CHA Family Medicine Residency

Tufts family medicine residents have "the best of both worlds"


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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.

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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


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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

 


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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.


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UberDx Chapter 6

Harding PPThe 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.


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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:

Cancer incidence

 

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?


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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

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?