URI

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A lecture for 3rd year med students about URI.

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  • URI

    1. 1. URIJonathan Ploudré, MD unchart.com December, 2011
    2. 2. Seriously, URI?• Um, Who cares?• It’s self-limiting…• This isn’t even important enough to score a chapter in my Pathology book
    3. 3. Primary Care disruption• November 2011: Wal-Mart has plans to go into Primary Care. (npr.org)• From 2007 to Now: 10x increase in retail clinic visits. (advisory.com)
    4. 4. #FMRevolution • FPs are just gatekeepers to proceduralists • FPs are wasting their talents • FPs will be replaced by mid-levels • Or: FPs are the center of a modern, high- quality, efficient health-care system.URI is a perfect example of ‘wasting talent’ or being replaceable, right?
    5. 5. Is Dr. Ploudré an Expert on URI?500375250125 0 URI Cough Sinusitis Pharyngitis ETD Strep Conjunctivitis Bronchitis AOMI’ve diagnosed these things a lot in the past 3 years…
    6. 6. OK-plateau?• Joshua Foer: How many of you are faster at typing than you were a year ago?• Autopilot or Deliberate Practice?• I can diagnose and treat URI-related illness 1000x in the past few years but unless I’m deliberately practicing, I may not be an expert.
    7. 7. Non Deliberate Medicine• In Med school/Residency everyone had an ‘Allegra’ Pen or ‘Claritin’ notepad.• Non-sedating antihistamines cost $100/ month then.• How did I get to be a 3rd year FP resident before I learned nasal corticosteroids were dramatically more effective than non- sedating antihistamines?
    8. 8. Deliberate EBM PICO • Patient / Population / Problem (among _____) • Intervention / Exposure (does _____) • Comparison (versus ______) • Outcome (affect _______)Keep asking questions. Check things you think you know.
    9. 9. 54yo Female presents with 5 day history ofillness. Initially started with a sore throat. Onthe second day she developed a runny noseand some nasal congestion. She’s justdeveloped a nonproductive cough.Exam: Afebrile, Unremarkable.
    10. 10. URI
    11. 11. Among healthy adults with viral URIdoes antibiotic treatmentvs watchful waitingaffect length of illness?
    12. 12. “Sure.” (55% of Patients) J Gen Intern Med 1999“Oh, last time I got that 5 day prescription that works for 10 days. It was great.”
    13. 13. 2 prescriptions for antibiotics (Respiratory/UTI) in primary care results in measurable increase in antibiotic resistance that can last as long as 12 months. BMJ 2010We know antibiotics are ineffective. And potentially harmful.
    14. 14. Antibiotics: Number Needed to Harm = ~16 Lancet, 2004Not to mention population level issues like MRSA and VRE…
    15. 15. Overprescription
    16. 16. • OK, no antibiotics. Now what?
    17. 17. What works for URI Use This: For This: Fever, Sore Throat, Acetaminophen Aches Fever, Sore Throat, NSAIDs Achesdextromethorphan cough pseudoephedrine congestion antihistamines sneezing, sedation
    18. 18. What works for Peds URI? Use This: For This: Fever, Sore Throat, Acetaminophen Aches Fever, Sore Throat, NSAIDs Aches antihistamines sedationFDA in 2007: Oops. Pseudoephedrine can overdose kids.
    19. 19. Among healthy adults with viral URIdoes guaifenisenvs watchful waitingaffect impact of cough?
    20. 20. What doesn’t workGuaifenisen for cough (except Smokers/COPD) Antihistamines for rhinorrhea phenylephrine (Sudafed PE)
    21. 21. Zinc for shortening URI? Saline Gargle for reducing URI frequency Probiotics for reducing URI frequency? Echinacea for shortening URI Vitamin C forshortening URI
    22. 22. Zinc for shortening URI? Saline Gargle for reducing URI frequency Probiotics for reducing URI frequency? Echinacea for shortening URI Vitamin C forshortening URI
    23. 23. Among patients with URIdoes prescribing antibioticsvs explaining why not to prescribeaffect length of the visit?
    24. 24. Maybe 0-1 minute longer visit. Arch Pediatr Adolesc Med, 2005. Clin Ther, 2003;
    25. 25. Explaining Inaction “Viral” “I think it isn’t right” “Resistance” “Microbiome” “Natural” “Overused”“Yeast Infection or Diarrhea” “I’m the Doctor” “Doesn’t work” …
    26. 26. A tale of 2 doctors
    27. 27. 27yo Male presents with 10 day history ofillness. Initially started with a sore throat,then runny nose then cough. Started toimprove until 3 days ago when he started todevelop purulent nasal discharge and mildchills.Exam: Afebrile, Unremarkable except facialtenderness over the left maxilla.
    28. 28. Sinusitis
    29. 29. Among adults with classic sinusitisdoes antibiotic treatmentvs watchful waitingaffect length of illness?
    30. 30. Yes. But NNT = 8. No symptom clearlyseparates bacterial from viral sinusitis.(Green discharge, ie, doesn’t matter.)Without Purulent Discharge NNT = 15.(Remember: NNH = 16.)Prevalencee studies: ~97% of sinusitis isnot bacterial. No treatment in somestudies for up to 3 week unless febrile. Lancet, 2008
    31. 31. Sinus Rinse?
    32. 32. Effective for Chronic SinusitisProbably effective for URI, AllergicRhinitis, Irritant Rhinitis.Ploudre Opinion: Whoa. Thatseriously gets snot out of my nose. But50% of patients dislike it. Am Fam Phys, 2009
    33. 33. Among adults with hx of recurrent sinusitisdoes adding nasal corticosteroids to abxvs antibiotics aloneaffect length of illness?
    34. 34. Yes 93% vs 73% clinical success rate. Median of 6 days vs 9 days. “If you take this nasal spray, you’ll probably get better about 3 days earlier.” JAMA, 2001I seriously just looked this up in PubMed in ~ 90 seconds.
    35. 35. 43 yo Female presents with cough. Illnessstarted with a mild runny nose but coughquickly became main issue. Now 16 days intothe illness with nonproductive cough. Coughdisrupts sleep now.Exam: 98% pulse ox, afebrile. Otherwiseunremarkable.
    36. 36. Bronchitis
    37. 37. Among adults with bronchitisdoes azithromycinvs Vitamin Caffect length of illness?
    38. 38. No. Lancet, 2002
    39. 39. rld Ethical Practice Wo ie rePrem E= E 3 Ethical = Evidenced x Economic x Etiquette
    40. 40. Ethical Azithromycin? Well: It doesn’t really work It used to cost $75 But patients love it’s tolerability and convenience.Contrast: Bronchitis, Smokers with Bronchitis, Smoker with COPD exacerbation
    41. 41. Bronchitis Etiquette“Bronchitis” vs “Chest Cold”26% vs 13% of Patients disatisfied aboutnot getting antibiotics. J. Am Board Fam Practice, 2005
    42. 42. See One, Do One, Teach One.Just this week I learned why I always use Nystatin for newborn thrush.
    43. 43. Is URI a waste of time?Yes: It might take a good programmer aweek to create a good statistical predictionrule to outperform most doctors inproviding evidence-based care.Yes: Another case of the US spending morethan anyone with little to show for it.
    44. 44. Is URI a waste of time?No: URI visits are a chance to ‘calibratesensors’ for patients through education.No: URI visits can be used to reduce ourdangerous habit of overprescription ofantibiotics.No: URI is a source of rapport and a deeperdoctor-patient relationship.
    45. 45. ?

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