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November/December 2016 Annals of Family Medicine tip sheet

November 14, 2016

Antibiotics Not Necessarily Warranted for Lower Respiratory Infection With a Bacterial Cause; Disease Course Similar to Nonbacterial Infection

The illness course of lower respiratory tract infection with a bacterial cause is generally mild, uncomplicated and similar to that of nonbacterial lower respiratory tract infection and does not warrant the immediate prescribing of antibiotics according to a study from researchers in Europe. Analyzing patient-recorded symptoms for 834 adults with acute cough, 162 of whom were diagnosed with a bacterial infection, researchers found patients with acute bacterial LRTI had only slightly worse symptoms at day two to four after the first office visit (P = .014) and returned more often for a second consultation (27 vs. 17 percent) than those without bacterial LRTI; however, the differences were small and not clinically meaningful. Resolution of symptoms rated moderately bad or worse did not differ between the groups (P = .375). The authors conclude that because there appears to be no meaningful difference in the illness course of bacterial LRTIs, physicians can reassure patients that LRTI, even if bacterial, is a self-limiting condition, and that rather than immediately prescribing an antibiotic, follow a strategy of watchful waiting.

Disease Course of Lower Respiratory Tract Infection With a Bacterial Cause
By Jolien Teepe, MD, MSc, et al
University Medical Center Utrecht, The Netherlands

Meta-Analyses Examine Prevalence of Atypical Bacterial Pathogens in Patients With Sore Throat, Cough and Community-Acquired Pneumonia

Two meta-analyses by Ebell, Marchello and colleagues synthesize the literature to provide new insights into potential respiratory pathogens that are not typically subjected to diagnosis and treatment.

In the first study, the researchers find high rates of atypical bacterial pathogens in patients with acute lower respiratory tract diseases, including cough, bronchitis and community-acquired pneumonia. Analyzing 50 studies, the researchers found that among adults with CAP, 14 percent had an atypical pathogen: 7 percent had mycoplasma pneumoniae, 4 percent had Chlamydophila pneumoniae, and 3 percent had Legionella pneumophila. Among children with CAP, 18 percent had Mycoplasma pneumoniae, only 1 percent had Chlamydophila pneumoniae, and Legionella pneumophila was extremely rare (only one case in 1,765 patients). Among patients with prolonged cough, 9 percent of adults and 18 percent of children had Bordetella pertussis. The authors conclude these findings suggest these conditions are underreported, underdiagnosed and undertreated in current clinical practice. They call for future research to help clinicians more accurately diagnose these pathogens and determine if and when antibiotic treatment is helpful.

In the second meta-analysis, Ebell, Marchello and colleagues find high rates of both Group C beta-hemolytic streptococcus and Fusobacterium necrophorum in patients presenting with sore throat. Most cases of sore throat are viral, and Group A beta-hemolytic streptococci are responsible for 10 percent of episodes in adults and up to 30 percent in children, but recently it has been suggested that these two other bacteria may be important causes of pharyngitis with similar clinical presentations. Analysis of 16 studies reveals overall prevalences of Group C streptococcus and F necrophorum were 6 percent and 19 percent, respectively, in patients presenting with sore throat in primary care. The authors call for future research to determine whether these bacteria are truly pathogenic in patients with sore throat and whether antibiotics reduce the duration of symptoms, the likelihood of complications or the spread to others.

Prevalence of Atypical Pathogens in Patients With Cough and Community-Acquired Pneumonia: A Meta-Analysis
Prevalence of Group C Streptococcus and Fusobacterium Necrophorum in Patients With Sore Throat: A Meta-Analysis
By Mark H. Ebell, MD, MS, et al
University of Georgia, Athens

Patients Who Discuss Opioid Risks With Their Physician Less Likely to Report Saving Pills for Later

A research brief by Harvard researchers finds that in a nationally-representative sample, the high-risk behavior of saving opioid pills for later use is substantially less likely among patients who report having been counseled by their physicians about the risks of prescription painkiller addiction. Evaluating data from telephone surveys of 385 respondents who reported they had been prescribed strong prescription painkillers within the last two years, the researchers found a 60 percent lower rate, after adjustment for covariates, in self-reported saving of pills among respondents who said they talked with their physicians about the risks of prescription painkiller addiction. The authors conclude these findings suggest that patient education efforts, as currently practiced in the United States, may have positive behavioral consequences that could lower the risks of prescription painkiller abuse. They call for future research in controlled settings to test the effectiveness of physician-patient discussions about addiction risk and related safety measures in promoting appropriate use, storage and disposal of prescription pain killers.

Discussing Opioid Risks With Patients to Reduce Misuse and Abuse: Evidence From 2 Surveys
By Joachim Hero, MPH, et al
Harvard University, Boston

Those Left Behind From Voluntary Medical Home Reforms in Ontario, Canada, More Likely to Be Poor, Urban Immigrants and Receive Lower Quality Care

Seeking to improve health outcomes and reduce cost, more than three-quarters of family physicians in Ontario, Canada, voluntarily transitioned from traditional fee-for-service practices to medical homes over the past decade. Amid these reforms, approximately one in six Ontarians still remain enrolled in fee-for service practices. Seeking to understand the characteristics and quality of care of patients who did not participate in the voluntary transition to medical homes, researchers found these patients are more likely than patients in medical homes to be poor, urban, and have immigrated in the last 10 years, and less likely to receive recommended screening services. Analyzing administrative data on 10.8 million patients attached to a medical home and 1.3 million patients receiving care from a fee-for-service physician, they found those attached to a fee-for-service physician were less likely to receive recommended testing for diabetes (25 percent vs. 34 percent) and less likely to receive screening for cervical (52 percent vs. 66 percent), breast (58 percent vs. 73 percent), and colorectal cancer (44 percent vs. 62 percent), compared with patients attached to a medical home physician. The authors note these differences in quality of care preceded medial home reforms. Those physicians who opted not to transition to a medical home were more likely to be older, to be international medical graduates and have smaller panel sizes. The authors call for strategies to improve care for patients left behind by medical home reforms in Ontario through improved primary care attachment or improved services with their existing physician.

Those Left Behind From Voluntary Medical Home Reforms in Ontario, Canada
By Tara Kiran, MD, MSc, CCFP, et al
University of Toronto, Canada

Subclinicial Peroneal Neuropathy: A Common, Unrecognized and Preventable Risk Factor for Falling

Researchers identify an unrecognized, preventable and treatable condition that may place hospitalized or recently hospitalized patients at increased risk for falling. In a study of 100 hospital inpatients, the researchers find that nearly one-third of patients at risk for falling have subclinical peroneal neuropathy, a condition in which compression of the peroneal nerve at the fibular neck causes foot drop that can lead to tripping and falling. Examination and history of study participants showed that patients with SCPN were nearly five times as likely to have fallen in the past year than those without the condition. The authors conclude that screening for SCPN, implementing preventive measures and treating the disorder may help reduce fall incidence in hospitalized and recently discharged patients.

Subclinical Peroneal Neuropathy: A Common, Unrecognized, and Preventable Finding Associated With a Recent History of Falling in Hospitalized Patients
By Susan E. Mackinnon, MD, et al
Washington University in St. Louis School of Medicine, Missouri

Caregiver Interviews Reveal Tensions Surrounding Child Mobile Technology Use

New guidelines released last month by the American Academy of Pediatrics suggest that media use by children is nearly inevitable, but it is up to parents to closely monitor their children's usage. This study sheds light on how primary care physicians can work with parents to realistically manage children's mobile technology use. Researchers interviewed a diverse sample of mothers, fathers and grandmothers to better understand caregivers' views about child mobile technology use, including the perceived benefits, concerns and effects on family interactions with the goal of informing pediatric guidance. The 35 caregivers interviewed reported feeling much uncertainty about whether mobile technologies are beneficial or harmful to their children's development, how to use digital devices beneficially when their rapid evolution seems out of control, and the important functional purposes media serves in their families despite displacing family time. Specifically, the authors identified three issues that invoked internal tensions between competing viewpoints: 1) effects on the child -- fear of missing out on the benefits of mobile devices vs. concerns about their effects on child thinking and behavior; 2) loss of control -- wanting to use mobile technology in educational ways vs. feeling that rapidly evolving technologies are beyond their control; and 3) family stress -- the necessity of mobile device use in stressed families vs. its displacement of high-quality family time. Given these findings, the authors propose a framework with which pediatric clinicians can respectfully and realistically discuss mobile technology use with caregivers so they can make informed and empowered decisions. They assert that the cognitive dissonance revealed in the responses presents prime opportunities for influencing behavior change; therefore exploring the inherent tensions in the unknowns surrounding emerging technologies may be an effective entry point into clinicians' conversations with parents.

Overstimulated Consumers or Next-Generation Learners? Parent Tensions About Child Mobile Technology Use
By Jenny S. Radesky, MD, et al
University of Michigan, Ann Arbor

Framework Describes How Health Coaches and Patients Work Together

Despite the growing use of health coaches to support patients in making health-related decisions and behavioral changes, there is little research about how health coaches support patients. Analyzing focus group and individual interviews with patients, family members, health coaches and clinicians, researchers identified several core features of successful coaching and developed a conceptual model to describe how health coaches and patients work together. Among the themes identified by respondents were: shared characteristics between health coaches and patients, availability of health coaches to patients, development of a strong relationship based on trust, educational role of the health coach, providing personal support for patients, providing support for decision making, and bridging between the patient and the clinician. The resulting model, which attempts to characterize how health coaches and patients optimally work together, can be used in training and supporting health coaches in practice.

A Qualitative Study of How Health Coaches Support Patients in Making Health-Related Decisions and Behavioral Changes
By David H. Thom, MD, PhD, et al
of California, San Francisco

Meta-Analysis Finds Peer Support Interventions Improve HbA1c Levels, Particularly Among Hispanic Patients

Peer support interventions delivered by people affected by diabetes are associated with a small but statistically significant reduction in glycosylated hemoglobin, with larger effects among predominantly minority participants, particularly Hispanic participants. The meta-analysis of 17 studies with 4,715 participants found an overall 0.24 percent improvement in HbA1c. The subgroup of studies with predominantly Hispanic participants showed an HbA1c improvement of 0.48 percent in the peer support intervention group compared with the control group. In contrast, the pooled effect size from the seven studies with predominantly white, non-Hispanic participants showed no improvement in HbA1c level with peer support interventions. The authors surmise that peer health coaches might be providing more culturally appropriate health education in ethnic minority populations, particularly in the Latino population. They call for future research to assess the effect of peer interventions on long-term patient-centered outcomes.

Peer Support Interventions for Adults With Diabetes: A Meta-Analysis of Hemoglobin A1c Outcomes
By Sonal J. Patil, MD, et al
University of Missouri, Columbia

Reflection: Are Physicians the Walking Dead?

Reflecting on physicians' struggles in medicine, in particular the high prevalence of burnout and the challenge to cultivate compassion and meaning, Benjamin R. Doolittle, MD, MDiv, program director of the Combined Internal Medicine-Pediatrics Residency Program at Yale University, asks, "Are we the walking dead?" Doolittle draws parallels between the plot and themes of the popular television show The Walking Dead, asserting that the zombie apocalypse metaphor could shed light on the state of medicine in 2016 as physicians struggle to survive. He challenges physicians to reclaim their central purpose -- to promote life, to focus on the healing of patients and the flourishing of their own lives -- in order to avoid becoming the walking dead.

Are We the Walking Dead? Burnout as Zombie Apocalypse
By Benjamin R. Doolittle, MD, MDiv
Yale University, New Haven, Connecticut
Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and the College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal's website,

American Academy of Family Physicians

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