Best Practices for the Medical Management of Overweight and Obese Patients

Last month we looked at surgical interventions for patients with morbid obesity. This month, we turn to the much more common problem of how to medically manage patients who are overweight or obese.

Case Study: On the same day that you saw Naomi, who expressed an interest in bariatric surgery to treat her morbid obesity, you also saw Lauren. Lauren is a 30-year-old woman who recently experienced a series of life stressors, including the serious illness of a parent and the loss of a long-term romantic relationship. Also during the past year, she left her job and moved back to the town where she had grown up in order to take her of her sick mother. Thankfully, Lauren’s mother is improving, but the past few months have taken a physical and emotional toll on Lauren. More specifically, she has gained 50 lbs. Lauren says,

“I have never weighed this much in my life. How do I lose all of this extra weight?”

As a first step, you calculate her body mass index (BMI). Lauren is 5 feet 4 inches tall and weighs 165 lbs. To calculate her BMI, you can either use an online calculator or convert her height to meters and weight to kilograms. The formula to calculate BMI is

BMI = weight (in kg)/(height (in m))2.

Using this equation, you find that Lauren’s BMI is 28.3 kg/m2, placing her in the overweight (but not obese) range for BMI. Now you should review her options for medical management. These options include lifestyle modifications such as behavioral changes, improved diet, and increased exercise. They may also include medications currently approved for weight loss in the United States.

What do you do next?

Although Lauren came to you for help with weight loss, you are not the only professional who will be involved in her care. You can refer Lauren to a vetted psychologist, nutritionist, physical trainer, and/or pharmacist for additional support.

Behavioral changes and stress management play critical roles in helping patients lose weight and keep weight off. You encourage Lauren to begin counseling to better understand how her eating is impacted by stress. If she is amenable to group support, support systems can be found through commercial programs (like Weight Watchers), religious organizations, the local YMCA, and community overeating support groups.

Despite the controversies and hard-line stances, there are numerous high-quality diets that are effective for weight loss and health long-term. The key component of any diet is decreased caloric intake. Safe, effective diets can be vegetarian, low-fat, low-carbohydrate, or protein-heavy/low glycemic index diets. A referral to a nutritionist would be a great idea. Similarly, you should encourage Lauren to start exercising, and work her way up to 150 minutes of exercise a week. You have already completed a physical examination, and she is in good cardiovascular health. Lauren does not have any co-morbid conditions, so you give her the green light to start an exercise program.

What about pharmaceutical options for treating obese and overweight patients?

In the United States, the Food and Drug Administration has approved five medications for long-term weight loss management: orlistat, lorcaserin, phentermine/topiramate, naltrexone/bupropion, and liraglutide. Indications for prescribing these medications are a BMI over 30 kg/m2 or a BMI over 27 kg/m2 with the presence of certain co-morbid conditions (including diabetes, hypertension, etc.). These medications are prescribed for use in conjunction with lifestyle changes.

Orlistat works by inhibiting pancreatic lipase, leading to the excretion of 30% of dietary fat in stool. Not surprisingly, its side-effects include gastrointestinal distress and decreased absorption of fat-soluble vitamins.

The remaining four medications work by regulating appetite. Lorcaserin is a selective serotonin 2C receptor agonist. Side-effects include nausea, headache, dizziness, constipation and hypoglycemia in diabetic patients. These medications are contraindicated during pregnancy.

Phentermine increases norepinephrine to suppress appetite while the mechanism of how topiramate produces weight loss is not well-understood. Side-effects include insomnia, paresthesias, dizziness, nausea and constipation.

Naltrexone/bupropion side-effects are headache, nausea/vomiting, diarrhea/constipation, and headache. Bupropion inhibits dopamine and norepinephrine reuptake, while naltrexone is an opioid receptor agonist.

Lastly, liraglutide is an injectable that works as a glucagon-like peptide-1 (GLP-1) receptor agonist. However, there are significant risks of medullary thyroid carcinoma and acute pancreatitis associated with this medication.

What sort of medical management would you recommend for Lauren?

Lauren should start with behavioral support, including psychological counseling, nutritional evaluation, and exercise. At this time, she is not a candidate for long-term pharmaceutical intervention because her BMI is less than 30 kg/m2 and she lacks co-morbidities.

Visit our Patient Education page, which includes an Obesity Shared Decision Making Tool called PEPtalk Weight Management. This weight management tool is designed to promote wellness and self-management through shared decision-making between patients and clinicians. It provides patients with the knowledge, skills, and confidence to actively participate with their clinicians when making decisions that can improve their health and healthcare.

References:

Bray GA, Frühbeck G, Ryan DH, Wilding JP. Management of obesity. Lancet. 2016;387(10031):1947-56.

Patel D. Pharmacotherapy for the management of obesity. Metab Clin Exp. 2015;64(11):1376-85.

Dr. V. Silverstein
Durham, NC

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Dyslipidemia and Diabetes

Dyslipidemia and Diabetes: Evolving Guidelines, Treatments, Goals

CME Information

1

Program Overview

This activity is part of the Joslin Diabetes Center Virtual Grand Rounds Series. This session will focus on understanding and interpreting the new lipid guidelines and utilizing new lipid treatments in this context to establish appropriate treatments for a variety of dyslipidemic syndromes.

Accreditation/Designation Statements

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Primary Care Network and PlatformQ Health Education, LLC. Primary Care Network is accredited by the ACCME to provide continuing medical education for physicians.

Live Online Activity – Wednesday, March 29, 2017 from 12:00 PM – 1:00 PM EST.

Primary Care Network designates this live activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Online On-Demand Enduring Material

Primary Care Network designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Enduring Material Date of Release/Expiration

The enduring material will be available from March 29, 2017 – September 29, 2017.


Learning Objectives

At the conclusion of this activity, participants will be able to:

  • Implement key elements and major changes in the updated treatment guidelines for dyslipidemia with a focus on how they would apply to treatment design for dyslipidemia and diabetes
  • Identify when newer non-statin drug therapies may be indicated for patients with high lipid-related CVD risk despite maximum tolerated statin therapy
  • Delineate the pharmacology, approved indications, and potential barriers to overcome ineffective use of PCSK9 inhibitors in patients at high risk for CVD events

Jointly provided by Primary Care Network, PlatformQ Health Education, LLC and its collaborating partner Joslin Diabetes Center.

PCN_web joslin_diabetes_center_logo

 

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Participant will need to initially complete a short registration form with Diabetes Series Live to participate in this activity. Future participation in Diabetes Series Live activities will allow you to skip the registration process and only require you to log-in.

Published March 17, 2017

 

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Reducing Hypoglycemia

Treatment of Type 2 Diabetes with Special Consideration to Reduce Hypoglycemia

 


Learning Objectives

After participating in this educational activity, participants should be better able to:

  1. Apply strategies to individualize glycemic targets in patients with type 2 diabetes
  2. Discuss the limitations of frequently used conventional therapies for the treatment of patients with type 2 diabetes
  3. Outline the risk factors and clinical consequences of hypoglycemia
  4. Implement strategies to minimize hypoglycemia risk in the treatment of patients with type 2 diabetes


Overview

This educational activity will focus on the optimal management of patients with type 2 diabetes while minimizing hypoglycemia risk. Specifically, this program will help clinicians identify patients who are at an increased risk for hypoglycemia and will highlight the limitations of frequently used conventional therapies. There will also be discussion on how to optimize therapy while minimizing the risk of hypoglycemia in patients with type 2 diabetes.

 

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This activity has expired and is no longer available for CME; however, we hope you still enjoy the education.

Published on March 10, 2015

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Understanding of Obesity

Neurobiological Understanding of Obesity: New Treatment Guidelines and Patient-Centered Approach


Learning Objectives

After participating in this educational activity, participants should be better able to:

  1. Screen for risk factors of obesity and diagnose obesity as a disease early in its evolution
  2. Prescribe pharmacological intervention for obesity based on the neurobiology and pathophysiology of the disease following the National Heart, Lung and Blood Institute (NHLBI) guidelines
  3. Describe the safety and efficacy studies of various agents and create awareness of post marketing and long term pharmacovigilance studies to assess long term risks
  4. Focus on obesity as disease and provide communication strategies to build ongoing collaborative relationships with obese patients


Overview

Obesity has reached epidemic proportions for both children and adults and has become a major public health problem. Two-thirds of adults are overweight; one-third of them are obese. Obesity is associated with significant health risks and comorbidities including diabetes, metabolic syndrome, cancer, heart disease, depression, sleep apnea, osteoarthritis, and others.

Lifestyle interventions focused on diet, physical activity, and behavioral therapy are essential components to treating obesity and should be incorporated throughout the continuum of care. Some patients will successfully achieve weight loss with these efforts alone; however it is well documented that long-term weight loss and maintenance is difficult to achieve. When “first-line” interventions alone have not succeeded, the National Heart Lung and Blood Institute (NHLBI) guidelines recommend pharmacological intervention as an option.

This CME article will present the clinical realities of obesity encouraging an open provider/patient relationship that enhances care, allowing for discussions on goals, adherence, barriers, and expectations.

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This activity has expired and is no longer available for CME; however, we hope you still enjoy the education.

Published on December 30, 2014

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Advance Directives

Preparing for Death with Dignity via Advance Directives

 

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Have you ever thought about how you are going to die? Will you die comfortably or tragically? Will death overtake you suddenly or perhaps be a slow, painful process? The uncertainties surrounding death abound, but one thing is for sure, it is inevitable. The subject of death can be an uncomfortable one for many people, for various reasons. Yet in medicine, death and dying are commonly encountered occurrences, particularly when dealing with patients within the geriatric population.

However, many elderly adults and their loved ones may not have given serious consideration to how their lives may end and how they will manage and react when that time comes. They are not prepared for the inevitable. But, preparation is just the thing they need, in order to make peace with death and dying. Advance directives are the key to being prepared. They encourage people to think about their own death and how to take some control over the process. For patients who want to prepare and learn more about developing an advance directive, they seek guidance from their healthcare provider. For this reason, healthcare providers need to be knowledgeable about advance directives and be able to advise their patients. The Agency for Healthcare Research and Quality (AHRQ) reported that only 12% of patients who had an advance directive involved their physician in its creation and 65% to 76% of providers were unaware that their patients had advance directives.[1]

For the patient that does not yet hold an advance directive, particularly if that patient is elderly, addressing this topic at the healthcare visit becomes particularly vital. As people age, their risk for developing any number of chronic diseases greatly increases. In fact, the AHRQ has determined that approximately 80% to 85% of people aged 65 and beyond, will eventually become ill and meet their demise related to a chronic illness. In particular, cerebrovascular and cardiovascular diseases, Alzheimer’s disease, diabetes, renal disease and obstructive pulmonary disease are the main culprits, as each lends itself to progressive declines in physiological and mental health and function over less predictable lengths of time. There can also be occasional exacerbations that may require hospital admission. [1] Furthermore, according to Dr. Peter Saul, in his presentation of “Dying in the 21st Century,” there are four main categories through which people face death. Because of these, advance directives are not only necessary, but should become a health initiative priority. They include: death related to frailty, organ failure in the case of chronic disease, terminal illness, and sudden (unexpected) death. [2]

What exactly is an advance directive? An advance directive consists of several components that document or help people to express their wishes regarding treatment actions to be taken if they were to become critically ill, involved in a serious accident, in a coma, or become severely cognitively impaired and therefore unable to express these wishes for themselves. The concept of the advance directive was created as a provision of the Omnibus Budget Reconciliation Act proposed in November 1990, in order to give patients a choice in the medical treatments they receive. Also, through the Patient Self-Determination Act passed by Congress in 1991, patients were empowered to become active participants in medical decisions “affecting the condition and length of their life,” including being able to accept or reject treatments and create an advance directive. [3, 4] The advance directive is formulated by patients, often in discussion with their loved ones, and/or healthcare provider, and/or pastor. Advance directive components include the living will, medical durable power of attorney, do-not-resuscitate (DNR) orders, Protective Medical Decisions Document (PMDD), and the Physician Orders for Life Sustaining Treatment (POLST).

The living will also known as a healthcare directive or declaration, is a document that contains the patients’ predetermined wishes regarding the treatment modalities and measures to sustain life they would want and expect for themselves, in any serious health situation where they were unable to express these needs themselves. [5] For example, a patient with a neurological disease may pre-express in the living will that if he/she were to one day end up in coma, he/she would not want to be given artificial nutrition or hydration via feeding tubes. Further, in this document, patients could state their wishes regarding the use of mechanical respiration ventilators, hemodialysis, and in the event of death, even donation of their organs. [5] The living will is initiated by the patient’s attending physician in the event of three concurrent occurrences: the patient has lost the ability to make medical decisions, the patient must have an end-stage illness or injury from which the person will most likely not recover, and that artificially sustaining the patient’s life will hinder the ability to die naturally. [6]

The medical or healthcare power of attorney (POA) is a document that identifies one particular person (such as a spouse or family member or close friend), named by the patient, to be the “agent” or “proxy” (also known as a “surrogate” or “representative”) to make decisions regarding treatment modalities, in the event that the person is seriously incapacitated and cannot speak for himself. The decision to choose an agent should be made with deliberation and thought, as the chosen one must be able to convey and abide by the patient’s predetermined wishes and make choices for the patient in any unforeseen situation. If this were to happen, the agent would then be able to make unbiased decisions, on the patient’s behalf, based on knowledge of the patient’s values and wishes. [5] Additionally, a person may consider a second or even a third agent in the event the first one named is not available or is unable to make the necessary decisions. [6]deathbed

The PMDD is a written form of the durable power of attorney for healthcare (DPOA). Available through the Patients’ Rights Council, its purpose is similar to that of the medical POA. However, the PMDD goes one step beyond, by providing patients with increased protection (in the event of their decision making incapacity) against an agent who decides to terminate their (patients’) lives directly and intentionally, via assisted suicide or euthanasia. Besides the primary agent, alternative representing agents may be named in the PMDD, as well. [7]

The DNR order is written by a physician. It states the patients’ wishes as to whether or not they would want cardiopulmonary resuscitation (CPR) in the event they sustained cardiac or pulmonary arrest. The DNR may exist in two forms; one that addresses the CPR situation within the hospital setting and another for pre-hospital CPR situations, such as at home or in a nursing facility. [8]

Finally, the POLST is a standardized form initiated by physicians with their patients, in order to document the patients’ wishes regarding certain types of life sustaining treatments they desire or do not wish to have when their health condition is serious and they are unable to express what they want (at that time). Signed by both the physician and patient, it becomes part of the medical record, thereby making it portable and valid in any locality that patients may be in, even if they were to experience a serious health crisis when away from home. [9]

When a patient without an advance directive is hospitalized with a serious medical condition and unable to communicate, physicians must delegate that responsibility to whomever they deem appropriate to make choices on behalf of the patient. Usually this is the patient’s next of kin. Given that physicians are often unaware of patients’ wishes or who their choice of agent would have been, the doctors will make that decision for the patients. But later, if the doctors do not agree with the choices made by the agent whom they have chosen, they may then feel free to choose another. [10] This whole situation can be turned around by having an advance directive ready and available. Then, if doctors are in disagreement with the patients’ or their agent’s decisions, under federal law, doctors are required to inform the patients or their agent of that in advance at time of potential admission. In states such as Texas with an even more stringent law, doctors/facilities must render care even if they consider it to be “futile care” until provisions can be made to transfer the patient to another facility or physician who will honor the patient or agent’s choices. [10]

The responsibility for the development of a patient’s advance directive lies not only with the patient, but ultimately with the patients’ healthcare provider, as this is a very important component of the patient’s comprehensive health care. In preparation for addressing this issue with the provider patients should contemplate and discuss various items with their trusted loved ones including: [6]

  • Their attitudes towards life, including activities that bring them joy and situations they fear
  • Their attitudes about potentially losing control and independence
  • How their attitudes may be influenced by religious beliefs
  • Their attitudes towards being seriously ill or injured
  • Their attitudes regarding overall health, being ill, dying, and death
  • Their understanding of the choices for medical treatment, in the event of serious illness or injury
  • Their feelings about being unable to communicate their wishes should they become brain dead, go into a perpetual coma, or become terminally ill
  • Their feelings about having healthcare providers make treatment decisions independent of the wishes of patients
  • Informing their loved ones of their expectations for treatment at the end of life
  • Informing loved ones of their fears and concerns regarding treatments under certain circumstances
  • Knowing how their loved ones would feel about the patient’s advance directive choices and if they could respect them
  • Selecting their primary medical POA and alternates based upon the knowledge that their chosen agents clearly understand the reasons behind the patient’s beliefs and decisions and could be trusted to abide by their wishes
  • Determining if their chosen agents would be willing to accept this responsibility
  • Ensuring that their agents understand the patient’s current health conditions, how these conditions could negatively progress, treatment options available,  adverse effects of these treatments, and prognosis with and without treatment including measures that may be used to prolong and sustain life
  • Their idea of what “quality of life” means to them
  • Their idea of what “dying with dignity” and “no heroic measures” means to them
  • Their thoughts about pain and their expectations regarding how their pain should be managed
  • Ensuring that they are informed about pain management options and effects
  • Their thoughts about life after death and how that thought may influence their advance directive choices
  • Discovering if they have any obstacles discussing issues regarding advance directives
  • Being aware of both their own and their loved ones’ understanding of the purpose of an advance directive

Healthcare providers, on the other hand, need to prepare to discuss advance directives with their patients by first being aware of their own feelings regarding the issues involved. Next, they must increase their own comfort level when discussing this topic with their patients. According to the results of patient surveys regarding advance directives, “most adults would prefer to discuss advance directives while they are well, preferably with a doctor who has known them over time…they look to their doctors to initiate the discussion”. [11] Yet, only approximately 15% to 25% of adults have actually completed advanced directives usually after hospitalization with a serious illness. [11] Further, a study of outpatients aged 65 years and older has determined that “a doctor’s inquiry increased two- to three-fold the chances that individuals would have an advance directive on file with their health plan”. [11]

Drs. Zwieg and Mehr from the University of Missouri-Columbia School of Medicine recommend that end-of-life care discussions between healthcare providers, their patients, and their families should consist of four main components. First, patient preferences should be determined. This could include their thoughts on treatments they want and those that they don’t. Second, prognosis for disease states that patients are experiencing should be discussed. This could include thoughts on how much time certain treatments or procedures would buy patients, as well as how these may affect their quality of life. Third, the goals of providing such treatments and procedures should be addressed. This could include knowing not only the outcomes hoping to be achieved, but also informing patients of the benefits, risks and even the financial cost involved. Lastly, a management plan should be developed keeping patients’ goals in the forefront. This could include advance directives that permit both broad and specific decisions to be made in various circumstances of serious illness and/or injury and death. [12]

Overall, it is most important for healthcare providers to be respectful and emotionally supportive of their patients’ choices. In discussing advance directives, providers must be aware of patients’ values and goals. [13] They should address any concerns, questions, and fears that patients and their families and/or agent’s may have and supply information necessary to make informed decisions.  Also, providers should keep a copy of advance directives in the patient’s medical record. Patients should be reminded to give copies to their primary agent and alternates, children, and any other people who need to know the patient’s wishes. Copies can be filed, without cost, at patients’ local hospitals. [6]

Of course, patients should be aware that they can change their advance care decisions if ever the need arises. Usually this will require destroying the original and copies of the old advance directives and replacing them with the updated ones. Living wills and medical power of attorney usually require two witnesses (one may need to be a notary) to observe the patient’s signing and dating the advance directive. [6] Patients should check their state regulations for guidance regarding the creation of advance directives (or consult the National Hospice and Palliative Care Organization’s website). [14] A lawyer is not required for this process. [5] Advance directives should be reviewed each year, dated and initialed. The original should be readily available when needed. Additionally a card stating that patients have advance directives should be kept in their wallet, in case of an emergency. [6]

Having an advance directive is a vitally important part of the healthcare plan. Healthcare providers need to make the time to address this topic with their patients. Advance directives will not only lessen their patients’ suffering and increase their peace of mind, but they will also provide a sense of autonomy and control over their death. [8] Additionally, they can take away some of the frustration, stress, confusion, guilt, and uncertainty for loved ones who are faced with the patient’s terminal situation. [15] Death and dying can be uncomfortable subjects to confront, but as healthcare providers, we must be able to do so every day. Providers may even teach by example by having an advance directive of their own. As was said by the late Dame Cicely Saunders, founder of the modern hospice movement, “You matter because you are you and you matter until the last moment of your life”. [16]


Karen Digby, BA, BSN, MS, GNP-BC, CWS

GNP Independent Contractor/Writer
Ann Arbor, Michigan

Published on November 26, 2013

 

Biosketch

Karen Digby is a nurse practitioner specializing in geriatrics. She received her training from New York University and the University of Michigan in Ann Arbor. In over ten years of practice, Karen has obtained a wealth of experience in various aspects of health care including home care, outpatient/ambulatory care, dementia care, subacute care, hospice, and assisted living and long-term care. Due to her expertise in geriatrics, Karen was selected as an item writer, by the American Nurses Credentialing Center, for the Gerontological Nurse Practitioner Board Certification Examination. She also co-authored an article on “Falls in the Elderly” in the Plastic Surgical Nursing Journal. Additionally, Karen is certified as a Wound Care Specialist through the American Academy of Wound Management.

References

  1. Kass-Bartelmes BL, Hughes R, Rutherford MK. Advance care planning: preferences for care at the end of life. Rockville (MD): Agency for Healthcare Research and Quality; 2003. Research in Action Issue #12. AHRQ Pub No. 03-0018. http://www.ahrq.gov/research/findings/factsheets/aging/endliferia/index.html
  2. Dr. Peter Saul. Dying in the 21st Century. TED Talk (TED x Newy). 2011. http://www.youtube.com/watch?feature=player_embedded&v=03h0dNZoxr8
  3. Department of Health and Human Services. Office of the Inspector General. Patient advance directives: early implementation experience. August 1993. http://oig.hhs.gov/oei/reports/oei-06-91-01130.pdf
  4. Rosen A, O’Neill J. Social work roles and opportunities in advance directives and health care decision making. National Association of Social Workers. March 1998. http://www.socialworkers.org/practice/aging/advdirct.asp
  5. Mayo Clinic. Consumer health. Living wills and advance directives for medical decisions. http://www.mayoclinic.com/health/living-wills/HA00014
  6. Advance medical directives. http://www.cpt.org/files/PP%20-%20Advance%20Directives.pdf
  7. Patients Right Council. Advance directive: protective medical decisions document. http://www.patientsrightscouncil.org/site/advance-directive-protective-medical-decisions-document/
  8. What is an advance health care directive? http://fcasocal.org/advance-directives.html
  9. Pope TM, Hexum M. Legal briefing: POLST: physician orders for life-sustaining treatment. J Clin Ethics. 2012 Winter;23(4):353-376.
  10. Marker RL. Patients Rights Council. Advance directive: protecting yourself and your family (part 2).  http://www.patientsrightscouncil.org/site/advance-directive-protecting-yourself-and-your-family-part-two/
  11. Wissow LS, Belote A, Kramer W, Compton-Phillips A, Kritzler R, Weiner JP. Promoting advance directives among elderly primary care patients. J Gen Intern Med. 2004 Sep;19(9):944-951.
  12. Zweig S, Mehr DR. Helping older patients and their families decide about end-of-life care. Missouri Medicine. 2003 Jan-Feb: 100(1): 62-28.
  13. Fischer GS, Arnold RM, Tulsky JA. Talking to the older adult about advance directives. Clin Geriatr Med. 2000 May;16(2):239-254.
  14. National Hospice and Palliative Care Organization. http://www.caringinfo.org/i4a/pages/index.cfm?pageid=1
  15. Span P. Why do we avoid advance directives? The New York Times. April 20, 2009. http://newoldage.blogs.nytimes.com/2009/04/20/why-do-we-avoid-advance-directives
  16. Clark D. Cicely Saunders: Selected writings 1958-2004. New York, NY: Oxford University Press, 2006.
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CLL Latest Advances

ASCO 2013: Making Relevant the Latest Advances for CLL

 

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Dr_Koffman_2     Dr_Wierda_2

Overview:

The world of Chronic Lymphocytic Leukemia (CLL) is constantly changing. These videos are intended to provide information and clarify a few of the important, yet very relevant, factors that affect patients with CLL, their choices, and your role as their healthcare provider.


This activity is targeted for healthcare providers with patients with CLL.

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Published on November 7, 2013

 

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Eclipse Retinopathy

Shortly after people throughout the United States had an opportunity to witness a total solar eclipse, primary care providers began hearing from patients who had viewed the eclipse without protective equipment and now have concerns about their vision.

Case study: You walk into the clinic the morning after a total solar eclipse passes through your state. Your nurse looks frazzled. He tells you that you have a waiting room full of add-on patients complaining of eye problems after they directly looked at the eclipse yesterday afternoon. You tell him to lead them into exam rooms, and you will start with a long-time patient of yours named Dave. Dave is an obese 70-year-old man with a past medical history of hypertension and elevated cholesterol. He presents to the clinic today because he watched the eclipse yesterday without wearing eye protection. An hour afterwards, he began having vision changes and is now panicked that he is going blind. What do you ask Dave?

You ask him to tell you additional information about his symptoms. He tells you that he watched the eclipse with his right eye, and he is now experiencing blurry vision with a blind spot in the middle of his field of vision in that eye. Not surprisingly, he denies any eye pain or changes in vision in his left eye. On physical exam, he does not have any redness, tearing, or discharge from either eye. He also has full range of motion in his eyes and no evidence of nystagmus.

You suspect that Dave has acute eclipse retinopathy. Acute eclipse retinopathy is a well-known eye disease that captures the attention of the medical establishment every few years after an eclipse. Eclipse retinopathy is caused by damage to photoreceptors and the retinal pigment epithelium cells of the macula. The signs and symptoms include blurry vision, wavy lines, blind spots, and other changes in visual perception. Symptoms begin one to four hours after exposure, and pain is not a symptom of eclipse retinopathy. What do you do next?

You decide to refer the patient to an ophthalmologist for further work-up. Work-up may include a slit lamp fundus examination, fluorescein angiography, and/or optical coherence tomography (OCT) investigation of the macula. Luckily, Dave is able to get an appointment within an hour. Later that afternoon, the ophthalmologist sends you an update. She discovered a small yellow spot surrounded by a gray ring in the fovea on fundus examination, suggesting damage from the eclipse. The ophthalmologist would like to follow up with Dave at regular intervals. Luckily for Dave, many of these cases of mild eclipse retinopathy at least partially resolve. How do you plan for the next eclipse?

You recommend that all your patients wear eye protection while watching the eclipse – even if they will only watch the eclipse for a few seconds with one eye. In the meantime, patients who have been diagnosed with eclipse retinopathy should be followed by an ophthalmologist until their symptoms stabilize or resolve.

Have you seen any recent patients with acute eclipse retinopathy? Share your experiences in the comment section below.

Khatib N, Knyazer B, Lifshitz T, Levy J. Acute eclipse retinopathy: a small case series. J Optom. 2014;7(4):225-8.

Photo Credit: © 2017 Richard Ball

Dr. V. Silverstein
Durham, NC

Published on 9/1/17

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Faculty Spotlight: Dr. Hutchinson

Susan L. Hutchinson, MD

Director, Orange County Migraine & Headache Center
Volunteer Clinical Faculty, UC Irvine Department of Family Medicine
Irvine, CA

Susan L. Hutchinson, MD, is board certified in Family Medicine and has a subspecialty in Headache. She is Director and Founder of Orange County Migraine & Headache Center in Irvine, CA. She is also on the Volunteer Faculty Department in the Department of Family Medicine at UC-Irvine Medical Center and loves teaching 3rd year Family Medicine Residents who rotate with her in her office. She concentrates on the management of migraine and mood disorders with a special interest in the relationship of both conditions to hormones. Dr. Hutchinson is a national speaker on both migraine and depression and was awarded the National Headache Foundation Lectureship Award in February 2003 in recognition of her contribution to headache education. She was selected as a Physician of Excellence by the Orange County Medical Association in January 2007. She served as Chair of the Women’s Issues Section of American Headache Society (AHS) from 2005-2010 and is on the board of the Headache Cooperative of the Pacific (HCOP); she is a Past-President of the Orange County Chapter of the California Academy of Family Physicians (CAFP). In recent years, she has co-authored numerous journal articles and chapters on the subject of migraine. In 2013, Dr. Hutchinson wrote and published her first book “The Woman’s Guide to Managing Migraine” to be used as a resource for female migraine sufferers.

To celebrate turning 60, Dr. Hutchinson participated in a 1/2 Ironman (1.2 mile swim, 56 mile bike, 13.1 mile run) competition in San Diego. She placed 1st in her age group and will be participating in the National 1/2 Ironman Competition in Chattanooga, TN this September. In addition to triathlons, she enjoys playing golf.

Dr. Hutchinson has been involved with Primary Care Network from the very beginning, helping PCN to create quality CME content and educating her peers on various therapeutic areas like migraine, depression, and women’s health issues. She’ll be presenting on fibromyalgia at this fall’s MEDX conferences in Dallas and Chicago.

To learn more about Dr. Hutchinson, visit http://drsusanhutchinson.com/.

I am both a headache specialist and a migraine sufferer. I know first-hand the disabling and unpredictable nature of migraine attacks. The driving passion in my life is to alleviate the suffering of migraine in patient’s lives and to help give them their life back.

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Clinical Challenges in Migraine: The Role of Emerging Therapies in New Treatment Paradigms

Clinical Challenges in Migraine: The Role of Emerging Therapies in New Treatment Paradigms

 

Program Overview
Join the discussion with our faculty as they present the most up-to-date information being reported in clinical trials for the new calcitonin gene-related peptide (CGRP) inhibitors. Whether you’re learning this information for the first time or you want to hear more of the newest information about how CGRP inhibitors may change your practice, you’ll leave this session with a new insight into how what’s happening in clinical trials today will impact your practice in the near future. This enduring program was streamed live from Headache Update 2017.

Learning Objectives
After completing this activity, the participant should be better able to:

  • Outline current challenges and barriers to the effective prevention of migraine
  • Describe the role of calcitonin gene-related peptide
  • Summarize data focusing on new and emerging preventive treatments for episodic and chronic migraine

Faculty/Planning Committee

Merle L. Diamond, MD – Chair
President, Managing Director
Diamond Headache Clinic
Chicago, Illinois

Stewart J. Tepper, MD
Professor of Neurology
Geisel School of Medicine at Dartmouth
Hanover, New Hampshire

Release/Expiration Dates
Release Date: August 1, 2017
Expiration Date: August 1, 2018

CME CREDIT
Accreditation Statement
: MediCom Worldwide, Inc. is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Designation Statement: MediCom Worldwide, Inc. designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.


CPE CREDIT
MediCom Worldwide, Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This activity is acceptable for 1.0 contact hour of Continuing Education Credit. Universal Activity Number: 827-0000-17-162-H01-P. Knowledge-based CPE activity.

In order for CPE Monitor to authenticate credit, pharmacists/technicians must provide their e-Profile ID number from NABP and date of birth (in MMDD format) when claiming credit for a CPE program.

NURSING CREDIT
Accreditation Statement
: MediCom Worldwide, Inc., 101 Washington Street, Morrisville, PA 19067 is approved by the California Board of Registered Nursing, Provider Number CEP11380. MediCom designates this CNE activity for 1.0 contact hour. Program Number: 17-162-062

Activity provided by MediCom Worldwide, Inc.

Published on Primary Issues, 8/11/2017

Participant will be leaving Primary Issues and completing this activity on the hosts website (Emerging Solutions in Pain).

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Overview of the Opioid Epidemic in the United States

In recent months, the opioid epidemic has dominated the news cycle in the United States, and health care providers are finding themselves at the center of these conversations.

From 2000 to 2014, the drug epidemic in the United States killed over 500,000 people, and 2014 was the most lethal year on record.[1] The Centers for Disease Control report that more than 60% of the 28,000 deaths caused by drug overdose in 2014 were due to an opioid overdose.[2]

Depending on the source, physicians and nurses have been accused of prescribing the medications that create dependency in patients, overprescribing prescription opioids to produce an illegal economy of diverted medications, and failing to identify patients addicted to prescription pain medications. At the same time, many health care providers have expressed tremendous interest in doing their part to address the opioid epidemic. Physicians have felt a moral obligation to manage patient pain control effectively and safely, while also decreasing the risk of abuse and diversion of prescription pain medications.

Physicians are actively seeking alternatives to opioid pain medication for the treatment of acute and chronic pain syndromes. In particular, they want to know what types of pain respond better to non-opioid treatments. For example, non-opioid modalities may be safer and more effective in treating conditions like chronic back pain and migraine headache. Professional and national guidelines for back pain and migraine headache recommend a series of non-opioid interventions for pain such as lifestyle changes, non-opioid medical management, and operative interventions. However, it is unclear if health care providers are aware of the existence of these guidelines or if they are encountering barriers to implementing them.

Physicians and other health care providers are also well-situated to prevent deaths caused by opioid overdoses. Risk factors for patients who may overdose include pre-existing liver problems, a history of opioid abuse, a history of overdose, a history of psychiatric problems, the administration of high doses of opioids, and long-acting opioids. In the immediate sense, providers should be able to accurately identify the signs and symptoms of opioid toxicity and appropriately treat patients who are overdosing with naloxone. Naloxone, the reversal agent for opioid overdose, is administered in patients who are suspected of overdose. However, this medication has a short half-life and must be re-administered every 20 minutes until the opioid has cleared the body. Increasingly, providers are encouraged to write prescriptions for naloxone for patients at risk of overdose and to teach patients, friends, and family members how to administer this medication if they suspect an overdose.

By attempting to manage acute and chronic pain through the use of non-opioid treatments, prescribing opioid medications judiciously, and learning how to reverse the effects of opioid overdose, physicians and other health care providers can do their part to combat the opioid epidemic.

[1] Drug Overdose Epidemic. Centers for Disease Control Web site. http://www.cdc.gov/drugoverdose/epidemic/index.html. Last Updated June 21, 2016. Accessed July 8, 2017.

[2] Drug Overdoses. Centers for Disease Control Web site. http://www.cdc.gov/drugoverdose/index.html. Last Updated March 16, 2016. Accessed July 8, 2017.

Dr. V. Silverstein
Durham, NC

Published on 7/27/17

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Faculty Spotlight: Dr. Burke

M. Susan Burke, MD, FACP

Clinical Associate Professor of Medicine
Sidney Kimmel Medical College at Thomas Jefferson University
Philadelphia, PA
Senior Advisor, Lankenau Medical Associates
Lankenau Medical Center
Wynnewood, PA

M. Susan Burke, MD, FACP, is a clinical associate professor of medicine at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, PA, an adjunct associate professor of geriatrics at the Philadelphia College of Osteopathic Medicine in Philadelphia, and senior advisor of Lankenau Medical Associates at the Lankenau Medical Center in Wynnewood, PA, where she has been a clinician and teaching attending for more than 30 years. Having earned her medical degree from the University of Pennsylvania Perelman School of Medicine (Philadelphia), she completed a residency in internal medicine at Lankenau Hospital (now the Lankenau Medical Center). Dr. Burke is board certified in internal medicine and geriatrics and is a fellow of the American College of Physicians.

A 2-time recipient of the Osler-Blockley Award for Excellence in Clinical Teaching from Thomas Jefferson University, Dr. Burke also has received the residents’ award for best teacher from the Lankenau Internal Medicine house staff. She has been named Best Doctor for Women and, more recently, Top Doctor by Main Line Today magazine. Dr. Burke lectures nationally and has published chapters and articles on numerous primary care and geriatric topics on continuing medical education web sites as well as in publications such as The Journal of the American Osteopathic Association and Annals of Long-Term Care. When not working, she enjoys visiting with family, taking pictures and traveling to national parks throughout the country.

Dr. Burke has been involved with Primary Care Network for many years, developing CME education and presenting at our Best Practices in Primary Care programs. Last year, Dr. Burke was not only a faculty presenter at the Medical Education Exchange (MEDX) regional CME conferences, but graciously moderated the conferences as well. Join her again this year in both Dallas and Chicago, where she’ll once again moderate those conferences as well as participate as a faculty presenter.

“My two professional passions are practicing medicine and teaching fellow clinicians. In my resident practice, my goal has always been to present the science and foster discussion while sprinkling useful ‘art of medicine’ tips along the way. Live conferences promote such exchange of ideas on a larger scale. Ultimately, attendees as well as patients benefit from this dynamic interaction.”

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Customizing an EMR Using Practice Guidelines for Clinical Decision Support

As mentioned in previous blogs, I volunteer as medical director of a free clinic for adults without health insurance. As an interfaith-based project, we’re supported by several local churches, a synagogue, a mosque, and individual donations. Culmore Clinic (www.culmoreclinic.org) is currently housed on the second floor of Columbia Baptist Church in Falls Church, VA. On Tuesday and Thursday mornings, the church classrooms are converted to exam rooms, an office, nurses’ station, conference room, counseling rooms, and returned to their usual configuration in the evening by a group of volunteers from Goodwin House, a nearby retirement community. Since I joined five years ago, Culmore Clinic has expanded from once to twice a week with two providers (a volunteer retired internist for a half day and a nurse practitioner for a full day) to currently three part-time NPs, a PA who also acts as executive director, a counseling team of clinical social workers, a physical therapist, and another volunteer internist. We now coordinate clinical services with a dozen volunteer nurses, a paid full time nursing director, NovaSalud HIV/hepatitis screening group, Fairfax women’s clinic, George Mason University NP student training practice, and several specialty referral centers including the University of Virginia, Inova Health System, NIH, and the Northern Virginia Medical Society telemedicine pilot program. We import data from a hospital lab system and several group radiology practices. We also have interfaith prayer ministry, interpreter service, patient education, and ombudsmen/navigators for local community health resources. The community we serve is almost entirely immigrants, most of whom work jobs that do not qualify for health insurance. We have 20-30 office visits per clinic day with efficiency limited by the necessity of language interpretation, and our patients’ multiple morbidities and lack of previous primary care.

When I accepted the position, I set a goal of implementing an electronic medical record (EMR) system. Since very few of our patients qualify for federal funding, we could not take advantage of the CMS incentive program to adopt an EMR, and we could not afford the communications hardware necessary to use Inova’s EpicCare EMR system. We decided on the web-based PracticeFusion (PF) system because we do not have the resources to maintain a server, it is free of charge to the practice, and it has most of the features we wanted in an EMR. We did receive a grant from the Phillip L. Graham Foundation which we used to buy computer and communications hardware, additional software for staff and volunteer administrative management, and to pay local health informatics consultants to help in the transition from a homegrown paper-based system including staff and provider training. Most of our patients have cell phones with only voice and text, and have internet access only through the public library. Many have very limited education and literacy even in their native languages.

The terms of the grant require us to show that the funds have improved at least the process if not the outcome of health care for our patients. We selected diabetes, hypertension, and depression – the three most common chronic conditions in our population – as targets to measure our performance. We chose as outcome variables HgbA1C, arterial blood pressure, and PHQ9 score and our study is still in progress.

Because PF does not allow users to customize the clinical decision support (CDS) reminders developed for CMS Meaningful Use, I used charting templates to implement CDS for our practice. PF has a charting template editing tool which I found quite easy to learn and there is a community of PF users that have already developed and published templates for various conditions.

I reviewed current clinical practice guidelines (CPG) for the three target conditions and found freely available online versions of the following:

Standards of Medical Care in Diabetes—2017 Abridged for Primary Care Providers at

https://professional.diabetes.org/sites/professional.diabetes.org/files/media/abridged_standards_of_medical_care_in_diabetes_2017_0.pdf

I cut and pasted text and tables from the article to the appropriate sections of the office visit template so that providers seeing a patient with diabetes can enter and edit the recommended data into a progress note for each visit of our patients with diabetes.

I used a similar approach for hypertension using Veterans Administration/Department of Defense CPG https://www.healthquality.va.gov/guidelines/CD/htn/VADoDHTNClinicianSummary.pdf. Depression has been more problematic because I could not find any one widely used CPG for US primary care: I synthesized information from USPTF on screening https://www.guidelines.gov/summaries/summary/49978/screening-for-depression-in-adults-us-preventive-services-task-force-recommendation-statement?q=depression+primary+care; from SAMHSA on suicidal risk assessment https://store.samhsa.gov/shin/content/SMA09-4432/SMA09-4432.pdf; and from AHRQ on evidence-based therapy https://effectivehealthcare.ahrq.gov/ehc/products/568/2152/major-depressive-disorder-executive-151202.pdf for our Culmore Clinic depression template.

I have only self-reported data on the extent to which the templates I developed are used by our providers, and can at best use historical audits of our patients’ outcomes before and after. Our counselors can now enter notes in the EMR and see our notes on the patients’ medical problems. Despite the limitations noted above, our preliminary data shows significant decreases in HgBA1C. We have not yet analyzed any other outcome or process data. Since we are now able to do group visits, increased use of insulins, and nutrition education with some of our diabetics it will be difficult to isolate any effect of the templated CDS, but we all agree that our EMR adoption has greatly increased our ability to share data between medical providers, counselors, and nurses and to expand our services to the community.

Charles Sneiderman, MD, PhD, DABFP
Culmore Clinic, Falls Church, VA
csneiderman@culmoreclinic.org

Published on 7/27/17

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Current Management of Diverticulitis

Case Study: Towards the end of your clinic day, your nurse comes up to you in the hallway and asks if you have time to see Robert, one of your long-time patients, for an urgent visit. Robert is a 39-year-old man with a history of obesity, acid reflux, and cigarette smoking, but he has not had any serious illnesses in the past. You agree to see the patient. A few minutes later, you walk into one of the exam rooms and see Robert, in visible discomfort, lying on the examining table. You ask him what is wrong, and he replies:

“Doc, I’ve never had stomach pain this bad in my life.”

You ask Robert for additional details, and he tells you that he has been having sharp pains in his left lower abdomen for two days now. The pain has gotten worse since this morning and is associated with nausea and constipation. The pain is significantly worse with straining. His stools are hard pellets, but he has not seen any blood. He generally smokes two packs per day, but has not smoked much today because of his nausea. Robert has had a long history of constipation and readily admits that he has recently been very busy with a construction job. As a result, he has not been drinking much water, despite the summer heat, and he has only had time to eat fast food.

What do you want to do now?

You take a quick glance at his vital signs and note that Robert is slightly febrile with a temperature of 38.9 degrees Celsius, slightly tachycardic with a heart rate of 110 beats per minute, and has normal blood pressure. His BMI is 35 kg/m2 and unchanged from his previous visit six months earlier. On physical exam, Robert is tender to moderate palpation in the left lower quadrant, but he does not have any signs of peritonitis.

What do you do next?

You decide to obtain imaging and labs. So you send Robert to the local hospital for a complete blood count, basic metabolic panel, and urinalysis. You are suspicious that he has diverticulitis, so you also order a CT scan of his abdomen and pelvis. When you see the lab report, you note that he has an elevated WBC. The read on the CT scan says that he has evidence of diverticulitis without any associated pericolonic fluid collections, obstructions, or large perforations.

As you know, diverticula are outpouchings of the intestinal wall usually caused by increased intraluminal pressure pushing out weakened areas of the bowel wall. Common causes of increased intraluminal pressure include straining due to constipation and obesity. The presence of diverticula is diverticulosis, and inflamed diverticula produce a diagnosis of diverticulitis. Diverticulitis with associated perforation, bleeding, abscess, fistula or obstruction is called complicated diverticulitis. Based on his CT scan and clinical findings, Robert has uncomplicated diverticulitis at this time.

What sort of medical management would you recommend for Robert?

Robert is able to hold down liquids, and his pain is controllable on oral pain medication. He does not need to be admitted to the hospital for serial abdominal exams, intravenous antibiotics, or intravenous pain control. You send him home on a clear liquid diet and a follow-up appointment in 3 days. If his pain or nausea become worse instead of improving over the next few days, he is to go to the local emergency room and request that they call you.

Three days later, he returns to clinic and tells you that he only has mild symptoms and is tolerating his liquid diet. On clinical exam, you observe that he is much less tender to palpation and does not have any signs of peritonitis. You decide that hospitalization is not necessary, but you send him home with ciprofloxacin and metronidazole and tell him to continue his liquid diet. He is to follow up with you in another 3 days unless his symptoms become worse.

The next time you see Robert in clinic, his symptoms have completely resolved. He is completing his course of oral antibiotics but is no longer requiring pain medication. You send him home to finish his antibiotics and slowly advance his diet. You also recommend that he lose weight, stop smoking, increase his fiber and water intake, and start an exercise program.

References:

Jacobs DO. Clinical practice. Diverticulitis. N Engl J Med. 2007;357(20):2057-66.

Wilkins T, Embry K, George R. Diagnosis and management of acute diverticulitis. Am Fam Physician. 2013;87(9):612-20.

Dr. V. Silverstein
Durham, NC

Published on 7/8/17

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Faculty Spotlight: Dr. Koffman

Brian Koffman, MDCM

Medical Director, CLL Society Inc.
Partner, St. Jude Heritage Medical Group
Diamond Bar, CA
Clinical Professor (Retired) Department of Family Medicine
Keck School of Medicine, USC Family Practice
Los Angeles, CA

Dr. Brian Koffman earned his medical degree from McGill University, completed his Family Practice residency at the University of Western Ontario, and his Psychiatry Fellowship at McMaster. Dr. Koffman taught at the University of Waterloo and is a retired Professor at the Keck School of Medicine, USC where he completed his Master of Science in Medical Education. His practice for the last 37 years has been with St. Jude Heritage Medical Group, Diamond Bar, California.

As the former Medical Director of Primary Care Network (PCN), he helped develop and provide quality accredited CME and continues to teach both patients and doctors on various medical topics around the world. He is proud to continue his involvement as faculty in ongoing PCN accredited CME programs.

He has dedicated himself to teaching and helping the chronic lymphocytic leukemia (CLL) community since his own CLL diagnosis in 2005. Dr. Koffman believes that his dual status as a physician and patient provides a unique experience and understanding which allows him to provide clear explanations of complex issues and to advocate for his fellow patients and inform his fellow healthcare providers.

As a doctor turned patient, his popular blog (http://bkoffman.blogspot.com) that shares and explains his CLL journey and the wide scope of his efforts in patient advocacy and education that has benefited countless patients with well over a million page views.

He founded and is the volunteer Medical Director of the highly respected nonprofit CLL Society (CLLS) (http://cllsociety.org) dedicated to the unmet needs of those with CLL. Dr. Koffman speaks around the world to fellow patients, physicians, and researchers sharing his unique perspective on how to best move forward in blood cancers.

Under his leadership, in only its first two years, CLLS has started 17 CLL patient support groups across Canada and the US, held several patient educational forums around the world, launched a website (http://cllsociety.org) with 25,000 page views a month, and done original research on how patients make decisions about their cancer treatment that was presented at the American Society of Hematology (ASH) annual meeting in 2016.

He is licensed and board certified in Family Medicine in the US and Canada. Dr. Koffman spends his little spare time reading, hiking, surfing, playing with his grandchildren, and enjoying his vegan diet.

“The greatest reward of being a physician is being able to share in my patients’ lives. Being informed by the always changing science of medicine is critical, but that serves only as the backdrop to the opportunity to teach and learn from my patients, as well as share in their joys and sorrows. Being a cancer patient myself affords a special insight and privilege into understanding both sides of the stethoscope.”

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June is National Migraine & Headache Awareness Month

Migraine is the third most common disease in the world with an estimated global prevalence of 14.7%.1 In the United States, migraine affects 38 million people.  About 85% of migraine sufferers are women. While most people experience attacks once or twice a month, over 4 million people suffer chronic daily migraine. It is an extremely debilitating condition in which headaches are often accompanied by symptoms such as nausea, vomiting, visual disturbances, extreme sensitivity to sound and light and tingling or numbness in the face. Approximately 25% have a migraine attack with an aura, a visual disturbance that lasts less than an hour.2

Migraine also affects children – half of all children who suffer from migraine have their first attack before the age of 12. Boys suffer more than girls, however, the proportion changes in adolescents. Despite being a major public health issue, migraine remains a poorly understood, under-diagnosed and under-treated condition. In fact, over half of all migraine sufferers are never diagnosed and majority of sufferers do not seek medical care for their pain. Migraine sufferers like those who suffer from other chronic illnesses, experience high costs of medical services, too little support, and limited access to quality care.2

Research efforts in migraine and headache have increased in the past 2 decades. Pubmed shows an increasing number of migraine and headache publications in the last 15 years (figure) leading to substantial accumulation of data and new information. The trend continues in 2016 (867 publications) and 2017 (506 publications so far!).3

Figure. ‘Migraine and Headache’ Publication Trend

 

Case Study: Diagnosing Migraine

A 40-year-old woman comes to your clinic, complaining about moderate headache for the past 2 days. She is a new patient and is scheduled for her annual routine check-up in a week. She said usually she would take a NSAID and not worry about the headache too much. However, this is the second time in the last 3 months that she had a pounding headache about 60 minutes. The lingering headache for the past two days has brought her to the clinic.

What would you do to address her concerns and symptoms?

You ask her if she has a family history of migraine. It turns out that her mother and maternal aunt both suffered from migraine. She does not have any comorbidities except type 2 diabetes, which is well-controlled with daily insulin injections. She does not take any other medications except an occasional NSAID. Her family history and current symptoms prompt you to further investigate her headache symptoms.

What specific questions should you ask her about her headache?

If migraine is suspected, detailed information about the headache and accompanying symptoms is essential for making a diagnosis.  This should include how often are the headaches, which other symptoms accompany the pain and how severe is the pain? How does the headache affect her daily routine? Does she have an aura? Migraine is typically diagnosed based on patients’ detailed symptom history and neurological imaging when appropriate. International Classification of Headache Disorders diagnostic criteria for migraine include headache attacks lasting 4–72 hours. Headache should have at least 2 of the following characteristics- unilateral location, pulsating quality, moderate or severe pain intensity, aggravation by routine physical activity. In addition, during the headache nausea and/or vomiting or photophobia and phonophobia must be present.4,5

Test Your Knowledge About Migraine and Headaches

How can you get involved? Show your support for migraine and headache advocacy, awareness, education and research.

Join the run! Milesformigraine is a non-profit organization with the mission of raising public awareness about headache disorders, improving the lives of migraine patients and their families, and helping find a cure for migraine. http://milesformigraine.org.

CME Activity: Tools for Successful Migraine Management http://www.primarycarenetwork.org/2016/11/migraine-management/

MigrainePro: An Interactive Learning System https://migrainepro.com/

References

  1. Steiner TJ, Stovner LJ, Birbeck GL. Migraine: the seventh disabler. J Headache Pain. 2013; 14(1): 1. Published online 2013 Jan 10. doi:  10.1186/1129-2377-14-1.
  2. Migraine Research Foundation. Migraine facts. https://migraineresearchfoundation.org/about-migraine/migraine-facts/. Accessed June 2, 2017.
  3. https://www.ncbi.nlm.nih.gov/pubmed/?term=migraine+and+headache. Accessed June 2, 2017.
  4. Weatherall The diagnosis and treatment of chronic migraine. Ther Adv Chronic Dis. 2015; 6(3): 115–123.
  5. Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33: 629–808.

 

Jayashree Gokhale, PhD
New York, NY

Published on 6/7/2017

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Telemedicine Applications for Pediatric Mental Health Services

Case Study

You are wrapping up the pediatric clinic for the afternoon when you see that a new patient has been added to your schedule. The intake form notes that the patient, Suzy, is an 8 year old girl who has been diagnosed with schizophrenia. As a primary care doctor, you have never taken care of a patient this young with schizophrenia and are somewhat uncertain about how to treat her. However, when you begin your examination, it becomes clear to you that the patient is stable on her current treatment plan.

Suzy’s parent, Linda, tells you that they recently relocated from a rural area of the country where her child’s psychiatric needs were being managed remotely. You ask Linda to elaborate, and she tells you that Suzy’s psychiatrist had been managing the little girl through an experimental telemedicine program. Intrigued, you decide to learn more about the uses of telemedicine in child mental health services.

What is telemedicine?

Telemedicine is broadly defined as a way to interact with a provider who is not located in the same place as the patient. To that end, telemedicine is used in a variety of settings and subspecialties. It is used in emergency medicine to help health providers at the scene determine if a patient injured in a remote location must be transferred to a higher level of care. In the military, telemedicine is used to treat service members who are stationed in combat zones and may not have access to the full range of health care services available to them in the United States. Telemedicine has even been used to expand health care access in scientific research stations in Antarctica, where a lone physician stationed at one of the most remote areas of the world can quickly consult with colleagues at major medical centers.

The specific technologies included under the heading of telemedicine are also highly variable. In some studies, telemedicine includes the distribution of written materials such as books or access to password-protected websites that educate patients and families about their disease. In other studies, patients and distantly-located providers interact through the telephone or monitors.

Unfortunately, we do not have great data about which of these technologies work or if some technologies work better than others. Similarly, health care providers do not currently have widespread access to “best practices” for using telemedicine. Most published studies have been done on a small, regional scale, and they have been led by the tiny number of self-described telemedicine specialists. At this time, telemedicine is not routinely taught in medical school or residencies, so early adopters do not have a systematic way of learning from one another or teaching interested colleagues.

What are some additional challenges of telemedicine?

There are significant difficulties associated with relying on the promise of this new technology to solve worsening social problems such as poverty, unequal distribution of resources, and low or no financial reimbursement to health care providers who adopt telemedicine.

Telemedicine requires human and material infrastructure in order to function correctly. At this time, it is being proposed as a way to treat people in underserved communities where health care providers either cannot, or do not, wish to live and work. As a result of their lack of access to care, many of these patients have complicated medical histories and would prove challenging to primary care providers working within traditional systems. Adding in the use of new technologies to the management of these complex patients can further pre-existing difficulties.

Another concern is that insurance companies and Medicaid/Medicare do not necessarily financially reimburse health care providers for telemedicine visits like they reimburse providers for traditional consults or office visits. In one recent review, less than 3% of telemedicine practitioners reported that they used Medicaid or Medicare to cover billing expenses.1 Not surprisingly, private insurance coverage for telemedicine is also limited. Most providers practicing using telemedicine have done so using small federal grants and fellowships – further limiting the wider distribution of this technology in a research climate of sharply decreased and threatened funding.

How is telemedicine used for the management of pediatric mental health?

Telemedicine is now being used to manage mental health in children living in underserved areas. There is currently a national shortage of child psychiatrists in the United States, and the number of child psychiatrists in training has not increased over the past thirty years. As a result, telemedicine has been touted as a novel solution to the problem of inadequate access to child mental health resources in underserved areas of the United States.

Telemedicine can be used in emergency situations to determine if a child needs higher levels of care. Non-emergency, non-mental health providers can request consultations with child psychologists and child psychiatrists working in other parts of the country. Additionally, some studies attempt to administer psychotherapy to older children and teenagers through telemedicine. One qualitative study examining telemedicine as a way to administer cognitive behavior therapy (CBT) to teenagers with anxiety found that parents expressed positive reactions to psychotherapy provided through telemedicine. However, parents and providers also described barriers to care, including time, convenience, and high required literacy levels.2

A review of the evidence in favor of using telemedicine for managing mental illness in children suggests several challenges.  At this time, a large number of published studies about telemedicine in pediatric mental health consist of small trials with few patients. They are also published by a small number of telepsychiatry practitioners. Primary care providers need better evidence that telemedicine works, including large studies showing efficacy or a robust meta-analysis. Second, a significant number of telemedicine tools have not been validated. As previously noted, providers are not sure which telemedicine tools work best and under what circumstances. Third, funding for the widespread distribution of telemedicine is limited and most funding comes from the VA system. Fourth, endpoints for many of these studies are “patient satisfaction,” which is an inadequate endpoint for a scientific study. Finally, providers and insurance companies have expressed concerns about the medico-legal risk associated with telemedicine. More specifically, they worry about pediatric mental health telephone consultation programs. Based on previously published data the medico-legal risk does not appear high, but these are small studies on carefully selected populations.

Most concerning, there is no Cochrane Review or any large, randomized controlled trials looking at the risks and benefits of using telemedicine to treat young children with mental illness. Smaller trials state that telemedicine works, but many of these trials have inappropriate endpoints such as “parent satisfaction” or “patient satisfaction.” While patient satisfaction is a laudable goal, it is not the same as effective treatment. For example, patients undergoing cancer treatment probably have low “patient satisfaction” with the side-effects and inherent misery of life-saving chemotherapy and radiation protocols. These protocols have endpoints involving resolution of the disease or extension of life, not patient satisfaction. Success in treating children with mental health problems should be taken as seriously and include hard endpoints such as the resolution of symptoms, decreased hospitalization, and stabilization of disease progression. We need better evidence that telemedicine is effective. That evidence should come in the form of large, randomized controlled trials or a thorough meta-analysis.

At the end of the day, the most vocal proponents of using telemedicine to treat children with mental illness point to cost-effectiveness. There aren’t enough child psychiatrists currently working the United States and the number of physicians training to be child psychiatrists remains low. Furthermore, child mental health workers are not currently working in the parts of the country where they are most needed. In addition to telemedicine, administrators have suggested that pediatricians and primary care providers pick up the slack and treat children for mental health disorders. Although pediatricians may be well-qualified to treat some disorders, such as ADHD, they are not trained to manage serious psychiatric problems any more than psychiatrists are trained to manage congestive heart failure.

How should you treat this patient?

Suzy appears to be in good physical health, is growing appropriately, and is up to date on all of her immunizations. You are pleased with her physical exam but want to make sure that her mental health needs are also appropriately managed. So you ask the patient’s parent if she has any preferences for Suzy’s mental health care. Linda notes that Suzy was enrolled in a telepsychiatry program as part of a clinical study. The clinical study recently ended, and Linda’s private insurance company does not reimburse for psychiatric visits conducted through telemedicine. However, now that they have moved to a more populated area of the country, Linda would like a referral to a local child psychiatrist who would be better able to manage Suzy’s complex mental health condition. You agree and give Linda a list of recommended providers with plans to follow up with Suzy during her annual well-child appointment in a year.

As part of your own continuing medical education, you decide to look into opportunities to extend your practice through telemedicine as a pediatrician reaching out to rural communities.

References:

1 Lauckner C, Whitten P. The State and Sustainability of Telepsychiatry Programs. J Behav Health Serv Res. 2016;43(2):305-18.

2 Chavira DA, Bustos CE, Garcia MS, Ng B, Camacho A. Delivering CBT to Rural Latino Children with Anxiety Disorders: A Qualitative Study. Community Ment Health J. 2017;53(1):53-61.

Dr. V. Silverstein
Durham, NC

Published on 6/1/2017

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