Does aspirin prophylaxis improve health in older adults?

Every day, family physicians are confronted with the clinical question of whether or not to start a patient on aspirin for the primary prevention of cardiovascular disease. The editorials in the June 15th issue of AFP by Dr. W. Fred Miser ("Appropriate Aspirin Use") and Drs. Bailey, Smyth, and Campbell ("The Case Against Routine Aspirin Use") highlight the current difficulties in putting the 2009 U.S. Preventive Services Task Force recommendations on aspirin prophylaxis into practice. There is limited information available to inform benefit versus risk decisions regarding aspirin prophylaxis in healthy older adults. Given the significant projected growth of the elderly population, especially of older minorities, family physicians will need to address aspirin prophylaxis decisions more frequently in the future.



To address areas of uncertainty beyond the 2009 USPSTF guidelines, the ASPirin in Reducing Events in the Elderly (ASPREE) clinical trial aims to answer a simple question with significant public health relevance: Does daily low-dose aspirin use maintain longevity without cognitive and functional disability in healthy men and women age 70 years or older? Currently, recruitment of 19,000 older adults who do not require aspirin for a cardiovascular condition is ongoing at over 20 sites in the U.S. in addition to general practices in Australia. In the U.S., results from ASPREE should hopefully provide insight on how aspirin works in all older persons, including members of minority groups. In order to succeed, ASPREE will require the engagement of family physicians and other primary care clinicians. Family physicians can make a significant contribution by identifying healthy, older persons from minority communities and providing them with information about how to participate in the study. More information about the study and locations of study sites in the United States can be found at www.ASPREE.org.

Raj C. Shah, MD

Rush University Medical Center

Chicago, Illinois

Raj_C_Shah@rush.edu



Disclosure: The author is a co-investigator on the ASPREE study.

Autism: to screen or not screen?

The August 15th issue of AFP features a pair of editorials that stake out opposite positions in the intensifying debate about the benefits of routinely screening young children for autism spectrum disorders (ASDs). Dr. Paul Lipkin and Susan Hyman argue that the rising incidence of ASDs and studies suggesting a benefit from early diagnosis and behavioral interventions make it imperative for pediatricians and family physicians to incorporate developmental screening tools into their practices. They assert that developmental screening does not impose significant time burdens on physicians, and that false-positive screening results can be minimized by scheduling follow-up interview visits.

On the other hand, Dr. Doug Campos-Outcalt counters that screening for ASDs has not yet met several critical criteria for establishing the effectiveness of a screening test. In particular, the following important questions remain unanswered:

1) What are the sensitivity and false-positive rate of the best screening test for ASDs available in an average clinical setting?



2) How much earlier can screening tests detect ASDs compared with an astute clinician who asks a few key questions about, and acts on, parental concerns regarding a child's communication and interactions?



3) What are the potential harms of testing?



4) Does earlier detection by screening result in meaningful and long-lasting improvements compared with detection through routine care?

Although a recent systematic review published in Pediatrics found limited evidence that early intensive behavioral interventions improve "cognitive performance, language skills, and adaptive behavior skills in some young children with ASDs," it remains uncertain if routine screening leads to improved outcomes. Therefore, Dr. Campos-Outcalt recommends, "Family physicians who provide care for young children should ask parents about any concerns, be alert for the signs and symptoms of ASDs, and use available diagnostic testing tools to assist in making clinical decisions when an ASD is suspected."

AFP Community Blog: Top 10 most-read posts

This month, the AFP Community Blog celebrates its first anniversary. For those of you who started following us recently, or don't read regularly, here is a list of the blog's top 10 most-read posts:

1) AFP By Topic now available for IPhone and Android (4/20/11)

2) Dabigatran for stroke prevention in atrial fibrillation: is it worth it? (1/18/11)

3) Prostate-specific antigen screening is not effective (3/30/11)

4) Screening and treatment of hyperlipidemia in children (9/1/10)

5) Autism spectrum disorders: increasing prevalence or diagnosis shift? (5/22/11)

6) Antibiotics for acute bronchitis: just don't do it (12/9/10)

7) Screening colonoscopies performed more often than necessary (5/9/11)

8) Geriatric assessment tools (1/3/11)

9) Should pharma have unrestricted access to your prescribing profile? (4/25/11)

10) Advice for physicians on using social media (7/6/11)

Thank you all for continuing to make American Family Physician the best-read journal in primary care!

Climate change and family physicians

At first glance, the topic of the cover article of AFP's August 1st issue, "Slowing Global Warming: Benefits for Patients and the Planet," might seem out of place in a journal that aims to provide practical clinical guidance for family physicians. Past summer-themed articles have included clinical reviews of heat-related illness, medical advice for commercial air travelers, and even health issues for surfers. By addressing climate change, AFP joins other widely read medical journals such as The Lancet and BMJ in recognizing the essential role that physicians can play in mitigating the negative impacts of environmental stress on patients' health.

After summarizing the serious potential health effects of climate change, Dr. Cindy Parker recommends that primary care clinicians counsel patients regarding two lifestyle changes that are likely to improve personal health as well as slow global warming: reducing meat consumption and increasing "active transportation" (substituting bicycling or walking for short car trips). In addition, physician practices and larger medical organizations can positively affect climate change by "going green":

Medical offices and hospitals can help by recycling; using recycled items and Energy Star certified appliances and computers; minimizing waste and waste transport by replacing single-use items with sterilizable or washable items; purchasing wind-generated electricity; and reducing energy use by turning off appliances, computers, and lights when not in use. In 2008, the U.S. health care sector spent $8.8 billion on energy to meet patient needs, not including the transportation of employees or patients to and from health care facilities, resulting in 8 percent of all U.S. greenhouse gas emissions.

In an accompanying editorial, Dr. Robert Gould reviews several national and international initiatives that encourage hospitals and health systems to reduce greenhouse gas emissions, including the Healthier Hospitals Initiative and Health Care Without Harm.

Tobacco quitlines suffer from budget cuts

An editorial in the July 15th issue of AFP by Drs. Stephen Rothemich and Scott Strayer extols the value of telephone quitlines in helping family physicians convince patients to stop smoking. Noting that many practices "lack the time and resources to provide effective counseling," the authors recommend that busy clinicians refer patients to the national toll-free quitline number (800-QUIT-NOW) to fill in these gaps. In addition, they review high-quality evidence that quitlines improve smoking cessation rates over counseling or medications alone:

The effectiveness of quitline counseling is well established. A Cochrane review reported successful cessation in patients who received counseling from quitlines (number needed to treat = 32). Quitline counseling combined with smoking cessation medications is particularly effective, with a cessation rate of 28.1 percent (more than three times the rates with minimal or no counseling or with self-help).

Unfortunately, funding for quitlines has recently fallen victim to budget cuts in at least two states. In Ohio and Washington State, quitlines that were once free to all smokers now only serve patients with certain types of insurance. State officials attributed their inability to continue to fully fund the quitlines to ending of federal grants and the need to divert funds from the 1998 Master Settlement Agreement with tobacco companies to other non-tobacco-related programs.

These cuts could not have come at a worse time, as the U.S. Food and Drug Administration's new requirement that cigarette packs display graphic health warning labels by September 2012 seems to have increased smokers' interest in using quitlines. For information about any eligibility limitations on your state's quitline, you can consult the website of the North American Quitline Consortium at http://www.naquitline.org/.

Diagnosing patients who itch

In a fascinating 2008 New Yorker article, "The Itch," Harvard surgeon Atul Gawande told the story of a patient who experienced a nearly fatal complication from treatment-resistant pruritis of her scalp following an episode of herpes zoster:

One morning, after she was awakened by her bedside alarm, she sat up and, she recalled, “this fluid came down my face, this greenish liquid.” She pressed a square of gauze to her head and went to see her doctor again. M. showed the doctor the fluid on the dressing. The doctor looked closely at the wound. She shined a light on it and in M.’s eyes. Then she walked out of the room and called an ambulance. Only in the Emergency Department at Massachusetts General Hospital, after the doctors started swarming, and one told her she needed surgery now, did M. learn what had happened. She had scratched through her skull during the night—and all the way into her brain.

Although this sort of complication is highly unusual, pruritis - far from being only a "nuisance" symptom - is often associated with underlying systemic conditions, Dr. Brian Reamy and colleagues observe in "A Diagnostic Approach to Pruritis" in the July 15th issue of AFP. Clinicians should consider evaluating patients who present with generalized, unexplained pruritis for thyroid disorders, lymphoma, kidney and liver diseases, and diabetes. Many dermatoses of pregnancy can cause intense pruritis. Also, some psychiatric disorders are associated with pruritic sensations, leading to "neurotic excorations." Certain historical findings, including recent travel, exposure to animals, and constitutional symptoms such as weight loss and fatigue, can help to narrow the extensive differential diagnosis of this common and troublesome symptom.

Making informed choices about family planning and contraception

For reproductive-age women who have medical comorbidities such as epilepsy, diabetes, and hypertension, choosing a family planning method can be challenging. The September 1, 2010 issue of AFP reviewed the risks and benefits of hormonal contraceptives for these patients, based on guidelines from the American College of Obstetricians and Gynecologists. However, the scope of that article did not include nonpharmacologic options such as barrier or fertility awareness-based methods, also known as natural family planning (NFP). Two letters in the July 1st issue of AFP remind readers that NFP is an effective family planning option for appropriately educated couples and provide helpful training resources for clinicians. As Drs. Robert Conkling and Leslie Chorun observe:

Counseling in natural methods of fertility regulation is currently being provided by a growing number of trained physicians, nurse practitioners, and allied health professionals. ... These family planning methods should not be confused with calendar rhythm method and are not dependent on the regularity of a woman's cycle. Population-based surveys have shown a significant interest in NFP—approximately 25 percent of women and 40 percent of men are interested in using NFP to avoid pregnancy, and 33 percent of women are interested in using NFP to conceive. This interest is not associated with religion, education, age, or income level.

For further reading on patient outcomes associated with various fertility awareness-based methods, family physicians can consult a clinical review published in the Journal of the American Board of Family Medicine. Also, a recent AFP By Topic collection compiles the journal's current online content on all aspects of family planning and contraception, including preconception care, the infertility evaluation, and advantages and disadvantages of hormonal and non-hormonal methods.