Episode 120 -- October 15, 2020 AFP: American Family Physician
The AFC PODCAST is supported by the American Academy of Family Physicians and by PD W and our PS on demand. A Library of twenty two self paced workshops on topics that are important to residency programs, including residency curriculum resident, assessment, program administration, and more full info at AFP dot Org Slash Twenty, twenty on demand. Welcome to the American family physician podcast for the October fifteenth. Twenty twenty issue I'm Steve I'm Evan and Kalina. We are faculty and graduates mostly graduates of the University of Arizona. College of Medicine, Phoenix Family Medicine residency. Today. On the PODCAST, we're going to talk about outpatient management of Covid nineteen school-based asthma programs on co mycosis, influenza vaccination guidelines, inguinal Hernias, outpatient testing for community acquired pneumonia, and we have a special diary of a family physician. The opinions expressed in the podcast, our own and do not represent the opinions of the American Academy of Family Physicians, the Editor of American family physician or banner health to not use this podcast for medical advice instead sear doctor for medical care. This is our podcast episode, a hundred and twenty. Quarantine. Fourteen were coming up on almost five years here we've had six seasons of the American family physician podcast and one of the advantages of recording in our closets. We can bring back some of our previous hosts. So we're so lucky to have Evan and Kalina here. Two of our season two hosts were excited to be here. So Evan, what are you up to so other than recording in my closet I am. Currently core faculty at the primary. CARE. Sports Medicine Program associated with the same program that I graduated from. So it's fun to stay around. Very exciting and cleaner. You're a little bit further away. It's great to see you likewise. Yeah I'm up in Denver Colorado so I'm an attending. The Same Commute Health Center that I that I left four originally. So this one's up in commerce city. So not that far from Denver but enjoying it quite a bit very cool and we're missing are your guys third co host from season to Dr e Brett daily who is working in underserved clinic in Kansas. City. So hopefully for the next season, two reunion will bring back Dr Daily as something about having a baby I dunno expenses at. Working on it we'll. We're so glad to have you guys back and we have a very hot off the presses topic here. But Management of Covid nineteen rapid evidence review from Doctors Chang Caruso, and McDougal, out of Oregon Health and Science University obviously things are coming at us from all directions right now. So I was excited to see a nice summary of the evidence as it currently stands around outpatient management of covid nineteen. So we're GONNA touch on a couple of common scenarios, but also I do recommend checking out of the tables figure two for a helpful flow sheet. To kind of just simplify self quarantine recommendations and be able to maximize public health at the same time. Okay Evan tell me about your patient. Yes I'm chatting with Nora of telehealth visit. Right now, she's sixty seven years old and tells me that she's had a fever of one hundred one degrees Fahrenheit and has been feeling pretty tired. She also just got a dry cough and his a little short of breath. She happens to have a pulse ox at home in her OA-TO. Sad. Is Ninety five percent in her pulses ninety seven and she wants to know, hey, is this. Cove in nineteen great questions. So definitely, she's got a lot of common Kobe nineteen symptoms and you can also make sure to think about Kobe. Nineteen when you hear about the classic loss of taste or smell but of course, we don't forget the usuals to viral Uri I pneumonia COPD exacerbation. So definitely look at the patient in front of you but for her a SARS Kobe to test is the only way to truly diagnosed her. Okay I think we should test her so which of the million tests directed? There's definitely a new test every time I turn around scenes, but a diagnosis can only be confirmed still with CR test. If you want to get into the nitty gritty of some of the different testing modalities. Table Three is a nice rundown of that. So so definitely check it out. Okay so she got the PTR test and that's positive. So now I've recommended that she self quarantine herself for ten days from winter symptoms started, and until her fevers been gone for at least twenty four hours without using any antibiotics and she has improvement of symptoms. But you know she mentioned she's been hanging out with her neighbor and her neighbors two year old little boy without a mask and enclose quarters, and she's wondering what to anticipate for them as well. Yeah. Great things to think about. So Cova nineteen can incubate anywhere from two to fourteen days. Usually, people will get symptomatic within five days. So CDC expert opinion, both recommend that her neighbors would have to quarantine from fourteen days after they were last hang out with Nora so that they don't go on to spread cope to someone else and the good news you can let her know is that kids who do get Kobe if that happens typically, we'll have milder symptoms and should they all get tested too short answer yes. But if they're a symptomatic, they should ideally wait five to seven days before going to get tested that's going to maximize the sensitivity of the test. So going right away won't be won't be as helpful and a bare minimum they need to wait forty eight hours otherwise they run the risk of having false negatives and being falsely reassured. Thanks. So Nora feels really good about this plan but last thing she also wants to know what treatments we have to help her get through her illness. So for her since she's had a mild illness and assuming it continues that way really supportive care is all we have right now now patient setting and if she seems to be getting worse in. Evaluating her in person beyond risk stratified, buying with age BMI and other Co Morbidity as well as evaluating for poxy into Neha are there any other lab tests that should clue me in on maybe more severe disease? If everything continues to look reassuring clinically for Nora I'm not sure of the ability of blood work but it's good to know that more Severe Cova can cause lymph opinion neutral phileas leukocyte. In High Crp L. D. H. D diamond in trans-shipment, itis. So if you notice these when you're working patients have general definitely perk your ears and have that on the differential including a more severe case. Okay. So now I want to kind of switch gears and talk and talk about a different patient of mine his name's Earl. He's one of the fourteen percent with more severe disease. So He's actually in the hospital with Covid nineteen what treatments have current best evidence for inpatient management, of Kobe. Is He hypoxia right now yeah. He's on supplemental oxygen. Okay since he's Hypoxia pick six milligrams of Methadone daily for ten days has evidence rating of be so that's backed by well-designed RC t evidence to reduce mortality with a number needed to treat of twenty nine decks. Methadone also hasn't entity of nine to reduce his need for mechanical ventilation. If we're talking about Nora though she's not hospitalized in not needing supplemental to Dexter Methadone is not currently recommended for her great. So earls GonNa get decks Methadone what about rim? Desa viewer will that reduces mortality to. Won't change his mortality, but it's been seen in at least one well powered. RC T.. So again, evidence rating of be to shorten his time to recovery. So in hospitalized patients, it can shorten time to recovery from fifteen to eleven days. So I'd go for it again, this hasn't been studied outpatient. So unfortunately nor nor continues to just get supportive care but good news for Earl at least. Great. So it sounds like we've got a plan for both of them. Yes. Definitely. Nice. To have a little bit more data we can act on in the acute setting. I unfortunately, I think the next wave we're going to see are those patients that aren't sick enough to need to be in the hospital or were sick and are recovering but symptoms just continue to kind of drag on in interesting stat that they had in this article was was that thirty five percent of people with cove nineteen aren't back to their prior level of health fourteen to twenty one days later so. In court kind of bracing for that. Down here to stay in more ways than one. Yeah sorry to end on a down note but glad to have sinked reference. We can all use to keep up with the evidence in provide some good consistency in ever changing times. Stay safe out there and please keep wearing a mask. Next we'RE GONNA. Talk about an ef pin help desk answer Penn is the family physicians, inquiries network, and this help desk answered comes to us from Doctors Lou and Kiani out of Minneapolis. MINNESOTA. And it's school based asthma management programs. Clean Evan do school based asthma management programs improve as outcomes. We'll wait wait what outcomes are we talking about here? Good question. The data here is based on nine studies. Seven of them are randomized control trials. The total number of patients in the study is one, thousand, seven, hundred, sixteen, the outcomes they looked at in this review were emergency department visits related to asthma urgent healthcare use or hospitalizations, and what are the school programs include. The studies look at Comprehensive Public School based programs which include supervised administration of Medicines Education for staff children, parents, and some include other nurse led initiatives. The schools were all urban. So does it work? Yes. All the studies show some benefit actually pretty impressive for example, one of the randomized controlled trials showed seven percent er visit rate in the intervention group and a fifteen percent er visit rate in the Control Group and of Thirteen Nice these studies have some limitations though yeah. But overall pretty solid helpdesk answer authors conclude with a strength of recommendation a that school based asthma management programs decrease Ed visits I'm sold. Next we have a poem poems are patient oriented evidence that matters in this comes to us from. ABM. Guru mark a bell. The clinical question here is, what is the preferred monotherapy for treatment of on a Komo's? So before this article I, don't know about you but I've always started with topical cyclo packs for any patient that I have with toenail ANA coasts. When it comes to monotherapy is it actually looks like continued use or in use or alter benefiting or tre CONNAH's all may be the best option. This Meta analysis concluded that if it's given every day for twelve to twenty, four weeks to benefit and I connah's all were the most likely to be effective for Mike Logic cure without much difference in adverse events. When you look at other therapies, even topical things like Cyclo Rocks, FM Connah's all Tabatabai role and even oral Fukang is all. And they also note that continuous administration was more effective than pulsed dosing and that's where it's just given everyday for one week out of a month while there was some evidence of bias. This is pretty strong evidence considered level one, a that worlds her benefiting and RECON is all are effective for toenail Monaco mycosis. It's really surprising that a drug with such a great name F. N. is all doesn't work better was really rooting for overcompensating name I guess Yup. It's flu shot time we have a practice guidelines summary here from the Centers for disease. Control, Advisory Committee on Immunization Practices. What's new this year? Because flu season is overlapping with the COVID. Nineteen pandemic making sure everybody overage six months is vaccinated. The super important to reduce symptoms that could be confused with covid nineteen to reduce stress on our healthcare system. And just like every year, the composition of the vaccine is updated. They're also two new high dose vaccine formulations which may be used in adults who are sixty five or over its recommended to get the vaccine by the end of October this year but you can still get it through December sooners better. But anytime is good. People with allergies can still use any of the vaccines people with a history of severe egg allergy should be monitored after their vaccination in a healthcare setting. Children's six months to eight years may require two doses a month apart check on their prior flu vaccine history. This is not a change. Okay. So go get your flu shots and make sure you get all your patients in for there's two. Let's hear from our Tennessee family doc musicians bill and Justin about what they think about getting the flu shot. They man to get your flu shot yet. Now, I never get the flu shot. Nixon fatigue is not the way it has been today. Get you shove. Gets after the brig blended on the shine. Unless you. Get you. Get. Our. Next feature article is. Hernias, diagnosis and management from Doctors Shaquille Apparition Barda, and Munez from Dallas. Texas. Is it just me or do the try and goal seem more like the Bermuda Triangle and you tried to learn it in medical school? Yes things just kind of get lost in there you get turned around. Totally. So, if you'll take yourselves back, remember that there are three different types of inguinal hernia and it's based on Hasselbeck triangle. So a direct inguinal hernia occurs directly through the post here wall of the inguinal canal, and this is medial to the inferior EPA gastric vessels. An indirect inguinal hernia occurs through the internal and external ring, and this is lateral to the inferior EPA gastric vessels, and finally the less Common Federal Hernias occur below the inguinal ligament. Sorry zoned out for a second there. Okay I remember. Ninety six percent hernias are either direct or indirect in about twenty percent occur bilaterally. In general, most inguinal Hernias are going to be an older man but a third of patients might not have any symptoms if they do have symptoms that'll usually be a bulge in the groin that might be uncomfortable. Maybe it gets worse withstanding lifting coughing that sort of thing in federal her news or the least common type of inguinal hernia. But these are more common in women and they're also at higher risk of strangulation because of this watchful waiting is not recommended if you have a non-pregnant woman with an internal hernia if an Inguinal hernias clinically apparent, no imaging is needed not even. Ultrasound Hashtag. Thanks choosing wisely if there is doubt or an hernia is suspected because of symptoms ultrasonography is then the first line for evaluation. If that's negative, then you can move onto Mri an excellent positive predictive value of ninety five percent and a pretty good negative predictive value of a five percent. Both of these are better than ultrasound. If they don't have pain that's their activity and you can reduce the hernia without issue, it is okay to do watchful waiting but if the hernia becomes symptomatic where campy reduced, there's a high risk of incarceration. So surgery would definitely be a more favorable. In that setting. and. As far as surgeries go if you're counseling or patients, laproscopy repair is preferred because of better recovery times especially in women. Mess techniques are also strongly recommended because of the lower recurrence rate after these procedures if neither of those are available than the open anterior approach becomes most favorable favourable. After surgery most patients should be encouraged to return to physical activity after about three to five days since early physical activity hasn't been shown to increase the risk of recurrence, even though a lot of people are used to being told to wait four to six weeks to get back to physical activity doesn't fun fact. A lot of new facts here for me so much finding the inguinal hernia topics. Just, don't get lost in there. Okay cleaner, you have a poem for us. Poems are patient oriented evidence that matters and the clinical question here is how accurate are biomarker c reactive, protein, Pro Calcitonin, and leukocitis in the diagnosis of community acquired pneumonia in adults with respiratory symptoms, this palm looked had biomarkers as a tool to diagnose community acquired pneumonia in adults with respiratory symptoms like Steve mentioned, they reviewed pubmed studies from both emergency department and outpatient settings for a total of stover sixty, five, hundred patients and found that CRP was the most accurate biomarker again, comparing this to protest the tonen. Leukocyte toast. In diagnosing adults with community acquired pneumonia. So based on existing clinical decision rules if a patient has a twenty, five percent or lower probability of having pneumonia than a CRP under twenty decreases the likelihood to less than ten percent. So the argument here is that you may be able to save them unnecessary imaging. If the Europeans low practically I have a hard time imagining getting labs but not imaging. If you evaluate a patient in suspect, they have pneumonia. But perhaps if you're a little more on the fence and you do have access to more rapid results than getting a CRP, could make an x ray clinically unnecessary. American family physician has a new feature diary of family physician. For our diary of a family physician Evan, you're going to read the first one, which is a diary from. Seiji Hiatchi, who's the chief transformation officer and Administrative Medical Director at Mary Center Washington DC and was also my senior resident in residency. Seven, forty, five am. Tears welled from is thinking about a patient who died this morning from Cova nineteen she died alone in a busy hospital despite her husband's plead visitor. I have twenty five patients with presumed cove in nineteen on my schedule. So I collected myself and I picked up my stethoscope. Eight. Am at the respiratory clinic I, noticed an oxygen tank set up. By is followed the clear vinyl tubing to a woman sitting in a tripod position. She presented with ten days of fever and worsening cough. Haroon Mir saturation was eighty, nine percent. The patient was refusing to go to the hospital because she feared she would die there. If you're to. Twelve, forty five PM. I grabbed a handful of almonds for lunch just as I received a notification on my phone. Notice of patient death. How do I tell my team that five of our patients died in the past seventy two hours? I'm currently the only physician at my community health center who can sign a death certificate online so I need to do this quickly. Families should not have to worry about administrative forms while grieving. It's one of the last acts of kindness I can do for my patient. Six PM a patient is angry that she can't see her doctor in person she lectures me through the phone. If doctors are so afraid of catching Kobe nineteen, they should not have become doctors. Eight PM I received an email from my sister who's internist in New York City. Her husband is a pulmonologist and they have three children under the age of nine she wrote. If something happens to us. It has to be you who takes the kids. are next diary will be read by Kalina, and this is from a net Chevenez. She's a family physician and owner, of Carrillo, family practice in Dayton Ohio. Eight thirty, A. N. it's been two months since Ohio walked down. I arrive at the office and note that my schedule looks a little busier. But it's definitely not full. I'm grateful that patients are starting to feel comfortable enough to make appointments to see me. Nine thirty am. A middle aged woman presents with a fluctuate warm mass over her left Scapula. She has obvious neuro-dermatitis and admits picking and scratching the area before it became expected. She mentioned that her brother and father recently died within the same year. I incised drain pack the wound, give her antibiotics for the surrounding cellulitis and schedule her for a follow up tomorrow to address her psychological concerns. My certified medical assistant trainees who are pre medical students doing a gap year with me enjoy watching the procedure. They both had to reschedule their mcat cat because of the pandemic. Eleven I am. A rarity these days is a new patient on the schedule, a woman with dementia who needs a history and physical examination to be admitted to an assisted living facility. She struggles with wearing masks so I help her As I review her previous medical records supplied by her brother I see that the woman has her mask off and is applying lipstick. Eleven thirty A. M? Had to the parking lot for one of my two visits that will take place there today. If it rains, my medical assistant holds the umbrella over US so far I have had only two positive Kobe nineteen test results out of about thirty patients I have tested. Three peon. After presenting another impromptu lecture on the pandemic to my students are first patient of the afternoon finally shows that. Office visit volume has improved by fifty percent since our low point. I've never experienced this lack of demand and I miss my patients. The office manager, my husband has calculated how many patients we need to see per day just to meet overhead costs. The number needed to treat it's twelve. Today. I'm, at minus, two patients. Please email us at AF podcast at AF DOT ORG or tweet at AF podcast. Please rate and comment on Apple PODCASTS OUR PODCAST team J. Anderson Jocelyn Boker Steve Brown Sarah Coles Kiana Espinosa Chris Russo genevieve Lambert on Wilson you Linley. Coney in Meredith Rosenthal are sound technical guru is Tyler Coles. Our theme song is written and recorded by family physicians bill. Dad's Ryan, Evans, and just Jenkins. This podcast is brought to you by the residents and Faculty of the University of Arizona, College of Medicine Phoenix Family Medicine residency. We'll talk to you soon for the next edition of the American family physician podcast.