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Optimizing Migraine Care

Optimizing Migraine Care

The American Headache Society (AHS) recently joined the Choosing Wisely initiative of the American Board of Internal Medicine in an effort to draw attention to tests and procedures that are associated with low-value care in headache medicine. An AHS committee of headache specialists produced a list of five such tests and treatments, and their methods and rationale were published in Headache. “We wanted the list to address common but often unnecessary or potentially risky tests and treatments for headache that in many cases do not represent evidence-based strategies,” explains Elizabeth W. Loder, MD, MPH, FAHS, who was lead author of the study.   Imaging According to the AHS, neuroimaging studies should not be performed in patients with stable headaches who meet criteria for migraine. In addition, CT scans should not be used in non-emergency situations as a diagnostic tool for headache patients when MRI is available. “MRIs can diagnose more underlying conditions that may cause headache that can otherwise be missed with CT,” says Dr. Loder. In addition, MRIs do not expose patients to radiation like CT scans. The recommendations note that MRI is of better value and safer than CT for migraineurs in all but a few emergency situations.   Treatments The AHS also recommends against prescribing opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders. “The effectiveness of opioids is not in question,” Dr. Loder explains, “but these agents pose serious long-term risks and should be reserved for select patients. Effective long-term treatments will in most cases be necessary to manage this chronic disorder.” In addition, the risk of dependency and abuse associated with opioid...

Radiologists and Primary Care Physicians Must Talk

Recently, I spoke with a primary care physician (PCP) about a young runner who had a syncopal episode. Because of the increasing awareness of sudden cardiac death in athletes, she had an electrocardiogram and an echocardiogram to look for structural abnormalities of the heart. The PCP was inclined to dismiss the syncope as an isolated episode. However, the echocardiogram, otherwise normal, equivocated: “possible hyper trabeculation of the left ventricular apex, consider cardiac MRI to exclude non compaction of the left ventricle”. The PCP was inquiring how to order a cardiac MRI. For reasons unbeknownst to me, for I do not habitually question clinicians why they are ordering tests, I should as a matter of clinical engagement but don’t, I asked about the circumstances that led to the echocardiogram. With the absence of a family history, no palpitations and a normal left ventricular function (she ran 5-minute miles, enough said), I speculated that the finding on the echocardiogram was most likely an overcall. The cardiac MRI would likely overcall as well, as these diseases are defined by numbers that are inevitably shared with normal individuals. I expressed lukewarm enthusiasm for the cardiac MRI. The PCP agreed. The athlete was spared another diagnostic test, a cardiology referral and possibly a life-long label. “One silver lining of the preceding decade of over utilization of imaging is that radiologists have developed a rich mental atlas of imaging findings of clinical irrelevance.” This is not a discussion of overdiagnosis of non-compaction. This is to restate a banal truism: physicians should speak to one another. In particular, PCPs and radiologists should talk to one another,...
Guidance for Using Intracoronary Diagnostic Tools

Guidance for Using Intracoronary Diagnostic Tools

As technology has advanced, intracoronary physiology assessments and imaging are increasingly being used in the management of patients with severe coronary stenosis. This shift in diagnostic use has been necessitated because of limitations when interpreting coronary angiography, which has been the traditional method for determining the severity of coronary stenosis. “The diagnostic effectiveness of coronary angiography is limited by inter-observer variability, even among the most experienced angiographers,” says Lloyd W. Klein, MD, FSCAI. Fortunately, several additional adjunctive techniques have emerged to further assist clinicians who care for these patients. In recent years, three diagnostic procedures have emerged that can improve decisions for coronary revascularization, guide the performance of PCI, and optimize procedural outcomes. These procedures include: 1) fractional flow reserve (FFR), 2) intravascular ultrasound (IVUS), and 3) optical coherence tomography (OCT). FFR is used to determine the functional significance of a coronary stenosis. IVUS offers excellent visualization of the intraluminal and transmural coronary anatomy. OCT was approved for use in the United States in 2010. It further improves vascular visualization to help determine causes of blood clots and blockages of critical blood flow.   “There is now persuasive evidence regarding intra-coronary diagnostic lesion assessments using these adjunctive diagnostic procedures,” adds Dr. Klein. “However, research suggests that these techniques are underutilized in contemporary practice.” Consensus Recommendations In 2011, the American College of Cardiology, American Heart Association, and Society for Cardiovascular Angiography and Interventions (SCAI) released joint guidelines for using PCI, but a deeper analysis of the available literature was necessary to guide clinicians when using FFR, IVUS, and OCT. In 2013, SCAI issued a consensus statement that reviewed recent studies on these diagnostic...
Enhancing Management of Lower Back Pain

Enhancing Management of Lower Back Pain

About 25% of adults report having low back pain lasting at least 1 whole day in the preceding 3 months. Imaging for acute low back pain is common, with a reported 42% of patients receiving imaging within 1 year, mostly plain radiography. Studies, however, indicate that lumbar imaging for low back pain without indications of serious underlying conditions does not improve clinical outcomes. More than 85% of patients seen in primary care have low back pain that cannot be attributed to specific disease or anatomic abnormalities. Refrain From Low Back Imaging Within First 6 Weeks In 2012, the National Physicians Alliance launched the initiative “Promoting Good Stewardship in Clinical Practice,” in which a list of the top five activities for primary care was developed to foster higher-quality care and better use of finite clinical resources. One of the top recommendations was to not perform imaging for low back pain within the first 6 weeks unless red flags are present. In the Archives of Internal Medicine, my colleagues and I had a study published in which we selectively researched benefits and risks of routine imaging in low back pain.             The available studies suggest that there is no clinically significant difference in low back pain or function between those who receive immediate lumbar spine imaging and those receiving usual care. Published data also document harms associated with early imaging for low back pain, including patient labeling, unneeded follow-up tests for incidental findings, radiation exposure, unnecessary surgery, and significant cost. By not routinely imaging patients with acute low back pain, there is potential to reduce harms...

Physician Decision-Making: Damned If You Do…

Here’s a little story from the early days of my first job as a chairman of surgery. Shortly after I assumed the role of surgical chairman in a community teaching hospital at the ripe old age of 40, and having absolutely no administrative experience, I visited a mentor of mine whom I had known since I was a medical student. He had been serving in a similar role at a larger hospital than mine, and I thought he might be able to share some wisdom about how to be a good chairman. He was dispensing sound advice for most of the hour or so I spent with him. Then he said something that struck me: “Sometimes the unexpected happens and there’s no simple solution.” He told me that among the challenges he was facing were two lawsuits. One was from the family of a patient who had died after a carotid endarterectomy that had been performed by a surgeon in his department. The plaintiffs were suing the hospital and my mentor, the surgical chairman, for allowing what they alleged was an incompetent surgeon to do complex vascular surgery. The other lawsuit was by a surgeon in his department who had requested privileges to perform carotid surgery, which had been denied by my mentor on the grounds that in his opinion, the surgeon was not adequately trained in carotid surgery. I never heard the outcome of either case, but it certainly seemed like a no-win situation. Although that encounter occurred some 25 years ago, the problem persists today. For example, patient advocates are concerned that pain is not being adequately...
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