Teaching
PHYSICIAN
The
April 2012
Volume 11, Issue 2
For those who teach students and residents in family medicine
n
Clinical Guidelines That Can Improve Your Care
Acute Rhinosinusitis in Adults, University of Michigan Guidelines
for Clinical Care
By Diana L. Heiman, MD, Quillen College of Medicine, ETSU
I figured that I’d have the column get
“blown away” for the final installation.
Rhinosinusitis doesn’t seem to be as
common a presenting complaint as in
the past. I’m not sure why, but maybe
it’s been related to a decrease in antibiotic prescriptions over the years from
me. Maybe patients think they will get
antibiotics more easily from the emergency department or an urgent care
center. Regardless, the University of
Michigan has updated their 2007 guideline on the diagnosis and treatment of
rhinosinusitis.
Acute rhinosinusitis is defined as
inflammation of the paranasal sinuses
and the nasal cavity lasting no longer
than 4 weeks. It includes viral and bacterial etiologies, but bacterial infection
follows the common cold in only five in
1,000 patients.
Diagnostic predictors of bacterial
rhinosinusitis are listed in Table 1.
Treatment of viral rhinosinusitis is
supportive, but if bacterial infection
is likely, antibiotic treatment can be
considered. The guideline points out
April 2012 | Volume 11, Issue 2
Teaching Points..............................2
FPIN HelpDesk Answers................4
POEMs...........................................5
that antibiotics have not been shown
to decrease complications or the risk
of progression to chronic rhinosinusitis.
Side effects, development of antibiotic
resistance, and allergic reactions to the
antibiotics should be considered along
with the severity of symptoms and
likelihood of bacterial infection before
prescribing the antibiotics. Antibiotic
therapy increases symptom resolution
at 2 weeks only by 15%, from 70% without antibiotics to 85% with antibiotics.
Recommended first-line antibiotic
therapy is amoxicillin and trimethoprim/
sulfamethoxazole for 10–14 days. If
the patient is allergic to both first-line
antibiotics, doxycycline also for 10–14
days or azithromycin 500 mg daily for
3 days are then recommended. (Cefuroxime, clarithromycin, cefprozil,
cefinidir, and levofloxacin may also
be considered if allergies exist but in
general are much more expensive alternatives.) For incomplete resolution
of symptoms, lengthening the course of
therapy to 3 weeks should be done. If
the patient still fails treatment, secondline antibiotics should be considered.
These include high-dose amoxicillin,
amoxicillin-clavulanic acid, levofloxacin, or moxifloxacin.
Recommending the use of ancillary
agents for symptom control is a part of
therapy. Therapies with good evidence
for symptom control are oral and topical decongestants, topical ipratropium,
and high-dose nasal steroids. No
Table 1
Predictors of Acute Bacterial Rhinosinusitis
• Maxillary toothache
• Poor response to decongestants
• Patient report of colored nasal discharge
• Visualization of purulent secretions on exam
• Symptoms beyond 10 days
significant benefit has been seen from
the use of nasal saline, standard dose
guaifenesin, steam, or antihistamines
(unless allergic rhinitis is an underlying
condition). See the guideline for specific
doses.1
As far as imaging, it is not recommended in acute cases. Computed
tomography (CT) is the recommended
imaging modality but is only recommended if symptoms last more than 3
weeks or if the patient has more than 3
recurrences in a year. The scan should
be performed when the patient is symptomatic to confirm the diagnosis and
determine if referral to otolaryngology
is warranted.
Reference
1. University of Michigan Health System. Acute
rhinosinusitis in adults. Ann Arbor, MI: University of Michigan Health System, August 9,
2011.
Caryl Heaton, DO, UMDNJ-New Jersey Medical School, Editor
Diana Heiman, MD, Quillen College
of Medicine, ETSU, Coeditor
Teaching PHYSICIAN
Teaching PHYSICIAN
The
n Teaching
The
Goodbye to the Teaching
Physician Newsletter
Points—A 2-minute Mini-lecture
Use of Proton Pump Inhibitors
By Lori Dickerson, PharmD, Trident/MUSC Family Medicine Residency Program
Editor’s note: The process of the 2-minute mini-lecture is to get a commitment, probe for supporting evidence,
reinforce what was right, correct any
mistakes, and teach general rules. Lori
Dickerson, PharmD, at the Trident/
MUSC Family Medicine Residency
Program in North Charleston, SC, authored this scenario. In this scenario, Dr
Dickerson (Dr D) works with a first-year
resident (R1) in considering when to
prescribe proton pump inhibitors.
R1: Dr Dickerson, which is the best acid
blocker? Across the street, they tell me
it’s Nexium.
Dr D: There is some evidence behind
that choice. But, what are you treating?
R1: The patient has GERD.
Dr D: What makes you call it that?
R1: She gets a burning pain in her epigastrium with bloating and some nausea. Are you questioning the diagnosis?
It’s not an ulcer—she had an upper
endoscopy that was negative for ulcer.
Dr D: OK, so no ulcer. But did they
describe esophagitis?
[They look at the endoscopy report.]
Dr D: Normal esophagus, stomach,
and duodenum. It’s not irritable bowel
syndrome—do you know why?
R1: There’s no constipation or diarrhea.
Dr D: Right. And, also, the pain is not
relieved by a bowel movement. So what
diagnosis are we left with? It’s not an
ulcer, esophagitis, or irritable bowel?
2
April 2012 | Volume 11, Issue 2
R1: Non-ulcer dyspepsia. Right. You
already gave me an article on this issue.1 So I was right, even if I said GERD,
and it’s dyspepsia. What about Nexium
for treatment?
Dr D: When that article came out in
2004, it was based on the latest information. But there was just a study that
said there is no clear benefit from a
proton pump inhibitor.2
R1: So I will add the diagnosis of nonulcer dyspepsia to my differential diagnosis of upper abdominal symptoms.
And I shouldn’t reach for a proton pump
inhibitor so automatically in the future.
There are other options listed in that
article. But what is the downside to
prescribing a proton pump inhibitor?
Everybody writes for them.
Dr D: Funny you should say that. Let’s
go to drugs.com and look at the 200
most widely prescribed medications
in 2010. There’s Nexium at the top.3 So
that’s a lot of money spent. And, if it’s
not helpful, then that’s money wasted.
What about other reasons not to prescribe a proton pump inhibitor?
R1: There was an article about how
blocking the stomach acid seems to
contribute to getting hospital acquired
pneumonia.4 It also affects other medications. And…
Dr D: Right, other things, too, like low
magnesium, fractures, risk of C. difficile.
Dr D: Right. That’s the indication with
the most evidence supporting its use.
But not for all patients admitted to
the hospital. Over half of all patients
admitted to the hospital receive acid
suppressive medications during hospitalization, and about half of those
hospitalized patients are receiving the
acid blocker as a new medication. Most
of the time, the patient does not even
need the medication in the hospital.
But—worse then that—about half of
the patients who get a new prescription
for an acid blocker during the hospital
stay actually continue the medication
at discharge. So we tend to start this
medication during hospital stays—for
no good reason in the majority of cases.
R1: OK. Forget proton pump inhibitors.
Let’s talk about a safer topic—what
about aspirin for primary prevention?
[smiles]
References
1. Dickerson LM, King DE. Evaluation and
management of nonulcer dyspepsia. Am Fam
Physician 2004;70:107-14.
2. Wong WM, Wong BCY, Hung WK, et al. Double
blind, randomized, placebo controlled study
of four weeks of lansoprazole for the treatment
of functional dyspepsia in Chinese patients.
Gut 2002;51:502-6.
3. www.drugs.com/top200.html. Pharmaceutical
sales: 2010. Accessed March 24, 2012.
4. Herzig SJ, Howell MD, Ngo LH, Marcantonio
ER. Acid-suppressive medication use and the
risk for hospital-acquired pneumonia. JAMA
2009;301(20):2120-8.
Alec Chessman, MD, Medical
University of South Carolina, Editor
This is the last issue of the Teaching Physician. Taking its place is
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540, Leawood, KS 66211
800-274-7928, ext. 5420
Fax: 913-906-6096
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Editorial Assistant:
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Subscriptions Coordinator:
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Editors
Clinical Guidelines That Can Improve
Your Care
Caryl Heaton, DO, editor
heaton@umdnj.edu
Diana Heiman, MD, coeditor
heiman@etsu.edu
Family Physicians Inquiries Network
(FPIN) HelpDesk
Jon Neher, MD, editor
ebpeditor@fpin.org
Information Technology
and Teaching in the Office
Richard Usatine, MD, editor
usatine@uthscsa.edu
Thomas Agresta, MD, coeditor
Agresta@nso1.uchc.edu
POEMs for the Teaching Family
Physician
Mark Ebell, MD, MS, editor
ebell@msu.edu
Teaching Points—A 2-minute Minilecture
Alec Chessman, MD, editor
chessmaw@musc.edu
R1: But we need to use it for patients
admitted to the Intensive Care Unit,
right?
Don't miss the nation’s most energized networking forum for family medicine educators.
April 2012 | Volume 11, Issue 2
3
Teaching PHYSICIAN
Teaching PHYSICIAN
The
The
From the “Evidence-Based Practice” HelpDesk
Answers Published by Family Physicians Inquiries
Network (FPIN)
n
Is Acupuncture Safe and Effective
for Smoking Cessation?
By Luis Otero, MD, David Grant FMR, Travis AFB, CA
Evidence-based Answer
Although acupuncture appears to be
safe (SOR: B, based on surveys of adverse reactions), there is currently no
consistent evidence showing that acupuncture is an effective intervention for
smoking cessation. (SOR: B, based on
a meta-analysis of low-quality RCTs.)
In 2011, the Cochrane collaboration
published a review of the existing
literature examining acupuncture’s effect on smoking quit rates.1 Results of
18 comparisons of acupuncture with
sham acupuncture in the short term (up
to 6 weeks after quit date) with 1,385
patients in the treatment arm and 1,143
in the control arm found a risk ratio of
1.18 (95% CI, 1.04–1.33) favoring acupuncture. Of note, the strong effect of
a single trial was the major contributor
to this positive result.
In the long-term (6–12 months after
quit date) analysis of six studies with
881 patients in the treatment arm
and 781 patients in the control arm,
acupuncture did not alter quit rates
(RR=1.03; 95% CI, 0.82–1.35). When
a waiting list or no intervention was
4
April 2012 | Volume 11, Issue 2
used as a control in three studies (197
intervention patients and 196 control patients), the pooled results also
showed no significant effect (RR=1.79;
95% CI, 0.98–3.28). Furthermore, in
comparison with nicotine replacement
therapy (496 patients), acupuncture
(418 patients) was found to be less effective in both the short term (RR=0.76;
95% CI, 0.59–0.98) and the long term
(RR=0.64; 95% CI, 0.42–0.98).1
The Cochrane review noted significant heterogeneity and risk of bias in
several of the published trials. A further limitation was the combination of
disparate forms of acupuncture with
different treatment periodicity into a
group effect. Safety outcomes were
not addressed.1
An investigation of physician acupuncturists in Germany examined the
question of safety.2 In the study, 9,249
practitioners reported on 97,733 patients over a 10-month period. Serious
adverse events reported as likely or
certainly attributable to acupuncture
were reported to be rare and included
two pneumothoraces and one vasovagal hypotensive episode.
A prospective survey of acupuncturists performed in the United Kingdom
also looked at the question of safety.3
A total of 547 practitioners reported on
34,407 treatments over a 4-week period. No serious adverse events (defined
as events requiring hospital admission,
leading to permanent disability, or resulting in death) were reported. Mild
transient reactions, such as bruising
or pain, were associated with 15% of
treatments. Minor adverse events were
found in 43 instances (0.1%), the most
common being severe nausea, fainting,
and dizziness.
Acknowledgments: The opinions and assertions
contained herein are the private views of the authors and are not to be construed as official or as
reflecting the views of the Medical Department
of the US Army or the US Army Service at large.
References
1. White AR, et al. Cochrane Database Syst Rev
2011;(1):CD000009. [LOE 2a]
2. Melchart D, et al. Arch Intern Med 2004;
164(1):104–105. [LOE 2b]
3. MacPherson H, et al. BMJ 2001;323(7311):486487. [LOE 2b]
SOR—strength of recommendation
LOE—level of evidence
Jon O. Neher, MD, University of
Washington, Editor
HelpDesk Answers are provided by
Evidence-based Practice, a monthly
publication of the Family Practice
Inquiries Network (www.fpin.org).
n
POEMs for the Teaching Physician
Prostate Cancer Screening: No
Mortality Benefit After 13 Years
of Follow-up
Clinical Question: Does screening of
asymptomatic men for prostate cancer
improve mortality?
Study Design: Randomized controlled
trial (single-blinded)
Funding: Government
Setting: Population-based
Synopsis: We have previously reported
on the first report from the PLCO study
(http://www.essentialevidenceplus.
com/content/poem/110501) in which
men between the ages of 55 years and 74
years at 10 centers were randomized to
receive prostate cancer screening
(annual PSA for 6 years plus digital
rectal examination for 4 years) or no
scheduled screening. The current
study reports additional follow-up
(up to 13 years). The authors report
having 92% follow-up at 10 years after
study enrollment but at the time of
this publication, only 57% of the participants had 13 years of follow-up.
The cumulative incidence rate of prostate cancer was 108 and 97 per 10,000
person-years in the screened and
control groups, respectively. We would
need to screen approximately 885
men annually to detect one additional
prostate cancer. However, the cumulative mortality rates were virtually
identical (3.7 and 3.4 per 10,000
person-years, respectively). Certainly,
the 10-year data appear to be similar to the 13-year data. The authors
found no difference in mortality whether
men were screened before entering
the trial or by age or comorbidity.
It appears that there is no overall
mortality benefit to screening asymptomatic men for prostate cancer.
Bottom Line: After more than a de-
cade of follow-up from the Prostate,
Lung, Colorectal, and Ovarian Cancer
study (PLCO), there appears to be
no mor tality benefit to screening
asymptomatic men for prostate cancer.
(LOE = 1b)
Source article: Andriole GL, Crawford ED, Grubb
RL 3rd, et al, for the PLCO Project Team. Prostate
cancer screening in the randomized prostate,
lung, colorectal, and ovarian cancer screening
trial: mortality results after 13 years of followup. J Natl Cancer Inst 2012;104(2):125-32.
Those Unnecessary “Little”
Tests Add Up: $5 Billion/Year
in the US
Clinical Question: What is the financial
impact of the typical practices of little
benefit used in primary care?
Study Design: Descriptive
Funding: Self-funded or unfunded
Setting: Population based
Synopsis: A previous project conducted
in three primary care specialties identified the “top 5” activities in each specialty that were thought to be common
in practice but of little benefit to patients
(Arch Intern Med 2011;171(15):138590). In this report, the authors used
data from two US surveys of practice—
the National Ambulatory Medical Care
Survey and the National Hospital
Ambulatory Medical Care Survey—to
estimate the frequency of these activities. They calculated the proportion
of times each of the top five activities
was performed as reported by these
surveys and used this percentage to
determine the additional costs to the
health care system. The costs lined
up as follows (in millions of US
dollars for 1 year):
General medical examination tests
or procedures
Routine complete blood count in adults
(56% of visits): $32.7
Basic metabolic panel in adults (16%):
$10.1
Annual electrocardiography (19%):
$16.6
Urinalysis (18%): $3.4
Antibiotics for viral pharyngitis (41%):
$116.3
Cough medicines for children (12%) : 10.3
Brand name statins(atorvastatin or
rosuvastatin) instead of generic statins
(34.6%): $5817 ($5.8 billion)
Papanicolaou tests for patients younger
than 21 years (2.9%): $47.7
DEXA scans for women younger than
64 years (1.4%): $527.4
Bottom Line: The routine “little” practices used in primary care add up when
multiplied across the US health care
system. Removing typical but not useful screening tests and procedures from
health maintenance examinations and
avoiding treating viral pharyngitis with
antibiotics and high cholesterol levels
with more expensive alternatives could
put more than $5 billion back into the
health care system. The list of not useful
habits, their frequency of use in the
United States, and their total costs can
be found in the synopsis. (LOE =5)
Source article: Kale MS, Bishop TF, Federman
AD, Keyhani S. “Top 5” lists top $5 billion. Arch
Intern Med 2011;171(20):1856-8.
LOE—level of evidence. This is on a scale of
1a (best) to 5 (worst). 1b for an article about
treatmen is a well-designed randomized
controlled trial with a narrow confidence
interval.
Mark Ebell, MD, MS, Michigan State
University, Editor
POEMS are provided by
InfoPOEMs Inc
(www.infopoems.com)
Copyright 2012
April 2012 | Volume 11, Issue 2
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