CME Needs Identification # 3: Antibiotics for Adult Sore Throat

Posted on by mrsmd1

This month I interviewed Dr. Abhishek Katiyar – a double board certified physician in both Emergency Medicine and Toxicology.  Dr. Katiyar is on staff at two different hospitals in the Chicago area, one of which is a large teaching institution and the other a busy community hospital.

OVERVIEW:

Urgent care clinics are becoming more popular in recent years.  They are often staffed by a physician or an allied health professional (AHP) such as a nurse practitioner or physician assistant.  These clinics are beneficial to patients as they can be seen quickly if their primary physician is unavailable.  Clinics based in pharmacies are also often staffed by AHPs and are becoming more widespread, allowing for prompt evaluation and treatment. As they continue to gain popularity they may start to help decrease the burden of patients presenting to the ER for urgent care type complaints. They also provide an alternative to the ER for patients who have no primary care doctor.

Dr. Katiyar has found however, that he frequently sees adult patients in the ED who report no improvement of their sore throat symptoms after receiving antibiotics at an urgent care clinic.  In approximately 90% of cases, these symptoms are caused by a viral infection which simply requires supportive care not antibiotics.  At times the patient may feel more satisfied if given antibiotics, however it is not the right course of treatment.  If education is trickled down to the patient from the practitioner, Dr. Katiyar feels “it will lead to less antibiotic resistance, less desire by the patient to have (or want) antibiotics or medication” and theoretically “less use of the ER for unnecessary visits”.

EDUCATIONAL/GAP ANALYSIS:

Dr. Katiyar identified a need for even more CME for AHPs (Nurse practitioners, Physician Assistants) and urgent care providers targeted to increase the knowledge regarding “the use of antibiotics for sore throat”.  This knowledge can in turn be used to educate the patient on their condition, and why they do not require treatment with antibiotics.

LEARNING OBJECTIVES:

Dr. Katiyar feels the most effective CME format would be “a lecture that is appealing and one that you can connect with” particularly “lectures that include cases”.

Learning objectives for CME on this topic must include review of the Centor Criteria and Modified Centor Criteria (which predicts likelihood of a bacterial infection of the throat).  As well it should highlight the CDC recommendations for treatment of pharyngitis.

CDC Adult Treatment Guidelines:

  • Likely 90% of cases are self-limiting and need only supportive care.  Only approximately 10% are from Group A beta hemolytic streptococcus (GABHS) 
  • Those not suspected to have GABHS infection should be treated with analgesics, antipyretics and supportive care. 
  • Limit antibiotics only to those with high likelihood of GABHS utilizing Centor Criteria: (1) history of fever, (2) tonsillar exudates, (3) no cough, and (4) tender anterior cervical lymphadenopathy (lymphadenitis).
  • Patients meeting 2 or more centor criteria can be tested with a rapid antigen test for GABHS, and treated if positive. 

POTENTIAL REFERENCES:

CDC Get Smart Campaign:  http://www.cdc.gov/getsmart/campaign-materials/info-sheets/adult-approp-summary.html

AAFP guidelines:  http://www.aafp.org/afp/2009/0301/p383.html

CME Identification # 2: Considerations of PSA Testing and Prostate Cancer

Posted on by mrsmd1

For February’s CME identification I sat down and interviewed Dr. Ike Oguejiofor.  Dr. Oguejiofor is a board certified physician Urologist on staff at Christ Hospital in the greater Chicago area.

OVERVIEW:

Dr. Oguejiofor enlightened me on an interesting discord in the current practice and perception of Prostate-Specific Antigen (PSA) screening by primary caregivers versus urologists. In 2012, the US Preventative Task Force released their recommendation that PSA based screening for prostate cancer should not be done at all at any age, reporting that “there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.”

Guidelines by the American Urological Association (AUA) generally agree, noting that PSA screening in men under age 40 years is not recommended and routine screening in men 40-54 who are at average risk is also no longer recommended.  As well, they agree that men over 70 years of age should not be screened.   However, for men 55 to 69 years of age the AUA recommends the following on their website:

“The decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, shared decision-making is recommended for men age 55 to 69 years that are considering PSA screening, and proceeding based on patients’ values and preferences. To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce over diagnosis and false positives.”

The way Dr. Oguejiofor translates this is that a risk/benefit analysis should be performed on a case by case basis. However, this can be confusing since our primary caregivers are now being told not to screen patients at all according the US Preventative Task Force Recommendations. So patients should be considered for revised or optional screening by their primary caregivers after an evaluation of their risk factors.

EDUCATIONAL/GAP ANALYSIS:

The Educational Gap identified by Dr. Oguejiofor is that early cases of prostate cancer may be missed in high risk patients, where screening may find elevated or PSA levels that are trending upwards, even if the level numbers are technically within the reference range.  Dr. Oguejiofor strongly feels “age, family history and ethnicity must be taken into consideration while examining PSA values so early cases aren’t missed”.

LEARNING OBJECTIVES:

Learning objectives for CME on this topic must include the guidelines set forth by the AUA as well as the recommendations by the US Preventative Task Force.   Dr. Oguejiofor strongly feels “age, family history and ethnicity must be taken into consideration while examining PSA values so early cases aren’t missed”.  Identification of high risk patients over 55 years of age who may benefit from modified screening should be highlighted.  High risk categories include:

Age – risk of prostate cancer rises rapidly after 50 years of age. About 6 in 10 cases are found in men over the age of 65.

Race – Prostate cancer occurrence is much in African-American men and in Caribbean men of African ancestry than in other races. African-American men are about wice as likely to die of prostate cancer than white men.

Family History – having a first relative with history of prostate cancer can more than double the risk of disease.

Genetic predisposition – a small number of cases of prostate cancer may be secondary to Inherited mutations of the BRCA1 or BRCA2 genes, or men who suffer from Lynch Syndrome.

Geography – Prostate cancer is more common in Australia, the Caribbean Islands,  North America and Northwestern Europe.  It less common  Africa, Asia, Central America and South America.

 

POTENTIAL REFERENCES:

https://www.auanet.org/education/guidelines/prostate-cancer-detection.cfm

http://www.uspreventiveservicestaskforce.org/Page/Topic/recommendation-summary/prostate-cancer-screening

CME identification #1: Measles (Rubeola)

Posted on by mrsmd1

Until July 2015, all interviews and CME identification pieces will be available in full text here (as seen below) and at the Mesh Medical Blog at http://meshmedblog.wordpress.com.

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CME IDENTIFICATION #1:  MEASLES (RUBEOLA)

OVERVIEW:

As is evident in the news, there has been an increase in significant measles outbreaks in the United States. Most recently an outbreak linked to exposure at Disneyland in California,  the source patient likely a visitor from outside of the United States. According to the cdc, in January 84 cases across 14 states were identified.  In 2014 a record number of cases were documented:  644 cases across 27 states.

EDUCATIONAL/GAP ANALYSIS:

In 2000 the USA declared elimination of measles (ie. absence of continuous disease transmission for 12 months).  Physicians over a broad spectrum of specialties including pediatrics, emergency medicine, family practice and internal medicine would benefit from re-education regarding measles.  For those physicians who have been practicing for at least 15 years, they have unlikely ever seen or examined a patient with measles. There are bulletins and information regarding measles on the CDC website, however when a web search is performed for CME regarding measles minimal courses can be found, and many are several years old.

LEARNING OBJECTIVES:

Clinicians should re-familiarize themselves with the following aspects of Measles (Rubeola):

  • Epidemiology:  Increased outbreaks since 2014, increased risk of complications in children < 5yo or adults > 20 yo
  • Presentation: fever, cough, coryza, conjunctivitis, koplik spots, rash
  • Complications: Pneumonia, Encephalitis, Low birth weight babies in pregnant women infected, fatality
  • Transmission sources in the US:  unvaccinated individuals, visitors from out of country
  • Identification: Visual stimuli of examples of rash and Koplik Spots seen secondary to Rubeola

POTENTIAL REFERENCES:

http://www.cdc.gov/measles/

http://www.uptodate.com/contents/clinical-presentation-and-diagnosis-of-measles

http://redbook.solutions.aap.org/book.aspx?bookid=886