Monday, October 27, 2014

Bariatric surgery for diabetes: does it work?

- Jennifer Middleton, MD, MPH

I can't remember the last time I referred a patient for weight loss surgery. I precept residents, and I can't remember the last time one of them told me that they'd like to refer their patient for bariatric surgery. I hear colleagues say, not infrequently, that they will not refer patients for bariatric surgery, usually alluding to its risks. Three recently published studies, though, describe the benefits of bariatric surgery to maintain weight loss and potentially reverse co-morbid disease.

The October 15 issue of AFP includes a POEM describing a recent study that compared diabetes outcomes in patients who underwent bariatric surgery compared with those who continued with conventional medication treatment. The study was published in the New England Journal of Medicine in March 2014 and randomized 150 patients with diabetes to either intensive medical management alone or intensive medical management with bariatric surgery (Roux-en-Y bypass or sleeve gastrectomy). Participants had A1Cs > 7.0% (average = 9.3%) at the study onset, had body mass indexes (BMI) that ranged from 27-43, and were between 20 and 60 years old. The researchers studied participants for 3 years and found bariatric surgery + medication superior to medication alone; the number needed to treat (NNT) to get A1Cs less than 6.0% was 3 for Roux-en-Y and 5 for sleeve gastrectomy.

A few months after this NEJM study, Cochrane published a systematic review evaluating the evidence regarding benefits of bariatric surgery. They included all randomized controlled trials (RCTs) comparing either surgery to non-surgical obesity management or different surgical procedures to each other. They looked at several outcomes, including maintenance of weight loss, quality of life, and remission of diabetes. They found that bariatric surgery, overall, "results in greater improvement in weight loss outcomes and weight associated comorbidities compared with non-surgical interventions, regardless of the type of procedures used." They also found, however, that studies did not adequately report complication rates.

Another group of researchers published a slightly different systematic review in the Journal of the American Medical Association (JAMA) a month later. These researchers only included studies whose participants had a BMI of at least 35 and who had at least 2 years of follow-up data, and they did not limit included studies to RCTs. And, although the researchers noted the overall lack of long-term follow-up studies, their findings from the available evidence base to date are in line with the Cochrane reviewers'.

Bariatric surgery is certainly not a zero-risk proposition. But given these outcomes, we should at least be presenting it to appropriate patients as an option among others for obesity and diabetes treatment. The AFP By Topic on Obesity contains further references if you'd like to read more.

How do you discuss bariatric surgery with your patients?

Wednesday, October 22, 2014

The natural history of symptoms in primary care

- Kenny Lin, MD, MPH

Not long ago, I was sitting in my office catching up on some electronic charting when I began to feel chilly, achy, and weak. I went home, skipped dinner, and went straight to bed. Although I felt mostly better the next morning, my appetite didn't fully return until later in the day. My self-diagnosis: probable viral infection. But the truth was that I had no idea if my symptoms were related to any kind of disease.

Medical education trains physicians to approach patients' symptoms foremost as manifestations of an underlying cause. Only "treating the symptoms," in contrast, can often feel like a sort of failure. But as Dr. Kurt Kroenke reported in a narrative review published in the Annals of Internal Medicine, at least one-third of common physical symptoms evaluated in primary care (including pain, fatigue, dizziness, sleep disturbances, and gastrointestinal symptoms) are "medically unexplained," meaning that they are never connected to a disease-based diagnosis after an appropriate history, physical examination, and testing.

Dr. Kroenke further asserted that viewing symptoms as purely disease-oriented influences the language physicians use to describe them:

The lack of a definitive explanation for many symptoms is further underscored by the use of adjectival modifiers indicating what a symptom is not ("noncardiac" chest pain or "nonulcer" dyspepsia) or implying causal explanations that are weakly defensible ("tension" headache, "mechanical" low back pain, or "irritable" bowel syndrome).

Not only do some symptoms have no obvious causes, but others have multiple possible causes which may be unproductive to approach separately. For example, why does a patient with congestive heart failure, anemia and depression feel tired all the time? Also, symptoms usually occur in a group, rather than in isolation; for example, a classic symptom cluster in cancer patients is SPADE (sleep  / pain / anxiety / depression / energy).

Studies show that about a quarter of symptoms that present to primary care eventually become chronic. Fortunately, very few of these patients harbor a serious missed diagnosis such as an occult infection or cancer. As family physicians know, even if we are uncertain about if or when a particular symptom might improve, communication still has great therapeutic value. "Is this normal, doctor?" is the question I hear most frequently from my patients who have persistent symptoms without diagnoses. I usually respond that there is a wide range of "normal," and what's more important to me is working with him or her to make these particular symptoms more manageable.

Monday, October 13, 2014

ADHD spotlight: treatment adherence issues and effects of meds on adult height

- Jennifer Middleton, MD, MPH

The October 1 AFP included a useful review article on ADHD in children, and not long after I read it, I saw two more articles on ADHD that got me thinking even more about this subject: one on adherence to ADHD medication and one on the effect of psychostimulant medication on height.

The AFP article on "Diagnosis and Management of ADHD in Children" reviews the diagnostic criteria for ADHD, the differential diagnoses for common presenting complaints, and initial treatment options. The authors review the data for various treatments and conclude that psychostimulants are still the most effective class of medications for those children in whom meds are indicated.

A recent article published earlier this year in Patient Preference and Adherence reviewed how adolescent patient beliefs affected treatment adherence to ADHD medications. The author reviewed several studies, both qualitative and mixed-methods, that investigated adolescent attitudes toward their ADHD medications. Multiple studies found that the strongest predictors of non-adherence were either adverse medication effects, lack of perceived benefit, and/or "changes to the patient's sense of self." Teens with ADHD rated the perceived efficacy of medications higher than behavioral interventions, yet adolescents themselves are more likely to stop their medications on their own than to involve a parent in that decision.

Another recent article, this one from Pediatrics, seeks to lay to rest concerns about psychostimulant medications' effect on final adult height. The researchers obtained medication and growth histories from around 1000 children born between 1976-1982 in a town in Minnesota; for every 1 child identified with ADHD, they matched 2 control children without ADHD. The researchers obtained growth records on these children along with their final adult height, and they found no difference in growth patterns or final adult height between children with ADHD and children without ADHD; they also found no difference between children with ADHD on medication compared to children with ADHD who were not on medication. This study followed only one geographically-limited cohort, though, and the authors acknowledge the impossibility of knowing whether these children's physicians adjusted their medications due to changes in their growth curves. Despite these limitations, this study's years of longitudinal data are still compelling.

I spend significant time reviewing growth charts with parents of children or teens with ADHD on stimulant medication, but I don't ask questions about medication adherence the way I do, for example, with my patients with other chronic conditions. These two articles suggest that my priorities need reversing.

According to the AFP article, "children with ADHD [on a stimulant] are less likely to be held back a grade." Being held back a grade is definitely Patient-Oriented-Evidence-that-Matters! Since adolescents typically make the decision to stop their medication, centering discussions related to medication issues on them, instead of their parents, during office visits makes sense. And it is nice to be able to share with adolescents and their parents the recent Pediatrics study that was reassuring regarding possible height loss due to long-term stimulant use.

Certainly, as Dr. Lin wrote about earlier this year, medication is not always the right course for treating ADHD. But when it is, these two articles will change my practice. If you'd like to read more, there's an AFP By Topic on ADHD.

How do you counsel parents and their children and/or teens about ADHD treatment?

Monday, October 6, 2014

Known and unknown: putting Ebola in perspective

- Kenny Lin, MD, MPH

At a recent morning huddle, I noticed that the hanging file of emergency protocols at my practice nurse's station held a new folder, labeled "Ebola." That same day, a patient who had returned from West Africa was isolated at a nearby hospital for symptoms consistent with infection with the virus. I had been following news about the Ebola epidemic for months, since its re-emergence in Guinea, rapid spread to neighboring Nigeria and other parts of West Africa, through the critical illness and miraculous recovery of family physician Kent Brantly. But until that day, I hadn't actually confronted the question, "As a family physician, what do I need to know about this?"

Many have pointed out that even though this is by far the largest and most lethal Ebola outbreak in history, it pales in importance next to more common and contagious viruses such as influenza or measles, or emerging infections closer to home, such as the enterovirus respiratory illness that has stricken children in 43 states. Family physician blogger Mike Sevilla expressed skepticism that patients who continue to decline influenza vaccines in droves would be willing to receive a vaccine against Ebola even if it could be produced quickly, and given our abysmal track record with pandemic flu vaccination, I tend to agree.

What terrifies health professionals and laypersons about Ebola, despite its thus-far limited impact in the United States, is that so much about it is unknown. Clinicians are prepared to tackle influenza, a known quantity from past years. We don't know what to expect from Ebola, a nebulous threat to cause disaster at any time, like bioterrorism. Until more is known, family physicians should remember that fever in returning international travelers is far more likely to be due to malaria (which turned out to be the diagnosis of the hospitalized patient I mentioned earlier), and to always ask and communicate about recent travel, rather than depending on an electronic medical record to do it.


Postscript: In an October 15th editorial on "Management of Influenza in the 2014-15 Season," Dr. Ronald Goldschmidt noted that the overlap between the international Ebola outbreak and the U.S. influenza season may lead to concerns about confusing these two viral diagnoses. He pointed out, however, that "influenza generally features rhinorrhea and upper respiratory symptoms (rare with the Ebola virus) and Ebola generally features gastrointestinal symptoms (not prominent with influenza),"and more importantly, a travel and contact exposure history should identify patients at risk for Ebola infection.