Folic acid for the prevention of neural tube defects

In 1992, the U.S. Public Health Service recommended that women of childbearing age take folate supplements to reduce the incidence of neural tube defects, which occur in about 1 in 1000 pregnancies. Subsequently, the Food and Drug Administration began requiring that enriched grain products be fortified with folic acid. Ten years later, the incidence of neural tube defects had declined, though there was little change in the percentage of women of childbearing age (25-30%) who reported taking folate supplements on a regular basis, as AFP reported in a Clinical Brief. A more recent study conducted in Canada found that 22% of women of childbearing age have red blood cell folate concentrations that are considered suboptimal for neural tube defect prevention.

The December 15th issue of AFP features the U.S. Preventive Service Task Force's updated recommendation statement on folic acid for the prevention of neural tube defects, along with a Putting Prevention Into Practice case study. Recognizing that a substantial proportion of pregnancies are unplanned, the USPSTF gives an "A" grade to the recommendation that "all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 mcg) of folic acid." (You can find more information about preconception and prenatal issues in AFP's Prenatal Care collection.)

USPSTF recommendations are written for primary care clinicians, but it is relatively rare for patients to present specifically for preconception care visits, where they can receive education about the need to take folic acid supplements. What alternative strategies does your practice use to inform patients about these and other important preventive health needs, such as healthy eating and exercise, that wouldn't necessarily bring them into the office?

Avoiding the perils of plagiarism

About a year ago, a primary care supplement sponsored by a prominent physician specialty organization arrived at my home address. The topic of the supplement was a professional interest of mine; in fact, I had published an original paper on the subject in a leading research journal the year before. Skimming the introduction to the first article, I felt a deja-vu sensation. Not only had I read these words before, I was pretty sure that I had actually written them. Indeed, comparing the text to my paper, the first three paragraphs were virtually identical, with only a few words changed here and there, and no citation.

The December 15th Inside AFP column reviews how to avoid the perils of plagiarism in medical and other publications. Plagiarism is a term that means different things to different people, but AFP's policies are that 1) wording should be paraphrased in such a way as to make it your own; 2) verbatim wording should be enclosed in quotation marks; 3) original sources should be cited for any wording or concepts taken from them.

As the Inside AFP column notes (direct quotation, crediting the source): "You can expose yourself to accusations of plagiarism by using another's words, even with proper attribution, if they are too close in form or content to the original source. This is a matter of degree, and sometimes is a judgment call, but it's best to err on the side of caution and make the phrasing your own." But if I were to rewrite this quoted passage along the lines of the following, I would be guilty of what is sometimes called the "too-perfect paraphrase":

You can open yourself up to accusations of plagiarism by using someone else's words, even with proper citation, if they are too close in form or content to the original. This is a matter of degree, and subject to interpretation, but it's best to err on the side of caution and make the words your own.

Even if the proper citation was included, this passage would still be considered plagiarism.

AFP's editors use the internationally recognized Committee on Publication Ethics guidelines for addressing claims of possible plagiarism in our pages. We carefully consider concerns raised by editors and readers and contact the authors for full explanations before taking any actions. Since plagiarism is a serious matter that can have professional and personal consequences, we strongly encourage prospective authors to contact us with questions or clarifications prior to submitting manuscripts for consideration.

Antibiotics for acute bronchitis: just don't do it

In 1998, AFP published an article on acute bronchitis that pointed out the discrepancy between usual practice and evidence demonstrating the lack of effectiveness of prescribing antibiotics for this condition:

Although many authorities have argued that antibiotics have no role in the treatment of acute bronchitis, these agents remain the predominant therapy offered to patients. Primary care physicians in the United States have treated acute bronchitis with a wide range of antibiotics even though scant evidence exists that antibiotics offer any significant advantage over placebo.

Twelve years later, it appears that little has changed. According to an updated review of the diagnosis and treatment of acute bronchitis by Ross Albert, MD, PhD in AFP's December 1st issue,

Because of the risk of antibiotic resistance and of Clostridium difficile infection in the community, antibiotics should not be routinely used in the treatment of acute bronchitis, especially in younger patients in whom pertussis is not suspected. Although 90 percent of bronchitis infections are caused by viruses, approximately two thirds of patients in the United States diagnosed with the disease are treated with antibiotics. ... Clinical data support that antibiotics do not significantly change the course of acute bronchitis, and may provide only minimal benefit compared with the risk of antibiotic use itself.

If the evidence has been this clear for so long, why do family physicians continue to prescribe antibiotics for patients with acute bronchitis? The usual explanations are that 1) patients expect to receive antibiotics; and 2) prescribing an antibiotic takes less time than talking the patient out of the prescription. However, Dr. Albert's article also observes that "studies have shown that the duration of office visits for acute respiratory infection is unchanged or only one minute longer when antibiotics are not prescribed." To help AFP's readers better manage patients' expectations, the article contains a handy table of communication strategies that clinicians can use to avoid unnecessary and potentially harmful antibiotic prescriptions.

Close-ups: bringing the patient perspective to AFP

In 2007, AFP introduced a new regular feature called "Close-ups: A Patient's Perspective." In an editorial explaining the rationale for Close-ups, which includes a patient's story in his or her own words, a photo of the patient, and a brief clinician commentary, Associate Deputy Editor Caroline Wellbery, MD wrote:

Physicians live in a health care environment that continually raises difficult issues, many of them of a magnitude that transcends our personal practices: uninsured patients, a fragmented health care system, epidemics of obesity and lung disease, the threat of bioterrorism, contentious issues such as abortion, and rising health care costs. For anyone overwhelmed by contemporary health care developments, going back to our roots—meaningful, healing relationships with the people and communities we care for—might put our daily practice into perspective. Close-ups offers an intimate, personal reminder of this most important task.

"The Blood Sugar Diaries" in the December 1st issue of AFP relates the fears of a man with type 2 diabetes when he is told by his physician that he will need to use insulin. Explaining that several close relatives suffered serious complications or death shortly after starting insulin, the man says: "These are the reasons why I told my doctor 'no way' when she told me that I needed insulin. I didn't want to end up like my family members. I didn't want to go on dialysis, lose my leg, go blind, or die." These sentences speak volumes about the need for family physicians not only to provide patient education to patients with chronic conditions, but to explore existing beliefs regarding health and to meet patients where they are.

You can find a collection of previously published Close-Ups at http://www.aafp.org/afp/closeups. We welcome new submissions from patients and clinicians. Guidelines for contributing to this feature can be found in our Authors' Guide.