Wednesday, December 22, 2010

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?

Wednesday, December 15, 2010

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.

Thursday, December 9, 2010

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.

Monday, December 6, 2010

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 We welcome new submissions from patients and clinicians. Guidelines for contributing to this feature can be found in our Authors' Guide.

Monday, November 22, 2010

Preventing cervical cancer with HPV vaccine

Human papillomaviruses (HPV) are the subject of the cover article of AFP's November 15th issue, authored by Drs. Gregory Juckett and Holly Hartman-Adams from the West Virginia University Robert C. Byrd Health Sciences Center School of Medicine. While "low risk" HPV types 6 and 11 cause up to 95 percent of genital warts, "high risk" HPV types 16 and 18 cause the majority of cervical cancers. In recognition of these risks, the American College of Obstetricians and Gynecologists recently recommended that women older than 30 years receive high-risk HPV DNA testing in addition to cytology for cervical cancer screening.

Previous issues of AFP reviewed the efficacy of the quadrivalent HPV recombinant vaccine and recommendations for its administration by the American Cancer Society and the CDC's Advisory Committee on Immunization Practices. HPV vaccine is only the second cancer-preventing vaccine, after hepatitis B vaccine (which prevents liver cancer). However, Drs. Juckett and Hartman-Adams observe in their article that implementing HPV vaccine recommendations has been challenging:

Controversy about HPV vaccination involves its high cost (approximately $150 per injection), uncertain duration of protection, and concerns that it provides tacit approval of sexual activity and a false sense of security. In addition, the necessity of vaccinating girls as young as nine to 11 years, before they become sexually active, unsettles many parents. There has been criticism for aggressive marketing of HPV vaccine to older women already exposed to HPV, while less attention has been given to the subpopulations at highest risk.

AAFP News Now recently reported that HPV vaccination rates in 2009 varied widely from state to state, with 44.3 percent of teenage girls nationally having received at least one dose and 26.7 percent having completed the 3-dose series. Just last week, a U.S. Food and Drug Administration advisory committee meeting reviewed the evidence that HPV vaccination prevents anal cancer in men who have sex with men. How the committee's reported decision to approve HPV vaccine for this indication will affect future national recommendations for vaccination in males remains to be seen.

How has the availability of HPV vaccine affected your practice? What approach do you take in discussions with adolescents and parents? We would love to hear about your experiences.

Sunday, November 14, 2010

Asthma management: a stepwise approach

The November 15th issue of AFP features an updated clinical review of medical therapies for asthma, based on the 2007 Expert Panel Report of the National Asthma Education and Prevention Program (NAEPP). This review recommends a "stepwise approach" for asthma management in patients 12 years and older, depending on the severity of asthma and response to first-line medications. Persons with intermittent symptoms may use an inhaled short-acting beta-agonist as needed; older children and adults with persistent asthma generally require daily inhaled corticosteroids, and possibly additional medications.

Another component of effective management is the use of written asthma action plans for patients to monitor asthma control outside of planned office visits and to take physician-approved steps to address worsening symptoms. The article includes examples of asthma action plans for children and adults, as well as a link to a short video about asthma action plans on

For information about related clinical issues such as the role of allergens in asthma, treatment of asthma in young children, managing acute exacerbations, and practice-level approaches to planned asthma care, you can consult our AFP By Topic collection.

Thursday, November 4, 2010

Telephone triage for suspected influenza

Although the Centers for Disease Control and Prevention's weekly flu tracking report showed "low" influenza activity in the U.S. as of the publication date of AFP's November 1, 2010 issue, we know that it is only a matter of time before family physicians' offices are filled with patients either seeking the vaccine or presenting with symptoms of an acute infection. Accordingly, this issue contains several key resources for managing influenza, including a focused clinical review of testing and treatment; a Tip on the effectiveness and limitations of oseltamivir (Tamiflu) for reducing flu duration in children; and an updated influenza management guide from the University of California at San Francisco's Department of Family and Community Medicine. The guide suggests using "telephone triage" to reduce office visits that can potentially transmit influenza to other patients and staff:

Telephone triage can assess severity of symptoms and identify patients at risk of complications who would benefit from expedited access to antiviral medications, which can then be prescribed by telephone or fax. This approach provides timely access to treatment while reducing waiting room exposures. Conversely, if telephone triage identifies concerning symptoms that would require outpatient or emergency department evaluation, this can be arranged and expedited.

For additional information about best practices and a sample protocol for telephone triage, you can refer to a previous editorial by Jonathan L. Temte, MD, PhD. This editorial and other up-to-date resources, including the CDC's 2010-11 vaccination guidelines, are all included in AFP's Influenza Topic Collection. Finally, you can also click on the CDC's Flu.Gov widget, located on the lower right border of this blog, for updates and alerts throughout the influenza season.

Sunday, October 31, 2010

Do you use AFP to teach evidence-based medicine?

For the past few days, I participated in the annual Northeast Region meeting of the Family Medicine Education Consortium in Hershey, Pennsylvania. In addition to presenting a well-received session on social media tools in family medicine (including the AFP Community Blog), I attended a thought-provoking seminar on "Reinventing Journal Club: Innovations in the Internet Age" led by faculty and residents from the University of Rochester. This seminar demonstrated their program's successful experience with increasing residents' use of AAFP-recommended evidence-based medicine resources such as reports from the Agency for Healthcare Research and Quality, the Cochrane Database of Systematic Reviews, and Essential Evidence Plus to answer clinical questions.

At the end of the seminar, I asked the presenters if they encouraged their residents to read American Family Physician, and what role the journal plays in their evidence-based medicine curriculum, if any. (After all, we require AFP's clinical review authors to consult the same types of EBM resources as part of their literature searches and to label key clinical recommendations using the rigorous Strength-of-Recommendation Taxonomy.) Their response was that everyone reads AFP, so they didn't necessarily see a need to promote the journal as a resource.

In a previous editorial, AFP Deputy Editor Mark Ebell, MD, MS argued that rather than focusing on the skills needed to analyze original research studies, the typical family physician should instead aim to be an "informed consumer of the secondary literature" and "an expert at assessing the quality of an information source." Since medical school and residency are the best times for family physicians to develop skills in answering clinical questions, we would like to know how teachers of family medicine are using the journal for this purpose. Are there any particular AFP features that you find especially useful for teaching EBM, or areas where you feel we could improve? We welcome your feedback and suggestions.

Monday, October 25, 2010

Complementary and alternative medicine: what should FPs and patients know?

Since 2003, AFP has published an occasional series of articles evaluating the evidence for complementary and alternative medicine (CAM) therapies, ranging from ecinachea to probiotics to yoga and meditation for anxiety and depression. In an editorial introducing the series, associate medical editor Sumi Sexton, MD wrote:

The intent of this new AFP series is to summarize and label the evidence behind various alternative therapies, starting with the most frequently prescribed and well-researched herbal remedies and supplements. ... Currently, an abundance of information on CAM exists in textbooks, journals, newsletters, and Web sites. The purpose of the series is not to replace the existing information or to encourage physicians to prescribe CAM therapies, but rather to extract the most important data in the literature and present it as concisely as possible.

However, as an exchange of letters in the October 15th issue of AFP about an article on acupuncture for pain demonstrates, drawing conclusions about the effectiveness of CAM therapies can be challenging. Dr. Paul Delaney asserts that "in a desire to present information regarding treatments designated as complementary and alternative medicine (CAM), the editors of American Family Physician seem willing to suspend the usual criteria for evidence-based medicine." In rebuttal, Dr. Robert Kelly cites a Cochrane review that supports the effectiveness of acupuncture in relieving chronic low back pain, and Dr. Sexton notes that the article's supporting references "included several RCTs, systematic reviews, and a meta-analysis, which would warrant an evidence level A for any review article."

A recent report from the National Center for Health Statistics found that U.S. adults spent nearly $34 billion in out-of-pocket costs for CAM practitioners and purchases of CAM therapies, classes, and educational materials in 2007. What do you think family physicians and patients should know about CAM, and how would you rate AFP's CAM series at meeting these needs?

Tuesday, October 19, 2010

Putting depression guidelines into practice

It's difficult to find time to ask about depressive symptoms in practice, and family physicians who want to make screening a priority must also ensure access to follow-up resources that improve patient outcomes. Recently, the U.S. Preventive Services Task Force and the AAFP both updated their clinical recommendations on screening adults for depression. Both organizations now recommend screening only "when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up." The October 15th issue of AFP contains several valuable depression care resources, including a clinical review of postpartum major depression, an abridged version of the USPSTF statement, a case study and quiz questions on applying the USPSTF and AAFP recommendations in practice, and an editorial about the experience of the integrated delivery system MaineHealth in improving depression screening and care for its members.

Readers seeking to remodel their care management processes to be consistent with the latest depression guidelines will find the editorial to be a good start. In addition, AFP and its sister publication, Family Practice Management, offer helpful online content on proven staff-assisted depression care supports, including validated screening tools, patient registries, and communication strategies to encourage self-management. Finally, you can find links to these resources and more in the AFP By Topic collection on depression and bipolar disorder.

Thursday, October 14, 2010

ACL injury and musculoskeletal care resources

The cover article of the October 15th issue of AFP reviews the diagnosis, management, and prevention of anterior cruciate ligament (ACL) injuries. Although we have always recognized the importance of including high-quality illustrations of relevant anatomy and physical examination maneuvers in articles like these, this article also includes short videos of diagnostic and prognostic tests that you can watch on the AFP web page or on the AFPJournal YouTube channel. Click on the image below to see a demonstration of the Lachman test, which the authors note is the most accurate test for detecting an ACL injury. Eventually, we hope to build a library of online videos of common examination skills and procedures in family medicine. In the meantime, don't miss the AFP By Topic collection on Musculoskeletal Care, which contains links to online content on joint injections, fracture management, and approaches to musculoskeletal problems organized by region of the body.

Wednesday, October 6, 2010

Feedback from the AAFP Scientific Assembly

We were delighted to meet many of you at the AAFP Publications Booth during the Scientific Assembly in Denver last week and listen to your thoughtful comments and suggestions about how to improve AFP's online experience. We received some valuable feedback on the new AFP By Topic feature, and are working to make it available as a mobile app within the next several months.

Our 40th topic collection on Menopause includes an updated review from the October 1st issue on how to counsel menopausal patients about hormone therapy and alternatives for vasomotor symptoms. Future topic collections will organize current AFP content on thyroid disorders, sleep disorders, and gastrointestinal conditions. Please let us know if you have suggestions for other topics that you commonly encounter in your practice, by posting a comment on this blog, AFP's Facebook page, or sending a tweet to @AFPJournal.

Wednesday, September 29, 2010

Cultural competency training should not rely on stereotypes

Two physician readers submitted the following post about a topic that is becoming increasingly important to family physicians. In addition to the Curbside Consultation discussed below, AFP has also previously published clinical reviews of cross-cultural medicine and cultural diversity at the end of life.


While we appreciate Dr. Gupta’s insights into culturally specific care for Indian patients in the July 1, 2010 Curbside Consultation, “Improving Sensitivity to Patients from Other Cultures,” we feel that the article's emphasis on learning culturally specific stereotypes can be potentially misleading for clinicians. Cultural competency training has traditionally involved memorizing culturally specific “rules” (e.g., Muslims don’t shake hands). Although learning about a particular group’s cultural norms can be helpful, it may also lead to stereotyping and false assumptions. Because clinicians are caring for increasingly diverse populations, including growing numbers of immigrants and refugees, there are too many cultural groups with too many norms to become familiar with.

A more practical approach to cultural competency has emphasized not the patient’s background, but instead, the “implementation of the principles of patient-centered care, including exploration, empathy, and responsiveness to patients’ needs, values, and preferences.” In the words of another useful definition, cultural competence involves an “examination of one’s own attitude and values, as well as the acquisition of the values, knowledge, skills and attributes that will allow an individual to work appropriately in cross cultural situations.” Published tools aid in learning and teaching these skill sets. Busy clinicians are better served by using these tools to practice culturally sensitive and individualized patient-oriented care, rather than memorizing lists of cultural norms and “rules."

Bernadette Kiraly, MD
Peter Weir, MD
Hartland Refugee Clinic
Department of Family & Preventive Medicine
University of Utah School of Medicine

Thursday, September 23, 2010

Autism: recognition and management

The September 15th edition of AFP Journal Club reviews an analysis of evidence behind the persistent but scientifically discredited hypothesis that the measles, mumps, and rubella (MMR) vaccine causes children to develop autism. Since a 1998 case series published in The Lancet first suggested this hypothesis, 13 large ecologic and observational studies performed worldwide have shown no association between the receipt of MMR vaccine and autism. Nonetheless, many parents continue to believe that delaying or refusing MMR vaccine and other immunizations will protect their children from harm. Dr. Andrea Darby-Stewart notes that this is a critical educational opportunity:

A national survey conducted in 2003 to 2004 indicated that more than one fourth of all U.S. parents were either unsure of vaccine safety or refused or delayed vaccination of their children because of safety concerns. However, the most important take-home point from that survey was that the parents who changed their minds and immunized their children did so because of information and assurance provided by their health care professional. Indeed, we do make a difference!

An AFP article published earlier this year reviews guidance for family physicians on how to coordinate medical and behavioral care for children who have been diagnosed with an autism spectrum disorder. More controversial is a 2007 practice guideline from the American Academy of Pediatrics that recommends that primary care clinicians routinely screen children at nine, 18, 24, and 30 months of age using an autism-specific screening tool. In light of the uncertain evidence for improved outcomes in children identified by screening, the American Academy of Family Physicians recently nominated "Screening for Autism in Children" as a new topic for review by the U.S. Preventive Services Task Force.

Given the steadily rising prevalence of autism spectrum disorders (approaching 1 in 100 U.S. children) and that autism can present with subtle symptoms in its early stages, what approach do you take to identify this condition in practice, if any?

Thursday, September 16, 2010

JUPITER, statins, and cardiovascular prevention

In February, the U.S. Food and Drug Administration approved the labeling of rosuvastatin (Crestor) for the primary prevention of heart disease in patients with an elevated C-reactive protein level and at least one other risk factor, based on a controversial study known as JUPITER (Justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin). In a previous editorial, AFP medical editors Colin Kopes-Kerr, MD and Mark Ebell, MD, MS estimated that implementing JUPITER's approach to screening and treatment in clinical practice would cost more than $800,000 in testing, physician visits, and medications to prevent a single premature cardiovascular death over two years. They argued that this approach would be far more costly, but less beneficial, than counseling patients about healthy lifestyle changes:

The biggest problem with the JUPITER study is that it suggests that physicians continue to test and treat. First, though, we need to take time to think. One of the things to ponder is this: Couldn’t we do something better for patients than measuring everyone’s CRP levels and treating those with elevated values? Instead, we should wait for a study comparing CRP measurement to routine coronary risk factor assessment, including studies on cost-benefit analysis. We already know that lifestyle changes are effective and, therefore, we should focus on innovative ways to assist patients in making these changes.

In an exchange of Letters in the September 15th issue of AFP, one of the JUPITER's principal investigators defends the conduct of the study (which ended earlier than planned due to a "dramatic" statistical difference in cardiovascular outcomes between the rosuvastatin and placebo groups) and challenges the editorial's portrayal of this intervention as not worth pursuing in primary care. Dr. Kopes-Kerr's and Dr. Ebell's rebuttal highlights some important concepts in evidence-based medicine, including interpretation of P values and numbers needed to treat. (See this short article by AFP editor Allen Shaughnessy, PharmD for more information on evaluating and understanding articles about treatment.)

Since coronary heart disease risk assessment, prevention, and management can be complex, we have organized all of AFP's relevant articles and other resources in a convenient collection that will be updated whenever new information is published. We hope that this and other AFP By Topic collections will help you make confident clinical decisions. Please let us know if there is anything we can do to make them more useful in your practice.

Monday, September 13, 2010

Addressing the root causes of obesity

A physician reader of AFP submitted the following post.


Family physicians are seeing overweight and obese patients now more than ever. Therefore, the June 15, 2010 AFP article "Office-Based Strategies for the Management of Obesity" was timely, relevant, and informative. The author’s recommendations regarding counseling to improve nutrition and increase physical activity were insightful. I would like to draw attention to additional issues that have a significant impact on the fight against obesity in our patients, particularly those in minority or low income populations.

Excess weight begins with an energy imbalance: more calories consumed than calories expended over a period of time. Choosing foods such as fresh fruits and vegetables and physical activities such as jogging or vigorous outdoor play are vital to living a healthy lifestyle. But for many of our patients, these choices are not so simple. African Americans, Hispanics, and American Indians are disproportionately affected by obesity. Geographically, southern states and many rural and urban communities have higher than average rates of obesity. These communities have additional barriers that make it particularly challenging to achieve and maintain a healthy weight.

Millions of minority children live in food deserts, places where healthy, fresh food is either scarce, expensive or both. This lack of access to affordable, quality fresh fruits and vegetables has been shown to be closely associated with childhood obesity. According to Trust for America's Health and the Robert Wood Johnson Foundation, an overabundance of fast food outlets and convenience stores stocked with calorie-dense, nutrient-poor foods in areas with predominantly minority populations is strongly related to excess weight in these populations. Media and food industries advertise these foods widely, often targeting children and families of color. Similarly, many minority and low-income neighborhoods discourage physical activity due to a dearth of sidewalks, walking or bike trails, poor air quality, inadequate lighting and unkempt or inaccessible parks and playgrounds. Other factors such as long work hours for low-wage workers and limited access to commercial weight management services also pose substantial barriers to positive health behavior changes.

While it is important for family physicians to know how to assist our patients with weight control in the office, we should understand that the root causes of this problem lie in our communities. In order to "bend the curve" on the linear trajectory of obesity in this country, we must focus as intently on effecting broader social and environmental changes as we do on encouraging individual lifestyle changes in overweight and obese patients. As we educate our patients on how to live healthier, we must also educate, motivate and mobilize patients, community leaders, school administrators, employers, and policymakers about what it will take to make healthier food choices and physical activity default options rather than difficult or unrealistic choices. Family physicians must use every resource at our disposal to combat obesity, or else in time, we will all be "the biggest losers.”

Jada Moore-Ruffin, MD
Satcher Health Leadership Institute
Morehouse School of Medicine

Tuesday, September 7, 2010

Pacifiers for SIDS prevention?

Reducing the risk of sudden infant death syndrome (SIDS) is an outstanding example of how family physicians have partnered with professional and community organizations to successfully address an important public health problem. In 2005, AFP published an editorial that examined the progress of the then decade-long "Back to Sleep" campaign in reducing the annual U.S. incidence of SIDS from more than 5,000 to fewer than 2,500.

In recent years, however, SIDS prevention has been the subject of controversy. In 2005, the American Academy of Pediatrics released new guidelines that suggested offering infants a pacifier at nap times and bedtime, based on evidence from observational studies showing a protective effect of pacifier use against SIDS. However, many physicians expressed concern that this practice could discourage women from prolonged breastfeeding and have unintended health consequences for mothers and babies.

We revisit the controversy regarding pacifiers and SIDS prevention in the September 1st issue's Letters to the Editor, which features an exchange of views prompted by recent review articles on SIDS and risks and benefits of pacifiers. Given this information, do you think that pacifier use should be encouraged after breastfeeding is well established, as the AAP and AFP's authors recommend? Or do you feel that the evidence isn't strong enough to support this practice, and may in fact "give parents a false sense of security," as Dr. David and Katherine Abdun-Nur argue?

Wednesday, September 1, 2010

Screening and treatment of hyperlipidemia in children

The September 1 issue of American Family Physician inaugurates a new editorial feature that presents two opposing views on a controversial clinical topic and asks readers to post comments online. In this issue, Dr. Robert Gauer argues that because atherosclerosis begins in childhood, using cholesterol-lowering drugs in children with hyperlipidemia is essential to prevent coronary events and cardiovascular mortality in later life. On the other hand, Dr. Michael LeFevre contends that since only 40 to 55 percent of children with elevated cholesterol levels will have persistent hyperlipidemia as adults, and the potential benefits and harms of decades of drug therapy are unknown, physicians should demand a high "evidence bar" for instituting screening and treatment.

Since hyperlipidemia causes no symptoms, these views reflect in large part the dueling guidelines of the American Academy of Pediatrics (AAP) and the U.S. Preventive Services Task Force (USPSTF) on lipid screening in children. While the AAP recommends that screening for hyperlipidemia begin at age 2 in children with a family history of hyperlipidemia, premature cardiovascular disease, or other risk factors, the USPSTF found insufficient evidence to recommend for or against screening in any group of children.

This leaves family physicians and other clinicians who care for children with an important clinical dilemma. Should they act now based on disease-oriented evidence and extrapolation from studies of primary prevention of cardiovascular disease in adults, or should they instead wait for patient-oriented evidence from long-term followup studies of children with elevated lipid levels? Which approach do you take in your practice, and why? You are welcome to post comments here or on AFP's Facebook page; AAFP members can also post comments on the AFP web page. We look forward to the discussion!

Thursday, August 26, 2010

Care of returning veterans: a story from the field

A physician reader of AFP's July 1, 2010 issue shared the following post.


I read with keen nostalgia your insightful and excellent article, “Care of the Returning Veteran.” I retired from the Navy in October 2007 and currently serve as the Director of the Deployment Stress Management Program at the U.S. Department of State. On April 16, 2007, our 2nd Marines Logistics Group, 2nd Shock Trauma Platoon had been in Al Taqaddum, Iraq in the Anbar Province for 2 months out of an 8 month deployment. We flew from Camp LeJeune, North Carolina, to Scotland, then spent four days in Kuwait before entering Taqaddum, Iraq inside of a hot C-130 plane.

While serving as the Combat Stress psychiatrist in the Post-Anesthesia Care Unit, I remember attempting to move the remains of Lieutenant Jones (not his real name) from a torn and leaking body bag to a new body bag. The emergency and surgical physicians, nurses and hospital corpsmen were occupied with incoming wounded in the shock trauma bay down the hallway of our large wood and tin Quonset Hut-shaped building. A psychologist colleague came to assist, but did an abrupt about-face when she recognized Lieutenant Jones. As a company Commanding Officer, he had often telephoned or stopped by to refer one of his troops for emotional support or to assess fitness for duty. Lieutenant Jones had stepped on an explosive device that blew off his legs and ends of his arms. His face was charred and partially separated from his skull, suggesting that he had been killed immediately and felt no pain.

I remember being engulfed by nausea and a surreal emptiness. I felt as if Lieutenant Jones was spiritually nearby and not letting go of his previous life, waiting to see if I would "screw up" and move him somewhere against his desires. I briefly and intensely thought about his family. Finally, I moved forward and asked two corpsmen next to me to each take a corner of the leaking body bag and carefully and respectfully empty it into the new and recently opened bag. Lieutenant Jones's body slipped effortlessly inside. Additional personnel arrived shortly to ensure that his personal items were accounted for, then closed the new body bag. An ironed United States flag was unpacked, unfurled and placed gingerly across the body bag.

Many State Department employees share in today’s overlapping deployments with Department of Defense veterans, serving in forward operating bases in Iraq and other hazardous areas of the world. The Department of State's Mental Health Department evaluates and treats many returning employees for post-deployment stress reactions and disorders that include post-traumatic stress disorder and traumatic brain injury. These unheralded heroes of the backwaters who work in Provincial Reconstruction Team areas of Iraq, as well as other deployments, serve one to five year tours of duty often in the most austere conditions. We wish to remind AFP's readers of their service during these challenging times.

Christopher J. Kowalsky, MD
CAPT, MC, USN (Retired)
Director, Deployment Stress Management Program
U.S. Department of State

Thursday, August 19, 2010

Welcome to the AFP Community Blog!

Welcome to the AFP Community Blog, written and moderated by the editors of American Family Physician, a peer-reviewed medical journal published twice monthly by the American Academy of Family Physicians.

The AFP Community Blog is a public forum for anyone interested in exchanging views on topics related to the journal and family medicine. You can comment on our articles or departments, as well as contribute practice management, policy, or public health perspectives on clinical topics. This blog is the most recent of several new ways that American Family Physician is building relationships with its readers. You can also follow AFP on Facebook and Twitter.

Whether you are a clinician, student, health educator, administrator, journalist, caregiver, or patient, I hope that the blog will have something to offer you - and that you will have something to offer the blog. You will notice that the right-hand sidebar includes an "FP Blog Log" containing links to blogs written by family physicians and other persons affiliated with the AAFP. This list is not intended to be comprehensive, nor a "best of" compilation, but rather an introduction to the richness and diversity of voices present in the specialty of family medicine today. If you know of another blog that you think should be included in the list, please let me know.

The cover article of AFP's July 1 issue, "Care of the Returning Veteran," elicited several heartfelt responses from veterans and physicians who have provided care to military servicemen and women and their families. The next blog post will include an excerpt from one particularly moving response. If you are interested in writing for the AFP Community Blog, please contact me. In the meantime, welcome again!

Kenny Lin, MD
Associate Editor for AFP Online
American Family Physician