Sean M. McNeeley, MD

Azithromycin May Not Be Helpful for Asthma

Key point: There is no proven benefit from taking azithromycin for asthma.
Citation: Johnston SL, Szigeti M, Cross M, et al; AZALEA Trial Team. Azithromycin for acute exacerbations of asthma: the AZALEA randomized clinical trial. JAMA Intern Med. 2016;176:1630–1637.
The randomized, double-blind, placebo-controlled trial reported here focused on treatment for 3 days for 199 adults with asthma exacerbations. One group received 500 mg of azithromycin; the other group received a placebo. Unfortunately, a limitation of the study was the number of patients who had already taken an antibiotic prior to enrollment. The primary outcome was a score on a self-reported symptom scale. The researchers found no effect of azithromycin on asthma exacerbations. Urgent care providers can glean two important points from the study: First, antibiotics are commonly prescribed for patients experiencing an asthma exacerbation. Second, azithromycin may not have any effect on exacerbations.

The Unpredictable Metabolism of Codeine Is a Problem

Key point: Just say no to codeine.
Citation: Tobias JD, Green TP, Coté CJ; Section on Anesthesiology and Pain Medicine; Committee on Drugs. Codeine: Time to say “no.” Pediatrics. 2016;138:e20162396.
This review of the literature focuses on just saying no to the use of codeine, which has been prescribed for decades to calm coughs and relieve pain. Codeine itself is not the concern in this scenario. The drug is rather easily dosed, but problems occur when it is metabolized to morphine. Its metabolism is unpredictable and may be accelerated in some patients, creating more morphine than is safe. Nonsteroidal anti-inflammatory drugs have been repeatedly shown to relive pain without negative effects, but no definite evidence of benefit from codeine for relieving cough has been found. Urgent care providers should give strong consideration to the evidence before prescribing codeine to a child.

Medical Scribes May Help Decrease Physician Workload

Key point: More research is needed on the effectiveness of scribes in health care.
Citation: Yan C, Rose S, Rothberg MB, et al. Physician, scribe, and patient perspectives on clinical scribes in primary care. J Gen Intern Med. 2016;31:990–995.
Although this study was done in a primary-care setting, its focus on the relationships among medical scribes, physicians, and patients provides useful information for urgent care centers. The use of electronic medical records (EMRs) has been shown to improve the quality of health care and reduce its cost, but using EMRs has also increased the workload of health-care providers. Thus, medical scribes have been increasingly brought in to reduce that workload. Study participants were 18 physicians and 17 scribes from 6 health-care systems, and 36 patients from a single health-care system. Physicians, patients, and scribes alike perceived EMR notes to be more detailed than paper records. Overall, patients were comfortable with scribes being in the examination room. Scribes who were also medical assistants got work done in addition to documentation while in the room. The biggest issues were with physician–scribe fit. As the need for increased productivity and increased documentation collide, scribes may be the best solution. [Editor’s note: See also “The Rise of Medical Scribes: A Fit for Urgent Care?” in the September 2016 issue of JUCM: https://jucm.com/rise-medical-scribes-fit-urgent-care/.]

The Number of Sexually Transmitted Infections Is at an All-Time High

Key point: Sexually transmitted infections are on the rise.
Citation: Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2015. Atlanta, GA: U.S. Department of Health and Human Services; 2016. Available from: http://www.cdc.gov/std/stats15/std-surveillance-2015-print.pdf
Findings from the 2015 surveillance study by the Centers for Disease Control and Prevention (CDC) of sexually transmitted infections (STIs) in the United States are anything but good: The occurrence rate for STIs is at the highest level on record. Chlamydia is seen twice as frequently among women as among men, and its rate was up 6%, to 479 per 100,000 population. The rate for gonorrhea was up 13% from the previous year, to 124 per 100,000 population. Of note is that resistance to azithromycin increased from 0.6% to 2.6%. The occurrence rate for syphilis (primary and secondary) also increased 19%, to 8 cases per 100,000 population. In 90% of cases, the patients were male. It is concerning for urgent care providers that there has been both an increase in the number of cases and an increase in the resistance of the causative bacteria. Although the CDC report is huge (176 pages), it is important to know at least about the general increase in the number of cases. Urgent care providers will also want to see https://www.cdc.gov/std/tg2015/default.htm for the CDC’s treatment guidelines for STIs.

Douching Is Correlated to Increased Risk of Ovarian Cancer

Key point: Douching is not safe.
Citation: Gonzalez NL, O’Brien KM, D’Aloisio AA, et al. Douching, talc use, and risk of ovarian cancer. Epidemiology. 2016;27:797–802.
Ovarian cancer is difficult to detect and usually is found at a late stage. In 2015 there were 21,290 cases of ovarian cancer and 14,180 deaths from the disease in the United States. Researchers sought to determine whether the use of talc or douching increases the risk of ovarian cancer. The Sister Study monitored women who had a sister with breast cancer, who, like those with a family history of ovarian cancer or nulliparity, are at increased risk for ovarian cancer. Participants were asked about whether they douched and used talc. Douching was shown to increase the risk for pelvic inflammatory disease and ectopic pregnancy, and it was correlated to increased ovarian cancer risk. Urgent care providers treating women with vaginal discharge or possible sexually transmitted infection should remind these patients of the potential harmful outcomes of douching. Larger studies may clarify the correlation between douching and risk of developing ovarian cancer.

Air Conditioning Reduces the Risk of Heat Illness in the Elderly

Key point: Turn on the air conditioner for the elderly.
Citation: Gagnon D, Romero SA, Cramer MN, et al. Cardiac and thermal strain of elderly adults exposed to extreme heat and humidity with and without electric fan use. JAMA. 2016;316:989–991.
Significant concern has been raised about heat illness in the elderly and about the use of electric fans dehydrating rather than cooling patients. Most studies of the use of electric fans have focused on young patients, but in this small study of fewer than 10 participants, fan use did not reduce temperature or prevent tachycardia in elderly patients exposed to high temperatures and humidity. Although larger studies would be helpful, this evidence should cause urgent care providers to rethink telling elderly patients that fans are adequate to counter high temperature and high humidity. Patients should be encouraged to be creative about finding air conditioning on long summer days.

Physicians Order Imaging for Back Pain Despite Knowing That It Is Unhelpful

Key point: Knowing is not always doing.
Citation: Sears ED, Caverly TJ, Kullgren JT, et al. Clinicians’ perceptions of barriers to avoiding inappropriate imaging for low back pain—knowing is not enough. JAMA Intern Med. 2016 October 17. doi: 10.1001/jamainternmed.2016.6364. [Epub ahead of print.]
The study reported in this research letter concerns knowledge of appropriate use of magnetic resonance imaging (MRI) for assessing causes of back pain, along with barriers to following imaging guidelines. Although not the findings are not directly applicable to most urgent care providers, the barriers noted are very similar to those seen when any treatment varies from what is usually recommended. Unfortunately, the letter does not provide all the answers to address the barriers. This study was performed within the U.S. Veterans Affairs system. Health-care providers were surveyed about how and why they would respond in a fictional case of a 45-year-old woman with back pain and no red flags who requested MRI or computed tomography. The good news is that only 3.3% of respondents thought that the patient would benefit from imaging, and 77% believed that imaging might cause further unnecessary testing. However, about 75% of clinicians believed that they must order further testing before referring the patient to a specialist. About half worried that the patient would be upset, and 25% believed that they would not have enough time to discuss the risks and benefits of imaging with the patient. Finally, more than 25% of physicians worried that they would be at risk of legal action if they did not order imaging.

Zika Virus May Be Associated with Guillain-Barré Syndrome

Key point: The Zika virus has additional consequences.
Citation: Parra B, Lizarazo J, Jiménez-Arango JA, et al. Guillain-Barré syndrome associated with Zika virus infection in Colombia. N Engl J Med. 2016;375:1513–1523.
The Zika virus has already caused significant fear throughout the Americas. What may be less widely known is that the virus may also be associated with Guillain-Barré syndrome (GBS). The authors of the study reported here noted an increased incidence of GBS in areas with Zika virus infections, and they decided to determine whether there was a relationship. Of 68 patients with GBS, 66 had symptoms of infection with the Zika virus. The mean time between exposure and appearance of GBS symptoms was 7 days, although some patients developed GBS almost immediately after infection. Most of the tested patients had some type of test findings consistent with Zika virus infection. Symptoms consisted of ascending limb weakness, paresthesia, and facial palsy. Although there were other interesting findings, the message for urgent care providers is to watch for GBS as a result of Zika virus infection.

Abstracts in Urgent Care – December 2016

Sean M. McNeeley, MD

Urgent Care Network Medical Director at University Hospitals of Cleveland, Clinical Instructor at Case Western Reserve University School of Medicine, President at Urgent Care Association of America, Editorial Board Member at Journal of Urgent Care Medicine
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