Episode 91 - August 1, 2019 AFP: American Family Physician
The a._f._p. Podcast is sponsored by the american academy of family physicians and buy a new offering from the a._f._p. Presenting counting select articles from the august issues of american family physician in audio format for listening anywhere learn more at a._f._p. Dot org slash journal audio welcome to the american family physician podcasts for the august. I twenty nine thousand nine hundred issue. I'm steve. I'm herbert. I'm melissa and i'm caroline. We are residents and faculty mostly residents from the university of arizona college of medicine phoenix family medicine residency this time on the podcast. We're going to talk about ingrown. Toenail controversies controversies in family medicine should adults with elevated blood glucose not meeting criteria for diabetes be prescribed forman hair scientism and women infantile untile i'm angie oma and skin-to-skin contact to support breastfeeding the opinions expressed in the podcast dr into 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 see your family doctor for medical care in welcome to the podcast eliza herbert and caroline yeah. I bet you are excited that your first topic as hosts will be ingrown toenail management. This feature article comes from doctors mayo carter and murphy from the university of south carolina china first of all. Do you guys know the fancy medical name for ingrown. Nail is unaccounted. Crypto sis or angus in-car knits no no me neither and i really can't pronounce it. So how do you manage ingrown nail. You can use nonsurgical treatments for mild or moderate ingrown nails but probably need surgical treatment for moderate or severe cases so first. Let's talk about what doesn't help. Ingrown nails orel topical local antibiotics don't improve outcomes other things that don't work post operative antibiotics manuka honey hydrogel pov- adine iodine with paraffin and or paraffin gauze basically all forms of paraffin. Don't work two thousand twelve. Cochran review tells us unsurprisingly that surgical treatments are better than the non surgical treatments at preventing recurrence so illicit. Can you tell us about the nonsurgical treatments yes. If you opt for a nonsurgical treatment you'll need to persist until normal nail grows past the edge of the lateral skin folds which takes two to twelve weeks accents. You might try better footwear soaks in warm soapy water or cotton or dental floss under the ingrowing nail edge. You can try tape to pull away the nail fold from the nail plate or you can try innovative gutter splint with a mini splint made out of vinyl i._v. Tubing you'll need to numb the tow for the splint all right carolyn. So what if your patient needs a surgical intervention. There's quite a few procedures mentioned here. The one i've used which the article says is the most common procedure is partial of version of the nail plate plus minus lateral horn matrix ectomy matrix ectomy reduces the likelihood of recurrence after removing the ingrowing portion of the nail. No antibiotic therapy is needed phenol chemical ablation of the matrix causes minimal bleeding and has less a five percent recurrence rate electro. Surgical ablation is also done herbert. What else did you learn about on akot crip toasts from this article all after a surgical procedure the patient can change the dressing in twenty four to forty eight hours and resume normal ambulation phenol helps with the pain because it ablaze the nerve endings endings okay listeners. Now your toe up-to-date on ingrowing nails. We have two editorials here. Controversies sees in family medicine should adults with prediabetes be prescribed met four men to prevent diabetes mellitus and the no oh side is written by me. Evidence does not show improvements in patient oriented outcomes and the yes side is written by dr mohan from u._c._l._a. So the format here is that we randomly chose who is yes treat prediabetes with metformin and who is no do not i treat prediabetes with metformin so herbert will be doing the no and caroline will be doing the yes and the format is a rap battle. No it is not a rap battle. Thank god how would that go not well okay so the format is each of them have three opportunities to make appoint which will be brief and then one counterpoint each which will be even briefer so three points three counter points for each yes you should prescribe prescribe metformin for prediabetes and no you should not so we randomly drew an order and caroline is going to go first and she's going to tell us why we should <unk> prescribe metformin for prediabetes to prevent diabetes mellitus here. We go arguments number. One there is high quality evidenced instead metformin can prevent or at least delay the onset of diabetes among people at greatest risk a large multi center randomized controlled trial by the diabetes prevention program research group found that compared to placebo metformin had a relative risk reduction of thirty one percent over three years ears similarly a meta analysis of three r._t.'s comparing metformin to placebo demonstrated number needed to treat a fourteen as well well prevention certainly the goal even delaying the onset of diabetes would help minimize the burden on both the individual and the healthcare system that comes with a diagnosis of diabetes <music> herbert. Why should we not prescribe metformin for prediabetes to prevent conversion to diabetes so again in the spirit of full disclosure. I should mention that the author author con articles my residency director and there's clearly no bias in this but even the american diabetes association recognizes that prediabetes is not a disease z's but merely a risk factor and really not a great one at that in fact most people was so called prediabetes will not develop diabetes within five years and that's according to the two thousand eighteen standards awards of medical care and diabetes released by the american diabetes association. Oh what do you have to say to that. Caroline you make a valid point herbert but in the diabetes diabetes prevention programs study at three year follow up nearly twenty nine percent of people in the placebo group develop diabetes those are still pretty high numbers all right carolyn another point our number two so let's consider the risk benefit analysis together. I think we would all agree. That metformin foreman is safe. Generally well tolerated and affordable. The most concerning adverse effect of metformin that we all think of is an increased risk of lactic acidosis doses but a cochrane review of over three hundred studies found that there really is no increased risk in that case the more relevant concern would be the risk of g._i. Side effects and b twelve deficiency but these effects can be monitored and managed on an individual basis at the trade off of the overwhelming benefits. It's of delaying or preventing diabetes. She's good herbert. She almost is talking me out of my own editorial all marginally so again here. We're talking about a maybe sorta kinda not really sure if there's benefit or not when we're talking about metformin so in these kinds of situations you really do have to consider the harms pretty seriously and those side effects that you mentioned particularly those g._i. Ones john's nausea vomiting and diarrhea those are pretty significant and can be life limiting for patients. These are patient centered concerns that shouldn't be ignored and the b twelve deficiency. There's something more insidious that can also develop from that are a herbert argument number two so speaking more to the point of patient oriented outcomes despite the outcomes listed in the diabetes prevention program which showed statistically significant outcomes for a one c. They actually failed to demonstrate any patient oriented outcomes such as quality of life benefits and mortality the benefits. I don't know what to say to that. We all love our poos over here or patient oriented outcomes poo all right all right carolyn so you have another. You have third point for us here. I do in a last bit effort as family way doctors as you mentioned we all value a patient centered approach which involves share decision making and this means having a conversation including all evidence based therapeutic european options and then letting the patient weigh the options herself in a qualitative study of thirty five adults with risk factors for developing diabetes metformin was deemed to be an acceptable management option in addition to lifestyle changes so while lifestyle interventions should absolutely be the first line treatment for anyone at risk of developing in diabetes. Metformin should be part of the discussion so i mean i guess sure shared decision making is fine and good but don't we have more things to do with our limited time in the clinic office your face boop okay herbert your final point kinda speaking more to the broader picture of metformin as a pharmaceutical agent. This really kinda fits a classic example of disease mongering which is for those who don't know the selling of sickness is that widens the boundaries of illness in order to grow the markets for those who saw deliver treatments where essentially medicalising persons in what is officially recognized as a non disease state based upon a notable lack of patient oriented evidence bolstered only by clinically meaningless endpoint while minimizing the side effects of metformin. This is a great way to further induce fear into our patients especially those things. I'd your depression. Who are we really benefiting with our pill pushing the patient or big pharma herbert. I understand your point but i go back to metformin is safe. Evidence based well tolerated generally for most people even at a low dose and it's affordable so therefore for it should be part of at least the discussion for patients that would be at higher risk so if i've convinced you at all that metformin may be useful in some some patients with prediabetes than the group that you would particularly be interested in addressing it with would be those less than sixty years old have a b._m._i. Greater than thirty five in a one c of six to six point four or women with a history of diabetes as these are the groups in which met foreman has has been shown to be most effective good job caroline herbert in this controversy in family medicine should metformin be prescribed for patients with abnormal glucose values values not meeting criteria for diabetes now you the listeners get to decide our next feature. Article is hair citizen in women from doctors mathison and bain at of the medical university of south carolina all right. Let's talk about harry situation. Uh-huh her citizen is the excessive growth of the long large course pigmented type of hair that defines terminal hairs in a typical male pattern in females although usually benign ideology it can have important reproductive and psychological implications for patients polycystic ovary syndrome or p. c. O. s. is by far the most common cause of her citizen accounting for over seventy percent of cases and it's something we see commonly in the primary <unk> care setting think p._c._s. In that patient with obesity insulin resistance infertility or menstrual dysfunction and acne androgen and levels can be normal or slightly elevated in transactional ultrasound would typically show polycystic ovary morphology. So what other workup should i consider are doing if i'm not convinced it's p. C. o. s. if your history and exam is including you into p. C. o. s. consider an early morning total testosterone level to start. If it's normal the patient might have idiopathic her citizen. If it's elevated you should pursue further hormonal workup based on the patient's other associated symptoms symptoms like thyroid testing or proacting level if indicated although rare non classic congenital adrenal hyperplasia can present around puberty liberty with her citizen so consider seventeen hydroxy progesterone level if you're suspicious if the testosterone level is elevated and you've ruled out everything else else you've probably got idiopathic hyper androgen ism lissa what might be a do not miss condition that presents with her scientism in women great question super rare but androgen secreting tumors typically of ovarian or adrenal origin can present with her citizen you definitely i don't wanna miss those as their malignant in over half of cases some red flags for tumors are rapid onset of her citizen over a few months in in addition to other signs of realization like increased muscle mass deepening of the voice breast atrophy and male pattern baldness moving moving onto treatment regardless of the cause first line therapy for her schism in women who are not actively trying to conceive is combined oral contraceptives. That's correct. It's important to council women that because of the growth cycle of hair follicles you should not expect to see changes until at least six months into treatment. What if your patients still has concerning facial hair after six month trial of o._c._p.'s consider adding anti androgen along with o._c._p.'s like sperone run a lack tone or finance deride but don't forget these are also terada jen's so avoid in patients who are attempting to become pregnant importantly insulin colin lowering therapy like met foreman while occasionally used in patients with p. c. O. ask are not effective in treating her citizen other cosmetic care removal methods can can also be used to treat her citizen shaving is effective and inexpensive but must be done frequently more permanent and thereby more expensive options also so exists like electrolysis or photo appalachian electrolysis isn't practical for moving here from large areas photo appalachian or a laser hair removal has varying reported efficacy rates but is up to sixty times faster to perform than electrolysis well elissa. Thank you so much for that wonderful review view of her citizen. Men women okay herbert. You have a practice guideline for us next yes i do the american academy of pediatrics has released their newest risk guidelines on infantile. Gemma's also known as strawberry marks these usually benign and self resolving vascular tumors are sometimes quite worrisome lie. What's it's a family doctor to do so. Let's do a pop quiz on how to do a risk assessment and how to manage infantile hamon gemma's ready podcast audience okay first first question how common are infantile ngoma's. The answer is five percent or one in twenty infants so somewhat common common. Oh i know i've seen a few clinic definitely see all right second question looking for an exact answer for this one blank occur more cutaneous <unk> ngoma's should make you suspicious for paddock manji oma looking for a number here. Take your time audience. If you said five or more you're correct zeiss hypnotic command yomas concerning because of their association with heart failure and hyperthyroidism serious area stuff and the reason we cannot write off all these lesions okay next question beyond number of lesions size is also important certain high risk areas can be worrisome at smaller sizes but elision greater than how many centimeters anywhere on the body is considered high risk. That's right five centimeters noticing a theme. These answers team five is apparently the magic number to consider an infantile ngoma's almas how convenient however lesions on the face extremities trunk or neck are considered high risk at how many centimeters yeah two centimeters reason being is anatomically these lesions can be associated with vision loss airway problems expectation and disfiguring scarring hiring especially in an area called the beard distribution next question infantile hamann's yomas our clinical diagnosis however if if you're concerned about deeper pathologies or have clinical uncertainty what is the first line imaging modality of choice and the correct answer is oltra sound final question fam- in the absence of other underlying pathology we have excellent evidence from well designed trials and systematic review that what what medication is first line for infantile ngoma's. That's right. It's oral propranolol. Add up your scores at home podcast audience. Tell us your infantile ngoma underscores out of six on twitter at af podcast and if you've got six six we're super impressed. Let's do an f. pin help desk answer f._m. Is the family physicians inquiries network and this comes from doctors cousteau and banco out of tacoma washington so caroline. What's the verdict as skin into skin. Contact in newborns improve duration of breastfeeding. The short answer is yes skin to skin contact for healthy vigorous chris newborns immediately after delivery should be recommended to all mothers because it is associated with a higher likelihood of exclusive breastfeeding at the time of discharge and in for up to six months postpartum and this gets a strength of recommendation a rating through a two thousand sixteen meta analysis of forty six randomized controlled all trials looked at newborns who had direct contact with their mothers for at least ten minutes and up to two hours after delivery versus newborns who were fully separated from their mothers. They then compared frequency duration of exclusive breastfeeding between the groups. They found that those in the skin to skin contact group were more likely to exclusively breastfeed lead at hospital discharge and up to six months postpartum with a number needed to treat only six to eight also published in two thousand sixteen in our c. T. performed ended a hospital in india randomized two hundred newborns to either forty five minutes of skin-to-skin contact versus being placed in a radiant warmer mothers in both groups received the same lactation counseling and they found that infants in the skin-to-skin group with thirty percent more likely to exclusively breastfeed at six weeks compared to those placed in the warmer ashtec golden hour you got it. Skin-to-skin contact improves breastfeeding this podcast today episode ninety one is historic for the two reasons one is because obviously it's herbert and caroline analysts first episode as host but also the credits you're about to hear are from new hampshire. This means that we have now had all fifty u s states represented in the credits of this podcast. Thank you so much to all of you for sharing the credits with us. This is amanda prayer and cmo go from the new hampshire dartmouth family medicine residency and the concord hospital. Oh family health centers in concord hillsborough new hampshire. Please email us asap podcasts at a p dot org or tweet at af podcast past. Please subscribe and rate us on itunes or season. Five podcast team is jake anderson caroline blocked burger steve brown sarah coles eliza quarantine ornstein victoria krantz herbert rosenbaum michelle summer and hilary tamar technical grew is tyler coles our theme songs. It's written and recorded by family. Physicians built apps ryan evans and jason 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.