Primary care

Acne in Primary Care: The Best of Times?

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The treatment of acne involves difficult choices. Should you prescribe oral antibiotics, knowing use of the drugs for acne plays a large role in driving up rates of antibiotic resistance? Are you willing to wade through the complex federal laws regulating isotretinoin before prescribing it to people who can become pregnant? And why do so many patients complain topical retinoids make them feel like their face is peeling off? 

But perhaps the biggest challenge in treating acne is lack of compliance: One study found half of patients prescribed a topical therapy had given up on the regimen within 3 months, either because they felt it wasn’t working or they could not tolerate the side effects.

Things have changed. 

The US Food and Drug Administration has approved several new medications in the last 6 years that address these shortcomings and require only one dose per day, potentially enhancing patient compliance and, as a result, improving outcomes.

Overview of New Medications

Here is the basic approach to acne care, as outlined in 2016 guidelines from the American Academy of Dermatology (AAD):

  • Topical treatment (eg, benzoyl peroxide [BPO], antibiotics, and retinoids) is generally used as first-line treatment in cases of mild-to-moderate acne with comedonal and inflammatory lesions.
  • Systemic treatment (eg, oral antibiotics and hormonal therapy) can be used as first-line treatment in cases of moderate to severe acne, in combination with a topical agent.

Dermatologists today rarely use oral clindamycin and erythromycin for acne since antibiotic resistance has severely limited the effectiveness of these drugs. That leaves the tetracycline class as the antibiotic of choice, since it also has a strong anti-inflammatory effect. But tetracyclines can disrupt the gut microbiome, and minocycline in particular may cause rare but serious complications like irreversible hyperpigmentation and hypersensitivity reactions.

photo of Hilary Baldwin
Dr Hilary Baldwin

That’s why Hilary Baldwin, MD, a dermatologist and director of the Acne Treatment & Research Center in Brooklyn, New York, welcomed the FDA approval in 2019 of topical minocycline. Far less of the topical formulation is absorbed by the body compared to a 3-week course of oral medication, Baldwin said. 

“The concentration in the skin is extraordinarily high, while the concentration in the body is extraordinarily low, which is just the kind of combination we want,” she said. And the drug is effective for inflammatory lesions that previously would have required oral treatment with antibiotics or hormonal therapy.

Baldwin also frequently prescribes sarecycline, a narrow-spectrum tetracycline that has been available since 2018. 

“It has all of the nice qualities of tetracycline in terms of its efficacy in treating acne, but it is probably less likely to do damage in the gut and hit off-target organisms,” she said. Another benefit is once-a-day dosing. Although sarecycline hasn’t undergone head-to-head trials with other tetracyclines, Baldwin said she has seen fewer side effects from the drug in her patients.

photo of Arash Mostaghimi
Dr Arash Mostaghimi

Although much of the drive to reformulate older topical medications is to allow manufacturers to maintain their patents on the products, research into ways to make a cream or lotion easier on the skin is another important avenue of research. “The vehicles do really matter,” said Arash Mostaghimi, MD, MPH, an associate professor of dermatology at Harvard Medical School in Boston. “A lot of the innovation in this space is actually in the delivery.” 

The payoffs from this line of research include two new versions of older topical agents, tretinoin and tazarotene, which the FDA approved in 2018 and 2019, respectively. The novel technology for these two agents, as Baldwin explained, allows the active ingredient to deposit on the skin in a honeycomb-like mesh that also contains a protective moisturizer. “It has taken a virtually intolerable drug like tazarotene and made it into one of the mildest formulations of topical retinoids that we have,” Baldwin said. 

The next trick is to use these technologies to create combination products. Although often prescribed together, topical retinoids and BPO creams cannot be applied at the same time because BPO oxidizes the retinoid, reducing its activity. Both drugs also cause significant skin irritation. 

A technology called microencapsulation gets around these obstacles. A silica shell traps the active ingredients, which prevents them from interacting with each other while allowing their slow release. Microencapsulated drugs can be packaged in the same bottle and used at the same time, so that patients do not need to apply one medication in the morning and the other at night. 

Trifarotene, initially developed for psoriasis, is another topical retinoid worthy of mention. Retinoids are vitamin A derivatives that bind different retinoic acid receptors (RARs); trifarotene is known as a next generation retinoid, because it is the first to selectively bind to RAR-gamma, the most common RAR in the skin. This affinity allows the drug to be effective at low concentrations, reducing systemic absorption and side effects. Studies have shown trifarotene is safe to use over large areas of the skin, so many dermatologists recommend it for people with acne extending to the shoulders and back.

The newest combination drug on the market, approved in October, is the first fixed-dose triple-combination topical treatment for acne. Containing clindamycin, BPO, and adapalene, a retinoid, the product should be available to consumers in 2024. “The amazing thing about the data is that it really looks as though the combination of all three have a synergistic effect. It is not just better — it’s dramatically better,” Baldwin said.

Mostaghimi said he also has been impressed with the data, and predicted providing triple treatment in a non-irritating fashion once daily would dramatically increase adherence. 

Topical clascoterone, approved in the United States in 2020, is the first acne drug with a novel mechanism of action to reach the market in 40 years. Clascoterone addresses hormonal acne, which is related to elevated androgen levels. The condition is most common in adult women, particularly during menses, but also affects men.

Androgens bind androgen receptors present in the skin and stimulate the production of sebum. Although its precise mechanism of action is not well understood, clascoterone inhibits binding to androgen receptors, and may work by disrupting sebum production. The drug also inhibits pro-inflammatory cytokines and inflammatory follicular activity.

photo of Dr. Leslie S. Baumann
Dr Leslie Baumann

Leslie Baumann, MD, founder of the Baumann Cosmetic & Research Institute in Miami, said she considers clascoterone a significant improvement over spironolactone, which often is used to manage hormonal acne in women. “In the past, people took spironolactone pills, which would block testosterone in their whole body,” Baumann, a cosmetic dermatologist, said. “Now we can just do it in their skin, which is a lot safer.” 

A study published earlier this year in JAMA Dermatology found prescriptions for spironolactone for women with acne rose nearly fourfold between 2017 and 2020, nearly matching orders for oral antibiotics by the end of that period. 

However, spironolactone cannot be safely used in men, nor in women who are pregnant or breastfeeding. Clascoterone provides a safe and effective topical option for men and women and works for both comedonal lesions and inflammatory acne. 

Acne in the Primary Care Setting

Almost everyone suffers from acne at some point in their lives. The AAD estimates that acne affects 85% of people between the ages of 12-24. Although pimples might be considered a rite of passage for teens or dismissed as a cosmetic problem, acne is associated with significant anxiety and depression, and a study published this month found that individuals with acne face stigma affecting their personal and work lives. 

So why don’t more people get treated successfully, and why do so many people drop out of treatment? 

“Let’s think about who uses these medicines,” Mostaghimi said. “They’re kids, right? That may be the first medication they ever take.” Many adolescents have trouble using the drugs consistently, put on the wrong amounts, or are unable to stick to regimens involving multiple medications that must be applied at different times of the day. He advised that the best regimens are “anything that is easier to use — and a combined product is better.”

Another reason that people don’t seek medical help for acne: “There are a lot of people who feel like they’re very actively doing something about their skin,” Mostaghimi said. “But they’re not doing it based on physician expertise. They’re doing it based on things that they see online.”

As for compliance, Baumann likened the behavior of acne patients to people joining a gym after New Year’s. “I notice that 3 weeks is the drop off rate,” she said. “It’s human nature to want to see results right away, and acne takes at least 8 weeks to see a difference.” 

And getting in to see a healthcare provider can be a barrier, especially for teens. ” Their parents don’t think it’s important or cannot afford the visit,” Baumann said. “Or they [the teen] don’t drive, and [the] parents are at work.” 

Baumann said she has also seen young women with hormonal acne respond well to oral contraceptives, but their parents may have issues with their teenage daughter taking birth control pills.

This list of reasons implies that most patients need more education about what to expect from acne treatment and the medications they are taking: how long they need to be taken before symptoms improve, how to apply them properly, why they might need to use more than one medication, and what side effects to expect. 

Many patients experiencing irritation from topical retinoids can manage the condition with moisturizers and milder cleansers. Or they could be switched to a newer topical retinoid in a vehicle that will be better tolerated. 

Baldwin generally does her own patient education, but she understands that busy primary care clinicians who must also address patients’ other health problems might not have that luxury. Her advice is to train staff on the basics of acne care and use patient cheat sheets with medication instructions and side effects. If patients aren’t improving on follow-up visits, the key is to find out how well they have been sticking to the recommended regimen — or not. To get the full story from teenage patients, she added, “You really want to question compliance with the mom not in the room.”

As for deciding when patients can be treated in primary care settings and when to refer to dermatology, Mostaghimi said primary care clinicians should feel comfortable treating comedonal acne using topical agents, which should work for a majority of patients. And all three dermatologists felt patients with more severe acne — those that may require oral isotretinoin or oral antibiotics — should be managed by dermatologists.

The availability of newer better-tolerated retinoid formulations, along with combination drugs that improve compliance, should make management in primary care settings more feasible.

But given the effectiveness of oral isotretinoin, why aren’t more adolescent boys with severe acne taking the drug, since they wouldn’t be affected by pregnancy restrictions? “Denial is the number one reason, but also lack of insurance,” Baldwin said. The costs of drugs, multiple visits, and lab tests can add up. 

Baldwin said acne is more culturally acceptable for men than women, who care more about a clear complexion because they feel they are being judged on their appearance. “It’s Mars/Venus stuff,” she said. ” Sometimes I see a male patient with really bad acne who has come in for treatment of a wart on his hand and is uninterested in acne treatment.”

In Baumann’s experience, concerns about side effects associated with oral isotretinoin, such as bone aches and risk for injury to the joints or tendons, may be a bigger deterrent for male athletes engaging in contact sports. And for any athlete who participates in outdoor sports, photosensitivity can be a problem. 

“If you’re dealing with someone who has primarily comedonal acne, the newer tretinoin lotion, the newer tazarotene lotion, and the new trifarotene cream are your best bets,” Baldwin said. She added that the average successfully treated acne patient requires two to three medications, making the fixed combination medications a logical next step. “I think that [triple therapy] will make a huge difference,” she said. 

Lastly, clascoterone offers a good alternative to oral isotretinoin for treatment of hormonal acne. According to Baumann, “If you have a cystic acne person, it’s hard to get that under control with just topicals.” But for patients with hormonal acne, she recommended a trial of topical clascoterone first, with oral contraceptives as another option for women.

And Mostaghimi’s parting advice to primary care clinicians? “We can do a lot of good for patients with pretty simple and accessible drugs. Don’t be afraid.” 

Associations between socioeconomic deprivation and pharmaceutical prescribing in primary care in England

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Abstract

Background Socioeconomic deprivation is associated with health inequality. Previous studies have described associations between primary care prescribing rates and deprivation for individual drugs or drug classes. We explore the correlation between socioeconomic deprivation and the rate of prescribing of individual pharmaceutical drugs, and drug classes, in primary care in England, to identify prescribing inequalities that would require further investigation.

Methods In this cross-sectional study, national primary care prescribing data, by primary care practice, were retrieved for the calendar year 2019 in England. Socioeconomic deprivation was quantified using the Index of Multiple Deprivation (IMD) score. Correlations were calculated using Spearman’s rank correlation coefficient (ρ), adjusting for practice list size and demographics, with a Bonferroni-corrected p value threshold of 5×10–5.

Results We included 1.05 billion prescription items dispensed from 6896 England practices. 142/206 (69%) drug classes and 505/774 (65%) drugs were significantly correlated with IMD score (p<5×10−5). Of the 774 included drugs, 31 (4%) were moderately positively associated with IMD score (ρ>0.4). Only one was moderately negatively correlated with IMD score (ρ<−0.4), suggesting higher prescribing rates in more affluent areas. The drug classes most strongly associated with IMD score included opioid and non-opioid analgesics, antipsychotics and reflux medications. Drug classes most strongly associated with affluence included epinephrine, combined oral contraceptives and hormone replacement therapy.

Conclusion We identify novel associations of prescribing with deprivation. Further work is required to identify the underlying reasons for these associations so that appropriate interventions can be formulated to address drivers of inequality.

Transcutaneous electrical nerve stimulation as adjunct to primary care management for tennis elbow: pragmatic randomised controlled trial .

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Abstract

Objective To investigate the effectiveness of supplementing information and advice on analgesia and exercise from a general practitioner with transcutaneous electrical nerve stimulation (TENS) as a non-drug form of analgesia to reduce pain intensity in patients with tennis elbow.

Design Pragmatic randomised controlled trial in primary care.

Setting and 38 general practices in the West Midlands, UK.

Participants 241 adults consulting with a first or new (no consultation in previous six months) clinical diagnosis of tennis elbow.

Interventions Participants were randomly allocated to either primary care management alone, consisting of a consultation with a general practitioner followed by information and advice on exercises, or primary care management plus TENS to be used once a day for 45 minutes over six weeks (or until symptom resolution) for pain relief.

Outcome measures The primary outcome was self reported intensity of elbow pain (0-10 rating scale) at six weeks. Primary and secondary outcomes were measured at baseline and at six weeks, six months, and 12 months by postal questionnaire. Analysis was by intention to treat.

Results 121 participants were randomised to primary care management plus TENS and 120 to primary care management only (first episode, n=197 (82%); duration <1-3 months, n=138 (57%)). Adherence to exercise and TENS recommendations reported at six weeks was low; only 42 participants in the primary care management plus TENS group met a priori defined adherence criteria. Both intervention groups showed large improvements in pain and secondary outcomes, especially during the first six weeks of follow-up. However, no clinically or statistically significant differences were seen between groups at any follow-up timepoint. At the primary endpoint (six weeks), the between group difference in improvement of pain was −0.33 (95% confidence interval −0.96 to 0.31; P=0.31) in favour of the primary care management only group, with adjustment for age, sex, and baseline pain score.

Conclusions This trial does not provide evidence for additional benefit of TENS as an adjunct to primary care management of tennis elbow. Poor adherence to interventions is evidence of the challenges of implementing self management treatment strategies in primary care.

 

Source: BMJ

 

Long term effect of depression care management on mortality in older adults: follow-up of cluster randomized clinical trial in primary care.

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Abstract

Objective To investigate whether an intervention to improve treatment of depression in older adults in primary care modified the increased risk of death associated with depression.

Design Long term follow-up of multi-site practice randomized controlled trial (PROSPECT—Prevention of Suicide in Primary Care Elderly: Collaborative Trial).

Setting 20 primary care practices in New York City, Philadelphia, and Pittsburgh, USA, randomized to intervention or usual care.

Participants 1226 participants identified between May 1999 and August 2001 through a two stage, age stratified (60-74; ≥75 years) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of patients who screened negative.

Intervention For two years, a depression care manager worked with primary care physicians in intervention practices to provide algorithm based care for depression, offering psychotherapy, increasing antidepressant dose if indicated, and monitoring symptoms, adverse effects of drugs, and adherence to treatment. This paper reports the long term follow-up.

Main outcome measure Mortality risk based on a median follow-up of 98 (range 0.8-116.4) months through 2008.

Results In baseline clinical interviews, 396 people were classified as having major depression, 203 had clinically significant minor depression, and 627 did not meet criteria for depression. At follow-up, 405 patients had died. Patients with major depression in usual care were more likely to die than were those without depression (hazard ratio 1.90, 95% confidence interval 1.57 to 2.31). In contrast, patients with major depression in intervention practices were at no greater risk than were people without depression (hazard ratio 1.09, 0.83 to 1.44). Patients with major depression in intervention practices, relative to usual care, were 24% less likely to have died (hazard ratio 0.76, 0.57 to 1.00; P=0.05). Preliminary data on cause of death are provided. No significant effect on mortality was found for minor depression.

Conclusions Older adults with major depression in practices provided with additional resources to intensively manage depression had a mortality risk lower than that observed in usual care and similar to older adults without depression.

What is already known on this topic

  • Prospective studies have consistently shown a relation between depression and increased mortality in older adults
  • No randomized trials have reported that a depression management program can decrease risk
  • A 24% lower mortality risk was seen after a median of 98 months among patients with major depression in practices provided with resources for depression care management compared with usual care
  • The decline in mortality was across all causes of death, but with fewer deaths from cancer among people with major depression in intervention practices
  • A depression care manager working with primary care physicians to provide algorithm based care for depression can mitigate the detrimental effects of depression on mortality

What this study adds

 

Source: BMJ

 

 

nitial9 �ta � spacing:0px’ id=p-70>Our patients presented relatively late after the onset of illness, a median of five days overall (seven days for H5N1). Despite administration of oseltamivir, about 30% of those enrolled remained positive for viral RNA (the primary endpoint) after five days of treatment. Timing of oseltamivir treatment is important as several studies have shown that early treatment confers greater virological and clinical benefits.4 5 6 32 33 34 In particular, later viral clearance has been noted with delayed treatment with oseltamivir compared with treatment within two to three days after onset of symptoms in observational reports from patients with H1N1-pdm09, especially those with severe illness.35 36 37 38 39 40 In the current trial, 73 (22.4%) patients presented within three days of illness, but even in this subpopulation, double dose oseltamivir was not associated with more rapid viral RNA clearance. Over a quarter of patients received neuraminidase inhibitors before enrolment, which could have influenced the effect size and contributed to the low proportion of patients shedding virus at day five in both treatment groups.

 

Although viral RNA detection in samples from the upper respiratory tract might not accurately reflect viral replication in the lower respiratory tract, especially in those with severe illness,39 prolonged viral RNA detection in upper respiratory tract samples has been shown to correlate with inpatient morbidity and prolonged hospital stay. In our study viral detection on day five was observed at about twofold the frequency in those meeting the criteria for clinical failure, although lack of clinical failure was not a surrogate for cessation of viral detection. Thus in our study the delays in starting treatment with oseltamivir also probably contributed to the substantial rates of admission to intensive care (18%), use of supplemental oxygen (30%), mechanical ventilation (12%), and mortality in hospital of 6.4%. Although our study was not placebo controlled for ethical reasons, other studies indicate that early oseltamivir treatment in people with severe influenza is associated with both clinical benefits and more rapid viral clearance from upper respiratory tract samples.

Possible reasons for findings

It is unclear why double dose oseltamivir does not seem to offer benefit over standard dose in patients with severe influenza. Blood trough concentrations of oseltamivir carboxylate from 75 mg or 150 mg twice daily in influenza exceed the IC50 (inhibitory concentration) of influenza viruses.42 43 Inhibition of viral neuraminidase by oseltamivir might be a saturable process, and maximal inhibition might be achieved with a standard dose; exceeding these concentrations might not produce an additional clinical or virological effect. In this regard, a randomised oseltamivir controlled study of intravenous peramivir (BioCryst Pharmaceuticals, Durham, NC), which reaches over 20-fold higher peak blood concentrations of active metabolite than oseltamivir carboxylate, found similar viral reductions in patients with influenza A virus admitted to hospital.44 Further studies of peramivir and other intravenous neuraminidase inhibitors currently in progress should provide additional evidence regarding this hypothesis.

Infection with avian H5N1 virus, higher baseline viral load, and severity of disease were independently associated with longer viral RNA detection. The association between avian H5N1, severe illness, and prolonged shedding has been well described.14 The clearance kinetics of influenza viruses, both without antiviral treatment and with oseltamivir treatment,32 41 could explain longer viral RNA detection with higher baseline viral loads. It is unclear whether the independent association with disease severity might be related to impaired mechanisms of viral clearance or higher intrinsic rates of viral replication or both in these patients. Severe chronic comorbidities are seen commonly in industrialised countries and are related to prolonged viral shedding but most of our patients lacked these comorbidities.40 41

The heterogeneous population characteristics, geographical differences in recruitment (most patients were from Vietnam but there were no significant differences between Vietnam and other sites), and the variety of infecting viruses in our trial reflect the clinical circumstances in South East Asia during our study but might be viewed as a limitation. Most of these patients were children and had low or normal BMI, and for all patients only about a fifth reported a chronic underlying medical condition. Thus, our findings are applicable primarily to the region where the study was conducted and other settings with similar characteristics of influenza epidemiology. We did not have many adults in our study and results were inconclusive but indicate no difference in efficacy between the two oseltamivir regimens. We would caution the extension of our results to, for example, morbidly obese adults with severe influenza and those who could have underlying chronic illnesses. We conducted several statistical comparisons and inevitably subgroup analyses involved small numbers; thus power was limited and some significant results could have resulted by chance. Additionally, as all patients were randomised to an active treatment, our study was not designed to evaluate the efficacy of oseltamivir in severe influenza nor in H5N1 infections. This large randomised trial did, however, examine an important clinical and public health question and showed a lack of a clinical or virological benefit of double dose compared with standard dose oseltamivir in patients admitted to hospital with severe influenza. Our results and other observational reports from avian H5N110 and H1N1-pdm0911 36 infections do not support routine use of double dose oseltamivir to treat severe influenza. These findings have implications for both clinical management and pandemic preparedness including during the current H7N9 epidemic.16 17 18

What is already known on this topic

  • Clinical trials in patients with uncomplicated influenza have shown that treatment with oseltamivir has clinical and virological benefit when administered within 48 hours of onset of symptoms
  • Observational studies in severe influenza have shown that oseltamivir treatment, if given early, is associated with reduced mortality and shorter length of hospital stay. Reduced mortality has also been reported for patients with H5N1 influenza treated with oseltamivir
  • Several authorities have suggested the use of double dose oseltamivir for severe influenza, although there is no clinical evidence to support this
  • In the largest randomised trial on the treatment of severe influenza, no clinical or virological benefit of double dose oseltamivir over standard dose was found
  • These findings have implications for both clinical management of severe influenza and for pandemic preparedness of emerging influenza viruses including the current H7N9 epidemic

What this study adds

 

 

Source: BMJ

 

 

patients presenting to primary care with acute cough: diagnostic study.

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Abstract

Objectives To quantify the diagnostic accuracy of selected inflammatory markers in addition to symptoms and signs for predicting pneumonia and to derive a diagnostic tool.

Design Diagnostic study performed between 2007 and 2010. Participants had their history taken, underwent physical examination and measurement of C reactive protein (CRP) and procalcitonin in venous blood on the day they first consulted, and underwent chest radiography within seven days.

Setting Primary care centres in 12 European countries.

Participants Adults presenting with acute cough.

Main outcome measures Pneumonia as determined by radiologists, who were blind to all other information when they judged chest radiographs.

Results Of 3106 eligible patients, 286 were excluded because of missing or inadequate chest radiographs, leaving 2820 patients (mean age 50, 40% men) of whom 140 (5%) had pneumonia. Re-assessment of a subset of 1675 chest radiographs showed agreement in 94% (κ 0.45, 95% confidence interval 0.36 to 0.54). Six published “symptoms and signs models” varied in their discrimination (area under receiver operating characteristics curve (ROC) ranged from 0.55 (95% confidence interval 0.50 to 0.61) to 0.71 (0.66 to 0.76)). The optimal combination of clinical prediction items derived from our patients included absence of runny nose and presence of breathlessness, crackles and diminished breath sounds on auscultation, tachycardia, and fever, with an ROC area of 0.70 (0.65 to 0.75). Addition of CRP at the optimal cut off of >30 mg/L increased the ROC area to 0.77 (0.73 to 0.81) and improved the diagnostic classification (net reclassification improvement 28%). In the 1556 patients classified according to symptoms, signs, and CRP >30 mg/L as “low risk” (<2.5%) for pneumonia, the prevalence of pneumonia was 2%. In the 132 patients classified as “high risk” (>20%), the prevalence of pneumonia was 31%. The positive likelihood ratio of low, intermediate, and high risk for pneumonia was 0.4, 1.2, and 8.6 respectively. Measurement of procalcitonin added no relevant additional diagnostic information. A simplified diagnostic score based on symptoms, signs, and CRP >30 mg/L resulted in proportions of pneumonia of 0.7%, 3.8%, and 18.2% in the low, intermediate, and high risk group respectively.

Conclusions A clinical rule based on symptoms and signs to predict pneumonia in patients presenting to primary care with acute cough performed best in patients with mild or severe clinical presentation. Addition of CRP concentration at the optimal cut off of >30 mg/L improved diagnostic information, but measurement of procalcitonin concentration did not add clinically relevant information in this group.

 

What is already known on this topic

  • Studies have evaluated the diagnostic accuracy of signs and symptoms for pneumonia, but there is limited evidence applicable to primary care
  • The added diagnostic value of C reactive protein (CRP) and procalcitonin concentrations to clinical signs and symptoms is unknown
  • Symptoms and signs (absence of runny nose and presence of breathlessness, crackles and diminished breath sounds on auscultation, tachycardia, and fever) have moderate diagnostic accuracy for pneumonia in patients who present in primary care with acute cough
  • CRP concentration at the optimal threshold of >30 mg/L adds some diagnostic information by increasing diagnostic certainty in the patients when doubt remains after history and physical examination
  • Procalcitonin concentration adds no clinically relevant information in primary care

What this study adds

 

Source: BMJ

Chest Pain: What Happens After the Emergency Department?

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Patients who follow up with cardiologists do best.

 

Researchers examined patterns of follow-up care and outcomes in high-risk patients with chest pain who presented to Ontario emergency departments (EDs) from 2004 to 2010. High risk was defined as having a prior diagnosis of cardiovascular disease, diabetes, or both. The primary outcome was a composite of all-cause death and hospitalization for myocardial infarction within 1 year after the index visit.

Of nearly 57,000 patients, 17% followed up with a cardiologist (with or without a visit to primary care) within 30 days after ED discharge, 57% followed up with a primary care practitioner only, and 25% did not have a visit to a physician recorded. After adjustment for clinical, demographic, and hospital characteristics, the cardiologist group had a significantly lower hazard ratio for the composite outcome (HR, 0.79; P<0.001) than the no–follow-up group and the PCP-only group (HR, 0.85; P<0.001). PCP-only follow-up was significantly beneficial compared to no follow-up (HR, 0.93; P<0.023). Patients seen by cardiologists underwent more testing and received more evidence-based therapies within 100 days after discharge.

Comment: These robust results demonstrate that what happens after the emergency department visit is as important as what happens during the ED visit, and that postdischarge care for patients with high-risk chest pain should include timely assessment by a cardiologist.

 

Source: Journal Watch Emergency Medicine

USPSTF Draft Recommendation: Clinicians Should Screen Adults for Alcohol Misuse, Provide Behavioral Counseling.

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Primary care clinicians should screen adults for risky drinking behaviors and offer brief behavioral counseling interventions to those who screen positive (grade B recommendation), according to a draft recommendation statement published by the U.S. Preventive Services Task Force.

With respect to hazardous drinking in adolescents, the task force says the evidence to weigh the risks and benefits of screening and counseling is insufficient (grade I). Both recommendations reaffirm the group’s last guidance on the topic, published in 2004.

A USPSTF evidence review supporting the draft statement appears in the Annals of Internal Medicine. The review points out that counseling can reduce, among adults, both the number of weekly drinks and the number of heavy-drinking episodes. In clinical trials, such counseling generally involved multiple, brief contacts with primary care clinicians. Of note, the trials usually excluded individuals with alcohol dependence, so the evidence is limited to those with drinking behaviors characterized as “risky” or “hazardous.”

Source: Annals of Internal Medicine article

A More Creative Version of Counting Sheep to Get to Sleep .

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In a small study among college students with insomnia, focusing on personally engaging but nonarousing thoughts (e.g., song lyrics, recipes) instead of ruminations seemed to be more effective than standardized sleep hygiene.

In Journal Watch Psychiatry, Peter Roy-Byrne writes: “Clinicians, especially those in primary care, could offer this technique to their patients as a first-line intervention before prescribing hypnotic medications. The intervention seems to be a creative variant of the old ‘counting sheep’ method, but is more likely to be effective because it employs personalized cognitive scripts that are more appealing and easier to focus on.”

Source: Journal Watch Psychiatry