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What's new in primary care

What's new in primary care
Literature review current through: Jan 2024.
This topic last updated: Feb 01, 2024.

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

SCREENING

Screening for major depressive disorder in adults (October 2023)

Major depressive disorder is a leading cause of disability in the United States, with a lifetime prevalence of approximately 20 percent; however, it remains underdetected and undertreated. Updated guidelines from the United States Preventive Services Task Force recommend screening for depression in adults (ages 19 years and above), including pregnant and postpartum women, based upon a systematic review that suggested a net benefit from screening [1]. These guidelines are consistent with our suggestion that primary care clinicians routinely screen adults for depression with diagnostic evaluation and treatment for those who screen positive. (See "Screening for depression in adults".)

Overdiagnosis of breast cancer in older women (October 2023)

Overdiagnosis, the detection of a disease that would not have caused morbidity or mortality if it had not been found, is a concern in breast cancer screening, particularly among older patients. In a 2023 study in over 54,000 women 70 years and older who had recently undergone screening, the percent of overdiagnosed breast cancer cases increased with age from 31 percent among women aged 70 to 74 years to 54 percent among women aged 85 years and older [2]. We utilize a shared decision-making framework for breast cancer screening in older women to balance potential risks and benefits. (See "Screening for breast cancer: Evidence for effectiveness and harms", section on 'Overdiagnosis'.)

IMMUNIZATIONS

2024 immunization schedule for adults (January 2024)

The United States Centers for Disease Control and Prevention has published the 2024 immunization schedule for adults (figure 1 and figure 2) [3]. Respiratory syncytial virus (RSV) vaccine is a new addition to the schedule; it is recommended for pregnant people 32 to 36 weeks' gestation during RSV season and is an option for adults ≥60 years of age. Mpox vaccine has also been added and is recommended for adults of all ages who are at risk for infection. Other changes include updates to COVID-19, polio, and meningococcal vaccine recommendations. Our approach to immunization is largely consistent with these updated recommendations. (See "Standard immunizations for nonpregnant adults", section on 'Immunization schedule for nonpregnant adults'.)

ACIP recommendations for 2023-24 seasonal influenza vaccination (September 2023)

The Advisory Committee on Immunization Practices (ACIP) issued new recommendations for seasonal influenza vaccination in August 2023 (table 1) [4]. The antigenic composition has been updated. In addition, the ACIP now states that egg allergy alone no longer necessitates additional safety measures for influenza vaccination, including with egg-based vaccines, beyond those recommended for any recipient of any vaccine, regardless of severity of previous reaction to egg. All vaccines should be administered in settings where personnel and equipment needed for prompt recognition and treatment of acute hypersensitivity reactions are available. This is consistent with our previous guidance. (See "Seasonal influenza vaccination in adults", section on 'Antigenic composition'.)

Updated COVID-19 mRNA vaccine recommendations (September 2023)

The US Food and Drug Administration and Centers for Disease Control and Prevention have updated COVID-19 vaccine authorizations and recommendations [5,6]. Available COVID-19 vaccines have been updated to target Omicron variant XBB.1.5 (Moderna COVID-19 vaccine 2023-2024 formula, Pfizer COVID-19 vaccine 2023-2024 formula, and Novavax 2023-2024 formula); bivalent vaccines are no longer available. An updated 2023-2024 formula vaccine is recommended for all individuals aged six months and older. Immunocompetent individuals five years and older should receive one updated vaccine, regardless of prior vaccination history. For individuals who are four years or younger or have an immunocompromising condition (table 2), the number of recommended updated vaccines depends on their vaccination history. Our approach to COVID-19 vaccination is consistent with these recommendations. (See "COVID-19: Vaccines", section on 'Indications and vaccine selection' and "COVID-19: Vaccines", section on 'Benefits of vaccination'.)

GENERAL INTERNAL MEDICINE

Long distance effect of wildfire smoke on asthma symptoms (October 2023)

Wildfire fine particulate matter (PM2.5) has been shown to affect respiratory health; however, previous work has focused on populations residing near and directly affected by wildfires. In June 2023, smoke from wildfires in Canada drifted hundreds of miles to New York City, resulting in increased ambient PM2.5. During smoke waves, emergency department visits for asthma in both pediatric and adult patients increased to 261 per day (reference during nonsmoke periods, 181.5 per day; incidence rate ratio 1.4) [7]. Wildfires have health effects far from their source and are particularly hazardous to those with underlying lung disease. (See "Climate emergencies", section on 'Changing wildfire exposure'.)

Nurse-delivered brief behavioral treatment for insomnia (October 2023)

A growing body of evidence supports the use of brief, behaviorally-focused treatments for insomnia, which involve fewer sessions than traditional cognitive behavioral therapy and can be delivered by clinicians with varied levels of expertise. In an open-label randomized trial in England involving nearly 650 adults with insomnia disorder recruited from 35 general practices, four sessions of nurse-delivered sleep restriction therapy (table 3) improved patient-reported insomnia severity scores and six-month response rates compared with a sleep hygiene booklet alone (table 4) [8]. Training nurses or advanced practice providers to deliver brief behavioral treatments may be a feasible and cost-effective way to improve outcomes for insomnia. (See "Cognitive behavioral therapy for insomnia in adults", section on 'Brief behavioral treatment approaches'.)

Over-the-counter opioid antagonist for opioid overdose (September 2023)

Drug overdose is a major public health problem; opioids were reported to be involved in nearly 80 percent of the 600,000 overdose deaths worldwide in 2019. The increasing rate of fatal overdose is driven by the presence of the synthetic opioid fentanyl. Naloxone 4 mg nasal spray rapidly reverses the effects of opioid overdose and is now the first opioid antagonist agent available for over-the-counter purchase in the United States [9]. The increased availability is part of an ongoing effort by the US Food and Drug Administration Overdose Prevention Framework to encourage harm reduction through developing and expanding access to novel overdose reversal products. (See "Prevention of lethal opioid overdose in the community", section on 'Community-based naloxone'.)

Exercise and cardiovascular risk reduction (July 2023)

Current guidelines from the American Heart Association and World Health Organization recommend at least 150 minutes of moderate-to-vigorous physical activity weekly. Two recent studies suggest that how one exercises matters more than when. In one prospective cohort of over 500,000 individuals, combining twice-weekly muscle strengthening activity to at least 150 minutes of moderate-to-vigorous physical activity was associated with optimal reductions in all-cause and cardiovascular mortality [10]. In a separate study of nearly 90,000 individuals, among those who had at least 150 minutes of weekly physical activity, "weekend warrior" patterns of exercise (at least 50 percent of activity occurring over one to two days) and "regular" patterns (physical activity distributed more evenly during the week) were associated with similar reductions in the risk of myocardial infarction, stroke, heart failure, and atrial fibrillation compared with inactivity [11]. These findings provide support for recommending exercise whenever it is most feasible for patients and adding regular resistance training. (See "Exercise and fitness in the prevention of atherosclerotic cardiovascular disease", section on 'Type, intensity, and duration of exercise'.)

PRIMARY CARE CARDIOVASCULAR MEDICINE

Semaglutide in patients with heart failure with preserved ejection fraction and obesity (September 2023)

In patients with heart failure with preserved ejection fraction (HFpEF), weight loss is likely to improve functional status and quality of life, but achieving weight loss in this group of patients is difficult. In a recent trial of more than 500 patients with HFpEF, patients randomly assigned to treatment with semaglutide had greater improvement in exercise capacity (ie, six-minute walk distance), quality of life, and weight loss (-13 percent mean change in body weight versus -2.6 percent) at 52 weeks than patients assigned to placebo [12]. An exploratory analysis suggested a lower risk of urgent HF hospitalizations in those treated with semaglutide. Similar to other patients with obesity, patients with HFpEF and obesity should receive appropriate management to achieve weight loss. (See "Treatment and prognosis of heart failure with preserved ejection fraction", section on 'Obesity'.)

PRIMARY CARE GASTROENTEROLOGY

Mortality risk in alcohol-associated liver disease (January 2024)

Few studies have reported the long-term outcomes of patients with alcohol-associated liver disease (ALD). In a national registry study including over 23,000 patients with ALD diagnosed at median age 58 years, 67 percent died during >100,000 person-years of follow-up and liver disease was the primary cause of death in 45 percent [13]. The 5- and 10-year mortality rates due to liver disease were 26 and 31 percent, respectively. These data emphasize the importance of treating patients with alcohol use disorder and may inform strategies to prevent liver-related mortality in those with ALD. (See "Management of alcohol-associated steatosis and alcohol-associated cirrhosis", section on 'Mortality'.)

Clinical practice update on risk stratification for colorectal cancer screening and postpolypectomy surveillance (December 2023)

The American Gastroenterological Association (AGA) recently published nine statements of best practice advice on risk stratification for colorectal cancer (CRC) screening and postpolypectomy surveillance [14]. They advise basing risk stratification on an individual's age, a known or suspected predisposing hereditary CRC syndrome, other CRC predisposing conditions (eg, inflammatory bowel disease), and/or a family history of CRC. They also suggest that the decision to continue postpolypectomy surveillance for individuals older than 75 years should be individualized. Shared decision-making discussions should include an assessment of the risks of incident CRC, procedure-related risks, comorbidities, and life expectancy (>5 years). Our approach is consistent with this guidance. (See "Overview of colon polyps", section on 'Risk assessment for subsequent colorectal cancer'.)

Model for End-stage Liver Disease (MELD) 3.0 for liver transplantation (October 2023, Modified December 2023)

The Model for End-stage Liver Disease (MELD) score is used to allocate livers for transplantation. Recently, the Organ Procurement and Transplantation Network implemented an updated score, MELD 3.0, for prioritizing liver transplantation candidates who are ages 12 and older [15]. MELD 3.0 includes variables from the original model (ie, serum bilirubin, serum creatinine, and international normalized ratio) in addition to other inputs (ie, serum sodium, patient sex, and serum albumin) and a lower creatinine ceiling. Goals of using MELD 3.0 include reducing overall waitlist mortality and improving access for female liver transplant candidates. (See "Model for End-stage Liver Disease (MELD)", section on 'MELD 3.0'. and "Liver transplantation for hepatocellular carcinoma", section on 'MELD 3.0'.)

Clinical practice update on exocrine pancreatic insufficiency (November 2023)

The American Gastroenterological Association (AGA) recently published best practice advice on exocrine pancreatic insufficiency (EPI) [16]. The AGA Clinical Practice Update advises considering a diagnosis of EPI in individuals with moderate-risk clinical conditions (eg, celiac disease, previous intestinal surgery, longstanding diabetes mellitus, Zollinger-Ellison syndrome). It emphasizes the importance of testing for EPI in patients with nonspecific symptoms and cautions against relying on a response to an empiric trial of pancreatic enzymes to diagnose EPI as this may be due to a placebo effect. Our approach is consistent with this guidance. (See "Exocrine pancreatic insufficiency", section on 'Diagnostic approach'.)

Clinical practice update on bloating and distention (November 2023)

The American Gastroenterological Association (AGA) recently published best practice advice on the evaluation and management of bloating and distention [17]. The AGA Clinical Practice Update endorses serologic evaluation for celiac disease and exclusion of carbohydrate enzyme deficiencies with dietary restriction and/or breath testing, but emphasizes reserving additional evaluation with abdominal imaging and upper endoscopy for patients with alarm features, recent worsening symptoms, or an abnormal physical examination. Our approach is consistent with this guidance. (See "Overview of intestinal gas and bloating", section on 'Evaluation'.)

Low-dose tricyclic antidepressants in irritable bowel syndrome (October 2023)

The efficacy of tricyclic antidepressants (TCAs) in the management of irritable bowel syndrome (IBS) has not been well established in the primary care setting. In a pragmatic randomized trial, 463 patients with IBS unresponsive to dietary advice and first-line therapies in primary care practices were assigned to titrated low-dose amitriptyline or placebo as a second-line therapy [18]. At six months, patients treated with low-dose amitriptyline had lower IBS-symptom severity scores and a higher rate of symptom relief. The most common side effects were related to the anticholinergic effects of amitriptyline, but the majority were mild. These data support current guidelines and our recommendation to use TCAs in the management of patients with IBS. (See "Treatment of irritable bowel syndrome in adults", section on 'Antidepressants'.)

PRIMARY CARE GERIATRICS

Global inappropriate medication use in older adults (September 2023)

Inappropriate medication use is common among older adults. In a meta-analysis of 94 studies representing over 371 million older adults in 17 countries, the prevalence of potentially inappropriate medication (PIM) use was over 37 percent, with benzodiazepines being the most common medication [19]. The study also showed that PIM use has increased over the past 20 years, especially in high-income countries. Deprescribing of inappropriate medications is a priority among older adults. (See "Drug prescribing for older adults", section on 'Inappropriate medications'.)

PRIMARY CARE GYNECOLOGY

Macular changes related to pentosan polysulfate sodium (November 2023)

Macular eye disease has been reported in patients who have taken pentosan polysulfate sodium (PPS), which is used for the treatment of interstitial cystitis. In a prospective cohort study of 26 eyes with PPS maculopathy and >3000 g cumulative PPS exposure, progression of macular changes continued 13 to 30 months after drug cessation [20]. Median visual acuity decreased slightly; most patients reported progression of symptoms, including difficulty in low-light environments and blurry vision. These results indicate that PPS maculopathy progresses despite drug discontinuation, underscoring the importance of regular screening for maculopathy in patients with current or prior PPS exposure. (See "Interstitial cystitis/bladder pain syndrome: Management", section on 'Pentosan polysulfate sodium as alternative'.)

Use of vaginal estrogen in breast cancer patients taking aromatase inhibitors (October 2023)

Use of vaginal estrogen to manage symptoms of genitourinary syndrome of menopause (GSM) may be harmful in patients with breast cancer on aromatase inhibitors (AIs). In a claims-based analysis, vaginal estrogen therapy was associated with a higher rate of breast cancer recurrence in patients taking versus not taking an AI [21]. Time to recurrence in the AI group was approximately 140 days. While this study had many limitations, these data support our general practice of avoiding vaginal estrogen for the management of GSM in most patients with breast cancer taking AIs. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Patients with breast cancer'.)

PRIMARY CARE HEMATOLOGY AND ONCOLOGY

Improvement in breast cancer mortality from 1975 to 2019 (January 2024)

Improvements in breast cancer screening and treatments are decreasing breast cancer mortality. In a study using four simulation models of breast cancer mortality rates in the United States (US), breast cancer screening and treatment in 2019 were associated with a 58 percent reduction in US breast cancer mortality compared with 1975 [22]. Approximately half of this reduction was due to treatment of early breast cancer, while the rest was divided roughly equally between treatment of metastatic breast cancer and breast cancer screening. We support breast cancer screening for appropriate candidates and incorporate novel, data-driven strategies into our treatment recommendations for breast cancer. (See "Overview of the treatment of newly diagnosed, invasive, non-metastatic breast cancer", section on 'Introduction' and "Screening for breast cancer: Strategies and recommendations".)

Omission of radiation in select patients with favorable-risk breast cancer (August 2023, Modified January 2024)

Trials are examining omission of radiation in early, favorable-risk breast cancer.

In a single-arm trial including 500 females ≥55 years with T1N0, grade 1 or 2, luminal A-breast cancer, breast-conserving surgery and endocrine therapy without radiation were associated with a low incidence of local recurrence at five years (2.3 percent) [23].

A prospective study found that patients ≥50 years with nontriple negative cT1N0 breast cancer that was unifocal on preoperative MRI and pT1N0 or N1mi at the time of surgery could omit adjuvant radiation and experience a low ipsilateral invasive recurrence rate (1 percent at five years) [24].

We consider omission of adjuvant radiation to be an option in women ≥65 years with clinically node-negative, small (tumor size <3 cm), hormone receptor-positive, HER2-negative breast cancer who are willing to take adjuvant endocrine therapy, but we await further data before omitting radiation in other patients. (See "Adjuvant radiation therapy for women with newly diagnosed, non-metastatic breast cancer", section on 'Possible omission of RT for select ER-positive, HER2-negative cancers'.)

PRIMARY CARE INFECTIOUS DISEASES

Simnotrelvir-ritonavir for mild to moderate COVID-19 (January 2024)

Although nirmatrelvir-ritonavir reduces hospitalization and death from COVID-19, the many drug interactions make it difficult to use in some patients. Simnotrelvir-ritonavir is a similar protease inhibitor combination that inhibits viral replication but does not have as many drug interactions. In a randomized, double-blinded study of over 1000 patients with mild to moderate COVID-19 (majority fully vaccinated), 5 days of simnotrelvir-ritonavir reduced time to symptom resolution by 1.5 days [25]. Since no participant progressed to severe disease or died by day 29, it is unknown whether the drug prevents hospitalizations or death from COVID-19. Simnotrelvir-ritonavir has emergency use approval in China but is not yet approved for use in other countries. (See "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Therapies of limited or uncertain benefit'.)

Statins for primary prevention of cardiovascular disease in persons with HIV (September 2023)

HIV infection is associated with an excess risk of cardiovascular disease. A randomized trial evaluated the efficacy of lipid-lowering therapy with pitavastatin for primary prevention in over 7700 persons with HIV ≥40 years of age receiving antiretroviral therapy who had a 10-year atherosclerotic cardiovascular disease (ASCVD) risk score <15 percent [26]. Pitavastatin reduced the relative risk of major cardiovascular events (eg, myocardial infarction, stroke) by 35 percent compared with placebo; the trial was stopped early for this apparent benefit. Based on these data, we now advise statins in all persons ≥40 years of age with an ASCVD score ≥5 percent, particularly if the score is ≥7.5 percent; for those with lower baseline risk, we also discuss statin use, although the absolute benefit is smaller. For persons younger than 40 years of age, our approach is the same as in persons without HIV. (See "Management of cardiovascular risk (including dyslipidemia) in patients with HIV", section on 'Indications for statins'.)

PRIMARY CARE NEPHROLOGY AND HYPERTENSION

Tenapanor for refractory hyperphosphatemia in patients on dialysis (November 2023)

Despite adequate dialysis, dietary restriction, treatment of hyperparathyroidism, and phosphate binders (PBs), hyperphosphatemia is common among patients on dialysis and associated with adverse outcomes. In a trial in which nearly 170 patients on hemodialysis with hyperphosphatemia despite PB therapy were randomly assigned to PBs plus either tenapanor (an inhibitor of intestinal sodium/hydrogen exchanger 3) or placebo for eight weeks, serum phosphorus levels were 1.76 mg/dL lower in the tenapanor group [27]. Diarrhea was more frequent among patients receiving tenapanor but was mild or moderate in all cases. These data, in conjunction with prior trial data, support our approach of using tenapanor as add-on therapy in patients on dialysis who have an inadequate response to PBs. (See "Management of hyperphosphatemia in adults with chronic kidney disease", section on 'Refractory hyperphosphatemia'.)

Novel aldosterone synthase inhibitor in the treatment of hypertension (October 2023)

Aldosterone synthase inhibitors may have the same antihypertensive benefit as mineralocorticoid receptor antagonists (such as spironolactone) without the associated hormonal adverse effects. Lorundrostat, an aldosterone synthase inhibitor, was tested in a trial of over 160 patients with a suppressed plasma renin activity and uncontrolled hypertension despite antihypertensive drug therapy (at least two medications) [28]. Compared with placebo, lorundrostat reduced automated office systolic blood pressure at eight weeks by 1.5 to 9.6 mmHg, depending upon the lorundrostat dose. Aldosterone synthase inhibitors such as lorundrostat may become useful in the treatment of resistant hypertension. (See "Treatment of resistant hypertension", section on 'Novel medications'.)

PRIMARY CARE NEUROLOGY

Time window to start dual antiplatelet therapy for high-risk TIA or minor ischemic stroke (January 2024)

There is evidence from several randomized trials that early initiation of short-term dual antiplatelet therapy (DAPT) for select patients with high-risk transient ischemic attack (TIA) or minor ischemic stroke reduces the risk of recurrent ischemic stroke. The evidence comes from trials that started DAPT within 12 to 24 hours of symptom onset. Results from the recent INSPIRES trial suggest that DAPT is still beneficial when started up to 72 hours after symptom onset [29]. Although the time window is extended by the results from INSPIRES, we start DAPT as soon as possible for patients with high-risk TIA or minor ischemic stroke. (See "Early antithrombotic treatment of acute ischemic stroke and transient ischemic attack", section on 'High-risk TIA and minor ischemic stroke'.)

Botulinum toxin injections for essential head tremor (November 2023)

Botulinum toxin (BoNT) injections have been used for refractory head tremor in patients with essential tremor (ET) based on limited data. In a randomized trial of 117 patients with essential or isolated head tremor, BoNT type A injections into each splenius capitis muscle improved subjective and objective head tremor severity measurements compared with placebo injections, with expected waning of response by 12 weeks after each injection [30]. Adverse effects were more frequent with BoNT (47 versus 16 percent), most commonly headache or neck pain, dysphagia, and posterior neck weakness. BoNT type A injections are an option for patients with bothersome head tremor due to ET who do not tolerate oral medications or whose tremor does not respond, but side effects are common and may outweigh potential benefits in some patients. (See "Essential tremor: Treatment and prognosis", section on 'Administration and efficacy'.)

Early use of ubrogepant to abort migraine headache (November 2023)

Acute migraine treatments, including calcitonin gene-related peptide (CGRP) antagonists, are typically given at headache onset, but the benefit of earlier dosing is uncertain. In a trial of 477 patients with migraine who were treated at the onset of prodromal symptoms (prior to headache), ubrongepant improved the proportion of patients who remained free of moderate to severe headache at 24 hours compared with placebo (46 versus 29 percent) [31]. Enrolled patients had migraines that consisted of prodromal symptoms (eg, photophobia, fatigue, neck pain) occurring one to six hours before headache onset in at least 75 percent of attacks. These results support our practice to administer acute migraine treatments, such as ubrogepant, early in the course of migraine symptoms. (See "Acute treatment of migraine in adults", section on 'CGRP antagonists'.)

PRIMARY CARE ORTHOPEDICS AND SPORTS MEDICINE

Barbotage procedure for calcific tendinopathy of shoulder (January 2024)

To date, few high-quality studies have assessed the effectiveness of barbotage, an ultrasound-guided procedure to remove deposits in patients with calcific tendinopathy of the shoulder. In a recent, multicenter trial, 220 adults with calcific tendinopathy of at least three months duration were randomly assigned to one of three treatment arms: barbotage plus injection with glucocorticoid and analgesic; sham barbotage plus injection with glucocorticoid and analgesic; or, sham barbotage plus injection of analgesic alone [32]. At four months, patients in all three groups experienced moderate improvement in shoulder symptoms and function, but no significant differences were noted among treatment groups. At 24 months, neither barbotage with glucocorticoid injection nor glucocorticoid injection alone was superior to sham treatment (ie, analgesic injection alone). While barbotage is likely less effective than previously thought, we believe it remains a useful therapy for some patients. (See "Calcific tendinopathy of the shoulder", section on 'Barbotage'.)

Return to sport following stress fracture (November 2023)

Evidence is limited regarding return to sport (RTS) following stress fracture. A new systematic review of 76 studies involving nearly 3000 cases,provides some guidance; most of the studies were retrospective and involved predominately male athletes [33]. The lowest overall rates for RTS were reported for injuries of the femoral neck (55 percent), talus (69 percent), anterior tibial shaft (76 percent), and tarsal navicular (83 percent). The longest average times for RTS were reported for stress fractures of the tarsal navicular (127 days), femoral neck (107 days), and medial malleolus (106 days). These figures are averages, and healing for individuals may vary substantially given the many factors involved, including location within the bone, radiologic grade, duration of symptoms, compliance with treatment, and underlying bone health. Nevertheless, these findings inform treatment decisions and anticipatory guidance for athletes. (See "Overview of stress fractures", section on 'Return to activity'.)

Heavy load resistance exercise for tendinopathy (November 2023)

Evidence supporting the effectiveness of resistance exercise for the treatment of chronic (overuse) tendinopathy is growing. A recent systematic review and meta-analysis of 110 studies with just under 4000 subjects assessed research primarily involving the rotator cuff, Achilles, lateral elbow, and patellar tendons [34]. While noting that resistance dose was not well documented in many studies, researchers found consistent evidence that rehabilitation programs using resistance loads in excess of body weight and performed less frequently (ie, less than daily) demonstrated greater efficacy. These findings are consistent with our approach to treatment. (See "Overview of the management of overuse (persistent) tendinopathy", section on 'Heavy-load resistance training'.)

6th International Conference on Concussion in Sport (August 2023)

Recently, a consensus statement and multiple systematic reviews and other studies were published based on work completed at the 6th International Conference on Concussion in Sport held in Amsterdam in late 2022 [35]. Highlights from the conference include evidence summaries emphasizing the effectiveness of policies to reduce the risk for sports-related concussion (SRC), including mouthguard use in ice hockey and limiting contact drills in American football, and updated clinical assessment tools. These tools include the sixth edition of the Sport Concussion Assessment Tool for adults and children (SCAT6 and Child SCAT6), designed for acute evaluations, and the new Sports Concussion Office Assessment Tool 6 for adults and children (SCOAT6 and Child SCOAT6). The conference affirmed the importance of physical activity and aerobic exercise that does not exacerbate symptoms as an early intervention. The conference consensus statement is consistent with our approach to the assessment and management of SRC. (See "Clinic-based evaluation of sports-related concussion in adolescents and adults", section on 'Introduction'.)

No benefit of opioids for acute low back pain (August 2023)

Opioid analgesics are often used to treat acute low back pain despite limited supporting evidence. In a randomized trial of 347 adults presenting to the emergency department or primary care clinic with acute, nonspecific low back pain, oxycodone (up to 20 mg daily for six weeks) was no more effective for pain relief or functional improvement than placebo [36]. There was a higher risk of potential opioid misuse in patients in the oxycodone group at one-year follow-up (20 versus 10 percent). These results support our recommendation against routine opioid use for acute low back pain, given the lack of benefit and potential for misuse. (See "Treatment of acute low back pain", section on 'Opioids'.)

PRIMARY CARE PULMONOLOGY

Guidelines for primary spontaneous pneumothorax (December 2023)

The British Thoracic Society (BTS) has recently issued new guidelines for the management of primary spontaneous pneumothorax (PSP) [37]. Major changes since 2010 include a symptom- rather than size-based approach. For patients with mild symptoms who are stable following adequate analgesia, monitored observation is preferred, while those with significant dyspnea should undergo a drainage procedure (eg, aspiration or catheter/chest tube thoracostomy). Also promoted was ambulatory management in select patients with adequate outpatient support. We agree with these recommendations. (See "Treatment of primary spontaneous pneumothorax in adults", section on 'Initial evaluation and management'.)

Long distance effect of wildfire smoke on asthma symptoms (October 2023)

Wildfire fine particulate matter (PM2.5) has been shown to affect respiratory health; however, previous work has focused on populations residing near and directly affected by wildfires. In June 2023, smoke from wildfires in Canada drifted hundreds of miles to New York City, resulting in increased ambient PM2.5. During smoke waves, emergency department visits for asthma in both pediatric and adult patients increased to 261 per day (reference during nonsmoke periods, 181.5 per day; incidence rate ratio 1.4) [7]. Wildfires have health effects far from their source and are particularly hazardous to those with underlying lung disease. (See "Climate emergencies", section on 'Changing wildfire exposure'.)

Efficacy and side effects of gefapixant treatment for refractory chronic cough (September 2023)

P2X3 inhibitors decrease sensitivity of airway sensory nerve fibers and are under investigation for the treatment of refractory chronic cough. In a recent meta-analysis of over 2000 patients receiving 45 mg twice daily of the P2X3 inhibitor gefapixant or placebo, the gefapixant group demonstrated greater reduction in 24-hour cough frequency (66 versus 50 percent) and improved cough quality of life (4- versus 3-point improvement on a 19-point scale), but nearly one-third of patients developed a taste disturbance [38]. The modest benefit compared with significant risk of adverse side effects continues to be a barrier to regulatory approval and widespread use of this agent. (See "Evaluation and treatment of subacute and chronic cough in adults", section on 'P2X3 antagonists'.)

Longitudinal risk of airway obstruction in symptomatic current or former smokers (August 2023)

Whether current or former smokers with early respiratory symptoms have a different risk for COPD development or complications is not well understood. In one longitudinal cohort of patients aged 40 to 80 years with a >20 pack-year smoking history, the risk of developing airway obstruction over five years was 30 to 35 percent regardless of the presence of respiratory symptoms [39]. However, patients with symptoms were significantly more likely to have respiratory exacerbations during follow-up. (See "Chronic obstructive pulmonary disease: Risk factors and risk reduction", section on 'Cigarette smoking'.)

PRIMARY CARE PSYCHIATRY

Esketamine for treatment-resistant depression (December 2023)

Although esketamine has established efficacy for treatment-resistant depression, direct comparisons with other agents are limited. In a recent open label randomized trial in 676 adults with treatment-resistant major depression receiving baseline antidepressant therapy, addition of esketamine nasal spray for 32 weeks led to higher remission rates than addition of quetiapine extended release (XR, 49 versus 33 percent) [40]. Rates of discontinuation for adverse events were nearly three times lower with esketamine then quetiapine XR (4 versus 11 percent). Nevertheless, clinicians and patients considering esketamine need to weigh its benefits and disadvantages, including the need to administer it in a certified medical clinic. (See "Unipolar depression in adults: Choosing treatment for resistant depression", section on 'Initial approach'.)

Written exposure therapy for posttraumatic stress disorder (November 2023)

Many effective psychotherapies for posttraumatic stress disorder (PTSD), such as prolonged exposure therapy, are time- and resource-intensive; written exposure therapy (WET) is emerging as an alternative brief intervention. In a randomized trial, WET resulted in largely similar improvements in PTSD symptoms compared with prolonged exposure therapy and had a lower dropout rate (13 versus 36 percent) [41]. In addition to an earlier study in which WET compared favorably with cognitive processing therapy, these findings suggest that WET may be a viable psychotherapeutic option for individuals with PTSD who cannot participate in more intensive options. (See "Posttraumatic stress disorder in adults: Psychotherapy and psychosocial interventions", section on 'Efficacy of exposure therapy'.)

Screening for major depressive disorder in adults (October 2023)

Major depressive disorder is a leading cause of disability in the United States, with a lifetime prevalence of approximately 20 percent; however, it remains underdetected and undertreated. Updated guidelines from the United States Preventive Services Task Force recommend screening for depression in adults (ages 19 years and above), including pregnant and postpartum women, based upon a systematic review that suggested a net benefit from screening [1]. These guidelines are consistent with our suggestion that primary care clinicians routinely screen adults for depression with diagnostic evaluation and treatment for those who screen positive. (See "Screening for depression in adults".)

Psilocybin for treatment-resistant depression (October 2023)

The psychedelic psilocybin is being evaluated for treatment-resistant unipolar major depression and may provide a relatively rapid and durable response. In a trial of 104 patients, a single dose of psilocybin resulted in greater improvements in depressive symptoms than a single dose of niacin (the active placebo control); this effect occurred as early as day 8 and persisted until the end of the trial, at day 43 [42]. In addition, anxiety, psychosocial functioning, and quality of life improved more with psilocybin. However, it resulted in more frequent adverse events. Additional trials are necessary to determine who is most likely to benefit from psychedelics, the optimal dose and number of psilocybin sessions, type of patient preparation, whether and what type of accompanying psychotherapy should be administered, and how long the benefit persists. (See "Unipolar depression in adults: Choosing treatment for resistant depression", section on 'Psilocybin'.)

MDMA-assisted therapy for posttraumatic stress disorder (October 2023)

Posttraumatic stress disorder (PTSD) is a chronic, disabling disorder that is often resistant to treatment despite combined medication and psychotherapeutic management. The synthetic stimulant 3,4 methylenedioxymethamphetamine (MDMA, or "ecstasy") appears effective for moderate or severe PTSD when combined with a specific psychotherapy. In a trial of 104 subjects with PTSD undergoing three months of psychotherapy, those randomly assigned to also receive MDMA had a greater reduction in PTSD symptoms overall and a higher likelihood of no longer meeting criteria for PTSD by the end of the study (71 versus 48 percent) compared with those who received placebo [43]. While research using MDMA-assisted therapy is promising, MDMA is a restricted substance in most locations worldwide and such therapy thus has limited availability. (See "Posttraumatic stress disorder in adults: Treatment overview", section on 'Medications with limited supporting evidence'.)

PRIMARY CARE RHEUMATOLOGY

Phosphodiesterase type 5 inhibition for Raynaud phenomenon (January 2024)

Phosphodiesterase type 5 (PDE5) inhibitors such as sildenafil and tadalafil are widely used to treat digital ischemia from Raynaud phenomenon. In an updated meta-analysis of nine randomized trials comprising 411 patients with Raynaud phenomenon (most of whom had scleroderma), treatment with PDE5 inhibition resulted in three fewer attacks weekly and a reduction in the average duration of the attacks by five minutes [44]. However, PDE5 inhibition led to minimal to no reduction in the pain associated with Raynaud phenomenon. This study implies that while PDE5 inhibition has a modest impact on the duration and frequency of Raynaud attacks, it might not be adequate to address all symptoms experienced by patients with severe disease. (See "Treatment of Raynaud phenomenon: Initial management", section on 'Phosphodiesterase type 5 inhibitor'.)

OTHER ADULT PRIMARY CARE

High-dose glucocorticoid therapy not preferred in patients with sudden sensorineural hearing loss (January 2024)

Glucocorticoid therapy is the initial treatment for patients with sudden sensorineural hearing loss (SSNHL), but optimal dosing is uncertain. In a trial among 325 patients with SSNHL, five days of either high-dose intravenous prednisolone (250 mg/d) or high-dose oral dexamethasone (40 mg/d) did improve hearing more than low-dose oral prednisone (five days at 60 mg/d followed by five days of tapering doses), but increased adverse events [45]. In patients with SSNHL, we use a low-dose regimen of oral glucocorticoids. (See "Sudden sensorineural hearing loss in adults: Evaluation and management", section on 'Initial therapy'.)

Cannabinoid-drug interactions (November 2023)

Data are scarce on the effects of cannabinoids on prescribed medications. In a pharmacokinetic study that evaluated blood levels of common medications (eg, losartan, omeprazole, midazolam) in 18 healthy adults, standardized cannabidiol (CBD) extract demonstrated potential to moderately inhibit the hepatic enzyme CYP2C19 and weakly inhibit CYPs 2C9, 3A4, and 1A2 [46]. Previous data have shown that CBD can also inhibit P-glycoprotein (P-gp) multidrug efflux pumps. Patients using cannabinoids in conjunction with narrow safety index medications cleared through CYP metabolism, including warfarin (2C9), phenytoin (2C19), dabigatran, digoxin, and tacrolimus (3A4 and P-gp), may be subject to adverse drug-cannabinoid interactions (table 5). Such patients may require closer monitoring and therapy modification. Specific interactions may be analyzed by use of the drug interactions tool included in UpToDate. (See "Medical use of cannabis and cannabinoids in adults", section on 'Drug-drug interactions'.)

Impact of flooding on mortality (October 2023)

Floods can increase mortality rates during the event by direct physical forces and hazards related to the flood, but subsequent deaths related to additional factors, such as decreased access to food, water, and health care and increased exposure to pathogens, are less well known. In a worldwide study that included 761 communities, all-cause mortality and cardiovascular and respiratory deaths increased after a flooded day, and this increased risk persisted for up to 60 days [47]. Up to 0.41 percent of respiratory deaths, 0.18 percent of cardiovascular deaths, and 0.10 percent of all-cause deaths were attributed to floods. The risk varied by local climate type, socioeconomic status, degree of human development, and proportion of older residents. (See "Climate emergencies", section on 'Hurricane and flood risks to health'.)

Lack of evidence that blue light-filtering lenses improve sleep (September 2023)

Blue light-filtering glasses are marketed widely to reduce adverse effects of light-emitting screens on sleep, but supporting evidence is lacking. A recent systematic review identified six small randomized trials examining sleep outcomes with use of blue light-filtering lenses [48]. Trial results were inconsistent, and meta-analysis could not be performed due to high heterogeneity and lack of quantitative outcome data. We counsel patients to avoid use of electronics at least 30 minutes before usual bedtime and in the middle of the night if nocturnal awakenings occur (table 4). Based on available evidence, we advise that blue light-filtering glasses are not a substitute for avoidance of screens. (See "Insufficient sleep: Evaluation and management", section on 'Counseling on lifestyle changes'.)

Glucagon-like peptide 1 (GLP-1) receptor agonists may increase risk of aspiration during anesthesia (July 2023)

Patients who take glucagon-like peptide 1 (GLP-1) receptor agonists (eg, semaglutide, liraglutide) for weight loss or diabetes may be at increased risk of aspiration during anesthesia due to delayed gastric emptying. In 2023, the American Society of Anesthesiologists suggested holding the day-of-surgery or weekly dose of GLP-1 agonists prior to elective surgery because of case reports of aspiration [49]. For patients who have not held their GLP-1 (ie, no drug on day of procedure/surgery for daily dosing, no drug in the week prior to procedure/surgery for weekly dosing), gastric ultrasound can be used to assess for gastric contents or a rapid sequence induction and intubation should be considered. (See "Rapid sequence induction and intubation (RSII) for anesthesia", section on 'Patients taking GLP-1 receptor agonists'.)

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Topic 8357 Version 12473.0

References

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