (B3). 
• Offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder. Detoxification on its own, without medications for opioid use disorder, is not recommended for opioid use disorder because of increased risks for resuming drug use, overdose, and overdose death (A1).

Mark’s Comments:

While none of this should be “news,” I am alarmed at how often many of these recommendations are not being followed by colleagues.   I recently facilitated an American Board of Family Medicine (ABFM) maintenance of certification “Group Knowledge Self-Assessment” workshop on Pain Management for the Virginia Academy of Family Physicians, and this guideline was highlighted numerous times.  The guideline provides extensive additional detail on “implementation considerations,” and I would strongly recommend reading these if you prescribe opioids in your practice.  

Reference:

Dowell D, et al.  Clinical Practice Guideline for Prescribing Opioids for Pain – United States 2022.  MMWR Recomm Rep 2022;71(No.RR-3):1-95.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  It’s Time to Do More Attending and Less Pretending

“Toxic positivity is positivity given in the wrong way, in the wrong dose, at the wrong time.”  David Kessler, author of “Finding Meaning: The Sixth Stage of Grief.”

“We just need to be more positive!”  These words from a healthcare executive in the midst of a discussion about the sobering results of a physician well-being survey still haunt me.  In this case, it felt much more like a disingenuous denial of reality rather than a misguided attempt at encouragement.  The impact was a “poisoning” of the conversation and shutting down of any meaningful dialogue.  In other words, it felt toxic.

In the midst of our demanding work, positivity is often seen as a beacon of hope guiding both clinicians and patients through the darkest of times.  Yet, there exists a shadow, a phenomenon known as "toxic positivity," which can undermine the very essence of genuine support and understanding.  Toxic positivity is the belief that one should have a positive mindset and express only positive emotions and thoughts at all times, particularly when things are difficult.   It often comes disguised as a simplistic attempt to circumvent a challenging circumstance, using phrases such as “No worries,” “It’s all good,” or “It could be worse.”  Although perhaps well-intentioned, it has the effect of discounting, dismissing, or even denying emotions that are not positive. 

Hopeful optimism is a process of anticipating positive circumstances and desirable outcomes without denying present reality and is a constructive coping strategy.  Forced optimism or toxic positivity, on the other hand, encourages us to deny any “negative” emotions we might be experiencing, even if they seem appropriate to the circumstances.  In healthcare, where emotional and physical stakes are high the resulting damage can be quite real, including the erosion of trust, emotional harm by devaluing a cry for help, and the suppression of vital dialogue or glossing over adverse circumstances that need to be addressed. Research has shown that acknowledging a range of emotions can lead to better coping strategies, resilience, and support networks in medical settings, and that imagining the future in a hopefully optimistic way can help promote thriving and sustain us during challenging times. 

How do we emphasize the positive without denying or suppressing the negative so we can break this all too pervasive tendency toward toxicity?  By practicing!  I found this wonderful resource on the website positivepsychology.com called “Harmful to Helpful Toxic Positivity Phrases” that provides a starting point for reframing some of the well-intended but often harmful reflexively used “just be positive” phrases.

This upcoming week, be aware of any tendencies you might have to dismiss or minimize the struggles of those around you (and your own!) and note when “positivity phrases” might be inappropriately used by yourself or others.  It’s likely not “all good” right now.  Far from it.  Pretending isn’t fooling anyone.  But there is good news.  You don’t have to navigate any “this is hard for me” alone.  The antidotes to our regular challenges are hopeful optimism and positive connection.  Let’s remember to use them generously and frequently to ensure that no one cares alone …. not now, not ever.

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

Alphabet soup and apologies

In last week's pointer about varicella and zoster immunization, there were unfortunately several places where I referred to "ZVL" (the abbreviation for the old, live zoster vaccine) when I should have used "RZV" (the abbreviation for the currently recommended, recombinant vaccine).  We have corrected the online version, and even though the abbreviations are the official CDC way to keep things straight, I think I may revert to using whole words for a complex article like that.  Please do let us know if you notice potential errors like that - it's really helpful.  Here’s a link to the corrected version.

From the Literature

1)  Fruit Intake and Obesity in Children

Obesity in children sometimes feels harder to deal with than adult obesity. The US Preventive Services Task Force advised screening children for obesity but found that the most successful interventions were multi-component interventions delivered in at least 26 sessions over at least six months. The role of fruit intake in obesity has been debated; there is concern from some research studies and popular belief that because fruit has sugar, it may cause weight gain. But avoiding whole fruit intake can reduce dietary fiber and antioxidants that can negatively impact health in other ways. Researchers in China performed a systematic review of diet trials that included interventions to increase fruit consumption in obese children to assess the impact on weight loss.

The review was generally well done. The authors did a comprehensive search of four databases, although they didn’t specify a search for unpublished literature. They had explicit inclusion exclusion criteria for the review and examined each included study for quality. They also explored the data for heterogeneity.

Twenty articles were ultimately included in the review – eight were in non-obese children and 12 included both obese and non-obese children. The studies lasted from 2 months to 30 months. The intervention groups in these studies ate an average of 79 grams more fruit than non-participants (a half-cup of grapes, or a medium orange or apple). The fruit intervention patients did not significantly change their BMI or their standardized BMI (BMI-z) but did improve their waist circumference and they had an overall reduction in the prevalence of obesity (odds ratio (OR) 0.74, 95% confidence interval (CI) 0.60-0.90) compared to the control groups. There was a lot of heterogeneity in the results (I² = 99.8%).

Multiple subgroup analyses were done to explore this heterogeneity. A sensitivity analysis excluding lower quality studies did not change the results. Interventions to increase fruit intake had a larger effect on BMI-z in those who were already overweight or obese. Interventions that combined education with other strategies (diet planning and recording, physical activity, food preparation, etc.) were more effective at increasing fruit consumption. Larger studies (>300 children) showed more fruit consumption and greater reduction in BMI.

John’s Comments: 

Overall, this study should allay the fears of advising fruit intake as part of dietary counseling for overweight or obese children. However just advising more fruit intake does not solve the whole problem. The 5-2-1-0 program created by Maine Health (emphasizing daily advice of 5 servings of fruit and vegetables, limiting screen time to 2 hours, advising 1 hour of physical activity, and zero sugar sweetened beverages) has been successful as a multi-component intervention and is widely adopted in state health programs and health systems. From this study, we can feel confident about advising fruit intake as part of this counseling.

Reference:

·         Wang F, Zhang P, Ren Y, et al. The estimated effect of increasing fruit interventions on controlling body weight in children and adolescents: A meta-analysis. Preventive Medicine. 2024;179:107785. Link

From the US News and World Report

2)  “Best Diet” Rankings for 2024

U.S. News recently released its annual assessment of the best diets, ranking 30 based on specific criteria and providing in-depth profiles for 38 popular eating plans.  The rankings were established by a reputable panel of 43 experts in nutrition, obesity, metabolic health, food psychology and chronic disease management, who rated each diet on 11 criteria, including nutritional completeness, healthiness, ease of use, adaptability to various preferences and restrictions, likelihood of promoting weight loss, sustainability, evidence-based effectiveness, and safety.  To ward off possible bias, each panelist had to provide information to ensure financial ties, bias, or affiliation with any of the commercial diet programs reviewed.   

For the 7^th consecutive year, the Mediterranean Diet ranks as the No. 1 Best Diet Overall with the DASH Diet rated 2^nd and the MIND diet (Mediterranean-DASH Intervention for Neurodegenerative Delay), rated 3^rd.

The Mediterranean diet was rated the best diet in 7 out of the 11 categories, including best diet for diabetes, best heart-healthy diet, easiest diet to follow, best diet for bone and joint health, best family-friendly diet, and best diet for healthy eating.  The DASH diet was rated in the top 3 in 7 out of 11 categories.  The Flexitarian, which might be thought of as a semi-vegetarian or “plant forward” diet was rated the best plant-based diet and was rated in the top 3 in 6 out of 11 categories.     

WeightWatchers was rated the top Weight-Loss Diet with the Mediterranean diet rated 2^nd and Volumetrics rated 3^rd.  The Keto diet was rated the best Fast Weight Loss diet.  The top Diet Program (formerly called commercial plans) was WeightWatchers followed by the Mayo Clinic diet and Noom.    

It is important to note that there isn't "a" Mediterranean diet.  The cultural lifestyle of people in countries bordering the Mediterranean Sea shares common principles, including an active lifestyle, weight control, and a diet high in produce, nuts and healthy oils and low in red meat, sugar, and saturated fat.   A Mediterranean diet pyramid has been developed to help guide those desiring to follow this nutritional approach (see References). 

The DASH Diet (Dietary Approaches to Stop Hypertension) is promoted by the NHLBI to stop or prevent HTN.  It emphasizes vegetables, fruits, whole grains, lean protein and low-fat dairy.  DASH also discourages foods that are high in saturated fat, such as fatty meats, full-fat dairy foods and tropical oils, as well as sugar-sweetened beverages, sweets, and sodium.  The NHLBI publishes free guides on the plan (See references). 

Mark’s Comments (With Guest Commentary):

The word “diet” is a misnomer.  The most highly rated “diets” are really about healthy, structured, intentional approaches to eating over a lifetime.  To that end, I reached out to faculty colleague and “Lifestyle Medicine guru” Beth Polk, MD, for her insights.  In addition to regularly speaking nationally on this topic, Beth served as one of 4 national faculty on an AAFP Advisory Committee for Lifestyle Medicine and is one of 3 co-chairs for the  AAFP Lifestyle Medicine conference.  Two years ago she started a clinic focusing on Lifestyle Medicine as part of her clinical practice. 

Beth replied:  "The best advice we are able to give our patients is still ‘eat food (unprocessed), mostly plants, and not too much.'  Rather than focusing on a "diet", if we think about the way we eat in terms of the general principles of increasing fiber: fruits, vegetables, beans, whole grains, nuts and seeds, and eliminating processed foods, sugar sweetened beverages and decreasing meat intake, the top 5 diets listed meet these criteria, and they can be easily adapted to regional and cultural differences. There are many alternative pyramids available to help promote creative thinking about using local produce, farmer’s markets and staples such as beans and rice to make this approach both more accessible and affordable.  

One such free resource that I recommend to all my patients to help them learn how to do this in a very simple, accessible way is called Full Plate Living.  Remember as well that the healthiest eating plans focus not only on attaining healthy body weight, but more importantly, to provide the best nutrition for optimal body functioning and disease prevention. As such, the new weight loss agents do not supplant the importance of healthy nutrition, but necessitate it even more, including the importance of healthy proteins to maintain lean body mass.”

References:

• U.S. News Best Diets Rankings for 2024.  January 2, 2024. Link
• Oldways Mediterranean Diet (Link) and Diet Pyramid (Link)
• DASH Eating Plan: Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Thanks Fascia ….

“I’m less interested in skin than in fascia – connective tissue.”  Matthew Barney, contemporary artist and film maker

Fascia is having a moment.  Well, at least it is for me, and apparently for many of our musculo-skeletally oriented colleagues as well.  Recently as I sat mesmerized by a fascinating talk titled “The Fascia” being given by one of those colleagues, I realized it was time for my understanding of the facia to enter the 21^st century. 

Fortunately, I’m not as “behind the times” as I first feared.  Apparently, the understanding of fascia as a living, dynamic tissue has evolved gradually rather than being a single moment of discovery.  It wasn't until the 1990s and early 2000s that a significant shift occurred as advanced imaging techniques provided a more in-depth exploration of fascia's properties.  This led to an appreciation of its optimal functioning as being crucial for our body’s overall health.

Indeed, as I listened and viewed numerous amazing ultrasound images, it became quite obvious that the fascia I was taught about in medical school as a passive covering and mechanical support structure was instead a vital connective tissue network, helping to create a harmonious symphony of movement and support.  As I looked around the conference room, it became quite apparent that this interconnected biological network mirrors the equally complex and essential web of connections in our lives as physicians – the relationships and communities that support, sustain, and empower us in our professional journey.

I could not help but be struck by the parallels between these recent “discoveries” regarding the importance of fascia for our bodies and those of the “loneliness epidemic” and the importance of relationships for our well-being.  It seems crucial for us to understand that our professional relationships are not simply static structures of support but rather are vital, interconnected networks that allow for our own adaptability and resilience.  Our professional networks, when actively engaged, encourage us to stretch beyond our individual capabilities, protect us from injury, and allow us to move through our days with greater strength and grace.  Embracing this interconnectedness not only enhances our well-being but also enriches the quality of care we provide to our patients.

As healers, we thrive on connection – with our patients, peers, and the broader medical community.  Let us challenge ourselves to actively nurture these connections, particularly with each other – to seek out mentorship, offer support, and collaborate with our peers.  In doing so, we strengthen not just ourselves but the entire fabric of the healthcare community.  Thanks for the reminder, fascia ….

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  Varicella and Zoster – same virus, different approaches

Over the past few weeks, I’ve gotten several questions about varicella and zoster vaccinations for adults. And last week’s Take 3 (# 528) apparently stoked more questions:

• Can we give recombinant zoster vaccine (RZV, Shingrix) with a negative varicella titer?
• Is there any data on folks who had live zoster vaccine (ZVL, Zostavax) in the past needing just one dose of RZV?
• Should we offer varicella vaccine (VAR) after an RZV or ZVL vaccine?
•  Is it ok to check a varicella titer after a RZV (or ZVL) vaccine?
• Will the RZV (or VZL) vaccine influence the varicella titer?

VAR and RZV are both vaccinations against the varicella-zoster virus, so it seems as though there should be a simple, logical connection between the two, but real life is more complex than that.

• The Centers for Disease Control and Prevention (CDC) recommends the live VAR vaccine at 12-15 months and again at 4 years alongside the live MMR vaccine.
• They recommend the recombinant RZV (which is not live) starting at age 50 in a two-dose series and have withdrawn the recommendation for ZVL, which is no longer manufactured.
• The CDC recommends AGAINST checking varicella titers prior to RZV vaccination in the United States because approximately 98% of people eligible for the vaccination will have either been vaccinated or been exposed to the virus. Titers from vaccination may be too weak to detect but can still provide sufficient prior immunity to build upon with the RZV vaccine.

Where this gets tricky is if we know that a patient eligible for RZV has a negative varicella titer status in the absence of prior immunization. In that case, the CDC recommends the complete VAR vaccination series (2 doses separated by at least 4 weeks) followed eight weeks later by a 2 dose RZV vaccination series (separated by 2-6 months).

There is no data on the question of only a single dose of RZV after ZVL. Titers are NOT yet recommended as a reliable way to assess the zoster immunity conferred by RZV, so there is no easy way to study zoster immunity except by a clinical outcome study…and that study has apparently not been done.

The rest of the questions above deal with preventing varicella in patients over 50 years who have received RZV. This is an area of active study in the literature, but currently the recommendation is to not create situations in which you are worried about varicella immunity after RZV (or ZVL) vaccination. This issue will mostly arise in healthcare workers who are checked for varicella immunity as part of their work requirements. VAR vaccine should not be given after a RZV (or VZL) vaccine – there should be no reason to give it and it has not been studied. There is no current recommendation for checking varicella titers after RZV to document immunity, despite some studies showing that RZV does increase varicella titers. The remainder of the population should be getting RZV because of presumed immunity to varicella.

John’s Comments: This is a clinical area in transition, and the number of edge cases outweigh the available evidence. The CDC is getting by with blanket recommendations in the absence of specific evidence, but hopefully that will change with more study. For the vast majority of our patients the basic recommendations should suffice: ensure childhood vaccination, re-vaccinate women of reproductive age immediately after delivery if varicella titers checked during pregnancy are negative, and give RZV to patients over 50 without checking titers.

References:

1.  Prevention of Varicella: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Accessed January 23, 2024. Link

2. Dooling KL. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep. 2018;67. Link

3. 9 Important Things To Know About Shingles Vaccination - NFID. https://www.nfid.org/. Accessed January 22, 2024. Link

From the Literature and the American Heart Association (AHA)

2)  New Risk Calculator for CVD, ASCVD, and HF

Obesity, diabetes, and chronic kidney disease (CKD) are each associated with a high burden of cardiovascular disease (CVD) morbidity and mortality, and they commonly co-occur and disproportionately affect disenfranchised populations (eg, underrepresented racial and ethnic groups).  Given the complex interplay of these chronic conditions, a comprehensive focus on CVD prevention that conceptually and therapeutically integrates prevention and management of obesity, diabetes, and CKD has been sought.   This has required moving beyond individual risk factor management approaches and toward a more comprehensive framework.  As covered in last week's Take 3, the AHA recently issued a Presidential Advisory introducing the term cardiovascular-kidney-metabolic (CKM) syndrome and outlining a staging process that reflects the spectrum of risk as well as opportunities for prevention and care optimization at each stage.    

The AHA followed up this Advisory with the introduction of a new CVD risk calculator, the PREVENT^TM (Predicting Risk of CVD Events) Online Calculator, the first in 10 years.  Intended for primary prevention, the calculator provides 10-year risk estimates for total CVD (composite of atherosclerotic CVD and heart failure) for individuals 30-79 years of age and as a new addition for risk calculators, provides 30-year risk estimates for individuals 30-59 years of age.  The risk equations were derived and validated in a large, diverse sample of over 6 million individuals.  Additionally, they include estimated glomerular filtration rate as a predictor and adjust for competing risk of non-CVD death.  Add-on models that incorporate hemoglobin A1c, urine albumin-to-creatinine ratio, and social determinants of health (social deprivation index) are currently under development and the calculator will be updated when these are available. 

As with previous risk calculators, it is hoped that the ability to estimate absolute risk may assist and guide clinicians and patients in shared decision-making for interventions targeting lifestyle behaviors and consideration of pharmacotherapies.

Mark’s Comments:

The ability to more precisely estimate risk can certainly be helpful in our clinical practice, remembering, of course, these are just estimates.  A concern of previous calculators is that that age was overemphasized in the equation, and the intention of having such a large data set is to help attenuate this.  In playing with the calculator and my personal health data, even subtle changes in age still appear to have significant impact.  Another challenge with this calculator is that eGFR measurements go up to 140, whereas many labs (ours included) presently only report “normal” eGFR as “>90.”  This also has an impact on the calculations.

Finally, in the 3^rd reference below, some of the enthusiasm for this new calculator went a bit over the top, including this statement; “So, for instance, pediatricians can screen and stage CKM risks beginning at birth”; and this quote, “I am giving you a medication for 40 years that may have some minor side effects to prevent you from having a stroke in 20 years that will have major side effects.”  In our enthusiasm for prevention, here’s hoping we don’t get way ahead of the evidence and further advance our “pill anticipating any ill” culture.

References:

• Khan SS et al.  Novel prediction equations for absolute risk assessment of total cardiovascular disease incorporating cardiovascular-kidney-metabolic health: a scientific statement from the American Heart Association.  Circulation. Published online November 10, 2023.  Link
• PREVENT Online Risk Calculator:  Link
• Larkin H.  What to Know About PREVENT, the AHA’s New Cardiovascular Disease Risk Calculator.  JAMA. 2024;331(4):277-279. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Vacation Rx

“What I realize (and our patients will never know), what they don’t teach in medical school is how to really take a vacation.”  Pam Lenkov, MD from her poem "Away Time" in her commentary “How to Take a Vacation.”

When is your next vacation?   And the one after that?  In our fast-paced professional world, we often find ourselves in a perpetual state of unending demands and “to do’s”, making the need for quality downtime not just a luxury, but a necessity for well-being and sanity.  At the same time, many find it very challenging to exactly that, often waiting until they “need” a vacation before scheduling one.  Yet, if you wait to take a vacation until you “need it,” you’ve waited too long, because most of your vacation will be spent in “recovery” rather than “rejuvenation” or “renewal.”   While recovery is sometimes required, prevention of the need for recovery is a much-preferred option.

Indeed, we clinicians are notorious for taking little if any vacation, and in many groups, the importance of taking regular vacation has not been role-modeled or encouraged.  Our reasons for not doing so are many, and on the surface seem rational, including patient care commitments and our sense of dedication, staffing shortages, financial considerations, poorly coordinated coverage, the inability to truly unplug, and the dread of returning to all the work that has piled up while we were gone. 

The challenge, however, is that numerous studies have shown that taking a vacation can have important and necessary physical and mental health benefits, including lower stress, a better outlook on life, and more motivation to achieve goals.  Adding to that body of research is a recent study published in JAMA Open Network.  The authors found that 60% of physicians who responded to a national survey took 3 or less weeks of vacation per year including 20% who took 1 week or less.  Additionally, 70% of those who did get away worked on a typical vacation day.  They concluded that taking more than 3 weeks of vacation per year and having full EHR inbox coverage while on vacation were associated with lower rates of burnout, whereas spending 30 minutes or longer per vacation day on patient-related work was associated with higher rates of burnout.  This, of course, is not good news.

As a response in the health system where I work, our department has begun to provide centralized inbox coverage during vacations, focusing initially on smaller practices.  For some colleagues, having this coverage has resulted in their first fully “unplugged” vacation of their career.  And while the process is evolving and there are some glitches to be worked out, the stories of true rest, vital connection, and returning with a fresh perspective have been heartening.  In talking with one of those “never unplugged before colleagues,” she shared, “That was incredible.  I feel like a new person, and we’re like an entirely different family with me feeling a part of it rather than a perpetually distracted appendage.”  For those of you who don’t have such coverage, consider having a “vacation buddy” who can cover for you and you for them.  That’s what I’ve done for many years and still do (our central coverage does not yet cover my group). 

So, back to my original questions:  When’s your next vacation, and the one after that?  If you already have them scheduled, kudos to you!  If not, there’s no better time than now to add “taking regular extended time for rest, restoration, recreation, and relationships” to your professional toolkit.  And by making plans now, you can leave plenty of time to be more intentional about schedules and coverage.  Remember, based on the data, taking at least 3 weeks of vacation this year is not simply an important break from your responsibilities but is also an integral part of your professional commitment to health - both your patients' and your own.   And if anyone asks, just tell them it was doctor’s orders … then ask them when their next vacation is ….

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  Improving Cardiovascular-Kidney-Metabolic (CKM) Healt

This past October, the American Heart Association (AHA) issued a Presidential Advisory introducing the term cardiovascular-kidney-metabolic (CKM) health and providing rationale and staging for CKM syndrome.  CKM syndrome is defined by the AHA as “a systemic disorder characterized by pathophysiological interactions among metabolic risk factors, CKD, and the cardiovascular system leading to multiorgan dysfunction and a high rate of adverse cardiovascular outcomes. CKM syndrome includes both individuals at risk for CVD due to the presence of metabolic risk factors, CKD, or both and individuals with existing CVD that is potentially related to or complicates metabolic risk factors or CKD.…”  The Advisory also provides a more simplified and patient-facing definition of CKM syndrome for use in the lay public:  “CKM syndrome is a health disorder due to connections among heart disease, kidney disease, diabetes and obesity leading to poor health outcomes.”

Current evidence indicates that CKM syndrome is a progressive condition that commonly begins in early life with biological, social and environmental exposures or pressures leading to the accumulation of excess and dysfunctional adipose tissue, with resultant inflammation, oxidative stress and insulin resistance. Excess and dysfunctional adipose tissue frequently progresses to the development of metabolic risk factors (eg, HTN, hypertriglyceridemia, metabolic syndrome [MetS], T2D) and CKD.  Over time, these often confluent comorbidities result in the development of subclinical coronary atherosclerosis (reflected by coronary artery calcification) and subclinical abnormalities of myocardial structure and function, as well as progressive declines in kidney function, which predispose to a high risk for clinical CVD, kidney failure, disability and death.

The Advisory provided a CKM staging construct that reflects the pathophysiology, spectrum of risk, and opportunities for prevention and care optimization:

• stage 0, no CKM risk factors (normal BMI, waist circumference, normoglycemia, normotension, normal lipid profile, no evidence of CKD or subclinical/clinical CVD).
• stage 1, excess or dysfunctional adiposity (BMI >25 (or >23 if Asian ancestry), waist circumference >88/102 in men/women (or if Asian ancestry >80/90) or fasting blood glucose >100-124 or HbA1c between 5.7%-6.4%).
• stage 2, metabolic risk factors (hypertriglyceridemia >135), hypertension, diabetes, metabolic syndrome) or moderate- to high-risk chronic kidney disease.
• stage 3, subclinical CVD in CKM syndrome or risk equivalents (high predicted CVD risk or very high-risk CKD.  NOTE: Subclinical ASCVD Dx by coronary artery calcification and/or catheterization/CT angiography.  Subclinical HF diagnosed by elevated cardiac biomarkers (NT-proBNP >125, hs-troponin t >14 in women and >22 in men.
• stage 4, clinical CVD in CKM syndrome (CAD, HF, stroke, PAD, A-fib) among individuals with excess/dysfunctional adiposity, other CKM risk factors, or CKD stages 4a or 4b. 

Management of patients with CKM syndrome Stages 1-3 (Modified from Figure 3):

Life’s Essential 8 referenced above were reviewed in the July 8, 2022 Edition of Take 3.

Mark’s Comments:

Given the prevalence of these disorders, the CKM syndrome and advancement of CKM health would certainly seem to be something we who practice primary health care should become experts in rather than having these patients managed by the Cardiologist, Endocrinologist, and Nephrologist (with Gastroenterologist/Hepatologist waiting in the wings). 

The AHA followed-up this Advisory in November with the introduction of a new

This calculator is intended for primary prevention patients (those without coronary heart disease, stroke, or heart failure) who are between the ages of 30-79 years.  I will cover this with a Pointer in next week’s Take 3

References:

• Ndumele C, et al.  Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association.  Circulation. 2023;148:1606–1635. Originally published 9 October 2023.  Link

A Question from a Colleague

2)  How long Does the Shingles Vaccine Last?

In 2018, the Advisory Committee on Immunization Practices recommended the recombinant zoster vaccination (RZV) for immunization against herpes zoster over the previous live virus zoster vaccine (ZVL). RZV was shown to have a higher vaccine effectiveness than ZVL and had the additional advantage of not being a live virus. The initial studies for vaccine approval (including over 30,000 participants) showed initial vaccine effectiveness (VE) rates of 96-97% and persisting VE rates of at least 84% for an average of 3 ½ years across all eligible age groups. The vaccine also reduced post-herpetic neuralgia (VE 88-91%). Cost effectiveness analyses favored use of RZV over ZVL because of its better effectiveness. At the time of the recommendation, the ACIP opined that the vaccine would “likely continue to provide substantial protection beyond 4 years as recipients age.”

A ”real-world” study of zoster vaccination has been published that provides information about how these vaccines are working in clinical care. The study is observational, using data from four health systems in the Vaccine Safety Datalink – a group of health systems that contribute EHR data to allow vaccine monitoring studies like this one. This network is an important component in the CDC’s vaccine safety program. This study compared the incidence of herpes zoster in patients who had the RSV vaccine compared with those who did not receive it in order to measure VE in clinical practice.

This study contained lots of careful definitions and measures for the variables they analyzed, as befits a good quality prospective cohort study. The investigators reviewed data from just under 2 million patients. The adjusted VE more than 30 days after a 2-shot series was 79% - almost 20 percentage points lower than the original studies. VE dropped slightly after 1 year but persisted into the fourth year post-vaccination at 73%. Single dose effectiveness 30 days after vaccination started at 70%, but quickly dropped into the 45-50% range after 1 year.

VE was adversely affected by age >= 65 years (74% vs. 81% in 50-65y), corticosteroid use prior to vaccination (65% vs. 77% for no use) but was NOT affected by time intervals even exceeding 1 year between the 1^st and 2^nd doses.

John’s Comments:

This principal limitation of this study was in ascertaining zoster rates – it’s possible the research team may have missed milder cases of zoster, or cases diagnosed elsewhere than in the patient’s health system. That may have contributed for lower VE rates than in the original studies, but, then again, most of our interventions work less well in “real life” than in controlled clinical studies. Zoster has traditional been a disease of older people, so moving the recommended vaccination age down to 50 worried some. But there’s no evidence we should worry just yet. The VE for ZVL was shown to drop significantly after 1 year and was <35% after 6 years, so RZV seems to be doing better, though more monitoring is required. Decisions about booster vaccinations would be made based on this data.  There is at least one other study showing that protection from this RZV lasts for seven years. It is important to get that second shot and, fortunately, getting it even over a year late is OK.

References:

• Dooling KL. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep. 2018;67. Link
• Zerbo O, Bartlett J, Fireman B, et al. Effectiveness of Recombinant Zoster Vaccine Against Herpes Zoster in a Real-World Setting. Annals of Internal Medicine. Published online January 9, 2024. Link

From PeerRxMed ( www.PeerRxMed.org )

3) Is it Time to Suppress Your Immunity … to Change? 

“Often, the very things we most wish to change are the most difficult to touch because they are protected by fears we have not examined." – Lisa Lahey, EdD, co-author of "Immunity to Change”

It was a statistic that immediately caught my attention.  The overall best-selling book on Amazon for both 2021 AND 2023 was “Atomic Habits” by James Clear about building and changing habits.  My surprise was not that the book was so popular (I have found his model helpful), but rather best expressed by that exasperated “little voice” in my head saying, “If this model so popular, where’s all the change happening!?”  Despite all we “know” about change, “change resistance” continues to be tenacious and persistent.  Why is it so challenging to alter habits or adopt new practices even when we anticipate positive benefits and have practical models to guide us?

For example, a seasoned physician sets a goal to become more technologically adept to enhance patient engagement and clinical efficiency.  Or a colleague is determined to incorporate more patient-centered communication in their practice.  Yet, despite their sincere efforts, they find themselves continually reverting to more ingrained methods.  . These struggles are not unique; they mirror the many examples in healthcare alone where personal growth and professional effectiveness clash with ingrained habits and tenacious “invisible” forces. 

This enigma is brilliantly addressed in the Immunity to Change model described by Robert Kegan, PhD and Lisa Lahey, EdD, which offers profound insights into our internal resistance to change.  Their model suggests that our resistance to change is not just due to external barriers but even more so by internal psychological “immunity.”    This resistance is composed of deeply held beliefs and hidden commitments that contradict our conscious goals and their accompanying powerful, though perhaps subconscious, emotions.  In order to overcome these forces, they posit we must  follow four key steps:  identifying a commitment to change, uncovering the behaviors that work against this commitment, digging deeper to find the hidden competing commitments, and finally, challenging the underlying assumptions that support these commitments.

In the examples above, one might be committed to become more technologically savvy, but have subtle behaviors working against it – like avoiding training sessions or relying excessively on staff for digital tasks.  The “hidden” commitment here might be the belief that these technologies could depersonalize patient care. The underlying assumption? "If I embrace technology fully, I might lose the personal touch in my practice."  Or one might aim to be more empathic but subconsciously fear losing objectivity, thus creating an internal conflict.  The “hidden” assumption could be the belief that emotional detachment is necessary for effective decision-making.  By applying the Immunity to Change model, new skills which balance empathy with objectivity can be learned, thus aligning actions with aspirations. 

This model is more than a tool; it's a mirror reflecting our deepest fears and assumptions when it comes to changing ingrained habits and beliefs.  This week, consider a desired change, whether personal or professional, that has been persistently resistant to change.  Click on the link above and work through the model to determine where your “change autoimmunity” might need some “immune suppression.”  Consider sharing what you are discovering with your PeerRx partner so they can help provide you some encouragement as well as accountability as you take action to overcome this resistance.  For those hard to change areas of your life, it might be just what the doctor ordered ….

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1)  Should We Use Cystatin C for Diagnosing Chronic Kidney Disease

We have focused a lot recently on the new “kidney health measure” – a combination of the calculated estimated glomerular filtration rate (eGFR) and the measured urine albumin-creatinine ratio (uACR) – to diagnose/monitor chronic kidney disease (CKD).

Cystatin C – measured from the serum – has been around for a while as an alternate way to measure kidney function. The 2012 “Kidney Disease: Improving Global Outcomes” (KDIGO) guideline recommends the use of cystatin C when additional confirmation is needed to diagnose CKD, in the case of a patient with low muscle mass (which limits the amount of circulating creatinine) or in someone with a borderline calculated eGFR for whom we are worried about adjusting the dose of a renally-cleared medication. Cystatin C is not perfect on its own – it can be incorrect in the presence of acute kidney injury, with certain patient characteristics (abnormal thyroid function, heterophilic antibodies that interfere with testing and corticosteroid use) and higher GFR levels. The ultimate recommendation of the 2012 KDIGO guideline was for a cystatin C-based eGFR calculation (rather than cystatin C levels alone) as the best way to use cystatin C when needed.

A NEJM study from 2021 used data from 23 studies to derive a combined creatinine/cystatin C calculation with the intent to remove race from the traditional eGFR equation (which has been done in most institutions at this point). The equation was then validated using data from 12 other studies. The results show that the combined creatinine/cystatin C calculation revealed only a minor difference between black and non-black patients and was more accurate compared to measured 24-hour creatinine clearance that the traditional equation.

A recent opinion piece from the National Kidney Foundation appeared to set the stage for the routine recommendation of this new combined creatinine/cystatin C-based eGFR calculation in the new KDIGO guidelines, scheduled for 2023. However, these guidelines have not yet been published.

John’s Comments:

Cystatin C appears promising as a way to develop more accurate GFR estimation equations but has not hit the routine guidelines yet. Avoid checking cystatin C by itself or using it regularly for now – there may still be problems with lab availability and insurance coverage. Focus instead on better completion of the existing kidney health measure and look for the soon-to-be published revisions of the KDIGO CKD guideline.

References:

• Chapter 1: Definition and classification of CKD. Kidney International Supplements. 2013;3(1):19-62. Link
• Inker LA, Eneanya ND, Coresh J, et al. New Creatinine- and Cystatin C–Based Equations to Estimate GFR without Race. New England Journal of Medicine. 2021;385(19):1737-1749. Link

From the Family of Cardiology Societies and the Guidelines

2)  Diagnosis/Management of Atrial Fibrillation (AF) in 2024

Atrial fibrillation (AF) is the most sustained common cardiac arrhythmia, and its incidence and prevalence are increasing in the US due to multiple reasons, including an  aging of the population, rising tide of obesity, increasing detection, and increasing survival with AF and other forms of CVD.   AF is associated with a 1.5- to 2-fold increased risk of death as well as a 2.4-fold risk of stroke, 1.5-fold risk of cognitive impairment or dementia, 1.5-fold risk of MI, 2-fold risk of sudden cardiac death, 5-fold risk of heart failure (HF), 1.6-fold risk of chronic kidney disease (CKD), and 1.3-fold risk of peripheral artery disease (PAD).  In Medicare beneficiaries, the most frequent outcome in the 5 years after AF diagnosis was death (19% at 1 year and 49% at 5 years), followed by HF (13.7%) and new-onset stroke (7.1%).

The American College of Cardiology (ACC), the American Heart Association (AHA), the American College of Chest Physicians (ACCP), and the Heart Rhythm Society (HRS) recently updated their 2019 guideline for preventing and optimally managing AF.   Selected messages include (some categorized by Strength of Recommendation/Level of Evidence):

• Although photoplethysmography monitors (smartphone cameras/smartwatches) may indicate the need to obtain an electrocardiographic tracing, they are not sufficiently reliable to establish an AF diagnosis.
• New Staging of atrial fibrillation (AF): The previous classification of AF was based only on arrhythmia duration and tended to emphasize therapeutic interventions. The new classification, using stages, recognizes AF as a disease continuum that requires a variety of strategies at the different stages, from prevention, lifestyle and risk factor modification, screening, and therapy.
  • Stage 1: At risk for AF due to the presence of risk factors: Modifiable = Obesity, DM, poor fitness, HTN, alcohol, OSA (smoking not RF but cessation advised)
  • Stage 2: Pre-AF – evidence of structural or electrical findings predisposing to A
  • Stage 3: AF, including paroxysmal (3A), persistent - > 7 days (3B), long-standing persistent - > 12 months (3C), successful AF ablation (3D)
  • Stage 4: Permanent AF
• Lifestyle and risk factor modification is a pillar of AF management to prevent onset, progression, and adverse outcomes (1/B-NR).  Specific pillars include assessing and treating stroke risk, optimizing modifiable risk factors, and minimizing AF burden (frequency and duration) through rhythm and rate control.
• For newly diagnosed AF, initial w/u should include cardiac ECHO, EKG, BMP, CBC, TSH, and other labs as clinically indicated based on risk factors or findings (1/B-NR).
• For newly diagnosed AF,  protocolized testing for ischemia, acute coronary syndrome (ACS) or PE are not indicated unless there are specific signs/symptoms.
• Caffeine cessation for those with AF not recommended.
• Those with AF should be evaluated yearly with a CHA₂DS₂-VASc score (1/B-NR).  For those with intermediate risk (equal to score of 1 in men or 2 in women) who remain uncertain about the benefit of anticoagulation, consider factors that may modify their risk of stroke to help inform the decision (2a/C-LD).  Anticoagulation is a reasonable option in these patients (2a/A).
• For those deemed at high risk for stroke, bleeding risk scores should not be used in isolation to determine eligibility for anticoagulation, but instead to identify and modify bleeding risk factors and to inform medical decision-making.
• For those with an estimated annual risk of stroke or thromboembolic events > 2% (score > 2 for men and > 3 for women), selection of anticoagulation therapy to reduce risk of stroke should be based on the risk regardless of the AF pattern (1/B-R).  DOACs are recommended over warfarin except for those with mechanical heart valves or moderate to severe rheumatic mitral stenosis (1/A).
• Reevaluation of the need for and choice of therapy should be done at periodic intervals to reassess stroke and bleeding risk, net clinical benefit, and dosing (1/B-R).
• Aspirin with or without clopidogrel is not recommended as an alternative to anticoagulation unless other indication for antiplatelet therapy (Harm/B-R).
• For those with AF without risk factors for stroke, aspirin monotherapy is of no benefit.
• For patients with AF and stable peripheral artery disease (PAD), monotherapy oral anticoagulation is reasonable over dual therapy (anticoagulation plus aspirin or P2Y12 inhibitor) to reduce the risk of bleeding (2a/B-NR).
• For those with AF at elevated risk for stroke and with CKD stage 3 or greater, consult the guideline for specific guidance.
• Shared decision-making (SDM) is recommended to discuss rhythm- versus rate-control strategies (1/B-NR).
• In those with reduced LV function and persistent (or high burden) AF, a trial of rhythm control should be recommended (1/B-R).
• In symptomatic AF, rhythm control can be useful to improve symptoms (2a/BR).
• For AF < 1 year, rhythm control has been shown to reduce hospitalizations, stroke, and mortality (2a/B-R).
• Rhythm control can reduce likelihood of AF progression (2a/B-NR).
• For AF duration > 48 hours, a 3-week duration of therapeutic anti-coagulation or imaging evaluation to exclude intracardiac thrombus is recommended before elective cardioversion (1/B-R).  Anticoagulation should be continued for at least 4 weeks after cardioversion (1/B-RM).
• For those who are hemodynamically stable, pharmacological cardioversion is a reasonable alternative to electrical cardioversion (2a/C-LD)
• Catheter ablation is a useful first-line therapy for those with symptomatic AF (1/A).
• For athletes who develop AF, catheter ablation is a reasonable strategy for rhythm control (2a/B-NR).

Mark’s Comments:

There’s a lot in this 156-page guideline and I’ve attempted to summarize some highlights relevant to our work providing primary medical care.  The sections on anticoagulation with CKD stage 3 or greater and the one on peri- and post-operative anticoagulation management are quite detailed and should be remembered as a future reference when managing patients with AF in these contexts.

Reference: 

• Joglar J, et al.  2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.  Circulation. 2024;149:e1–e156.  Link

From PeerRxMed ( www.PeerRxMed.org )

3) Word Up!  It’s Looking to be an Awepique Year …

"The real voyage of discovery consists not in seeking new landscapes, but in having new eyes." - Marcel Proust

As I shared in last week's blog, I believe words matter, which is why one of my New Year’s rituals is to pick my “word for the year.”   This is a word that represents a personal and/or professional aspiration that will serve as an inspiration, motivation, guide, anchor, or “theme” for the upcoming year.   Mine has traditionally been a self-created word, as I have found that for me most existing words either don’t adequately capture what I’m seeking or have become overlaid with so much baggage or “cliché” that they’ve lost their impact for me.  The Merriam-Webster Dictionary’s “word for the year” for 2023, "authentic", would be one such example.

For me, the concept of choosing a personal word for the year is more than a trend; it's a psychological anchor.  It helps in focusing my thoughts and actions, aligning them with core values and goals.  For anyone, such a practice can lead to increased self-awareness, motivation, and a sense of purpose. It's a way to simplify aspirations into a single, powerful concept that can easily be recalled and reflected upon daily.

My 2024 word is “awe pique,” which is a blend of awepique (stimulate), and “epique” (French for “epic”).  I define awepique as: “The quality or state of regularly experiencing a profound sense of wonder and reverence for everyday moments, combined with a feeling of being gently prodded or nudged towards recognizing the extraordinary in the ordinary, leaving one to know that each moment of this life is part of an incredible poetic journey.” 

The word awepique will be a “lens” that will encourage me to explore and appreciate the richness of everyday life, to “catch” myself in those moments when I am deviating from this path (driving in traffic and the EMR specifically tend to do this for me), and to remember and recognize the wonderment in the small details and routine experiences of life.  I intend that my leading a more awepique life will open me to new levels of awareness and presence, and ultimately a greater sense of both elation and peace.  There will be playfulness as well.  In order to lead an awepique life, other words that will accompany me for the year include my practice for the year (“awelchemy”), my journey (an “awedessy”), and my attitude along the way (“awedacity”).   

How about you?  What might be the word or words to help you frame your year – or perhaps for you it’s a picture, quote, song, or poem (or all of the above!).  Consider picking one or more and sharing their meaning for you with those close to you, including your PeerRx partner.  I’ve found that doing so is great fun, can provide you insights into your psyche, and by inviting others into the conversation, can supercharge your intention by providing some encouragement and accountability around it.  When you look back one year from now, what will have defined your 2024?  That journey begins right now, so “Word Up” ….

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org

1) New Immunization Schedules for 2024

The Advisory Committee for Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) have released the 2024 Immunization schedules for both adults and adolescents/children. You may have noticed that it is not the usual February release, and that is because the CDC has adopted a new strategy for how the recommendations roll out over the year. The ACIP meets at least three times per year, and usually makes at least one recommendation at each meeting. Those recommendations would become official CDC recommendations once they were published in the MMWR (the CDC’s official publication). However, it often took a couple of months for the article to be ready, and the new recommendations would not appear on the schedule until the next February. Now, the schedule committee will immediately place them in a dedicated Addendum to each year’s schedule so that, on any new download, the schedule will be immediately up to date.

As for new adult and child recommendations on the 2024 schedule, we have covered most of them this year, but we will review the important changes. There is always some minor rewording and clarification that occurs as part of the schedule committee’s work throughout the year, which we will not review.

Changes for both schedules:

Updated guidance for COVID-19 vaccines to use only the latest formulation of the vaccine for all vaccination (ages 6 months and older). The specific guidance is slightly different for different ages and brands of vaccine, so checking the schedule carefully is strongly recommended.

• Influenza vaccine notes were updated to completely remove the restriction from influenza vaccination in those with egg allergy. These patients can be vaccinated like anyone else. (Take3 #510)
• Mpox and RSV vaccines were excluded from the Vaccine Injury Compensation Program (VICP). There is a bureaucratic process to include these vaccines under the program and that has not yet been completed.
• Mpox vaccine was added to the Countermeasures Injury Compensation Program. This is a separate compensation program for vaccines that counter epidemics and are not included under the VICP.

Child and Adolescent Schedule Changes:

• Meningococcal ABCWY (pentavalent) has been added to the schedule. It may be used any time you’re giving both MenACWY and MenB in the same visit. Recall that MenACWY is recommended at age 11-12 and 16-18 routinely, but MenB is a shared decision-making recommendation starting at age 16. Those rules still apply, so the pentavalent vaccine just helps if you would be giving both at the same time.
• Pneumococcal vaccine:

o   PCV20 or PCV15 can be used for the infant series (4 doses)

o   For ages 2-5 with chronic conditions (heart, lung, liver, or kidney disease, diabetes, etc.), or immune compromising conditions (asplenia, complement deficiency, medications):

• If no PCV20 has been given, either a PCV20 or a PPSV23 is needed 8 weeks after last PCV.

o   For ages 6-18 with chronic or immune compromising conditions:

• If no PCV20 given as an infant dose, give PCV20 or PPSV23 eight weeks after last PCV. If PPSV23 used, after 5 years, give either PCV20 or another PPSV23. (However, if 1 dose PCV13 and 1 dose PPSV23 given at or after age 6 years, do not give any more pneumococcal vaccine).
• RSV immunization (not vaccination) using monoclonal antibody is recommended in anticipation of RSV season for all infants (whose mothers did not get vaccinated during pregnancy) and for some high-risk children in their second year of life. (Take3 #511)

Adult Schedule Changes:

• Hepatitis A vaccination is allowable for anyone who requests vaccination. However, this recommendation does not constitute a routine recommendation, so insurance coverage is not guaranteed.
• Hepatitis B vaccination is recommended for anyone under age 60 (including catch up for those not vaccinated as children). For patients aged 60 and older, those at high risk (incarceration, liver disease, sexual exposure, HIV, etc.) should be vaccinated. For patients aged 60 or greater with diabetes, vaccination is a shared decision-making recommendation.
• Mpox vaccine is recommended for those at high-risk of acquisition (through sexual behaviors including sex in a commercial sex venue, multiple sexual partners, or sex with others in a geographic area where Mpox is spreading) starting at age 18.
• Pneumococcal vaccine:

o   Ages 19-64: with chronic conditions or immune compromise, a PCV20 or PCV15 + PPSV23 in one year are indicated. (If PCV15/PPSV23 used, repeat PPSV23 at age 65+ if five years have elapsed since last PPSV23).

o   Age 65+: If no PCV given in adulthood, give PCV20 or PCV15 + PPSV23 in one year. (Take 3 #516)

•  An additional poliovirus vaccine can be given to adults (18 years and older) who have completed their primary series. While most children born and raised in the US can be assumed to have had the vaccination, anyone known to have been incompletely vaccinated should complete the primary polio vaccine three dose series.
• RSV vaccination (with Pfizer’s Abrysvo only) is recommended for all pregnant women who will deliver during RSV season to benefit the babies. (Take3 #516)
• RSV vaccination of high-risk older adults is a shared decision-making recommendation. (Take3 # 506)

John’s Comments: 

Unfortunately, we have not had to worry much about the RSV recommendations for children and pregnant women because of the extremely limited supply of the approved vaccine and antibody preparation for these indications. On the other hand, pharmacies are heavily marketing the over-sixty RSV vaccine directly to patients, really subverting any chance we have of incorporating shared decision-making about this vaccine, which will result in maldistribution of the vaccine.

Fortunately, Carilion has decided to go primarily with the PCV20 option for pneumococcal vaccination, which makes things a lot simpler. So far, it looks like the “only one dose of PCV in adulthood” rule still applies but stay tuned.

The situations with hepatitis A and B vaccinations are confusing, though important. For Hepatitis A, recall that prior to COVID-19, we were facing a local epidemic of Hepatitis A and encouraging vaccination of at-risk populations. That’s less of an issue these days, but if your patient has any liver disease (including fatty liver), it is indicated. Hepatitis B has a new-ish recommendation for catchup vaccination for all adults under 60.

References: 

• Immunization Schedule Changes | CDC. Published November 16, 2023. Accessed January 3, 2024. Link
• Adult Immunization Schedule – Healthcare Providers | CDC. Published November 14, 2023. Accessed January 1, 2024. Link
• CDC. Immunization Schedules for 18 & Younger. Centers for Disease Control and Prevention. Published November 16, 2023. Accessed January 1, 2024. Link

From the Literature and the US Surgeon General

2)  A Lonely Heart Could Lead to a Broken Heart

Social isolation is defined as the objective state of having few or infrequent social contacts.  Loneliness is perceived isolation that is distressing for the individual.  Individuals can lead a relatively isolated life and not feel lonely; conversely, individuals with many social contacts may still experience loneliness.  The US Surgeon General’s office reported that prior to COVID, approximately 50% of US adults reported experiencing loneliness.  Data suggest that social isolation and loneliness may have increased since the start of the COVID‐19 pandemic, particularly among young adults (18–25 years of age), older adults, women, and low‐income individuals

A 2022 scientific statement from the American Heart Association noted the negative effects of social isolation and perceived loneliness on cardiovascular and brain health.  This was followed In May of 2023 by an advisory from the US Surgeon General's office

indicating that loneliness has been found to be associated with a greater risk of cardiovascular disease, dementia, stroke, depression, anxiety, and premature death with an impact estimated to be greater than that associated with obesity and physical inactivity and similar to that caused by smoking up to 15 cigarettes a day.

A recently published study investigated the prospective associations of the loneliness and social isolation scales with CVD risk in persons with diabetes and particularly compared the relative importance of loneliness and social isolation to traditional risk factors (e.g. lifestyle factors and metabolic risk factors) in predicting CVD risk.  Using data from the UK Biobank, more than 18,000 persons with diabetes were followed for a mean of 10.7 years.  The authors found that a higher loneliness scale, but not social isolation scale, was significantly associated with a higher risk of CVD in those with T2D.  Loneliness ranked lower in relative strength for predicting CVD than LDL cholesterol, BMI, and ACR, similar to eGFR, HbA1c, and systolic BP levels, and higher than depression score and lifestyle risk factors such as smoking, physical activity, and diet. 

An accompanying editorial made the following recommendations for clinicians based on the results of this study:

• Consider loneliness as a CVD risk factor
• Use screening instrument to identify loneliness, e.g. UCLA 3-Iten Loneliness Scale
• Refer patient to a therapist for supportive therapy to improve perceived relationship quality by targeting maladaptive cognition

Mark’s Comments:

This study adds to a growing body of literature indicating that identifying and helping to address perceived loneliness appears to be an important opportunity to potentially impact individual and population-level CV risk.  Interestingly (and in line with the 3^rd bullet above), a meta-analysis looking at interventions to reduce loneliness compared the effectiveness of four distinct intervention approaches: improving social skills; enhancing social support; increasing opportunities for social contact; and targeting maladaptive social cognition.  While all interventions showed some positive impact on perceived loneliness, the authors found that addressing maladaptive social cognition had a greater benefit on loneliness compared with the others.  Since all interventions have shown some benefit, I recommend that a multipronged approach looking at the patient context would likely yield even more positive results.

References:

• Wang X et al. Joint association of loneliness and traditional risk factor control and incident cardiovascular disease in diabetes patients. European Heart Journal, Volume 44, Issue 28, 21 July 2023, Pages 2583–2591. Link
• Kahl K et al.  A lonely heart is a broken heart: it is time for a biopsychosocial cardiovascular disease model.  Eur Heart J 2023 Jul 21;44(28):2592-2594. Link

From PeerRxMed ( www.PeerRxMed.org )

3) Let Your “Word” Help Create Your World in 2024

“Words create worlds.”  – Attributed to many.  “Worlds create words.” – Me

I believe words matter.   Apparently, so do the many others who, as with me, make one of their New Year’s rituals to pick their “word for the year.”  This is a word, short phrase, or quote that represents a personal and/or professional aspiration that will serve as an inspiration, motivation, guide, anchor, or “theme” for the upcoming year.  Mine has traditionally been a “made-up” word, often a combination of words, that energizes me and serves as a compass to help keep me aligned with my stated priorities … it helps me “create my world” for the year.  

Indeed, words are symbols for thoughts and ideas, and we personalize them according to the meaning we associate with them.  One of my favorite books for 2023 was The Dictionary of Obscure Sorrows by John Koenig, which is described as a compendium of invented words that aims to fill holes in our language by giving names to emotions we all feel but don't have a word for.  Words such as sonder, chrysalism, scabulous, and dystoria are now part of my way of understanding my emotional world.  This year the folks at Merriam-Webster added 690 "new words" (or new definitions of previously used words) to their dictionary, many of which we had been already using collectively, such as hallucination, doomscroll, and prosocial.  In these cases, the world we are creating helped necessitate the need for new words to describe it, and by creating a commonly accepted meaning, these allow for us to more effectively communicate with each other.