- Jennifer Middleton, MD
A recent follow-up study of the Women's Health Initiative (WHI) trial is bringing hormone replacement therapy (HRT) back into the news. The WHI aimed to demonstrate that HRT improved cardiovascular outcomes in women, but instead they found not only an increased risk of coronary artery disease (CAD) and stroke but also breast cancer and venous thromboembolism (VTE) in participants taking HRT compared to those who were not taking HRT. The WHI intervention trial was stopped due to these findings, but researchers continued following these women for the next several years. They found that all-cause mortality did not differ between groups who had and had not been taking HRT when the intervention was halted.
When the WHI intervention was halted, women with a uterus who were taking estrogen and progesterone (and their corresponding control group taking placebo) had been enrolled for a median of 5.6 years, and women without a uterus taking estrogen only (and their corresponding control group taking placebo) had been enrolled for a median of 7.2 years. Following all of these women for a median of 18 years after the intervention groups stopped taking their HRT,* the hazard ratio (HR) for all-cause mortality in the estrogen and progesterone group compared to placebo was 1.02 (95% confidence interval 0.96-1.08); for the estrogen only group compared to placebo, the HR was 1.00 (95% confidence interval 0.88-1.01). HRs for deaths due to cardiovascular disease and cancer were similarly non-significant.
Breast cancer, CAD, stroke, and VTE are all serious conditions that certainly give me pause before prescribing HRT, and I have done so for only a small number of women. That small number of women, however, have disabling symptoms from menopause, and they have been willing to accept the risk of those complications in exchange for the ability to function during the day and sleep restfully at night. It is somewhat reassuring to know that, while their risk of these complications is significant, their overall mortality risk appears to be unchanged compared to women not taking HRT.
Using HRT to prevent chronic conditions still has a D grade from the United States Preventive Services Task Force (USPSTF), and this new study won't have me rushing to prescribe HRT to women with mild to moderate menopausal symptoms. There are several safer alternatives to ameliorate hot flashes and vaginal dryness as described in this 2016 AFP article on "Hormone Therapy and Other Treatments of Menopause." If you'd like to read more, there's also an AFP By Topic on Menopause.
*Less than 4% of enrolled women reported taking HRT at some point after the WHI intervention was halted in 2002.
Monday, October 30, 2017
Monday, October 23, 2017
Can social media misuse be a downer?
- Kenny Lin, MD, MPH
As previous AFP Community Blog posts have mentioned, social media use provides several professional benefits for family physicians: it can promote one's practice and engage patients, increase the dissemination of insightful or practice changing conference findings, and amplify the voice of our specialty to advocate on public health concerns. Similarly, patients can also benefit from social media's networking and community-enhancing functions. However, social media's potential downsides include cyberbullying, which targets persons of all ages but may be particularly damaging to children, and problematic internet use / Internet gaming disorder. The American Academy of Pediatrics issued a policy statement last year on office counseling for families and children five to 18 years of age on media use.
A Curbside Consultation in the October 15 issue of AFP explored the relationship between social media and mood disorders. For some persons, particularly in the millenial age group, social media misuse can cause or contribute to the anxiety-related condition "fear of missing out" (FOMO), wrote Drs. Kaitlyn Watson and David Slawson:
Viewing social media intensifies feelings of irritability, anxiety, and inadequacy. Additionally, the drive to stay in the loop can contribute to a cycle of unhealthy social media use. The more time individuals spend on social media, the more likely they are to feel that they are missing out on something, which many will then try to alleviate through more social media activity. Higher FOMO scores, as measured by a validated 10-question scale, are significantly associated with lower feelings of competence, autonomy, and connectedness with others compared with persons who do not worry about being left out.
For patients whose social media misuse is causing adverse emotional or physical symptoms, physicians can recommend any of several free or low-cost apps that help users "unplug" by limiting total social media time per day or restricting use of certain sites (e.g., Facebook, Snapchat) to specific time windows. Other suggested interventions include "changing notification settings to daily or weekly instead of instantly, developing offline relationships, committing to daily personal improvement practices (e.g., yoga, meditation, exercise), and cutting back on the number of social media formats on which the same person is followed." Finally, cognitive behavioral therapy and mindfulness exercises may also be helpful.
As previous AFP Community Blog posts have mentioned, social media use provides several professional benefits for family physicians: it can promote one's practice and engage patients, increase the dissemination of insightful or practice changing conference findings, and amplify the voice of our specialty to advocate on public health concerns. Similarly, patients can also benefit from social media's networking and community-enhancing functions. However, social media's potential downsides include cyberbullying, which targets persons of all ages but may be particularly damaging to children, and problematic internet use / Internet gaming disorder. The American Academy of Pediatrics issued a policy statement last year on office counseling for families and children five to 18 years of age on media use.
A Curbside Consultation in the October 15 issue of AFP explored the relationship between social media and mood disorders. For some persons, particularly in the millenial age group, social media misuse can cause or contribute to the anxiety-related condition "fear of missing out" (FOMO), wrote Drs. Kaitlyn Watson and David Slawson:
Viewing social media intensifies feelings of irritability, anxiety, and inadequacy. Additionally, the drive to stay in the loop can contribute to a cycle of unhealthy social media use. The more time individuals spend on social media, the more likely they are to feel that they are missing out on something, which many will then try to alleviate through more social media activity. Higher FOMO scores, as measured by a validated 10-question scale, are significantly associated with lower feelings of competence, autonomy, and connectedness with others compared with persons who do not worry about being left out.
What has been your experience with managing symptoms of depression or anxiety linked to patients' social media use?
Monday, October 16, 2017
Interview with AFP's incoming editor-in-chief
- Jennifer Middleton, MD, MPH
On February 1, 2018, AFP will have its first new editor-in-chief in 29 years. In an interview this past week, Dr. Sumi Sexton shared some of her ideas with me about the journal's online presence (hyperlinks below are my additions):
How do AFP's online platforms (Facebook, Twitter, Community Blog, podcast, website) fit into your overall goals for the journal going forward?
On February 1, 2018, AFP will have its first new editor-in-chief in 29 years. In an interview this past week, Dr. Sumi Sexton shared some of her ideas with me about the journal's online presence (hyperlinks below are my additions):
How do AFP's online platforms (Facebook, Twitter, Community Blog, podcast, website) fit into your overall goals for the journal going forward?
I'd like to engage readers through the various platforms to generate discussion ranging from comments on various articles or AFP features to feedback on what we can do to improve. We don't always have room to include everything we want on a topic in print, so it is nice to be able to include some of these online. I love the concept of Twitter chats, and how the most recent one on antibiotic prescribing incorporated an AFP editorial, a Cochrane for Clinicians, an AHRQ review, and was mentioned on the Community Blog. I look forward to seeing more of that.AFP's Facebook page, Twitter feed, podcast, and Community Blog offer several different ways for readers to connect with us online, but the number of readers who engage with us on those platforms is a relatively small proportion of total AFP subscribers. How might AFP encourage more readers to connect with these platforms?
I intend to brainstorm with the AFP team on how we can enhance an article on a clinical topic through these platforms. For example, the "Diabetes Self-Management" article in the September 15 issue could be enhanced by a more personal story akin to Diary from a Week in Practice which I used to edit and dearly miss. Another example would be to provide information to family docs on what their colleagues are doing; in the September 1 issue, for example, the article on "Aseptic and Bacterial Meningitis" mentions the meningococcal type B vaccines. How many of our readers are giving this vaccine and why or why not?In your recent AAFP news interview, you mentioned wanting to speak with readers "in person and online to see how we can better meet their needs." How do you envision connecting with readers online? What information would you like to learn from them?
It would be interesting to see responses from readers to online polling for certain features like editorials (for example, Controversies in Family Medicine) or articles on more controversial topics (like the article and editorial on "Testosterone Therapy" in the October 1 issue). While it may take a little time to post a comment, it is easy to click on a link to answer a quick yes or no on Twitter or Facebook. In addition to knowing what our readers think about medical topics, I'd like to know how they like to receive information. How could AFP be more accessible at the point of care? Is there anything we can do to make CME through the journal easier for them?
AFP's online presence will certainly continue to grow under Dr. Sexton's leadership, and we'll keep you updated about new tools and ways to connect. In the meantime, what additions would you like to see in AFP's online content?
Monday, October 9, 2017
Key updates in preventive services from the USPSTF
Kenny Lin, MD, MPH
In the third installment of a series that began in 2015 and continued with last year's one-page Preventive Health Care schedule, American Family Physician recently published "USPSTF Recommendations: New and Updated in 2016," authored by Deputy Editor and former U.S. Preventive Services Task Force (USPSTF) member Mark Ebell, MD, MS. Dr. Ebell's editorial summarized 15 recommendations released by the USPSTF in 2016 and provided more details about several key updates.
1) Colorectal cancer screening: "the USPSTF now recommends that physicians offer any one of seven options for colorectal cancer screening:
- Annual fecal immunochemical testing (FIT);
- Colonoscopy every 10 years;
- FIT plus fecal DNA (Cologuard) every one to three years;
- Computed tomographic colonography every five years;
- The combination of flexible sigmoidoscopy and FIT;
- Flexible sigmoidoscopy alone every five years; or
- Annual guaiac-based fecal occult blood testing."
The recommended duration of routine screening remains from ages 50-75, with selective screening advised for adults aged 76-85 years, based on the patient's overall health, prior screening history, and personal preferences.
2) Aspirin for primary prevention of cardiovascular (CV) disease and colorectal cancer: "the USPSTF now recommends aspirin use only in adults 50 to 69 years of age who have a 10-year risk of a CV event of at least 10%, are willing to take aspirin for at least 10 years, and are not at increased risk of bleeding."
3) Statins for prevention of CV disease: "Like the [2013 ACC/AHA guidelines], the USPSTF recommendations for statin use base the decision on the patient's 10-year CV risk and do not identify specific low-density lipoprotein targets. They differ from the ACC/AHA guidelines in that they give a B rating for a low- or moderate-dose statin for patients with a 10-year CV risk event of 10% or greater, but a C rating for those with a 7.5% to 10% risk."
4) Depression screening in adults: "The recommendation ... now explicitly includes pregnant and postpartum women. The Edinburgh Postnatal Depression Scale is the recommended screening tool."
5) Screening for autism spectrum disorder (ASD): "Although there have been several small clinical trials showing the benefit of treatment in children with ASD, all trials were conducted in children who were identified by parents or caregivers and who have relatively severe symptoms. The USPSTF [insufficient evidence] recommendation covers screening in asymptomatic children whose parents and teachers have not identified any concerns."
For a complete list of Task Force recommendations on clinical preventive services, family physicians can consult the USPSTF's website or the Agency for Healthcare Research and Quality's Electronic Preventive Services Selector (ePSS) tool. For easy reference, AFP and the American Academy of Family Physicians have also collected USPSTF recommendations for children, adolescents/young adults (ages 11-26), and adults (ages 18 and older).
In the third installment of a series that began in 2015 and continued with last year's one-page Preventive Health Care schedule, American Family Physician recently published "USPSTF Recommendations: New and Updated in 2016," authored by Deputy Editor and former U.S. Preventive Services Task Force (USPSTF) member Mark Ebell, MD, MS. Dr. Ebell's editorial summarized 15 recommendations released by the USPSTF in 2016 and provided more details about several key updates.
1) Colorectal cancer screening: "the USPSTF now recommends that physicians offer any one of seven options for colorectal cancer screening:
- Annual fecal immunochemical testing (FIT);
- Colonoscopy every 10 years;
- FIT plus fecal DNA (Cologuard) every one to three years;
- Computed tomographic colonography every five years;
- The combination of flexible sigmoidoscopy and FIT;
- Flexible sigmoidoscopy alone every five years; or
- Annual guaiac-based fecal occult blood testing."
The recommended duration of routine screening remains from ages 50-75, with selective screening advised for adults aged 76-85 years, based on the patient's overall health, prior screening history, and personal preferences.
2) Aspirin for primary prevention of cardiovascular (CV) disease and colorectal cancer: "the USPSTF now recommends aspirin use only in adults 50 to 69 years of age who have a 10-year risk of a CV event of at least 10%, are willing to take aspirin for at least 10 years, and are not at increased risk of bleeding."
3) Statins for prevention of CV disease: "Like the [2013 ACC/AHA guidelines], the USPSTF recommendations for statin use base the decision on the patient's 10-year CV risk and do not identify specific low-density lipoprotein targets. They differ from the ACC/AHA guidelines in that they give a B rating for a low- or moderate-dose statin for patients with a 10-year CV risk event of 10% or greater, but a C rating for those with a 7.5% to 10% risk."
4) Depression screening in adults: "The recommendation ... now explicitly includes pregnant and postpartum women. The Edinburgh Postnatal Depression Scale is the recommended screening tool."
5) Screening for autism spectrum disorder (ASD): "Although there have been several small clinical trials showing the benefit of treatment in children with ASD, all trials were conducted in children who were identified by parents or caregivers and who have relatively severe symptoms. The USPSTF [insufficient evidence] recommendation covers screening in asymptomatic children whose parents and teachers have not identified any concerns."
For a complete list of Task Force recommendations on clinical preventive services, family physicians can consult the USPSTF's website or the Agency for Healthcare Research and Quality's Electronic Preventive Services Selector (ePSS) tool. For easy reference, AFP and the American Academy of Family Physicians have also collected USPSTF recommendations for children, adolescents/young adults (ages 11-26), and adults (ages 18 and older).
Monday, October 2, 2017
Learning about our patients via their pets
- Jennifer Middleton, MD, MPH
A Close-up on Pet Therapy in the October 1 issue of AFP shares one patient's benefit from caring for her dog through the challenges of an abusive relationship and subsequent homelessness. The patient's family physician helped her find low-cost veterinary care and allowed the dog to accompany the patient to visits; the patient's appreciation of these acts is clear in her narrative. Asking about pets as part of the social history can not only provide family physicians with important information about our patients' personal health but may also help us develop meaningful wellness strategies with patients that incorporate their pets.
Pet ownership correlates with several health benefits; pets can provide meaningful social support, encourage regular physical activity, and possibly even improve cardiovascular health. Pets may help children develop compassion and enjoy a higher quality of life. Similar to the Close-up mentioned above, the homeless youth who own pets report that they help them to not only feel safe but also help to attenuate loneliness.
Knowing about our patients' pets may help us understand their health better, but we can also incorporate our patients' pets into treatment plans for mental health conditions and cardiovascular disease. Regular time with pets can increase anxious individuals' willingness to engage with themselves and others in treatment. Creating an exercise routine that involves a pet may appeal to some patients. Discussing the risk to pets of second-hand tobacco smoke may motivate some patients to quit.
We can also work with our veterinary colleagues to ensure that pet ownership is healthy for pets and humans alike. This 2016 AFP editorial about the One Health initiative describes this partnership between veterinary and human medicine to reduce the prevalence of zoonotic infections such as rabies, ringworm, and toxoplasmosis. Here's a link to AFP articles that include the keyword Animal-Related Diseases if you'd like to read more.
Encouraging our patients who don't have pets to consider obtaining one, however, may be ill-advised; it's likely beyond our scope to investigate whether patients have the resources and ability to care adequately for a pet. If we feel interacting with animals might benefit a patient without a pet, we could suggest opportunities to interact with animals such as volunteering at a shelter or caring for a friend or family member's pet. Animal-assisted therapy may also be available in your community; this Curbside Consultation from 2016 describes animal-assisted therapy and its benefits in more detail.
What have you learned about your patients by asking about their pets? Have you incorporated patients' pets into their wellness strategies?
A Close-up on Pet Therapy in the October 1 issue of AFP shares one patient's benefit from caring for her dog through the challenges of an abusive relationship and subsequent homelessness. The patient's family physician helped her find low-cost veterinary care and allowed the dog to accompany the patient to visits; the patient's appreciation of these acts is clear in her narrative. Asking about pets as part of the social history can not only provide family physicians with important information about our patients' personal health but may also help us develop meaningful wellness strategies with patients that incorporate their pets.
Pet ownership correlates with several health benefits; pets can provide meaningful social support, encourage regular physical activity, and possibly even improve cardiovascular health. Pets may help children develop compassion and enjoy a higher quality of life. Similar to the Close-up mentioned above, the homeless youth who own pets report that they help them to not only feel safe but also help to attenuate loneliness.
Knowing about our patients' pets may help us understand their health better, but we can also incorporate our patients' pets into treatment plans for mental health conditions and cardiovascular disease. Regular time with pets can increase anxious individuals' willingness to engage with themselves and others in treatment. Creating an exercise routine that involves a pet may appeal to some patients. Discussing the risk to pets of second-hand tobacco smoke may motivate some patients to quit.
We can also work with our veterinary colleagues to ensure that pet ownership is healthy for pets and humans alike. This 2016 AFP editorial about the One Health initiative describes this partnership between veterinary and human medicine to reduce the prevalence of zoonotic infections such as rabies, ringworm, and toxoplasmosis. Here's a link to AFP articles that include the keyword Animal-Related Diseases if you'd like to read more.
Encouraging our patients who don't have pets to consider obtaining one, however, may be ill-advised; it's likely beyond our scope to investigate whether patients have the resources and ability to care adequately for a pet. If we feel interacting with animals might benefit a patient without a pet, we could suggest opportunities to interact with animals such as volunteering at a shelter or caring for a friend or family member's pet. Animal-assisted therapy may also be available in your community; this Curbside Consultation from 2016 describes animal-assisted therapy and its benefits in more detail.
What have you learned about your patients by asking about their pets? Have you incorporated patients' pets into their wellness strategies?
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