Kenneth W. Lin

Is widespread screening for hepatitis C justified

Several organisations have recommended greatly expanded screening for hepatitis C infection. Ronald Koretz and colleagues are concerned that no study has tested whether this will lead to net clinical benefit or harm in screened populations

Clinical Practice Guideline (Update)

Objective This update of the 2008 American Academy of Otolaryngology—Head and Neck Surgery Foundation cerumen impaction clinical practice guideline provides evidence-based recommendations on managing cerumen impaction. Cerumen impaction is defined as an accumulation of cerumen that causes symptoms, prevents assessment of the ear, or both. Changes from the prior guideline include a consumer added to the development group; new evidence (3 guidelines, 5 systematic reviews, and 6 randomized controlled trials); enhanced information on patient education and counseling; a new algorithm to clarify action statement relationships; expanded action statement profiles to explicitly state quality improvement opportunities, confidence in the evidence, intentional vagueness, and differences of opinion; an enhanced external review process to include public comment and journal peer review; and 3 new key action statements on managing cerumen impaction that focus on primary prevention, contraindicated intervention, and referral and coordination of care. Purpose The primary purpose of this guideline is to help clinicians identify patients with cerumen impaction who may benefit from intervention and to promote evidence-based management. Another purpose of the guideline is to highlight needs and management options in special populations or in patients who have modifying factors. The guideline is intended for all clinicians who are likely to diagnose and manage patients with cerumen impaction, and it applies to any setting in which cerumen impaction would be identified, monitored, or managed. The guideline does not apply to patients with cerumen impaction associated with the following conditions: dermatologic diseases of the ear canal; recurrent otitis externa; keratosis obturans; prior radiation therapy affecting the ear; previous tympanoplasty/myringoplasty, canal wall down mastoidectomy, or other surgery affecting the ear canal. Key Action Statements The panel made a strong recommendation that clinicians should treat, or refer to a clinician who can treat, cerumen impaction, defined as an accumulation of cerumen that is associated with symptoms, prevents needed assessment of the ear, or both. The panel made the following recommendations: (1) Clinicians should explain proper ear hygiene to prevent cerumen impaction when patients have an accumulation of cerumen. (2) Clinicians should diagnose cerumen impaction when an accumulation of cerumen, as seen on otoscopy, is associated with symptoms, prevents needed assessment of the ear, or both. (3) Clinicians should assess the patient with cerumen impaction by history and/or physical examination for factors that modify management, such as ≥1 of the following: anticoagulant therapy, immunocompromised state, diabetes mellitus, prior radiation therapy to the head and neck, ear canal stenosis, exostoses, and nonintact tympanic membrane. (4) Clinicians should not routinely treat cerumen in patients who are asymptomatic and whose ears can be adequately examined. (5) Clinicians should identify patients with obstructing cerumen in the ear canal who may not be able to express symptoms (young children and cognitively impaired children and adults), and they should promptly evaluate the need for intervention. (6) Clinicians should perform otoscopy to detect the presence of cerumen in patients with hearing aids during a health care encounter. (7) Clinicians should treat, or refer to a clinician who can treat, the patient with cerumen impaction with an appropriate intervention, which may include ≥1 of the following: cerumenolytic agents, irrigation, or manual removal requiring instrumentation. (8) Clinicians should recommend against ear candling for treating or preventing cerumen impaction. (9) Clinicians should assess patients at the conclusion of in-office treatment of cerumen impaction and document the resolution of impaction. If the impaction is not resolved, the clinician should use additional treatment. If full or partial symptoms persist despite resolution of impaction, the clinician should evaluate the patient for alternative diagnoses. (10) Finally, if initial management is unsuccessful, clinicians should refer patients with persistent cerumen impaction to clinicians who have specialized equipment and training to clean and evaluate ear canals and tympanic membranes. The panel offered the following as options: (1) Clinicians may use cerumenolytic agents (including water or saline solution) in the management of cerumen impaction. (2) Clinicians may use irrigation in the management of cerumen impaction. (3) Clinicians may use manual removal requiring instrumentation in the management of cerumen impaction. (4) Last, clinicians may educate/counsel patients with cerumen impaction or excessive cerumen regarding control measures.

Evaluating the Evidence for Choosing WiselyTM in Primary Care Using the Strength of Recommendation Taxonomy (SORT)

Objective: The goal of this study was to evaluate the quality of evidence supporting primary care–relevant Choosing WiselyTM recommendations using the Strength of Recommendation Taxonomy (SORT). Methods: All Choosing Wisely “top 5” lists published by American medical specialty societies through June 2014 were reviewed for relevance to primary care. Both authors independently applied SORT to generate an evidence letter grade for each of the included recommendations, relying on citations supplied by the nominating organizations. Results: Of 310 recommendations, 224 were identified as being relevant to primary care. We rated 43 (19%) as SORT level of evidence A, 57 (25%) as B, and 124 (55%) as C. Conclusion: We found that a majority of primary care–relevant Choosing Wisely recommendations are based on expert consensus or disease-oriented evidence. Further research is warranted to strengthen the evidence base supporting these recommendations in order to improve their acceptance and implementation into primary care.

Clinical Practice Guideline (Update): Earwax (Cerumen Impaction) Executive Summary

The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue of Otolaryngology–Head and Neck Surgery featuring the updated Clinical Practice Guideline: Earwax (Cerumen Impaction). To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 11 recommendations emphasize proper ear hygiene, diagnosis of cerumen impaction, factors that modify management, evaluating the need for intervention, and proper treatment. An updated guideline is needed due to new evidence (3 guidelines, 5 systematic reviews, and 6 randomized controlled trials) and the need to add statements on managing cerumen impaction that focus on primary prevention, contraindicated intervention, and referral and coordination of care.

Public health implications of overscreening for carotid artery stenosis, prediabetes, and thyroid cancer

BackgroundOverscreening occurs when people without symptoms undergo tests for diseases and the results will not improve their health. In this commentary, we examine three examples of how campaigns to screen and treat specific vascular, metabolic, and oncologic diseases in asymptomatic individuals have produced substantial overdiagnosis and may well have contributed to more harm than good. These conditions were chosen because they may not be as well known as other cases such as screening for breast or prostate cancer.Main textScreening for carotid artery stenosis can be a lucrative business using portable equipment and mobile vans. While this fatty buildup of plaque in the arteries of the neck is one risk factor for ischemic stroke, current evidence does not suggest that performing carotid dopplers to screen for CAS reduces the incidence of stroke or provide long-term benefits. After a positive screening, the follow-up procedures can lead to heart attacks, bleeding, strokes, and even death. Similarly, many organizations have launched campaigns for “prediabetes awareness.” Screening for prediabetes with a blood sugar test does not decrease mortality or cardiovascular events. Identifying people with prediabetes could lead to psychological stress and starting medication that may have significant side effects. Finally, palpating people’s necks or examining them with ultrasounds for thyroid cancer is common in many countries but ineffective in reducing mortality. Deadly forms of thyroid cancer are rare, and the overall 5-year survival rate is excellent. Interventions from treatment for more prevalent, less aggressive forms of thyroid cancer can lead to surgical complications, radiation side effects, or require lifelong thyroid replacement therapy.ConclusionsScreening for carotid artery stenosis, prediabetes, and thyroid cancer in an asymptomatic population can result in unnecessary, harmful, and costly care. Systemic challenges to lowering overscreening include lack of clinician awareness, examination of conflicts of interests, perverse financial incentives, and communication with the general public.

Comparing levels of evidence between Choosing Wisely and Essential Evidence Plus

Although there has been increasing emphasis on the use of evidence to guide medical practice, using primary research studies to answer questions at the point-of-care is too time-consuming for most primary care physicians. Instead, physicians generally rely on secondary sources of evidence-based medicine from trusted curators. The American Board of Internal Medicine Foundation’s Choosing Wisely campaign is an example of a secondary source of evidence focused on common medical practices that clinicians and patients should rethink in light of poor evidence …

ATRIAL FIBRILLATION GUIDELINE SUMMARY

The AAFP recently released an updated clinical practice guideline on the pharmacologic management of atrial fibrillation. An executive summary appears below. ### Executive Summary Atrial fibrillation (AF) is one of the most common arrhythmia types in adults worldwide, with an estimated 2.7–6.1

Authors' reply to Foster and colleagues.

We thank Foster and colleagues for their comments.1 2 Projections of disease progression that are based on natural history studies from tertiary referral centres may exaggerate hepatitis C virus (HCV) related morbidity and mortality. Inception cohort and epidemiological data suggest that only a minority of infected people will progress to end stage liver disease over their lifetime.1 Foster and colleagues repeatedly asserted that treatment is effective, but the cited evidence cannot show this.3 4 5 Van der Meer summarised …

Authors' reply to Selvapatt and colleagues, Matthews and colleagues, Badrinath, and Ward and Lee.

Selvapatt and colleagues made several points: large numbers of people are infected; birth cohort screening is cost effective; previously treated patients without severe fibrosis are unlikely to progress; sustained virological response improves quality of life; treatment reduces mortality; and newer agents have fewer side effects (last two also alluded to by Matthews and colleagues).1 2 3 The number of patients is not the issue, which is whether …