Neil S. Skolnik, MD

It is always noteworthy when the headlines in the medical and mainstream media appear to be the same.

Typically, this means one of two things: 1) Sensationalism has propelled a minor issue into the common lexicon; or 2) a truly serious issue has grown to the point where the whole world is finally taking notice.

With the recent resurgence of Zika virus, something that initially seemed to be the former has unmistakably developed into the latter, and health care providers are again facing an age-old question: How do we adequately fight an evolving and serious illness in the midst of an ever-changing battlefield?

As has been the case countless times before, the answer to this question really lies in early identification. One might think that the advent of modern technology would make this a much easier proposition, but that has not exactly been the case.

In fact, recent Ebola and Zika outbreaks have actually served to demonstrate a big problem in many modern electronic health records: poor clinical decision support.

In this column, we felt it would be helpful to highlight this shortcoming, and make the suggestion that in the world of EHRs …

Change needs to be faster than Zika

Zika virus is not new (it was first identified in the Zika Forest of Uganda in 1947), and neither is the concept of serious mosquito-born illness. While the current Zika hot zones are South America, Central America, Mexico, and the Caribbean, case reports indicate the virus is quickly migrating. At the time of this writing, more than 150 travel-associated cases of Zika have been identified in the continental United States, and it is clear that the consequences of undiagnosed Zika in pregnancy can be devastating.

Furthermore, Zika is just the latest of many viruses to threaten the health and welfare of modern civilization (for example, Ebola, swine flu, SARS, and so on), so screening and prevention is far from a novel idea.

Unfortunately, electronic record vendors don’t seem to have gotten the message that the ability to adapt quickly to public health threats should be a core element of any modern EHR.

On the contrary, EHRs seem to be designed for fixed “best practice” workflows, and updates are often slow in coming (typically requiring a major upgrade or “patch”). This renders them fairly unable to react nimbly to change.

This fact became evident to us as we attempted to implement a reminder for staff members to perform a Zika-focused travel history on all patients. We felt it was critical for this reminder to be prominent, be easy to interact with, and appear at the most appropriate time for screening.

Despite multiple attempts, we discovered that our top-ranked, industry-leading EHR was unable to do this seemingly straightforward task, and eventually we reverted to the age-old practice of hanging signs in all of the exam rooms. These encouraged patients to inform their doctor “of worrisome symptoms or recent travel history to affected areas.”

We refuse to accept the inability of any modern electronic health record to create simple and flexible clinical support rules and improve on the efficacy of the paper sign. This, especially in light of the fact that one of the core requirements of the Meaningful Use (MU) program – for which all EHRs are certified – is clinical decision support!

Unfortunately, the MU guidelines are not specific, so most vendors choose to include a standard set of rules and don’t allow the ability for customization. That just isn’t good enough. If Ebola and Zika have taught the health information technology community one thing, it’s that …

It is time for smarter EHRs!

For many people, the notion of artificial intelligence seems to be science fiction, but they don’t realize they are carrying incredible “AI” devices with them everywhere they go. We are, of course, referring to our cell phones, which seem to be getting more intelligent all the time.

If you own an iPhone, you may have noticed it often seems to know where you are about to drive and how long it will take you to get there. This can be a bit creepy at first, until you realize how helpful – and smart – it actually is.

Essentially, our devices are constantly collecting data, reading the patterns of our lives, and learning ways to enhance them. Smartphones have revolutionized how we communicate, work, and play. Why, then, can’t our electronic health record software do the same?

It will surprise exactly none of our readers that the Meaningful Use program has fallen short of its goal of promoting the true benefits of electronic records. Many critics have suggested that the incentive program has faltered because EHRs have made physicians work harder, without helping them work smarter.

Zika virus proves the critics correct. Beyond creating just simple reminders as mentioned above, EHRs should be able to make intelligent suggestions based on patient data and current practice guidelines.

Some EHRs get it half correct. For example, they are “smart” enough to remind clinicians that women of a certain age should have mammograms, but they fall short in the ability to efficiently update those reminders when the U.S. Preventive Services Task Force updates the screening recommendation (as they did recently).

Other EHRs do allow you to customize preventative health reminders, but do not place them in a position of prominence – so they are easily overlooked by providers as they care for patients.

Few products seem to get it just right, and it’s time for this to change.

Simply put, as questions in the media loom about how to stop this rising threat, we as frontline health care providers should have the tools – and the decision support – required to provide meaningful answers.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

It is always noteworthy when the headlines in the medical and mainstream media appear to be the same.

Typically, this means one of two things: 1) Sensationalism has propelled a minor issue into the common lexicon; or 2) a truly serious issue has grown to the point where the whole world is finally taking notice.

With the recent resurgence of Zika virus, something that initially seemed to be the former has unmistakably developed into the latter, and health care providers are again facing an age-old question: How do we adequately fight an evolving and serious illness in the midst of an ever-changing battlefield?

As has been the case countless times before, the answer to this question really lies in early identification. One might think that the advent of modern technology would make this a much easier proposition, but that has not exactly been the case.

In fact, recent Ebola and Zika outbreaks have actually served to demonstrate a big problem in many modern electronic health records: poor clinical decision support.

In this column, we felt it would be helpful to highlight this shortcoming, and make the suggestion that in the world of EHRs …

Change needs to be faster than Zika

Zika virus is not new (it was first identified in the Zika Forest of Uganda in 1947), and neither is the concept of serious mosquito-born illness. While the current Zika hot zones are South America, Central America, Mexico, and the Caribbean, case reports indicate the virus is quickly migrating. At the time of this writing, more than 150 travel-associated cases of Zika have been identified in the continental United States, and it is clear that the consequences of undiagnosed Zika in pregnancy can be devastating.

Furthermore, Zika is just the latest of many viruses to threaten the health and welfare of modern civilization (for example, Ebola, swine flu, SARS, and so on), so screening and prevention is far from a novel idea.

Unfortunately, electronic record vendors don’t seem to have gotten the message that the ability to adapt quickly to public health threats should be a core element of any modern EHR.

On the contrary, EHRs seem to be designed for fixed “best practice” workflows, and updates are often slow in coming (typically requiring a major upgrade or “patch”). This renders them fairly unable to react nimbly to change.

This fact became evident to us as we attempted to implement a reminder for staff members to perform a Zika-focused travel history on all patients. We felt it was critical for this reminder to be prominent, be easy to interact with, and appear at the most appropriate time for screening.

Despite multiple attempts, we discovered that our top-ranked, industry-leading EHR was unable to do this seemingly straightforward task, and eventually we reverted to the age-old practice of hanging signs in all of the exam rooms. These encouraged patients to inform their doctor “of worrisome symptoms or recent travel history to affected areas.”

We refuse to accept the inability of any modern electronic health record to create simple and flexible clinical support rules and improve on the efficacy of the paper sign. This, especially in light of the fact that one of the core requirements of the Meaningful Use (MU) program – for which all EHRs are certified – is clinical decision support!

Unfortunately, the MU guidelines are not specific, so most vendors choose to include a standard set of rules and don’t allow the ability for customization. That just isn’t good enough. If Ebola and Zika have taught the health information technology community one thing, it’s that …

It is time for smarter EHRs!

For many people, the notion of artificial intelligence seems to be science fiction, but they don’t realize they are carrying incredible “AI” devices with them everywhere they go. We are, of course, referring to our cell phones, which seem to be getting more intelligent all the time.

If you own an iPhone, you may have noticed it often seems to know where you are about to drive and how long it will take you to get there. This can be a bit creepy at first, until you realize how helpful – and smart – it actually is.

Essentially, our devices are constantly collecting data, reading the patterns of our lives, and learning ways to enhance them. Smartphones have revolutionized how we communicate, work, and play. Why, then, can’t our electronic health record software do the same?

It will surprise exactly none of our readers that the Meaningful Use program has fallen short of its goal of promoting the true benefits of electronic records. Many critics have suggested that the incentive program has faltered because EHRs have made physicians work harder, without helping them work smarter.

Zika virus proves the critics correct. Beyond creating just simple reminders as mentioned above, EHRs should be able to make intelligent suggestions based on patient data and current practice guidelines.

Some EHRs get it half correct. For example, they are “smart” enough to remind clinicians that women of a certain age should have mammograms, but they fall short in the ability to efficiently update those reminders when the U.S. Preventive Services Task Force updates the screening recommendation (as they did recently).

Other EHRs do allow you to customize preventative health reminders, but do not place them in a position of prominence – so they are easily overlooked by providers as they care for patients.

Few products seem to get it just right, and it’s time for this to change.

Simply put, as questions in the media loom about how to stop this rising threat, we as frontline health care providers should have the tools – and the decision support – required to provide meaningful answers.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

It is always noteworthy when the headlines in the medical and mainstream media appear to be the same.

Typically, this means one of two things: 1) Sensationalism has propelled a minor issue into the common lexicon; or 2) a truly serious issue has grown to the point where the whole world is finally taking notice.

With the recent resurgence of Zika virus, something that initially seemed to be the former has unmistakably developed into the latter, and health care providers are again facing an age-old question: How do we adequately fight an evolving and serious illness in the midst of an ever-changing battlefield?

As has been the case countless times before, the answer to this question really lies in early identification. One might think that the advent of modern technology would make this a much easier proposition, but that has not exactly been the case.

In fact, recent Ebola and Zika outbreaks have actually served to demonstrate a big problem in many modern electronic health records: poor clinical decision support.

In this column, we felt it would be helpful to highlight this shortcoming, and make the suggestion that in the world of EHRs …

Change needs to be faster than Zika

Zika virus is not new (it was first identified in the Zika Forest of Uganda in 1947), and neither is the concept of serious mosquito-born illness. While the current Zika hot zones are South America, Central America, Mexico, and the Caribbean, case reports indicate the virus is quickly migrating. At the time of this writing, more than 150 travel-associated cases of Zika have been identified in the continental United States, and it is clear that the consequences of undiagnosed Zika in pregnancy can be devastating.

Furthermore, Zika is just the latest of many viruses to threaten the health and welfare of modern civilization (for example, Ebola, swine flu, SARS, and so on), so screening and prevention is far from a novel idea.

Unfortunately, electronic record vendors don’t seem to have gotten the message that the ability to adapt quickly to public health threats should be a core element of any modern EHR.

On the contrary, EHRs seem to be designed for fixed “best practice” workflows, and updates are often slow in coming (typically requiring a major upgrade or “patch”). This renders them fairly unable to react nimbly to change.

This fact became evident to us as we attempted to implement a reminder for staff members to perform a Zika-focused travel history on all patients. We felt it was critical for this reminder to be prominent, be easy to interact with, and appear at the most appropriate time for screening.

Despite multiple attempts, we discovered that our top-ranked, industry-leading EHR was unable to do this seemingly straightforward task, and eventually we reverted to the age-old practice of hanging signs in all of the exam rooms. These encouraged patients to inform their doctor “of worrisome symptoms or recent travel history to affected areas.”

We refuse to accept the inability of any modern electronic health record to create simple and flexible clinical support rules and improve on the efficacy of the paper sign. This, especially in light of the fact that one of the core requirements of the Meaningful Use (MU) program – for which all EHRs are certified – is clinical decision support!

Unfortunately, the MU guidelines are not specific, so most vendors choose to include a standard set of rules and don’t allow the ability for customization. That just isn’t good enough. If Ebola and Zika have taught the health information technology community one thing, it’s that …

It is time for smarter EHRs!

For many people, the notion of artificial intelligence seems to be science fiction, but they don’t realize they are carrying incredible “AI” devices with them everywhere they go. We are, of course, referring to our cell phones, which seem to be getting more intelligent all the time.

If you own an iPhone, you may have noticed it often seems to know where you are about to drive and how long it will take you to get there. This can be a bit creepy at first, until you realize how helpful – and smart – it actually is.

Essentially, our devices are constantly collecting data, reading the patterns of our lives, and learning ways to enhance them. Smartphones have revolutionized how we communicate, work, and play. Why, then, can’t our electronic health record software do the same?

It will surprise exactly none of our readers that the Meaningful Use program has fallen short of its goal of promoting the true benefits of electronic records. Many critics have suggested that the incentive program has faltered because EHRs have made physicians work harder, without helping them work smarter.

Zika virus proves the critics correct. Beyond creating just simple reminders as mentioned above, EHRs should be able to make intelligent suggestions based on patient data and current practice guidelines.

Some EHRs get it half correct. For example, they are “smart” enough to remind clinicians that women of a certain age should have mammograms, but they fall short in the ability to efficiently update those reminders when the U.S. Preventive Services Task Force updates the screening recommendation (as they did recently).

Other EHRs do allow you to customize preventative health reminders, but do not place them in a position of prominence – so they are easily overlooked by providers as they care for patients.

Few products seem to get it just right, and it’s time for this to change.

Simply put, as questions in the media loom about how to stop this rising threat, we as frontline health care providers should have the tools – and the decision support – required to provide meaningful answers.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Gastroesophageal reflux disease (GERD) is commonly encountered in the primary care setting, occurring in between 10% and 20% of patients in the Western world. GERD is defined as symptoms or complications resulting from the reflux of gastric contents into the esophagus, oral cavity, and/or lung. While GERD may lead to erosions seen on endoscopic examination, this is not part of the definition.

Symptoms

Most common GERD symptoms are heartburn and regurgitation. Chest pain, dysphagia, laryngitis, and respiratory symptoms may also occur. When dysphagia is present, further workup is needed to rule out the presence of an underlying motility disorder, stricture, Schatzki’s ring, or malignancy. Atypical symptoms include dyspepsia, epigastric pain, nausea, bloating, and belching.

Secondary symptoms that may raise suspicion for GERD include respiratory symptoms such as cough, dental erosions, sinusitis, chronic laryngitis, and voice disturbance.

Diagnosis

GERD can be presumed in the setting of typical symptoms of heartburn and regurgitation. Endoscopy is not required in the presence of typical symptoms. Empiric medical therapy with a proton pump inhibitor (PPI) is strongly recommended in this setting. Improvement with a PPI essentially confirms the diagnosis of GERD, but a negative trial does not exclude GERD.

If a patient with suspected GERD continues to have symptoms on a PPI, then endoscopy is warranted. Endoscopy is also indicated in the presence of alarm symptoms, such as dysphagia. The guidelines state that screening with endoscopy to rule out Barrett’s esophagus "may be reasonable" in certain high-risk groups such as overweight white males over age 50 with chronic GERD symptoms. Once Barrett’s esophagus is ruled out, there is no role for repeat endoscopy.

Ambulatory esophageal reflux monitoring is the only test that actually shows abnormal reflux of stomach acid into the esophagus. The percent of time that the esophageal pH is less than 4 is the best indication of the diagnosis of GERD. Ambulatory esophageal reflux monitoring is indicated before consideration of endoscopic or surgical therapy in patients with nonerosive disease and in situations where the diagnosis of GERD is in question. Screening for Helicobacter pylori infection is not recommended in GERD.

Management

Weight loss is recommended in all patients who are overweight or have had a recent weight gain. Head-of-bed elevation and avoidance of meals 2-3 hours before bedtime is also recommended for patients with nocturnal GERD, although there is a low level of evidence to support this recommendation.

While tobacco, chocolate, and carbonated beverages have been shown in some studies to decrease the lower esophageal pressure, eliminating these substances, as well as eliminating alcohol, has not been shown to lead to improvement in GERD symptoms and so is not recommended for the treatment of GERD. Elimination of a specific food that causes symptoms in an individual may be considered.

An 8-week course of a PPI is the therapy of choice for symptom relief and healing of erosive esophagitis. This has a high level of evidence and is strongly recommended. There are no significant differences in efficacy for symptom relief between the different PPIs. Whichever one is prescribed, PPIs should be dosed once daily, 30-60 minutes before the first meal of the day. If patients have partial response, dose adjustment, twice-daily dosing, or switching to another PPI may be considered. Patients who do not respond to PPI therapy should be evaluated by endoscopy.

Maintenance PPI use should be administered for patients with GERD who continue to have symptoms after a PPI is discontinued or in patients with complications including erosive esophagitis and Barrett’s esophagus. The lowest dose that provides symptomatic relief is the recommended dose. H₂ receptor antagonist therapy can be used as maintenance options in patients without erosive disease if patients experience heartburn relief.

Adverse effects of PPIs include osteoporosis and increased risk for Clostridium difficile infection and community-acquired pneumonia. There is strong evidence that PPI therapy does not need to be altered in concomitant clopidogrel users.

There is a high level of evidence that surgical options including laparoscopic fundoplication or bariatric surgery in obese patients with GERD produce good long-term control of GERD symptoms. However, surgery is not recommended for GERD in patients who do not respond to PPIs.

Extraesophageal presentations of GERD

GERD can be a cofactor either causing or exacerbating asthma, chronic cough, and laryngitis. GERD is apparent in approximately 50% of patients with asthma and may be the cause in approximately one-third of patients with chronic cough. It is unusual for GERD to be a factor in these disorders without symptoms of GERD being apparent. If a patient has typical symptoms of GERD in addition to the aforementioned illnesses, then treatment with a PPI should be initiated. If a patient does not have typical symptoms, reflux monitoring may be considered before a PPI is started.

Bottom line

The diagnosis of GERD is based on clinical presentation with typical symptoms of heartburn and regurgitation. Empiric therapy with a plan for weight loss and a PPI for 8 weeks is strongly recommended. Endoscopy should be done for individuals who do not respond to initial therapy.

Reference

Katz, Philip et al. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am. J. Gastroenterol. 2013;108:308-28.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Rosner is a graduate of Jefferson Medical College, Philadelphia, and a third-year resident in the family medicine residency at Abington Memorial Hospital.

Gastroesophageal reflux disease (GERD) is commonly encountered in the primary care setting, occurring in between 10% and 20% of patients in the Western world. GERD is defined as symptoms or complications resulting from the reflux of gastric contents into the esophagus, oral cavity, and/or lung. While GERD may lead to erosions seen on endoscopic examination, this is not part of the definition.

Symptoms

Most common GERD symptoms are heartburn and regurgitation. Chest pain, dysphagia, laryngitis, and respiratory symptoms may also occur. When dysphagia is present, further workup is needed to rule out the presence of an underlying motility disorder, stricture, Schatzki’s ring, or malignancy. Atypical symptoms include dyspepsia, epigastric pain, nausea, bloating, and belching.

Secondary symptoms that may raise suspicion for GERD include respiratory symptoms such as cough, dental erosions, sinusitis, chronic laryngitis, and voice disturbance.

Diagnosis

GERD can be presumed in the setting of typical symptoms of heartburn and regurgitation. Endoscopy is not required in the presence of typical symptoms. Empiric medical therapy with a proton pump inhibitor (PPI) is strongly recommended in this setting. Improvement with a PPI essentially confirms the diagnosis of GERD, but a negative trial does not exclude GERD.

If a patient with suspected GERD continues to have symptoms on a PPI, then endoscopy is warranted. Endoscopy is also indicated in the presence of alarm symptoms, such as dysphagia. The guidelines state that screening with endoscopy to rule out Barrett’s esophagus "may be reasonable" in certain high-risk groups such as overweight white males over age 50 with chronic GERD symptoms. Once Barrett’s esophagus is ruled out, there is no role for repeat endoscopy.

Ambulatory esophageal reflux monitoring is the only test that actually shows abnormal reflux of stomach acid into the esophagus. The percent of time that the esophageal pH is less than 4 is the best indication of the diagnosis of GERD. Ambulatory esophageal reflux monitoring is indicated before consideration of endoscopic or surgical therapy in patients with nonerosive disease and in situations where the diagnosis of GERD is in question. Screening for Helicobacter pylori infection is not recommended in GERD.

Management

Weight loss is recommended in all patients who are overweight or have had a recent weight gain. Head-of-bed elevation and avoidance of meals 2-3 hours before bedtime is also recommended for patients with nocturnal GERD, although there is a low level of evidence to support this recommendation.

While tobacco, chocolate, and carbonated beverages have been shown in some studies to decrease the lower esophageal pressure, eliminating these substances, as well as eliminating alcohol, has not been shown to lead to improvement in GERD symptoms and so is not recommended for the treatment of GERD. Elimination of a specific food that causes symptoms in an individual may be considered.

An 8-week course of a PPI is the therapy of choice for symptom relief and healing of erosive esophagitis. This has a high level of evidence and is strongly recommended. There are no significant differences in efficacy for symptom relief between the different PPIs. Whichever one is prescribed, PPIs should be dosed once daily, 30-60 minutes before the first meal of the day. If patients have partial response, dose adjustment, twice-daily dosing, or switching to another PPI may be considered. Patients who do not respond to PPI therapy should be evaluated by endoscopy.

Maintenance PPI use should be administered for patients with GERD who continue to have symptoms after a PPI is discontinued or in patients with complications including erosive esophagitis and Barrett’s esophagus. The lowest dose that provides symptomatic relief is the recommended dose. H₂ receptor antagonist therapy can be used as maintenance options in patients without erosive disease if patients experience heartburn relief.

Adverse effects of PPIs include osteoporosis and increased risk for Clostridium difficile infection and community-acquired pneumonia. There is strong evidence that PPI therapy does not need to be altered in concomitant clopidogrel users.

There is a high level of evidence that surgical options including laparoscopic fundoplication or bariatric surgery in obese patients with GERD produce good long-term control of GERD symptoms. However, surgery is not recommended for GERD in patients who do not respond to PPIs.

Extraesophageal presentations of GERD

GERD can be a cofactor either causing or exacerbating asthma, chronic cough, and laryngitis. GERD is apparent in approximately 50% of patients with asthma and may be the cause in approximately one-third of patients with chronic cough. It is unusual for GERD to be a factor in these disorders without symptoms of GERD being apparent. If a patient has typical symptoms of GERD in addition to the aforementioned illnesses, then treatment with a PPI should be initiated. If a patient does not have typical symptoms, reflux monitoring may be considered before a PPI is started.

Bottom line

The diagnosis of GERD is based on clinical presentation with typical symptoms of heartburn and regurgitation. Empiric therapy with a plan for weight loss and a PPI for 8 weeks is strongly recommended. Endoscopy should be done for individuals who do not respond to initial therapy.

Reference

Katz, Philip et al. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am. J. Gastroenterol. 2013;108:308-28.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Rosner is a graduate of Jefferson Medical College, Philadelphia, and a third-year resident in the family medicine residency at Abington Memorial Hospital.

Gastroesophageal reflux disease (GERD) is commonly encountered in the primary care setting, occurring in between 10% and 20% of patients in the Western world. GERD is defined as symptoms or complications resulting from the reflux of gastric contents into the esophagus, oral cavity, and/or lung. While GERD may lead to erosions seen on endoscopic examination, this is not part of the definition.

Symptoms

Most common GERD symptoms are heartburn and regurgitation. Chest pain, dysphagia, laryngitis, and respiratory symptoms may also occur. When dysphagia is present, further workup is needed to rule out the presence of an underlying motility disorder, stricture, Schatzki’s ring, or malignancy. Atypical symptoms include dyspepsia, epigastric pain, nausea, bloating, and belching.

Secondary symptoms that may raise suspicion for GERD include respiratory symptoms such as cough, dental erosions, sinusitis, chronic laryngitis, and voice disturbance.

Diagnosis

GERD can be presumed in the setting of typical symptoms of heartburn and regurgitation. Endoscopy is not required in the presence of typical symptoms. Empiric medical therapy with a proton pump inhibitor (PPI) is strongly recommended in this setting. Improvement with a PPI essentially confirms the diagnosis of GERD, but a negative trial does not exclude GERD.

If a patient with suspected GERD continues to have symptoms on a PPI, then endoscopy is warranted. Endoscopy is also indicated in the presence of alarm symptoms, such as dysphagia. The guidelines state that screening with endoscopy to rule out Barrett’s esophagus "may be reasonable" in certain high-risk groups such as overweight white males over age 50 with chronic GERD symptoms. Once Barrett’s esophagus is ruled out, there is no role for repeat endoscopy.

Ambulatory esophageal reflux monitoring is the only test that actually shows abnormal reflux of stomach acid into the esophagus. The percent of time that the esophageal pH is less than 4 is the best indication of the diagnosis of GERD. Ambulatory esophageal reflux monitoring is indicated before consideration of endoscopic or surgical therapy in patients with nonerosive disease and in situations where the diagnosis of GERD is in question. Screening for Helicobacter pylori infection is not recommended in GERD.

Management

Weight loss is recommended in all patients who are overweight or have had a recent weight gain. Head-of-bed elevation and avoidance of meals 2-3 hours before bedtime is also recommended for patients with nocturnal GERD, although there is a low level of evidence to support this recommendation.

While tobacco, chocolate, and carbonated beverages have been shown in some studies to decrease the lower esophageal pressure, eliminating these substances, as well as eliminating alcohol, has not been shown to lead to improvement in GERD symptoms and so is not recommended for the treatment of GERD. Elimination of a specific food that causes symptoms in an individual may be considered.

An 8-week course of a PPI is the therapy of choice for symptom relief and healing of erosive esophagitis. This has a high level of evidence and is strongly recommended. There are no significant differences in efficacy for symptom relief between the different PPIs. Whichever one is prescribed, PPIs should be dosed once daily, 30-60 minutes before the first meal of the day. If patients have partial response, dose adjustment, twice-daily dosing, or switching to another PPI may be considered. Patients who do not respond to PPI therapy should be evaluated by endoscopy.

Maintenance PPI use should be administered for patients with GERD who continue to have symptoms after a PPI is discontinued or in patients with complications including erosive esophagitis and Barrett’s esophagus. The lowest dose that provides symptomatic relief is the recommended dose. H₂ receptor antagonist therapy can be used as maintenance options in patients without erosive disease if patients experience heartburn relief.

Adverse effects of PPIs include osteoporosis and increased risk for Clostridium difficile infection and community-acquired pneumonia. There is strong evidence that PPI therapy does not need to be altered in concomitant clopidogrel users.

There is a high level of evidence that surgical options including laparoscopic fundoplication or bariatric surgery in obese patients with GERD produce good long-term control of GERD symptoms. However, surgery is not recommended for GERD in patients who do not respond to PPIs.

Extraesophageal presentations of GERD

GERD can be a cofactor either causing or exacerbating asthma, chronic cough, and laryngitis. GERD is apparent in approximately 50% of patients with asthma and may be the cause in approximately one-third of patients with chronic cough. It is unusual for GERD to be a factor in these disorders without symptoms of GERD being apparent. If a patient has typical symptoms of GERD in addition to the aforementioned illnesses, then treatment with a PPI should be initiated. If a patient does not have typical symptoms, reflux monitoring may be considered before a PPI is started.

Bottom line

The diagnosis of GERD is based on clinical presentation with typical symptoms of heartburn and regurgitation. Empiric therapy with a plan for weight loss and a PPI for 8 weeks is strongly recommended. Endoscopy should be done for individuals who do not respond to initial therapy.

Reference

Katz, Philip et al. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am. J. Gastroenterol. 2013;108:308-28.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Rosner is a graduate of Jefferson Medical College, Philadelphia, and a third-year resident in the family medicine residency at Abington Memorial Hospital.

The decision to revoke an older person’s driver’s license has large implications for his or her ability to live independently, yet continued unsafe driving can have adverse consequences for the individual, the family, and others on the road. In addition, in many states there is a legal obligation to assess and identify individuals who may be unsafe behind the wheel.

Patients with mild dementia are at higher risk of accidents while driving than are patients without dementia. However, 76% are still able to pass an on-road driving test (ORDT).

Evaluation

The American Academy of Neurology recently updated its guidelines on the evaluation of driving risk in dementia. Those guidelines recommend assessing the degree of risk for driving according to the following parameters:

• Clinical Dementia Rating (CDR) scale. The CDR is a survey with a scoring system ranging from 0 (normal) to 3 (severe dementia). To assess dementia, the tool measures memory, orientation, judgment, problem solving, community affairs, home and hobbies, and personal care. This rating system has been determined to be a useful predictor. However, it is important to note that 41%-85% of patients with CDR scores indicating mild dementia were found to be safe drivers by an ORDT.

• Mini Mental Status Exam (MMSE). There is conflicting evidence in determining the utility of the MMSE in assessing driver safety. Generally, a MMSE score of 24 or less is useful in predicting an increased risk of unsafe driving in elderly demented patients. However, most studies did not show a correlation between the MMSE score and a driver who is unsafe.

• Patient’s or caregiver’s report. Patients who continue to drive with self-determined restrictions to their driving have a fivefold increase in the risk of crashes. Patients who have mild Alzheimer’s dementia and who rate themselves as safe at driving have a pass rate of only 41% on the ORDT. In fact, in one study, all of the patients with mild dementia who failed the ORDT considered themselves to be safe drivers.

Caregivers can provide useful information, because a marginal or unsafe rating is a useful predictor of risk. Caregivers have a 47% sensitivity and 82% specificity in predicting driver safety, compared with a professional neurologist’s assessment, which has a 61% sensitivity and 91% specificity. What this means is that either a patient’s or a caregiver’s assessment that a patient is not safe to drive is likely to be correct – but an assessment that the patient is safe to drive is often inaccurate.

• History of crashes and/or traffic violations. A history of crashes and/or traffic violations has a strong correlation with unsafe driving in all age groups. A history of crashes within the past 5 years puts a driver at an approximate twofold risk for future accidents, compared with drivers without a history of a crash, which is a higher risk than that for mild dementia alone. A history of traffic violations in the past 2-3 years is also useful in identifying patients with decreased driving ability.

• Reduced driving mileage or self-reported situation avoidance. When patients begin to impose self restrictions or exhibit behaviors of avoidance, it is useful to use this as a sign that they may be unsafe on the road. In one study, patients older than 65 years who reported changing their driving habits because of safety concerns had a fivefold increase in the risk of crashes. This does not mean that patients who do not report being concerned about their driving are cleared from a safety standpoint.

• Aggressive or impulsive personality characteristics. One study reported that agitation and aggression were predictors for demented patients who would refuse to discontinue driving. When patients with dementia deliberately violated driving laws, there was a higher rate of accidents.

• Neuropsychological testing. Currently, there is insufficient evidence regarding the value of neuropsychological testing in helping to assess a patient’s ability to drive.

• Interventions. The next question to ask is whether there are available interventions (such as driver training) that might reduce the risk of accidents in older patients with dementia. Unfortunately, no intervention – including in-person license renewal, licensing restrictions, or driver training – has been shown to reliably decrease the risk of accidents for this group of patients.

Bottom Line

The decision about whether a patient can or cannot drive involves balancing a moral and often legal obligation to identify unsafe drivers in order to ensure public safety with the desire and often need of older patients to drive in order to maintain independence.

Physicians should be aware that patients with mild dementia as a group are at increased risk for accidents while driving. Clinicians should assess patients according to the criteria described above to try to identify patients who are at increased driving risk. Patients who are identified as high risk should be asked to give up their driver’s license. If a patient prefers not to, or if there is uncertainty about their degree of risk, the patient can be referred for a formal professional or government on-road driving evaluation.

Reference

D.J. Iverson, G.S. Gronseth, M.A. Reger, et al. Neurology 2010;74;1316-24.

This column, "Clinical Guidelines for Family Physicians," regularly appears in Family Practice News, an Elsevier publication. Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Lin is a first-year resident in the family medicine residency program at Abington Memorial Hospital.

The decision to revoke an older person’s driver’s license has large implications for his or her ability to live independently, yet continued unsafe driving can have adverse consequences for the individual, the family, and others on the road. In addition, in many states there is a legal obligation to assess and identify individuals who may be unsafe behind the wheel.

Patients with mild dementia are at higher risk of accidents while driving than are patients without dementia. However, 76% are still able to pass an on-road driving test (ORDT).

Evaluation

The American Academy of Neurology recently updated its guidelines on the evaluation of driving risk in dementia. Those guidelines recommend assessing the degree of risk for driving according to the following parameters:

• Clinical Dementia Rating (CDR) scale. The CDR is a survey with a scoring system ranging from 0 (normal) to 3 (severe dementia). To assess dementia, the tool measures memory, orientation, judgment, problem solving, community affairs, home and hobbies, and personal care. This rating system has been determined to be a useful predictor. However, it is important to note that 41%-85% of patients with CDR scores indicating mild dementia were found to be safe drivers by an ORDT.

• Mini Mental Status Exam (MMSE). There is conflicting evidence in determining the utility of the MMSE in assessing driver safety. Generally, a MMSE score of 24 or less is useful in predicting an increased risk of unsafe driving in elderly demented patients. However, most studies did not show a correlation between the MMSE score and a driver who is unsafe.

• Patient’s or caregiver’s report. Patients who continue to drive with self-determined restrictions to their driving have a fivefold increase in the risk of crashes. Patients who have mild Alzheimer’s dementia and who rate themselves as safe at driving have a pass rate of only 41% on the ORDT. In fact, in one study, all of the patients with mild dementia who failed the ORDT considered themselves to be safe drivers.

Caregivers can provide useful information, because a marginal or unsafe rating is a useful predictor of risk. Caregivers have a 47% sensitivity and 82% specificity in predicting driver safety, compared with a professional neurologist’s assessment, which has a 61% sensitivity and 91% specificity. What this means is that either a patient’s or a caregiver’s assessment that a patient is not safe to drive is likely to be correct – but an assessment that the patient is safe to drive is often inaccurate.

• History of crashes and/or traffic violations. A history of crashes and/or traffic violations has a strong correlation with unsafe driving in all age groups. A history of crashes within the past 5 years puts a driver at an approximate twofold risk for future accidents, compared with drivers without a history of a crash, which is a higher risk than that for mild dementia alone. A history of traffic violations in the past 2-3 years is also useful in identifying patients with decreased driving ability.

• Reduced driving mileage or self-reported situation avoidance. When patients begin to impose self restrictions or exhibit behaviors of avoidance, it is useful to use this as a sign that they may be unsafe on the road. In one study, patients older than 65 years who reported changing their driving habits because of safety concerns had a fivefold increase in the risk of crashes. This does not mean that patients who do not report being concerned about their driving are cleared from a safety standpoint.

• Aggressive or impulsive personality characteristics. One study reported that agitation and aggression were predictors for demented patients who would refuse to discontinue driving. When patients with dementia deliberately violated driving laws, there was a higher rate of accidents.

• Neuropsychological testing. Currently, there is insufficient evidence regarding the value of neuropsychological testing in helping to assess a patient’s ability to drive.

• Interventions. The next question to ask is whether there are available interventions (such as driver training) that might reduce the risk of accidents in older patients with dementia. Unfortunately, no intervention – including in-person license renewal, licensing restrictions, or driver training – has been shown to reliably decrease the risk of accidents for this group of patients.

Bottom Line

The decision about whether a patient can or cannot drive involves balancing a moral and often legal obligation to identify unsafe drivers in order to ensure public safety with the desire and often need of older patients to drive in order to maintain independence.

Physicians should be aware that patients with mild dementia as a group are at increased risk for accidents while driving. Clinicians should assess patients according to the criteria described above to try to identify patients who are at increased driving risk. Patients who are identified as high risk should be asked to give up their driver’s license. If a patient prefers not to, or if there is uncertainty about their degree of risk, the patient can be referred for a formal professional or government on-road driving evaluation.

Reference

D.J. Iverson, G.S. Gronseth, M.A. Reger, et al. Neurology 2010;74;1316-24.

This column, "Clinical Guidelines for Family Physicians," regularly appears in Family Practice News, an Elsevier publication. Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Lin is a first-year resident in the family medicine residency program at Abington Memorial Hospital.

The decision to revoke an older person’s driver’s license has large implications for his or her ability to live independently, yet continued unsafe driving can have adverse consequences for the individual, the family, and others on the road. In addition, in many states there is a legal obligation to assess and identify individuals who may be unsafe behind the wheel.

Patients with mild dementia are at higher risk of accidents while driving than are patients without dementia. However, 76% are still able to pass an on-road driving test (ORDT).

Evaluation

The American Academy of Neurology recently updated its guidelines on the evaluation of driving risk in dementia. Those guidelines recommend assessing the degree of risk for driving according to the following parameters:

• Clinical Dementia Rating (CDR) scale. The CDR is a survey with a scoring system ranging from 0 (normal) to 3 (severe dementia). To assess dementia, the tool measures memory, orientation, judgment, problem solving, community affairs, home and hobbies, and personal care. This rating system has been determined to be a useful predictor. However, it is important to note that 41%-85% of patients with CDR scores indicating mild dementia were found to be safe drivers by an ORDT.

• Mini Mental Status Exam (MMSE). There is conflicting evidence in determining the utility of the MMSE in assessing driver safety. Generally, a MMSE score of 24 or less is useful in predicting an increased risk of unsafe driving in elderly demented patients. However, most studies did not show a correlation between the MMSE score and a driver who is unsafe.

• Patient’s or caregiver’s report. Patients who continue to drive with self-determined restrictions to their driving have a fivefold increase in the risk of crashes. Patients who have mild Alzheimer’s dementia and who rate themselves as safe at driving have a pass rate of only 41% on the ORDT. In fact, in one study, all of the patients with mild dementia who failed the ORDT considered themselves to be safe drivers.

Caregivers can provide useful information, because a marginal or unsafe rating is a useful predictor of risk. Caregivers have a 47% sensitivity and 82% specificity in predicting driver safety, compared with a professional neurologist’s assessment, which has a 61% sensitivity and 91% specificity. What this means is that either a patient’s or a caregiver’s assessment that a patient is not safe to drive is likely to be correct – but an assessment that the patient is safe to drive is often inaccurate.

• History of crashes and/or traffic violations. A history of crashes and/or traffic violations has a strong correlation with unsafe driving in all age groups. A history of crashes within the past 5 years puts a driver at an approximate twofold risk for future accidents, compared with drivers without a history of a crash, which is a higher risk than that for mild dementia alone. A history of traffic violations in the past 2-3 years is also useful in identifying patients with decreased driving ability.

• Reduced driving mileage or self-reported situation avoidance. When patients begin to impose self restrictions or exhibit behaviors of avoidance, it is useful to use this as a sign that they may be unsafe on the road. In one study, patients older than 65 years who reported changing their driving habits because of safety concerns had a fivefold increase in the risk of crashes. This does not mean that patients who do not report being concerned about their driving are cleared from a safety standpoint.

• Aggressive or impulsive personality characteristics. One study reported that agitation and aggression were predictors for demented patients who would refuse to discontinue driving. When patients with dementia deliberately violated driving laws, there was a higher rate of accidents.

• Neuropsychological testing. Currently, there is insufficient evidence regarding the value of neuropsychological testing in helping to assess a patient’s ability to drive.

• Interventions. The next question to ask is whether there are available interventions (such as driver training) that might reduce the risk of accidents in older patients with dementia. Unfortunately, no intervention – including in-person license renewal, licensing restrictions, or driver training – has been shown to reliably decrease the risk of accidents for this group of patients.

Bottom Line

The decision about whether a patient can or cannot drive involves balancing a moral and often legal obligation to identify unsafe drivers in order to ensure public safety with the desire and often need of older patients to drive in order to maintain independence.

Physicians should be aware that patients with mild dementia as a group are at increased risk for accidents while driving. Clinicians should assess patients according to the criteria described above to try to identify patients who are at increased driving risk. Patients who are identified as high risk should be asked to give up their driver’s license. If a patient prefers not to, or if there is uncertainty about their degree of risk, the patient can be referred for a formal professional or government on-road driving evaluation.

Reference

D.J. Iverson, G.S. Gronseth, M.A. Reger, et al. Neurology 2010;74;1316-24.

This column, "Clinical Guidelines for Family Physicians," regularly appears in Family Practice News, an Elsevier publication. Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Lin is a first-year resident in the family medicine residency program at Abington Memorial Hospital.

The decision to revoke an older person’s driver’s license has large implications for his or her ability to live independently, yet continued unsafe driving can have adverse consequences for the individual, the family, and others on the road. In addition, in many states there is a legal obligation to assess and identify individuals who may be unsafe behind the wheel.

Patients with mild dementia are at higher risk of accidents while driving than are patients without dementia. However, 76% are still able to pass an on-road driving test (ORDT).

Evaluation

The American Academy of Neurology recently updated its guidelines on the evaluation of driving risk in dementia. Those guidelines recommend assessing the degree of risk for driving according to the following parameters:

• Clinical Dementia Rating (CDR) scale. The CDR is a survey with a scoring system ranging from 0 (normal) to 3 (severe dementia). To assess dementia, the tool measures memory, orientation, judgment, problem solving, community affairs, home and hobbies, and personal care. This rating system has been determined to be a useful predictor. However, it is important to note that 41%-85% of patients with CDR scores indicating mild dementia were found to be safe drivers by an ORDT.

• Mini Mental Status Exam (MMSE). There is conflicting evidence in determining the utility of the MMSE in assessing driver safety. Generally, a MMSE score of 24 or less is useful in predicting an increased risk of unsafe driving in elderly demented patients. However, most studies did not show a correlation between the MMSE score and a driver who is unsafe.

• Patient’s or caregiver’s report. Patients who continue to drive with self-determined restrictions to their driving have a fivefold increase in the risk of crashes. Patients who have mild Alzheimer’s dementia and who rate themselves as safe at driving have a pass rate of only 41% on the ORDT. In fact, in one study, all of the patients with mild dementia who failed the ORDT considered themselves to be safe drivers.

Caregivers can provide useful information, because a marginal or unsafe rating is a useful predictor of risk. Caregivers have a 47% sensitivity and 82% specificity in predicting driver safety, compared with a professional neurologist’s assessment, which has a 61% sensitivity and 91% specificity. What this means is that either a patient’s or a caregiver’s assessment that a patient is not safe to drive is likely to be correct – but an assessment that the patient is safe to drive is often inaccurate.

• History of crashes and/or traffic violations. A history of crashes and/or traffic violations has a strong correlation with unsafe driving in all age groups. A history of crashes within the past 5 years puts a driver at an approximate twofold risk for future accidents, compared with drivers without a history of a crash, which is a higher risk than that for mild dementia alone. A history of traffic violations in the past 2-3 years is also useful in identifying patients with decreased driving ability.

• Reduced driving mileage or self-reported situation avoidance. When patients begin to impose self restrictions or exhibit behaviors of avoidance, it is useful to use this as a sign that they may be unsafe on the road. In one study, patients older than 65 years who reported changing their driving habits because of safety concerns had a fivefold increase in the risk of crashes. This does not mean that patients who do not report being concerned about their driving are cleared from a safety standpoint.

• Aggressive or impulsive personality characteristics. One study reported that agitation and aggression were predictors for demented patients who would refuse to discontinue driving. When patients with dementia deliberately violated driving laws, there was a higher rate of accidents.

• Neuropsychological testing. Currently, there is insufficient evidence regarding the value of neuropsychological testing in helping to assess a patient’s ability to drive.

• Interventions. The next question to ask is whether there are available interventions (such as driver training) that might reduce the risk of accidents in older patients with dementia. Unfortunately, no intervention – including in-person license renewal, licensing restrictions, or driver training – has been shown to reliably decrease the risk of accidents for this group of patients.

Bottom Line

The decision about whether a patient can or cannot drive involves balancing a moral and often legal obligation to identify unsafe drivers in order to ensure public safety with the desire and often need of older patients to drive in order to maintain independence.

Physicians should be aware that patients with mild dementia as a group are at increased risk for accidents while driving. Clinicians should assess patients according to the criteria described above to try to identify patients who are at increased driving risk. Patients who are identified as high risk should be asked to give up their driver’s license. If a patient prefers not to, or if there is uncertainty about their degree of risk, the patient can be referred for a formal professional or government on-road driving evaluation.

Reference

D.J. Iverson, G.S. Gronseth, M.A. Reger, et al. Neurology 2010;74;1316-24.

This column, "Clinical Guidelines for Family Physicians," regularly appears in Family Practice News, an Elsevier publication. Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Lin is a first-year resident in the family medicine residency program at Abington Memorial Hospital.

The decision to revoke an older person’s driver’s license has large implications for his or her ability to live independently, yet continued unsafe driving can have adverse consequences for the individual, the family, and others on the road. In addition, in many states there is a legal obligation to assess and identify individuals who may be unsafe behind the wheel.

Patients with mild dementia are at higher risk of accidents while driving than are patients without dementia. However, 76% are still able to pass an on-road driving test (ORDT).

Evaluation

The American Academy of Neurology recently updated its guidelines on the evaluation of driving risk in dementia. Those guidelines recommend assessing the degree of risk for driving according to the following parameters:

• Clinical Dementia Rating (CDR) scale. The CDR is a survey with a scoring system ranging from 0 (normal) to 3 (severe dementia). To assess dementia, the tool measures memory, orientation, judgment, problem solving, community affairs, home and hobbies, and personal care. This rating system has been determined to be a useful predictor. However, it is important to note that 41%-85% of patients with CDR scores indicating mild dementia were found to be safe drivers by an ORDT.

• Mini Mental Status Exam (MMSE). There is conflicting evidence in determining the utility of the MMSE in assessing driver safety. Generally, a MMSE score of 24 or less is useful in predicting an increased risk of unsafe driving in elderly demented patients. However, most studies did not show a correlation between the MMSE score and a driver who is unsafe.

• Patient’s or caregiver’s report. Patients who continue to drive with self-determined restrictions to their driving have a fivefold increase in the risk of crashes. Patients who have mild Alzheimer’s dementia and who rate themselves as safe at driving have a pass rate of only 41% on the ORDT. In fact, in one study, all of the patients with mild dementia who failed the ORDT considered themselves to be safe drivers.

Caregivers can provide useful information, because a marginal or unsafe rating is a useful predictor of risk. Caregivers have a 47% sensitivity and 82% specificity in predicting driver safety, compared with a professional neurologist’s assessment, which has a 61% sensitivity and 91% specificity. What this means is that either a patient’s or a caregiver’s assessment that a patient is not safe to drive is likely to be correct – but an assessment that the patient is safe to drive is often inaccurate.

• History of crashes and/or traffic violations. A history of crashes and/or traffic violations has a strong correlation with unsafe driving in all age groups. A history of crashes within the past 5 years puts a driver at an approximate twofold risk for future accidents, compared with drivers without a history of a crash, which is a higher risk than that for mild dementia alone. A history of traffic violations in the past 2-3 years is also useful in identifying patients with decreased driving ability.

• Reduced driving mileage or self-reported situation avoidance. When patients begin to impose self restrictions or exhibit behaviors of avoidance, it is useful to use this as a sign that they may be unsafe on the road. In one study, patients older than 65 years who reported changing their driving habits because of safety concerns had a fivefold increase in the risk of crashes. This does not mean that patients who do not report being concerned about their driving are cleared from a safety standpoint.

• Aggressive or impulsive personality characteristics. One study reported that agitation and aggression were predictors for demented patients who would refuse to discontinue driving. When patients with dementia deliberately violated driving laws, there was a higher rate of accidents.

• Neuropsychological testing. Currently, there is insufficient evidence regarding the value of neuropsychological testing in helping to assess a patient’s ability to drive.

• Interventions. The next question to ask is whether there are available interventions (such as driver training) that might reduce the risk of accidents in older patients with dementia. Unfortunately, no intervention – including in-person license renewal, licensing restrictions, or driver training – has been shown to reliably decrease the risk of accidents for this group of patients.

Bottom Line

The decision about whether a patient can or cannot drive involves balancing a moral and often legal obligation to identify unsafe drivers in order to ensure public safety with the desire and often need of older patients to drive in order to maintain independence.

Physicians should be aware that patients with mild dementia as a group are at increased risk for accidents while driving. Clinicians should assess patients according to the criteria described above to try to identify patients who are at increased driving risk. Patients who are identified as high risk should be asked to give up their driver’s license. If a patient prefers not to, or if there is uncertainty about their degree of risk, the patient can be referred for a formal professional or government on-road driving evaluation.

Reference

D.J. Iverson, G.S. Gronseth, M.A. Reger, et al. Neurology 2010;74;1316-24.

This column, "Clinical Guidelines for Family Physicians," regularly appears in Family Practice News, an Elsevier publication. Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Lin is a first-year resident in the family medicine residency program at Abington Memorial Hospital.

The decision to revoke an older person’s driver’s license has large implications for his or her ability to live independently, yet continued unsafe driving can have adverse consequences for the individual, the family, and others on the road. In addition, in many states there is a legal obligation to assess and identify individuals who may be unsafe behind the wheel.

Patients with mild dementia are at higher risk of accidents while driving than are patients without dementia. However, 76% are still able to pass an on-road driving test (ORDT).

Evaluation

The American Academy of Neurology recently updated its guidelines on the evaluation of driving risk in dementia. Those guidelines recommend assessing the degree of risk for driving according to the following parameters:

• Clinical Dementia Rating (CDR) scale. The CDR is a survey with a scoring system ranging from 0 (normal) to 3 (severe dementia). To assess dementia, the tool measures memory, orientation, judgment, problem solving, community affairs, home and hobbies, and personal care. This rating system has been determined to be a useful predictor. However, it is important to note that 41%-85% of patients with CDR scores indicating mild dementia were found to be safe drivers by an ORDT.

• Mini Mental Status Exam (MMSE). There is conflicting evidence in determining the utility of the MMSE in assessing driver safety. Generally, a MMSE score of 24 or less is useful in predicting an increased risk of unsafe driving in elderly demented patients. However, most studies did not show a correlation between the MMSE score and a driver who is unsafe.

• Patient’s or caregiver’s report. Patients who continue to drive with self-determined restrictions to their driving have a fivefold increase in the risk of crashes. Patients who have mild Alzheimer’s dementia and who rate themselves as safe at driving have a pass rate of only 41% on the ORDT. In fact, in one study, all of the patients with mild dementia who failed the ORDT considered themselves to be safe drivers.

Caregivers can provide useful information, because a marginal or unsafe rating is a useful predictor of risk. Caregivers have a 47% sensitivity and 82% specificity in predicting driver safety, compared with a professional neurologist’s assessment, which has a 61% sensitivity and 91% specificity. What this means is that either a patient’s or a caregiver’s assessment that a patient is not safe to drive is likely to be correct – but an assessment that the patient is safe to drive is often inaccurate.

• History of crashes and/or traffic violations. A history of crashes and/or traffic violations has a strong correlation with unsafe driving in all age groups. A history of crashes within the past 5 years puts a driver at an approximate twofold risk for future accidents, compared with drivers without a history of a crash, which is a higher risk than that for mild dementia alone. A history of traffic violations in the past 2-3 years is also useful in identifying patients with decreased driving ability.

• Reduced driving mileage or self-reported situation avoidance. When patients begin to impose self restrictions or exhibit behaviors of avoidance, it is useful to use this as a sign that they may be unsafe on the road. In one study, patients older than 65 years who reported changing their driving habits because of safety concerns had a fivefold increase in the risk of crashes. This does not mean that patients who do not report being concerned about their driving are cleared from a safety standpoint.

• Aggressive or impulsive personality characteristics. One study reported that agitation and aggression were predictors for demented patients who would refuse to discontinue driving. When patients with dementia deliberately violated driving laws, there was a higher rate of accidents.

• Neuropsychological testing. Currently, there is insufficient evidence regarding the value of neuropsychological testing in helping to assess a patient’s ability to drive.

• Interventions. The next question to ask is whether there are available interventions (such as driver training) that might reduce the risk of accidents in older patients with dementia. Unfortunately, no intervention – including in-person license renewal, licensing restrictions, or driver training – has been shown to reliably decrease the risk of accidents for this group of patients.

Bottom Line

The decision about whether a patient can or cannot drive involves balancing a moral and often legal obligation to identify unsafe drivers in order to ensure public safety with the desire and often need of older patients to drive in order to maintain independence.

Physicians should be aware that patients with mild dementia as a group are at increased risk for accidents while driving. Clinicians should assess patients according to the criteria described above to try to identify patients who are at increased driving risk. Patients who are identified as high risk should be asked to give up their driver’s license. If a patient prefers not to, or if there is uncertainty about their degree of risk, the patient can be referred for a formal professional or government on-road driving evaluation.

Reference

D.J. Iverson, G.S. Gronseth, M.A. Reger, et al. Neurology 2010;74;1316-24.

This column, "Clinical Guidelines for Family Physicians," regularly appears in Family Practice News, an Elsevier publication. Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Lin is a first-year resident in the family medicine residency program at Abington Memorial Hospital.

The decision to revoke an older person’s driver’s license has large implications for his or her ability to live independently, yet continued unsafe driving can have adverse consequences for the individual, the family, and others on the road. In addition, in many states there is a legal obligation to assess and identify individuals who may be unsafe behind the wheel.

Patients with mild dementia are at higher risk of accidents while driving than are patients without dementia. However, 76% are still able to pass an on-road driving test (ORDT).

Evaluation

The American Academy of Neurology recently updated its guidelines on the evaluation of driving risk in dementia. Those guidelines recommend assessing the degree of risk for driving according to the following parameters:

• Clinical Dementia Rating (CDR) scale. The CDR is a survey with a scoring system ranging from 0 (normal) to 3 (severe dementia). To assess dementia, the tool measures memory, orientation, judgment, problem solving, community affairs, home and hobbies, and personal care. This rating system has been determined to be a useful predictor. However, it is important to note that 41%-85% of patients with CDR scores indicating mild dementia were found to be safe drivers by an ORDT.

• Mini Mental Status Exam (MMSE). There is conflicting evidence in determining the utility of the MMSE in assessing driver safety. Generally, a MMSE score of 24 or less is useful in predicting an increased risk of unsafe driving in elderly demented patients. However, most studies did not show a correlation between the MMSE score and a driver who is unsafe.

• Patient’s or caregiver’s report. Patients who continue to drive with self-determined restrictions to their driving have a fivefold increase in the risk of crashes. Patients who have mild Alzheimer’s dementia and who rate themselves as safe at driving have a pass rate of only 41% on the ORDT. In fact, in one study, all of the patients with mild dementia who failed the ORDT considered themselves to be safe drivers.

Caregivers can provide useful information, because a marginal or unsafe rating is a useful predictor of risk. Caregivers have a 47% sensitivity and 82% specificity in predicting driver safety, compared with a professional neurologist’s assessment, which has a 61% sensitivity and 91% specificity. What this means is that either a patient’s or a caregiver’s assessment that a patient is not safe to drive is likely to be correct – but an assessment that the patient is safe to drive is often inaccurate.

• History of crashes and/or traffic violations. A history of crashes and/or traffic violations has a strong correlation with unsafe driving in all age groups. A history of crashes within the past 5 years puts a driver at an approximate twofold risk for future accidents, compared with drivers without a history of a crash, which is a higher risk than that for mild dementia alone. A history of traffic violations in the past 2-3 years is also useful in identifying patients with decreased driving ability.

• Reduced driving mileage or self-reported situation avoidance. When patients begin to impose self restrictions or exhibit behaviors of avoidance, it is useful to use this as a sign that they may be unsafe on the road. In one study, patients older than 65 years who reported changing their driving habits because of safety concerns had a fivefold increase in the risk of crashes. This does not mean that patients who do not report being concerned about their driving are cleared from a safety standpoint.

• Aggressive or impulsive personality characteristics. One study reported that agitation and aggression were predictors for demented patients who would refuse to discontinue driving. When patients with dementia deliberately violated driving laws, there was a higher rate of accidents.

• Neuropsychological testing. Currently, there is insufficient evidence regarding the value of neuropsychological testing in helping to assess a patient’s ability to drive.

• Interventions. The next question to ask is whether there are available interventions (such as driver training) that might reduce the risk of accidents in older patients with dementia. Unfortunately, no intervention – including in-person license renewal, licensing restrictions, or driver training – has been shown to reliably decrease the risk of accidents for this group of patients.

Bottom Line

The decision about whether a patient can or cannot drive involves balancing a moral and often legal obligation to identify unsafe drivers in order to ensure public safety with the desire and often need of older patients to drive in order to maintain independence.

Physicians should be aware that patients with mild dementia as a group are at increased risk for accidents while driving. Clinicians should assess patients according to the criteria described above to try to identify patients who are at increased driving risk. Patients who are identified as high risk should be asked to give up their driver’s license. If a patient prefers not to, or if there is uncertainty about their degree of risk, the patient can be referred for a formal professional or government on-road driving evaluation.

Reference

D.J. Iverson, G.S. Gronseth, M.A. Reger, et al. Neurology 2010;74;1316-24.

This column, "Clinical Guidelines for Family Physicians," regularly appears in Family Practice News, an Elsevier publication. Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Lin is a first-year resident in the family medicine residency program at Abington Memorial Hospital.

The decision to revoke an older person’s driver’s license has large implications for his or her ability to live independently, yet continued unsafe driving can have adverse consequences for the individual, the family, and others on the road. In addition, in many states there is a legal obligation to assess and identify individuals who may be unsafe behind the wheel.

Patients with mild dementia are at higher risk of accidents while driving than are patients without dementia. However, 76% are still able to pass an on-road driving test (ORDT).

Evaluation

The American Academy of Neurology recently updated its guidelines on the evaluation of driving risk in dementia. Those guidelines recommend assessing the degree of risk for driving according to the following parameters:

• Clinical Dementia Rating (CDR) scale. The CDR is a survey with a scoring system ranging from 0 (normal) to 3 (severe dementia). To assess dementia, the tool measures memory, orientation, judgment, problem solving, community affairs, home and hobbies, and personal care. This rating system has been determined to be a useful predictor. However, it is important to note that 41%-85% of patients with CDR scores indicating mild dementia were found to be safe drivers by an ORDT.

• Mini Mental Status Exam (MMSE). There is conflicting evidence in determining the utility of the MMSE in assessing driver safety. Generally, a MMSE score of 24 or less is useful in predicting an increased risk of unsafe driving in elderly demented patients. However, most studies did not show a correlation between the MMSE score and a driver who is unsafe.

• Patient’s or caregiver’s report. Patients who continue to drive with self-determined restrictions to their driving have a fivefold increase in the risk of crashes. Patients who have mild Alzheimer’s dementia and who rate themselves as safe at driving have a pass rate of only 41% on the ORDT. In fact, in one study, all of the patients with mild dementia who failed the ORDT considered themselves to be safe drivers.

Caregivers can provide useful information, because a marginal or unsafe rating is a useful predictor of risk. Caregivers have a 47% sensitivity and 82% specificity in predicting driver safety, compared with a professional neurologist’s assessment, which has a 61% sensitivity and 91% specificity. What this means is that either a patient’s or a caregiver’s assessment that a patient is not safe to drive is likely to be correct – but an assessment that the patient is safe to drive is often inaccurate.

• History of crashes and/or traffic violations. A history of crashes and/or traffic violations has a strong correlation with unsafe driving in all age groups. A history of crashes within the past 5 years puts a driver at an approximate twofold risk for future accidents, compared with drivers without a history of a crash, which is a higher risk than that for mild dementia alone. A history of traffic violations in the past 2-3 years is also useful in identifying patients with decreased driving ability.

• Reduced driving mileage or self-reported situation avoidance. When patients begin to impose self restrictions or exhibit behaviors of avoidance, it is useful to use this as a sign that they may be unsafe on the road. In one study, patients older than 65 years who reported changing their driving habits because of safety concerns had a fivefold increase in the risk of crashes. This does not mean that patients who do not report being concerned about their driving are cleared from a safety standpoint.

• Aggressive or impulsive personality characteristics. One study reported that agitation and aggression were predictors for demented patients who would refuse to discontinue driving. When patients with dementia deliberately violated driving laws, there was a higher rate of accidents.

• Neuropsychological testing. Currently, there is insufficient evidence regarding the value of neuropsychological testing in helping to assess a patient’s ability to drive.

• Interventions. The next question to ask is whether there are available interventions (such as driver training) that might reduce the risk of accidents in older patients with dementia. Unfortunately, no intervention – including in-person license renewal, licensing restrictions, or driver training – has been shown to reliably decrease the risk of accidents for this group of patients.

Bottom Line

The decision about whether a patient can or cannot drive involves balancing a moral and often legal obligation to identify unsafe drivers in order to ensure public safety with the desire and often need of older patients to drive in order to maintain independence.

Physicians should be aware that patients with mild dementia as a group are at increased risk for accidents while driving. Clinicians should assess patients according to the criteria described above to try to identify patients who are at increased driving risk. Patients who are identified as high risk should be asked to give up their driver’s license. If a patient prefers not to, or if there is uncertainty about their degree of risk, the patient can be referred for a formal professional or government on-road driving evaluation.

Reference

D.J. Iverson, G.S. Gronseth, M.A. Reger, et al. Neurology 2010;74;1316-24.

This column, "Clinical Guidelines for Family Physicians," regularly appears in Family Practice News, an Elsevier publication. Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Lin is a first-year resident in the family medicine residency program at Abington Memorial Hospital.

The decision to revoke an older person’s driver’s license has large implications for his or her ability to live independently, yet continued unsafe driving can have adverse consequences for the individual, the family, and others on the road. In addition, in many states there is a legal obligation to assess and identify individuals who may be unsafe behind the wheel.

Patients with mild dementia are at higher risk of accidents while driving than are patients without dementia. However, 76% are still able to pass an on-road driving test (ORDT).

Evaluation

The American Academy of Neurology recently updated its guidelines on the evaluation of driving risk in dementia. Those guidelines recommend assessing the degree of risk for driving according to the following parameters:

• Clinical Dementia Rating (CDR) scale. The CDR is a survey with a scoring system ranging from 0 (normal) to 3 (severe dementia). To assess dementia, the tool measures memory, orientation, judgment, problem solving, community affairs, home and hobbies, and personal care. This rating system has been determined to be a useful predictor. However, it is important to note that 41%-85% of patients with CDR scores indicating mild dementia were found to be safe drivers by an ORDT.

• Mini Mental Status Exam (MMSE). There is conflicting evidence in determining the utility of the MMSE in assessing driver safety. Generally, a MMSE score of 24 or less is useful in predicting an increased risk of unsafe driving in elderly demented patients. However, most studies did not show a correlation between the MMSE score and a driver who is unsafe.

• Patient’s or caregiver’s report. Patients who continue to drive with self-determined restrictions to their driving have a fivefold increase in the risk of crashes. Patients who have mild Alzheimer’s dementia and who rate themselves as safe at driving have a pass rate of only 41% on the ORDT. In fact, in one study, all of the patients with mild dementia who failed the ORDT considered themselves to be safe drivers.

Caregivers can provide useful information, because a marginal or unsafe rating is a useful predictor of risk. Caregivers have a 47% sensitivity and 82% specificity in predicting driver safety, compared with a professional neurologist’s assessment, which has a 61% sensitivity and 91% specificity. What this means is that either a patient’s or a caregiver’s assessment that a patient is not safe to drive is likely to be correct – but an assessment that the patient is safe to drive is often inaccurate.

• History of crashes and/or traffic violations. A history of crashes and/or traffic violations has a strong correlation with unsafe driving in all age groups. A history of crashes within the past 5 years puts a driver at an approximate twofold risk for future accidents, compared with drivers without a history of a crash, which is a higher risk than that for mild dementia alone. A history of traffic violations in the past 2-3 years is also useful in identifying patients with decreased driving ability.

• Reduced driving mileage or self-reported situation avoidance. When patients begin to impose self restrictions or exhibit behaviors of avoidance, it is useful to use this as a sign that they may be unsafe on the road. In one study, patients older than 65 years who reported changing their driving habits because of safety concerns had a fivefold increase in the risk of crashes. This does not mean that patients who do not report being concerned about their driving are cleared from a safety standpoint.

• Aggressive or impulsive personality characteristics. One study reported that agitation and aggression were predictors for demented patients who would refuse to discontinue driving. When patients with dementia deliberately violated driving laws, there was a higher rate of accidents.

• Neuropsychological testing. Currently, there is insufficient evidence regarding the value of neuropsychological testing in helping to assess a patient’s ability to drive.

• Interventions. The next question to ask is whether there are available interventions (such as driver training) that might reduce the risk of accidents in older patients with dementia. Unfortunately, no intervention – including in-person license renewal, licensing restrictions, or driver training – has been shown to reliably decrease the risk of accidents for this group of patients.

Bottom Line

The decision about whether a patient can or cannot drive involves balancing a moral and often legal obligation to identify unsafe drivers in order to ensure public safety with the desire and often need of older patients to drive in order to maintain independence.

Physicians should be aware that patients with mild dementia as a group are at increased risk for accidents while driving. Clinicians should assess patients according to the criteria described above to try to identify patients who are at increased driving risk. Patients who are identified as high risk should be asked to give up their driver’s license. If a patient prefers not to, or if there is uncertainty about their degree of risk, the patient can be referred for a formal professional or government on-road driving evaluation.

Reference

D.J. Iverson, G.S. Gronseth, M.A. Reger, et al. Neurology 2010;74;1316-24.

This column, "Clinical Guidelines for Family Physicians," regularly appears in Family Practice News, an Elsevier publication. Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Lin is a first-year resident in the family medicine residency program at Abington Memorial Hospital.

Endometriosis occurs in approximately 8% of reproductive-age women and can have severe consequences, including chronic pelvic pain and infertility. It occurs in approximately one-third of infertile women and up to 87% of women with chronic pelvic pain.

Clinical Manifestations

Pelvic pain is a common complaint in the outpatient office. Symptoms of endometriosis include dysmenorrhea, cyclic chronic pelvic pain, and dyspareunia that is worse during menses.

Diagnosis

Frequently, there are no abnormalities on physical exam that would indicate endometriosis, and labs typically are normal. It is important to consider other diagnoses, including irritable bowel syndrome, interstitial cystitis, and tubal scarring secondary to pelvic inflammatory disease.

Consideration can be given to obtaining a CBC, urinalysis, and gonococcal and chlamydia testing. Pelvic imaging is of limited use but can be considered as part of the initial work-up. If there is an adnexal mass on palpation, imaging studies are accurate in differentiating an endometrioma from other masses. Ultrasound is best utilized in determining the presence of an endometrioma on the ovary in a fertility work-up, rather than as an initial diagnostic tool of endometriosis.

The only definitive way to diagnose endometriosis is through laparoscopy and a histologic examination. Visual examination with laparoscopy or surgery can be helpful, but studies have shown discrepancies between visual assessment and histologic findings. The importance of laparoscopy to diagnose endometriosis has been debated in the literature, with investigators weighing the impression and risks of surgery against the importance of a precise diagnosis when treating with medications.

Medical Treatment

When a woman presents to the office with symptoms consistent with endometriosis, the initial plan should be control of pain and preservation of future fertility. There is no need to verify the diagnosis of endometriosis with imaging or surgery prior to starting therapy.

The first-line therapy in a woman in whom a clinical diagnosis has been made and who has mild symptoms is NSAIDs. If NSAIDs are not sufficient to control pain, then the next line of therapy is oral contraceptives. If the patient is having pain with the withdrawal bleed associated with OCs, then continuous OCs may be beneficial. There is evidence that continuous therapy can provide a significant reduction in pain after a woman has failed cyclic OC therapy.

If first-line treatment with NSAIDs and OCs fails, consider laparoscopic surgery to confirm a diagnosis of endometriosis. An alternative approach includes more empiric therapy or attempting other medical therapies.

Gonadotropin-releasing hormone (GnRH) analogues are effective in reducing dysmenorrhea. But they are no more effective than OCs, and have greater associated side effects, including hot flashes, vaginal dryness, and osteopenia.

When relief of pain supports ongoing therapy, the addition of progestins as add-back therapy decreases bone density loss and side effect–related symptoms without compromising symptomatic efficacy. Add-back therapy can be started concurrently with the GnRH analogues. It should be noted that the Food and Drug Administration has approved GnRH agonist therapy for a 12-month course only.

Depo medroxyprogesterone acetate (DMPA) is also effective suppressive therapy, though it’s less preferred by women looking to become pregnant soon, as there may be a long delay until return to ovulation. It also can be used for a limited time only, and has the side effect of osteopenia.

The levonorgestrel IUD is effective in reducing pain associated with endometriosis, and it has shown persistent benefit at 3 years. The IUD is no better or worse than the GnRH analogues; however, many women discontinue use of the IUD because of weight gain, irregular bleeding, or pain. The IUD does not have FDA approval for the treatment of endometriosis.

Androgens such as danazol are effective treatment but have undesirable side effects, including acne, hirsutism, and myalgias. Therefore, they are not recommended as a first-line therapy.

Surgical Treatment

While surgery may need to be considered in patients with severe pain that is unresponsive to medical treatment, it is not a first-line therapy. Surgery is also considered as the choice of therapy when a woman is suffering from endometriosis-induced infertility and is attempting to conceive.

Such infertility is thought to be due to the presence of an endometrioma on the ovary. Because the endometrioma can invade the ovary, it must be explained to the patient that removing an endometrioma may remove ovarian tissue. There is evidence that an excision of the endometrioma will give a better pregnancy rate than a simple ablation of the cyst, as an endometrioma is likely to reform after an ablation. Although the data do show that there is an improvement in pregnancy rates after surgery, the extent of benefit is not as clear.

Bottom Line

Endometriosis is a common gynecologic condition affecting women of childbearing age. It can be diagnosed in the office on an outpatient basis and often responds to simple medical treatment. First-line therapy is NSAIDs and oral contraceptives. The oral contraceptives can be given as a continuous therapy. If the patient fails conservative medical management, then one can choose to perform a laparoscopy or try further medical management. Surgery may be considered when a woman has endometriosis-induced infertility.

Management of pain and control of symptoms will benefit patients by increasing quality of life and preserving future fertility.

Reference:

• Management of Endometriosis: ACOG Practice Bulletin. (Obstet. Gynecol. 2010;116:223-36).

This column, "Clinical Guidelines for Family Physicians," regularly appears in Family Practice News, an Elsevier publication. Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Thuener is a first-year resident in the family medicine residency at Abington Memorial Hospital. E-mail them.

Endometriosis occurs in approximately 8% of reproductive-age women and can have severe consequences, including chronic pelvic pain and infertility. It occurs in approximately one-third of infertile women and up to 87% of women with chronic pelvic pain.

Clinical Manifestations

Pelvic pain is a common complaint in the outpatient office. Symptoms of endometriosis include dysmenorrhea, cyclic chronic pelvic pain, and dyspareunia that is worse during menses.

Diagnosis

Frequently, there are no abnormalities on physical exam that would indicate endometriosis, and labs typically are normal. It is important to consider other diagnoses, including irritable bowel syndrome, interstitial cystitis, and tubal scarring secondary to pelvic inflammatory disease.

Consideration can be given to obtaining a CBC, urinalysis, and gonococcal and chlamydia testing. Pelvic imaging is of limited use but can be considered as part of the initial work-up. If there is an adnexal mass on palpation, imaging studies are accurate in differentiating an endometrioma from other masses. Ultrasound is best utilized in determining the presence of an endometrioma on the ovary in a fertility work-up, rather than as an initial diagnostic tool of endometriosis.

The only definitive way to diagnose endometriosis is through laparoscopy and a histologic examination. Visual examination with laparoscopy or surgery can be helpful, but studies have shown discrepancies between visual assessment and histologic findings. The importance of laparoscopy to diagnose endometriosis has been debated in the literature, with investigators weighing the impression and risks of surgery against the importance of a precise diagnosis when treating with medications.

Medical Treatment

When a woman presents to the office with symptoms consistent with endometriosis, the initial plan should be control of pain and preservation of future fertility. There is no need to verify the diagnosis of endometriosis with imaging or surgery prior to starting therapy.

The first-line therapy in a woman in whom a clinical diagnosis has been made and who has mild symptoms is NSAIDs. If NSAIDs are not sufficient to control pain, then the next line of therapy is oral contraceptives. If the patient is having pain with the withdrawal bleed associated with OCs, then continuous OCs may be beneficial. There is evidence that continuous therapy can provide a significant reduction in pain after a woman has failed cyclic OC therapy.

If first-line treatment with NSAIDs and OCs fails, consider laparoscopic surgery to confirm a diagnosis of endometriosis. An alternative approach includes more empiric therapy or attempting other medical therapies.

Gonadotropin-releasing hormone (GnRH) analogues are effective in reducing dysmenorrhea. But they are no more effective than OCs, and have greater associated side effects, including hot flashes, vaginal dryness, and osteopenia.

When relief of pain supports ongoing therapy, the addition of progestins as add-back therapy decreases bone density loss and side effect–related symptoms without compromising symptomatic efficacy. Add-back therapy can be started concurrently with the GnRH analogues. It should be noted that the Food and Drug Administration has approved GnRH agonist therapy for a 12-month course only.

Depo medroxyprogesterone acetate (DMPA) is also effective suppressive therapy, though it’s less preferred by women looking to become pregnant soon, as there may be a long delay until return to ovulation. It also can be used for a limited time only, and has the side effect of osteopenia.

The levonorgestrel IUD is effective in reducing pain associated with endometriosis, and it has shown persistent benefit at 3 years. The IUD is no better or worse than the GnRH analogues; however, many women discontinue use of the IUD because of weight gain, irregular bleeding, or pain. The IUD does not have FDA approval for the treatment of endometriosis.

Androgens such as danazol are effective treatment but have undesirable side effects, including acne, hirsutism, and myalgias. Therefore, they are not recommended as a first-line therapy.

Surgical Treatment

While surgery may need to be considered in patients with severe pain that is unresponsive to medical treatment, it is not a first-line therapy. Surgery is also considered as the choice of therapy when a woman is suffering from endometriosis-induced infertility and is attempting to conceive.

Such infertility is thought to be due to the presence of an endometrioma on the ovary. Because the endometrioma can invade the ovary, it must be explained to the patient that removing an endometrioma may remove ovarian tissue. There is evidence that an excision of the endometrioma will give a better pregnancy rate than a simple ablation of the cyst, as an endometrioma is likely to reform after an ablation. Although the data do show that there is an improvement in pregnancy rates after surgery, the extent of benefit is not as clear.

Bottom Line

Endometriosis is a common gynecologic condition affecting women of childbearing age. It can be diagnosed in the office on an outpatient basis and often responds to simple medical treatment. First-line therapy is NSAIDs and oral contraceptives. The oral contraceptives can be given as a continuous therapy. If the patient fails conservative medical management, then one can choose to perform a laparoscopy or try further medical management. Surgery may be considered when a woman has endometriosis-induced infertility.

Management of pain and control of symptoms will benefit patients by increasing quality of life and preserving future fertility.

Reference:

• Management of Endometriosis: ACOG Practice Bulletin. (Obstet. Gynecol. 2010;116:223-36).

This column, "Clinical Guidelines for Family Physicians," regularly appears in Family Practice News, an Elsevier publication. Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Thuener is a first-year resident in the family medicine residency at Abington Memorial Hospital. E-mail them.

Endometriosis occurs in approximately 8% of reproductive-age women and can have severe consequences, including chronic pelvic pain and infertility. It occurs in approximately one-third of infertile women and up to 87% of women with chronic pelvic pain.

Clinical Manifestations

Pelvic pain is a common complaint in the outpatient office. Symptoms of endometriosis include dysmenorrhea, cyclic chronic pelvic pain, and dyspareunia that is worse during menses.

Diagnosis

Frequently, there are no abnormalities on physical exam that would indicate endometriosis, and labs typically are normal. It is important to consider other diagnoses, including irritable bowel syndrome, interstitial cystitis, and tubal scarring secondary to pelvic inflammatory disease.

Consideration can be given to obtaining a CBC, urinalysis, and gonococcal and chlamydia testing. Pelvic imaging is of limited use but can be considered as part of the initial work-up. If there is an adnexal mass on palpation, imaging studies are accurate in differentiating an endometrioma from other masses. Ultrasound is best utilized in determining the presence of an endometrioma on the ovary in a fertility work-up, rather than as an initial diagnostic tool of endometriosis.

The only definitive way to diagnose endometriosis is through laparoscopy and a histologic examination. Visual examination with laparoscopy or surgery can be helpful, but studies have shown discrepancies between visual assessment and histologic findings. The importance of laparoscopy to diagnose endometriosis has been debated in the literature, with investigators weighing the impression and risks of surgery against the importance of a precise diagnosis when treating with medications.

Medical Treatment

When a woman presents to the office with symptoms consistent with endometriosis, the initial plan should be control of pain and preservation of future fertility. There is no need to verify the diagnosis of endometriosis with imaging or surgery prior to starting therapy.

The first-line therapy in a woman in whom a clinical diagnosis has been made and who has mild symptoms is NSAIDs. If NSAIDs are not sufficient to control pain, then the next line of therapy is oral contraceptives. If the patient is having pain with the withdrawal bleed associated with OCs, then continuous OCs may be beneficial. There is evidence that continuous therapy can provide a significant reduction in pain after a woman has failed cyclic OC therapy.

If first-line treatment with NSAIDs and OCs fails, consider laparoscopic surgery to confirm a diagnosis of endometriosis. An alternative approach includes more empiric therapy or attempting other medical therapies.

Gonadotropin-releasing hormone (GnRH) analogues are effective in reducing dysmenorrhea. But they are no more effective than OCs, and have greater associated side effects, including hot flashes, vaginal dryness, and osteopenia.

When relief of pain supports ongoing therapy, the addition of progestins as add-back therapy decreases bone density loss and side effect–related symptoms without compromising symptomatic efficacy. Add-back therapy can be started concurrently with the GnRH analogues. It should be noted that the Food and Drug Administration has approved GnRH agonist therapy for a 12-month course only.

Depo medroxyprogesterone acetate (DMPA) is also effective suppressive therapy, though it’s less preferred by women looking to become pregnant soon, as there may be a long delay until return to ovulation. It also can be used for a limited time only, and has the side effect of osteopenia.

The levonorgestrel IUD is effective in reducing pain associated with endometriosis, and it has shown persistent benefit at 3 years. The IUD is no better or worse than the GnRH analogues; however, many women discontinue use of the IUD because of weight gain, irregular bleeding, or pain. The IUD does not have FDA approval for the treatment of endometriosis.

Androgens such as danazol are effective treatment but have undesirable side effects, including acne, hirsutism, and myalgias. Therefore, they are not recommended as a first-line therapy.

Surgical Treatment

While surgery may need to be considered in patients with severe pain that is unresponsive to medical treatment, it is not a first-line therapy. Surgery is also considered as the choice of therapy when a woman is suffering from endometriosis-induced infertility and is attempting to conceive.

Such infertility is thought to be due to the presence of an endometrioma on the ovary. Because the endometrioma can invade the ovary, it must be explained to the patient that removing an endometrioma may remove ovarian tissue. There is evidence that an excision of the endometrioma will give a better pregnancy rate than a simple ablation of the cyst, as an endometrioma is likely to reform after an ablation. Although the data do show that there is an improvement in pregnancy rates after surgery, the extent of benefit is not as clear.

Bottom Line

Endometriosis is a common gynecologic condition affecting women of childbearing age. It can be diagnosed in the office on an outpatient basis and often responds to simple medical treatment. First-line therapy is NSAIDs and oral contraceptives. The oral contraceptives can be given as a continuous therapy. If the patient fails conservative medical management, then one can choose to perform a laparoscopy or try further medical management. Surgery may be considered when a woman has endometriosis-induced infertility.

Management of pain and control of symptoms will benefit patients by increasing quality of life and preserving future fertility.

Reference:

• Management of Endometriosis: ACOG Practice Bulletin. (Obstet. Gynecol. 2010;116:223-36).

This column, "Clinical Guidelines for Family Physicians," regularly appears in Family Practice News, an Elsevier publication. Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Thuener is a first-year resident in the family medicine residency at Abington Memorial Hospital. E-mail them.

Polycystic ovary syndrome, with a prevalence of approximately 7% of women, is a common, important, and often underrecognized condition.

Although definitions vary, PCOS is characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovaries. Obesity often results in hyperinsulinemia, which may contribute to decreased levels of sex hormone–binding globulin (SHBG), increased circulating androgen, and increased androgen production. Obesity may exacerbate the clinical manifestations of PCOS, but not all women with PCOS are obese.

Diagnostic Criteria

The three following diagnostic criteria are commonly referenced for PCOS:

• NIH criteria. Hyperandrogenism and menstrual abnormalities (amenorrhea or oligomenorrhea) must be present.

• Rotterdam criteria. Ultrasonography of polycystic ovaries is an important component of the diagnosis of PCOS (12 or more follicles, 2- to 9-mm diameter, or increased ovarian volume greater than 10 cm3). This testing has been criticized for increasing the number of PCOS diagnoses and subjecting women without PCOS to unwarranted management.

• Androgen Excess Society criteria. Hyperandrogenism (whether present clinically or in serum) must be present.

Appropriate history and physical should include medications, onset of androgen excess, menstrual history, family history, blood pressure, body mass index, waist circumference, signs of hyperandrogenism (acne, clitoromegaly, body hair distribution, balding), and signs of insulin resistance (acanthosis nigricans, obesity). Lab assessments should include fasting lipids, fasting glucose, 2-hour oral glucose tolerance test, total testosterone (free testosterone and SHBG), as well as thyroid-stimulating hormone, prolactin, and 17-hydroxyprogesterone. If Cushing’s disease is suspected, 24-hour urinary free-cortisol excretion test or low-dose dexamethasone suppression test should be obtained. A pelvic ultrasonography can be used to evaluate for polycystic ovaries and endometrial abnormalities.

Clinical Manifestations

Clinical manifestations include menstrual dysfunction, infertility, hirsutism, acne, androgenic alopecia, insulin resistance, and metabolic syndrome. Long-term sequelae include an increased risk of type 2 diabetes, cardiovascular disease, and endometrial cancer.

Differential Diagnosis

Diseases to consider in patients with the clinical manifestations listed above are thyroid disease, exogenous androgens, primary ovarian failure, and prolactin disorders. In addition, be aware of rare disorders that can cause symptoms similar to PCOS, including Cushing’s syndrome, androgen-secreting tumors of the ovaries or adrenals, and nonclassical congenital adrenal hyperplasia.

Weight Loss With PCOS

Weight loss in obese women with PCOS produces increases in SHBG, decreased circulating-androgen levels, resumption of menses, and improved pregnancy rates. Weight loss also decreases hirsutism, insulin resistance, and lipid levels. Weight loss that occurs by lifestyle modifications, pharmacologic agents (such as orlistat), and gastric bypass have shown similar effects.

PCOS and Diabetes Risk

There is a two- to fivefold increased risk of diabetes in women with PCOS. Women with PCOS should be screened with a fasting-glucose level and a 2-hour glucose level after a 75-g glucose load. Metabolic syndrome (defined as blood pressure greater than 130/85, waist circumference greater than 35 inches, fasting glucose greater than 100 mg/dL, HDL cholesterol less than 50 mg/dL, and triglycerides greater than 150 mg/dL) affects nearly 33% of women with PCOS. Although there are insufficient data to recommend insulin-sensitizing pharmacological agents prophylactically, the National Institute of Diabetes and Digestive and Kidney Diseases’ Diabetic Prevention Program trials showed a decreased risk of developing type 2 diabetes in women with PCOS when lifestyle modifications or metformin (1,500-2,000 mg/day) were used by those with impaired glucose tolerance.

Cardiovascular Disease Risk

There is no well-documented evidence of increased risk of cardiovascular events in women with PCOS. However, given the increase in cardiovascular risk factors, their cardiovascular risk should be periodically assessed. These risks can be reduced through exercise, caloric restriction, weight control, and possibly by introducing statins and insulin-sensitizing agents.

Menstrual Dysfunction

Combination low-dose hormonal contraceptives are the primary treatment for menstrual dysfunction. They work by suppressing luteinizing hormone and androgen secretion by the ovaries and increasing circulating SHBG. Progestin-only contraceptives or intrauterine devices prevent endometrial cancer in women with PCOS and can be used as an alternative. There is an increased risk (50%-89%) of abnormal bleeding.

Although not FDA approved for treating menstrual abnormalities, insulin-sensitizing agents are associated with improved ovulation and glucose tolerance, and decreased circulating androgen levels by increasing SHBG.

Ovulation Induction in PCOS

Clomiphene citrate is the first-line agent that is recommended to induce ovulation, followed by either laparoscopic ovarian surgery or exogenous gonadotropins. Ovulation induction carries the risk of ovarian hyperstimulation, multiple births, and hypertensive disorder. Gonadotropins carry a lesser risk of ovarian hyperstimulation but an increased risk of multiple births. Aromatase inhibitors have been proposed to be similar to clomiphene, with higher implantation rates, less risk of multiple pregnancies, and a shorter half-life. Although metformin has been suggested, success rates are not as high as with clomiphene – although some studies show increased success rates when metformin is combined with clomiphene.

Treating Hirsutism

Topical eflornithine is the only FDA-approved treatment for hirsutism; it has a 60% improvement rate after 6 months. Some nonrandomized studies have shown improvement with hormonal contraceptives, especially when they are combined with spironolactone (an androgen receptor antagonist). Antiandrogens have been used empirically and are often combined with oral contraceptives because of their teratogenic effects. There is no evidence that metformin improves hirsutism. Mechanical hair removal (by shaving, waxing, plucking, electrolysis, or laser) is often the treatment of choice.

Bottom Line

PCOS is characterized by a combination of hyperandrogenism, insulin resistance, menstrual dysfunction, polycystic ovaries, infertility, hirsutism, acne, androgenic alopecia, and metabolic syndrome. The most effective intervention for PCOS appears to be lifestyle management, with a goal of exercise and weight loss. Further treatment is geared toward symptom relief and reduction of long-term cardiovascular risk. (Reference: ACOG Practice Bulletin No. 108: Polycystic Ovary Syndrome. Obstet. Gynecol. 2009;114:936-49.)

This column, "Clinical Guidelines for Family Physicians," regularly appears in Family Practice News, an Elsevier publication. Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Myers is a chief resident in the family medicine residency program at Abington Memorial Hospital.

Polycystic ovary syndrome, with a prevalence of approximately 7% of women, is a common, important, and often underrecognized condition.

Although definitions vary, PCOS is characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovaries. Obesity often results in hyperinsulinemia, which may contribute to decreased levels of sex hormone–binding globulin (SHBG), increased circulating androgen, and increased androgen production. Obesity may exacerbate the clinical manifestations of PCOS, but not all women with PCOS are obese.

Diagnostic Criteria

The three following diagnostic criteria are commonly referenced for PCOS:

• NIH criteria. Hyperandrogenism and menstrual abnormalities (amenorrhea or oligomenorrhea) must be present.

• Rotterdam criteria. Ultrasonography of polycystic ovaries is an important component of the diagnosis of PCOS (12 or more follicles, 2- to 9-mm diameter, or increased ovarian volume greater than 10 cm3). This testing has been criticized for increasing the number of PCOS diagnoses and subjecting women without PCOS to unwarranted management.

• Androgen Excess Society criteria. Hyperandrogenism (whether present clinically or in serum) must be present.

Appropriate history and physical should include medications, onset of androgen excess, menstrual history, family history, blood pressure, body mass index, waist circumference, signs of hyperandrogenism (acne, clitoromegaly, body hair distribution, balding), and signs of insulin resistance (acanthosis nigricans, obesity). Lab assessments should include fasting lipids, fasting glucose, 2-hour oral glucose tolerance test, total testosterone (free testosterone and SHBG), as well as thyroid-stimulating hormone, prolactin, and 17-hydroxyprogesterone. If Cushing’s disease is suspected, 24-hour urinary free-cortisol excretion test or low-dose dexamethasone suppression test should be obtained. A pelvic ultrasonography can be used to evaluate for polycystic ovaries and endometrial abnormalities.

Clinical Manifestations

Clinical manifestations include menstrual dysfunction, infertility, hirsutism, acne, androgenic alopecia, insulin resistance, and metabolic syndrome. Long-term sequelae include an increased risk of type 2 diabetes, cardiovascular disease, and endometrial cancer.

Differential Diagnosis

Diseases to consider in patients with the clinical manifestations listed above are thyroid disease, exogenous androgens, primary ovarian failure, and prolactin disorders. In addition, be aware of rare disorders that can cause symptoms similar to PCOS, including Cushing’s syndrome, androgen-secreting tumors of the ovaries or adrenals, and nonclassical congenital adrenal hyperplasia.

Weight Loss With PCOS

Weight loss in obese women with PCOS produces increases in SHBG, decreased circulating-androgen levels, resumption of menses, and improved pregnancy rates. Weight loss also decreases hirsutism, insulin resistance, and lipid levels. Weight loss that occurs by lifestyle modifications, pharmacologic agents (such as orlistat), and gastric bypass have shown similar effects.

PCOS and Diabetes Risk

There is a two- to fivefold increased risk of diabetes in women with PCOS. Women with PCOS should be screened with a fasting-glucose level and a 2-hour glucose level after a 75-g glucose load. Metabolic syndrome (defined as blood pressure greater than 130/85, waist circumference greater than 35 inches, fasting glucose greater than 100 mg/dL, HDL cholesterol less than 50 mg/dL, and triglycerides greater than 150 mg/dL) affects nearly 33% of women with PCOS. Although there are insufficient data to recommend insulin-sensitizing pharmacological agents prophylactically, the National Institute of Diabetes and Digestive and Kidney Diseases’ Diabetic Prevention Program trials showed a decreased risk of developing type 2 diabetes in women with PCOS when lifestyle modifications or metformin (1,500-2,000 mg/day) were used by those with impaired glucose tolerance.

Cardiovascular Disease Risk

There is no well-documented evidence of increased risk of cardiovascular events in women with PCOS. However, given the increase in cardiovascular risk factors, their cardiovascular risk should be periodically assessed. These risks can be reduced through exercise, caloric restriction, weight control, and possibly by introducing statins and insulin-sensitizing agents.

Menstrual Dysfunction

Combination low-dose hormonal contraceptives are the primary treatment for menstrual dysfunction. They work by suppressing luteinizing hormone and androgen secretion by the ovaries and increasing circulating SHBG. Progestin-only contraceptives or intrauterine devices prevent endometrial cancer in women with PCOS and can be used as an alternative. There is an increased risk (50%-89%) of abnormal bleeding.

Although not FDA approved for treating menstrual abnormalities, insulin-sensitizing agents are associated with improved ovulation and glucose tolerance, and decreased circulating androgen levels by increasing SHBG.

Ovulation Induction in PCOS

Clomiphene citrate is the first-line agent that is recommended to induce ovulation, followed by either laparoscopic ovarian surgery or exogenous gonadotropins. Ovulation induction carries the risk of ovarian hyperstimulation, multiple births, and hypertensive disorder. Gonadotropins carry a lesser risk of ovarian hyperstimulation but an increased risk of multiple births. Aromatase inhibitors have been proposed to be similar to clomiphene, with higher implantation rates, less risk of multiple pregnancies, and a shorter half-life. Although metformin has been suggested, success rates are not as high as with clomiphene – although some studies show increased success rates when metformin is combined with clomiphene.

Treating Hirsutism

Topical eflornithine is the only FDA-approved treatment for hirsutism; it has a 60% improvement rate after 6 months. Some nonrandomized studies have shown improvement with hormonal contraceptives, especially when they are combined with spironolactone (an androgen receptor antagonist). Antiandrogens have been used empirically and are often combined with oral contraceptives because of their teratogenic effects. There is no evidence that metformin improves hirsutism. Mechanical hair removal (by shaving, waxing, plucking, electrolysis, or laser) is often the treatment of choice.

Bottom Line

PCOS is characterized by a combination of hyperandrogenism, insulin resistance, menstrual dysfunction, polycystic ovaries, infertility, hirsutism, acne, androgenic alopecia, and metabolic syndrome. The most effective intervention for PCOS appears to be lifestyle management, with a goal of exercise and weight loss. Further treatment is geared toward symptom relief and reduction of long-term cardiovascular risk. (Reference: ACOG Practice Bulletin No. 108: Polycystic Ovary Syndrome. Obstet. Gynecol. 2009;114:936-49.)

This column, "Clinical Guidelines for Family Physicians," regularly appears in Family Practice News, an Elsevier publication. Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Myers is a chief resident in the family medicine residency program at Abington Memorial Hospital.

Polycystic ovary syndrome, with a prevalence of approximately 7% of women, is a common, important, and often underrecognized condition.

Although definitions vary, PCOS is characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovaries. Obesity often results in hyperinsulinemia, which may contribute to decreased levels of sex hormone–binding globulin (SHBG), increased circulating androgen, and increased androgen production. Obesity may exacerbate the clinical manifestations of PCOS, but not all women with PCOS are obese.

Diagnostic Criteria

The three following diagnostic criteria are commonly referenced for PCOS:

• NIH criteria. Hyperandrogenism and menstrual abnormalities (amenorrhea or oligomenorrhea) must be present.

• Rotterdam criteria. Ultrasonography of polycystic ovaries is an important component of the diagnosis of PCOS (12 or more follicles, 2- to 9-mm diameter, or increased ovarian volume greater than 10 cm3). This testing has been criticized for increasing the number of PCOS diagnoses and subjecting women without PCOS to unwarranted management.

• Androgen Excess Society criteria. Hyperandrogenism (whether present clinically or in serum) must be present.

Appropriate history and physical should include medications, onset of androgen excess, menstrual history, family history, blood pressure, body mass index, waist circumference, signs of hyperandrogenism (acne, clitoromegaly, body hair distribution, balding), and signs of insulin resistance (acanthosis nigricans, obesity). Lab assessments should include fasting lipids, fasting glucose, 2-hour oral glucose tolerance test, total testosterone (free testosterone and SHBG), as well as thyroid-stimulating hormone, prolactin, and 17-hydroxyprogesterone. If Cushing’s disease is suspected, 24-hour urinary free-cortisol excretion test or low-dose dexamethasone suppression test should be obtained. A pelvic ultrasonography can be used to evaluate for polycystic ovaries and endometrial abnormalities.

Clinical Manifestations

Clinical manifestations include menstrual dysfunction, infertility, hirsutism, acne, androgenic alopecia, insulin resistance, and metabolic syndrome. Long-term sequelae include an increased risk of type 2 diabetes, cardiovascular disease, and endometrial cancer.

Differential Diagnosis

Diseases to consider in patients with the clinical manifestations listed above are thyroid disease, exogenous androgens, primary ovarian failure, and prolactin disorders. In addition, be aware of rare disorders that can cause symptoms similar to PCOS, including Cushing’s syndrome, androgen-secreting tumors of the ovaries or adrenals, and nonclassical congenital adrenal hyperplasia.

Weight Loss With PCOS

Weight loss in obese women with PCOS produces increases in SHBG, decreased circulating-androgen levels, resumption of menses, and improved pregnancy rates. Weight loss also decreases hirsutism, insulin resistance, and lipid levels. Weight loss that occurs by lifestyle modifications, pharmacologic agents (such as orlistat), and gastric bypass have shown similar effects.

PCOS and Diabetes Risk

There is a two- to fivefold increased risk of diabetes in women with PCOS. Women with PCOS should be screened with a fasting-glucose level and a 2-hour glucose level after a 75-g glucose load. Metabolic syndrome (defined as blood pressure greater than 130/85, waist circumference greater than 35 inches, fasting glucose greater than 100 mg/dL, HDL cholesterol less than 50 mg/dL, and triglycerides greater than 150 mg/dL) affects nearly 33% of women with PCOS. Although there are insufficient data to recommend insulin-sensitizing pharmacological agents prophylactically, the National Institute of Diabetes and Digestive and Kidney Diseases’ Diabetic Prevention Program trials showed a decreased risk of developing type 2 diabetes in women with PCOS when lifestyle modifications or metformin (1,500-2,000 mg/day) were used by those with impaired glucose tolerance.

Cardiovascular Disease Risk

There is no well-documented evidence of increased risk of cardiovascular events in women with PCOS. However, given the increase in cardiovascular risk factors, their cardiovascular risk should be periodically assessed. These risks can be reduced through exercise, caloric restriction, weight control, and possibly by introducing statins and insulin-sensitizing agents.

Menstrual Dysfunction

Combination low-dose hormonal contraceptives are the primary treatment for menstrual dysfunction. They work by suppressing luteinizing hormone and androgen secretion by the ovaries and increasing circulating SHBG. Progestin-only contraceptives or intrauterine devices prevent endometrial cancer in women with PCOS and can be used as an alternative. There is an increased risk (50%-89%) of abnormal bleeding.

Although not FDA approved for treating menstrual abnormalities, insulin-sensitizing agents are associated with improved ovulation and glucose tolerance, and decreased circulating androgen levels by increasing SHBG.

Ovulation Induction in PCOS

Clomiphene citrate is the first-line agent that is recommended to induce ovulation, followed by either laparoscopic ovarian surgery or exogenous gonadotropins. Ovulation induction carries the risk of ovarian hyperstimulation, multiple births, and hypertensive disorder. Gonadotropins carry a lesser risk of ovarian hyperstimulation but an increased risk of multiple births. Aromatase inhibitors have been proposed to be similar to clomiphene, with higher implantation rates, less risk of multiple pregnancies, and a shorter half-life. Although metformin has been suggested, success rates are not as high as with clomiphene – although some studies show increased success rates when metformin is combined with clomiphene.

Treating Hirsutism

Topical eflornithine is the only FDA-approved treatment for hirsutism; it has a 60% improvement rate after 6 months. Some nonrandomized studies have shown improvement with hormonal contraceptives, especially when they are combined with spironolactone (an androgen receptor antagonist). Antiandrogens have been used empirically and are often combined with oral contraceptives because of their teratogenic effects. There is no evidence that metformin improves hirsutism. Mechanical hair removal (by shaving, waxing, plucking, electrolysis, or laser) is often the treatment of choice.

Bottom Line

PCOS is characterized by a combination of hyperandrogenism, insulin resistance, menstrual dysfunction, polycystic ovaries, infertility, hirsutism, acne, androgenic alopecia, and metabolic syndrome. The most effective intervention for PCOS appears to be lifestyle management, with a goal of exercise and weight loss. Further treatment is geared toward symptom relief and reduction of long-term cardiovascular risk. (Reference: ACOG Practice Bulletin No. 108: Polycystic Ovary Syndrome. Obstet. Gynecol. 2009;114:936-49.)

This column, "Clinical Guidelines for Family Physicians," regularly appears in Family Practice News, an Elsevier publication. Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Myers is a chief resident in the family medicine residency program at Abington Memorial Hospital.

The incidence of childhood obesity is on the rise, with recent data from the Centers for Disease Control and Prevention suggesting that 12%-18% of children aged 2-19 years are considered obese. This represents a three- to sixfold increase in the prevalence of pediatric obesity since the 1970s.

Obesity has clear complications and comorbidities, including increased risk of type 2 diabetes, asthma, and nonalcoholic fatty liver disease, as well as an increased risk of adverse psychological issues such as depression. Characteristics that increase the risk for pediatric obesity include male gender, advancing age (adolescents are at high risk), and minority status.

In 2005, the U.S. Preventive Services Task Force released a recommendation statement promoting the use of body mass index (BMI) as a suitable screening method for obesity in the pediatric population. Recently, the USPSTF released an updated statement on pediatric obesity with a stronger focus on treatment and outcomes.

Screening

Screening for overweight and obese children should be performed utilizing BMI, which is calculated as weight in kilograms divided by height in meters squared. This is a grade “B” recommendation, meaning that there is a moderate degree of certainty that the net benefit is moderate. The BMI is then plotted on growth charts against gender- and age-specific norms. These growth charts were published by the CDC in 2000 and were formulated with data from multiple national health examination surveys spanning 3 decades.

In the pediatric population, “overweight” is defined as BMI in the 85th-94th percentiles; “obese” is defined as a BMI of at least the 95th percentile, as plotted for age and sex, based on data collected from 1963 to 1995.

Although the USPSTF found moderate evidence to utilize BMI an acceptable screening method for obesity, it did not find adequate evidence to recommend screening timing and intervals other than routine measurements performed at regularly scheduled health maintenance visits. The USPSTF also found sufficient evidence to recommend initiation of screening for obesity beginning at 6 years of age.

Behavioral Treatment

On review of thirteen trials including more than 1,200 children and adolescents aged 4-18 years, the USPSTF found moderate evidence that identification of an obese pediatric patient via BMI screening with subsequent referral to a moderate- to high-intensity intervention at a specialty health care center resulted in modest weight loss over 12 months; these programs were defined as providing at least 25 hours of contact between the child and/or family and the health care center over a 6-month period. Very low or low-intensity programs (defined as less than 25 hours of patient to health professional interaction over a 6-month period) were not found to be statistically significant in terms of weight loss.

Interventions were deemed comprehensive if they included the following characteristics: weight loss/diet counseling, physical activity counseling, behavior management instruction, and sustained support regarding new diet and exercise changes. Behavioral management often included cognitive behavioral therapy in reference to self-monitoring, impulse control, and triggers for overeating/poor food choices.

Examples of moderate weight loss in a 16-year-old were, on average, 19 pounds for a female and 22-23 pounds for a male.

There was limited evidence that moderate- to high-intensity programs yielded improvements in insulin resistance in pediatric patients. However, there was not a consistent reduction in other cardiovascular risk factors, including blood pressure or cholesterol levels.

Pharmacologic Treatment

Two medications are FDA-approved for weight reduction in the adolescent population. Orlistat is a pancreatic lipase inhibitor and is approved for children 12 years and older; sibutramine is a centrally acting appetite suppressant and serotonin reuptake inhibitor approved for adolescents 16 years and older. Small but significant improvements in BMI were found when these medications were used in conjunction with behavioral interventions.

While the addition of either of the two medications did not appear to affect growth or mental health, gastrointestinal side effects – such as abdominal cramping, flatus, or oily spotting – were common and found in about 30% of the patient population, particularly with sibutramine. Sibutramine also has been associated with an increase in blood pressure and heart rate, with recent questionable links to increased cardiovascular events in the adult population. Cardiovascular effects in the pediatric population are unknown. Data also are lacking regarding weight maintenance in the pediatric population after discontinuation of these medications.

Limitations

The USPSTF statement did not address children younger than 6 years of age. In addition, the effects of intensive behavioral interventions on overweight children – but not obese children – have not been carefully studied. Further limitations include a need for more information on appropriate obesity interventions for low-income children.

The USPSTF concluded that low-intensity interventions, which could be applied in the primary care outpatient setting, were not found to have a significant effect on BMI in the obese pediatric patient. More studies and subsequent recommendations on the role of the primary care physician in the treatment of the overweight and/or obese pediatric patient are needed.

Bottom Line

Recommendations are clear that primary care physicians at routine checkups should screen all pediatric patients 6 years and older for obesity using BMI. Once identified, obese pediatric patients should then offered referral to a moderate- to high-intensity weight-management program.

Reference

U.S. Preventive Services Task Force. Screening for obesity in children and adolescents. Pediatrics 2010;125:361-7.

Dr. Skolnik is an associate director of the Family Medicine Residency Program at Abington (Pa.) Memorial Hospital. Dr. Mady is an attending physician with the Geisinger Health System in Orwigsburg, Pa.

The incidence of childhood obesity is on the rise, with recent data from the Centers for Disease Control and Prevention suggesting that 12%-18% of children aged 2-19 years are considered obese. This represents a three- to sixfold increase in the prevalence of pediatric obesity since the 1970s.

Obesity has clear complications and comorbidities, including increased risk of type 2 diabetes, asthma, and nonalcoholic fatty liver disease, as well as an increased risk of adverse psychological issues such as depression. Characteristics that increase the risk for pediatric obesity include male gender, advancing age (adolescents are at high risk), and minority status.

In 2005, the U.S. Preventive Services Task Force released a recommendation statement promoting the use of body mass index (BMI) as a suitable screening method for obesity in the pediatric population. Recently, the USPSTF released an updated statement on pediatric obesity with a stronger focus on treatment and outcomes.

Screening

Screening for overweight and obese children should be performed utilizing BMI, which is calculated as weight in kilograms divided by height in meters squared. This is a grade “B” recommendation, meaning that there is a moderate degree of certainty that the net benefit is moderate. The BMI is then plotted on growth charts against gender- and age-specific norms. These growth charts were published by the CDC in 2000 and were formulated with data from multiple national health examination surveys spanning 3 decades.

In the pediatric population, “overweight” is defined as BMI in the 85th-94th percentiles; “obese” is defined as a BMI of at least the 95th percentile, as plotted for age and sex, based on data collected from 1963 to 1995.

Although the USPSTF found moderate evidence to utilize BMI an acceptable screening method for obesity, it did not find adequate evidence to recommend screening timing and intervals other than routine measurements performed at regularly scheduled health maintenance visits. The USPSTF also found sufficient evidence to recommend initiation of screening for obesity beginning at 6 years of age.

Behavioral Treatment

On review of thirteen trials including more than 1,200 children and adolescents aged 4-18 years, the USPSTF found moderate evidence that identification of an obese pediatric patient via BMI screening with subsequent referral to a moderate- to high-intensity intervention at a specialty health care center resulted in modest weight loss over 12 months; these programs were defined as providing at least 25 hours of contact between the child and/or family and the health care center over a 6-month period. Very low or low-intensity programs (defined as less than 25 hours of patient to health professional interaction over a 6-month period) were not found to be statistically significant in terms of weight loss.

Interventions were deemed comprehensive if they included the following characteristics: weight loss/diet counseling, physical activity counseling, behavior management instruction, and sustained support regarding new diet and exercise changes. Behavioral management often included cognitive behavioral therapy in reference to self-monitoring, impulse control, and triggers for overeating/poor food choices.

Examples of moderate weight loss in a 16-year-old were, on average, 19 pounds for a female and 22-23 pounds for a male.

There was limited evidence that moderate- to high-intensity programs yielded improvements in insulin resistance in pediatric patients. However, there was not a consistent reduction in other cardiovascular risk factors, including blood pressure or cholesterol levels.

Pharmacologic Treatment

Two medications are FDA-approved for weight reduction in the adolescent population. Orlistat is a pancreatic lipase inhibitor and is approved for children 12 years and older; sibutramine is a centrally acting appetite suppressant and serotonin reuptake inhibitor approved for adolescents 16 years and older. Small but significant improvements in BMI were found when these medications were used in conjunction with behavioral interventions.

While the addition of either of the two medications did not appear to affect growth or mental health, gastrointestinal side effects – such as abdominal cramping, flatus, or oily spotting – were common and found in about 30% of the patient population, particularly with sibutramine. Sibutramine also has been associated with an increase in blood pressure and heart rate, with recent questionable links to increased cardiovascular events in the adult population. Cardiovascular effects in the pediatric population are unknown. Data also are lacking regarding weight maintenance in the pediatric population after discontinuation of these medications.

Limitations

The USPSTF statement did not address children younger than 6 years of age. In addition, the effects of intensive behavioral interventions on overweight children – but not obese children – have not been carefully studied. Further limitations include a need for more information on appropriate obesity interventions for low-income children.

The USPSTF concluded that low-intensity interventions, which could be applied in the primary care outpatient setting, were not found to have a significant effect on BMI in the obese pediatric patient. More studies and subsequent recommendations on the role of the primary care physician in the treatment of the overweight and/or obese pediatric patient are needed.

Bottom Line

Recommendations are clear that primary care physicians at routine checkups should screen all pediatric patients 6 years and older for obesity using BMI. Once identified, obese pediatric patients should then offered referral to a moderate- to high-intensity weight-management program.

Reference

U.S. Preventive Services Task Force. Screening for obesity in children and adolescents. Pediatrics 2010;125:361-7.

Dr. Skolnik is an associate director of the Family Medicine Residency Program at Abington (Pa.) Memorial Hospital. Dr. Mady is an attending physician with the Geisinger Health System in Orwigsburg, Pa.

The incidence of childhood obesity is on the rise, with recent data from the Centers for Disease Control and Prevention suggesting that 12%-18% of children aged 2-19 years are considered obese. This represents a three- to sixfold increase in the prevalence of pediatric obesity since the 1970s.

Obesity has clear complications and comorbidities, including increased risk of type 2 diabetes, asthma, and nonalcoholic fatty liver disease, as well as an increased risk of adverse psychological issues such as depression. Characteristics that increase the risk for pediatric obesity include male gender, advancing age (adolescents are at high risk), and minority status.

In 2005, the U.S. Preventive Services Task Force released a recommendation statement promoting the use of body mass index (BMI) as a suitable screening method for obesity in the pediatric population. Recently, the USPSTF released an updated statement on pediatric obesity with a stronger focus on treatment and outcomes.

Screening

Screening for overweight and obese children should be performed utilizing BMI, which is calculated as weight in kilograms divided by height in meters squared. This is a grade “B” recommendation, meaning that there is a moderate degree of certainty that the net benefit is moderate. The BMI is then plotted on growth charts against gender- and age-specific norms. These growth charts were published by the CDC in 2000 and were formulated with data from multiple national health examination surveys spanning 3 decades.

In the pediatric population, “overweight” is defined as BMI in the 85th-94th percentiles; “obese” is defined as a BMI of at least the 95th percentile, as plotted for age and sex, based on data collected from 1963 to 1995.

Although the USPSTF found moderate evidence to utilize BMI an acceptable screening method for obesity, it did not find adequate evidence to recommend screening timing and intervals other than routine measurements performed at regularly scheduled health maintenance visits. The USPSTF also found sufficient evidence to recommend initiation of screening for obesity beginning at 6 years of age.

Behavioral Treatment

On review of thirteen trials including more than 1,200 children and adolescents aged 4-18 years, the USPSTF found moderate evidence that identification of an obese pediatric patient via BMI screening with subsequent referral to a moderate- to high-intensity intervention at a specialty health care center resulted in modest weight loss over 12 months; these programs were defined as providing at least 25 hours of contact between the child and/or family and the health care center over a 6-month period. Very low or low-intensity programs (defined as less than 25 hours of patient to health professional interaction over a 6-month period) were not found to be statistically significant in terms of weight loss.

Interventions were deemed comprehensive if they included the following characteristics: weight loss/diet counseling, physical activity counseling, behavior management instruction, and sustained support regarding new diet and exercise changes. Behavioral management often included cognitive behavioral therapy in reference to self-monitoring, impulse control, and triggers for overeating/poor food choices.

Examples of moderate weight loss in a 16-year-old were, on average, 19 pounds for a female and 22-23 pounds for a male.

There was limited evidence that moderate- to high-intensity programs yielded improvements in insulin resistance in pediatric patients. However, there was not a consistent reduction in other cardiovascular risk factors, including blood pressure or cholesterol levels.

Pharmacologic Treatment

Two medications are FDA-approved for weight reduction in the adolescent population. Orlistat is a pancreatic lipase inhibitor and is approved for children 12 years and older; sibutramine is a centrally acting appetite suppressant and serotonin reuptake inhibitor approved for adolescents 16 years and older. Small but significant improvements in BMI were found when these medications were used in conjunction with behavioral interventions.

While the addition of either of the two medications did not appear to affect growth or mental health, gastrointestinal side effects – such as abdominal cramping, flatus, or oily spotting – were common and found in about 30% of the patient population, particularly with sibutramine. Sibutramine also has been associated with an increase in blood pressure and heart rate, with recent questionable links to increased cardiovascular events in the adult population. Cardiovascular effects in the pediatric population are unknown. Data also are lacking regarding weight maintenance in the pediatric population after discontinuation of these medications.

Limitations

The USPSTF statement did not address children younger than 6 years of age. In addition, the effects of intensive behavioral interventions on overweight children – but not obese children – have not been carefully studied. Further limitations include a need for more information on appropriate obesity interventions for low-income children.

The USPSTF concluded that low-intensity interventions, which could be applied in the primary care outpatient setting, were not found to have a significant effect on BMI in the obese pediatric patient. More studies and subsequent recommendations on the role of the primary care physician in the treatment of the overweight and/or obese pediatric patient are needed.

Bottom Line

Recommendations are clear that primary care physicians at routine checkups should screen all pediatric patients 6 years and older for obesity using BMI. Once identified, obese pediatric patients should then offered referral to a moderate- to high-intensity weight-management program.

Reference

U.S. Preventive Services Task Force. Screening for obesity in children and adolescents. Pediatrics 2010;125:361-7.

Dr. Skolnik is an associate director of the Family Medicine Residency Program at Abington (Pa.) Memorial Hospital. Dr. Mady is an attending physician with the Geisinger Health System in Orwigsburg, Pa.