No more codeine

FDA: The safety of codeine in children 18 years of age and younger  12/10/2015

Reference ID: 3200177

This is kind of old news, but FDA is coming down harder on codeine-containing meds, especially in kids and adolescents. Includes similar conclusions by European Medicines Agency. A lot of information in this document, including some good graphics on pharmacology and why codeine can be so dangerous.

I would broaden that to “all humans”. Probably other species as well. Really just no good indication for codeine for anything. Any combination drug with a “C” or “AC” after it could contain codeine. Also, of course, “Tylenol #3”. I still  see a lot of Cheratussin AC out there, sadly sometimes prescribed by Malden providers.

Let’s just not use this stuff at all.

Especially if you see a child who has been prescribed it by some ED or urgent care. Tell them to throw it out.

Let them eat cake!

Randomized Trial of Introduction of Allergenic Foods in Breast-Fed Infants – n engl j med 374;18 nejm.org May 5, 2016

The plot thickens. I can’t imagine how difficult it must have been to try to cram all that stuff into a 3-4 month old! The four we had would have spit out at least 75%. I compute the NNT to be around 66 overall, and 20 in the “per protocol” analysis. – even though the P value was high (need to figure out how to reduce unnecessary variance in babies!).

Bottom line for me is that it’s ok to ask babies if they want to try some interesting foods, starting at around 4 months of age, including those who might be at high risk for food allergy. Most of the stuff on the web, powered by AAP and USDA, says start introduction of solids between 4 and 6 months. WIC starts handing out baby food at 6 months, but they ok introducing solids between 4 and 6 months. Unclear whether these recent studies are going to change those eminence-based recommendations.

http://www.fns.usda.gov/sites/default/files/feedinginfants-ch7.pdf

• Introduce foods to a baby that have been previously introduced,with no problems, by the baby’s parents;
• Introduce new foods one at a time;
• Introduce new foods gradually, for example, wait at least 1 week(7 days) between each new food;
• Introduce a small amount (e.g., about 1 to 2 teaspoons) of a new food at first (this allows a baby to adapt to a food’s flavor and texture);
• Use single-ingredient foods at first to easily see how the baby reacts to each new food. Caregivers who are preparing foods at home for a baby and older children should separate the baby’s portion before adding other ingredients; and
• Observe the baby closely for reactions after feeding a new food

Quinolones and FDA

FDA: Quinolones are mo’ bad.

http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm500665.htm

Avoid antibiotics in general. Right?

Nitrofurantoin seems generally ok for UTI, but some elders weird-out on that as well.

Macrolides can kill you. Suddenly. Rarely. Especially azithro. QTc and whatnot.

Amoxicillin, cephalosporins of course are options.

Doxycycline is sometimes forgotten as an option for respiratory/cutaneous/GI/GU infections. Don’t go in the sun.

SXT-TMP (Bactrim) – effective for a lot of infections, but E coli often resistant.

Consider IM ceftriaxone for elderly in nursing home with UTI

 

Ten Commandments

Ten Commandments for patient-centred treatment

Richard Lehman, Aaron M Tejani, James McCormack, Tom Perry, John S Yudkin

DOI: 10.3399/bjgp15X687001 Published 1 October 2015

http://bjgp.org/content/65/639/532

1. Thou shalt have no aim except to help patients, according to the goals they wish to achieve.

2. Thou shalt always seek knowledge of the benefits, harms, and costs of treatment, and share this knowledge at all times.

3. Thou shalt, if all else fails or if the evidence is lacking, happily consider watchful waiting as an appropriate course of action.

4. Thou shalt honour balanced sources of knowledge, but thou shalt keep thyself from all who may seek to deceive thee.

5. Thou shalt treat according to level of risk and not to level of risk factor.

6. Thou shalt not bow down to treatment targets designed by committees, for these are but graven images.

7. Honour thy older patients, for although they often have the highest risk, they may also have the highest risk of harm from treatment.

8. Thou shalt stop any treatment that is not of clear benefit and regularly reassess the need for all treatments and tests.

9. Thou shalt diligently try to find the best treatment for the individual, because different treatments work for different people.

10. Thou shalt seek to use as few drugs as possible.

UberDx Chapter 6

The latest salvo in the mammography overdiagnosis debate, from Harding et al at

JAMA Intern Med. Published online July 06, 2015. doi:10.1001/jamainternmed.2015.3043

A classic overdiagnosis curve, showing a dramatic increase in breast cancer diagnosis, as related to proportion of women getting mammograms, without a commensurate change in 10 year mortality.

If we can’t stop the mammography juggernaut, we should at least inform our patients of the risks of overdiagnosis.

TUFMR at the Boston Marathon

On Patriot’s Day several of our teaching faculty volunteered for the Boston Marathon with current and former residents. Former resident Nathan Cardoos is currently at UMass doing a sports medicine fellowship and current PGY2 resident Sam Hwu is applying for sports medicine fellowship. Jess Knapp is our new sports medicine faculty member from UConn and this was her second year volunteering at the marathon. Nicole O’Connor recently graduated from our family medicine residency and was scooped up to stay on as faculty. This is Nicole’s 3rd year as a volunteer and she ran the marathon in 2011 as well! Our tent was busier than in years past and at one point we reached max capacity and runners were diverted to other finish line tents. Most of the runners were seen for hypothermia due to the running conditions and improved with warm blankets and warm drink. Overall we had fun listening to the stories told by runners and volunteers while patching up our nations athletes.

Boston Strong!

Massachusetts Family Medicine Advocacy Day

On Wednesday afternoon, April 15 the Tufts University Family Medicine Residency at Cambridge Health Alliance had a fantastic field trip to the Massachusetts State House for the Annual Massachusetts Academy of Family Physician’s Advocacy Day. We had a group of PGY-2 and 3 residents along with 3 faculty attend the event.

This great annual event that is one of our key activities to get residents training, exposure and practice with direct face-to-face political advocacy with their state legislators, and for many participants, this was their first trip to a state house to interact with legislators and their staff.  In preparation for the day, residents completed the Society of Teachers of Family Medicine on-line advocacy course which gives a great orientation to political advocacy. The afternoon then started with an orientation from the Mass AFP’s lobbying team who gave a legislative Overview, as well as Policy and Advocacy briefing and they also “armed us” with some “one-pagers” describing some of the talking and position points that we could share in our legislative meetings.

After this coaching we broke up into small teams of constituents to go visit the offices of our Senators and Representatives. We had many great conversations with staffers and legislators sharing some of our “real life doctoring stories” to illustrate how policies and the current healthcare climate effect our day to day practice and our patients. Massachusetts (now down to 1.8% of our population being uninsured after passing universal coverage in 2007) is ahead of the rest of the nation in closing the gaps of care. Our state also points to “next step” challenges; once near universal-coverage has been obtained, the primary care shortage gets amplified when patients finally have coverage – they want to use it! We’re also in the throes of figuring out how shifts to “value based payment” models replacing the disincentives of our traditional fee-for-servcies are  requiring us to proactively create teams that can produce health and wellness, not just just respond to disease.

Many of our conversations that day were around Chapter 224, “An Act Improving The Quality Of Health Care And Reducing Costs Through Increased Transparency, Efficiency And Innovation” passed in 2012. Though not yet fully enacted, this act establishes a Health Planning Council and an independent Health Policy Commission that monitor the supply and demand of health resources and supervises and monitor transitions to Accountable Care Organizations. Pipeline and residency funding streams for primary care loan repayment programs and funding for primary care residencies are also part of this legislation. Massachusetts has passed some great legislation that will help move our health system in good directions – but there is clearly much to be figured out in the details.

For those in our program new to political advocacy the Family Medicine Advocacy Day provided a thrill in learning how to make their voices heard, and that we can serve as valuable resources to our legislators who are trying to make difficult decisions to direct our government in responsible ways. Our day at the capitol fell on the heels of a major political win for family medicine nationally when earlier in the week the US Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (HR 2), which repealed SGR and extended several key programs of importance to family medicine. It was a great week for political advocacy at TuftsFMR@CHA!!

UberDiagnosis – Chapter 5: the NNT and NNH

You’ve heard about the “Number Needed to Treat” and the “Number Needed to Harm.” This statistic guesstimates how many people we need to screen in the clinic/hospital before we find a benefit or harm from a treatment.

Has your family or friends ever heard of the NNT? Have your patients ever asked: “what’s the NNH for this?”

 

Well, this is an exciting year for biostatistics because NNT and NNH have hit pop culture and the mainstream media in a big way!

 

First, it started in October 2014 in the Wired Magazine.

Then, PBS spread the word in December 2014.

Next, it hit the NY Times two months ago:How to Measure a Medical Treatment’s Potential for Harm

Then the AFP decided to get in on the action in this month’s AAFP: Introducing Medicine by the Numbers: A Collaboration of The NNT Group and AFP.  “This new series will appear in the online-only edition of AFP. Each month, medical editors from AFP and TheNNT.com will select a topic to feature. We will use TheNNT.com’s color-coding to quickly convey the relative merits of an intervention, and present the numbers for benefit and harm in a summary box. A discussion outlines the background evidence and the rationale for the rating, accompanied by key supporting references.”

 

If you’ve worked with me, you might have heard me quoting things like “1 out of 8 to 9 people who are treated for AOM or sinusitis with antibiotics with GI upset and diarrhea.”

Where did I get these facts? How do I know them off the top of my head?

From the great website theNNT.com! In addition to facts on treatment, they also have launched a new section on diagnosis (and most relevantly here, on harms associated with overdiagnosis.)

 

Here are some of the relevant links to check out below. How often have you asked yourself a question about these clinical issues in the past month?

Primary Care: Diagnosis

• Carpal Tunnel Syndrome
• Hypovolemia
• Malaria in Returning Travelers
• Migraine
• Pertussis (Whooping Cough)
• Spinal Stenosis in the Elderly
• Streptococal Pharyngitis
• Temporal Arteritis

 

Primary Care: Treatment

• Anti-Hypertensives for Cardiovascular Prevention in Mild Hypertension
• Anti-Hypertensives to Prevent Death, Heart Attacks, and Strokes
• Antibiotics for Clinically Diagnosed Acute Sinusitis
• Antivirals for Preventing Post-Herpetic Neuralgia
• Aspirin for Cardiovascular Prevention (After Prior Heart Attack or Stroke)
• Aspirin to Prevent a First Heart Attack or Stroke
• Bisphosphonates for Fracture Prevention in Post-Menopausal Women With Prior Fractures or Very Low Bone Density
• Bisphosphonates for Fracture Prevention in Post-Menopausal Women Without Prior Fractures
• Clopidogrel Added to Aspirin During and After a Coronary Event or Stenting
• Clopidogrel for Cardiovascular Prevention (After Prior Heart Attack or Stroke)
• Clopidogrel with Aspirin for Prevention (After Prior Heart Attack or Stroke)
• Combination Inhalers (Steroids Plus Bronchodilators) for Adult Asthma
• Combination Inhalers (Steroids Plus Bronchodilators) for Childhood Asthma
• Coronary Heart Bypass Surgery for Prevention of Death
• Corticosteroids for Preventing Post-Herpetic Neuralgia
• CT Scans to Screen for Lung Cancer
• Diagnostic Testing for Patient Reassurance
• Epidural Steroids for Sciatica
• Hormone Replacement Therapy and Breast Cancer Risk
• Hormone Replacement Therapy For Cardiovascular Prevention (After Prior Heart Attack or Stroke)
• Hormone Replacement Therapy for Cardiovascular Prevention of a First Heart Attack or Stroke
• Inhaled Epinephrine, Steroids for Bronchiolitis
• Mediterranean Diet for Heart Disease Prevention (Without Known Heart Disease)
• Nicotine Replacement Therapy for Smoking Cessation
• Ondansetron for Pediatric Gastroenteritis
• Packing Abscesses for Recurrent Infection
• Probiotics for Preventing C. Difficile Diarrhea
• PSA Test to Screen for Prostate Cancer
• Routine Health Checks for Reducing Mortality and Morbidity
• Screening Mammography for Reducing Deaths
• Steroids for Pharyngitis
• Tap Water for Wound Irrigation
• Tight Glycemic Control for Type 2 Diabetes (Over 5 Years)
• Vitamin D for Fracture Prevention (Community)
• Vitamin D for Fracture Prevention (Elderly, Nursing Home)
• Vitamins and Antioxidants for Primary Prevention of Cardiovascular Disease

 

UberDx Chapter 4

So now you know about Overdiagnosis Bias. The answer to Question 1 in Chapter 3 is “False”. In this scenario, screening does not diagnose more cancers, but the numerator and denominator are inflated because of all the false positives and “pseudodisease” screening creates. So it looks like the 10 year survival is better. Have you had to deal with this recently, as CHA has embarked on screening smokers for lung cancer? I certainly have. I really try to engage patients in shared decision-making about that and I basically try to talk them out of it. We know how to prevent lung cancer.

Ok, so take a look at this:

 

Can you think if some cancers that fit the A graph: we pick up more aggressive cancers by screening? How about the B graph: we seem to diagnose more, but there is no corresponding increase in number of people dying from the diagnosis? In B we are: 1. Picking up more benign cancers, 2. Simultaneously improving treatment while picking up more cancers, 3. Diagnosing more, maybe earlier, but having no effect on survival.

There aren’t too many good examples of “A”, at least for cancer. Alzheimer’s disease fits the graph pretty well, though. Cervical cancer is actually a good example, but the death rate begins to fall off after time, because we have good interventions.

There are a lot of examples that fit “B”. Prostate cancer. Thyroid cancer. Can you think of any others?

UberDx Chapter 3

Did you read http://en.wikipedia.org/wiki/Overdiagnosis? (See emails below)

If not, proceed no further. Even if you think you know everything, you still have to read it.

If you have, then this graphic should look familiar:

Overdiagnosis Bias: The over-inflation of survival statistic by “early diagnosis”.

So, now think about these questions:

1. More lung cancers are detected in screened populations than in unscreened populations. True or false?
2. What are some examples of “pseudodisease” in the case of lung cancer screening? (“the small solitary pulmonary nodule”)
3. What reactions have your patients had from a CT scan that requires follow up to rule out cancer?