AAFP Scientific Assembly

SAN DIEGO – "It’s not your fault."

Family physicians should relay those words of assurance to patients who present to them with early pregnancy loss, according to Dr. Linda Prine.

"In busy emergency rooms, that’s rarely the kind of thing an ER doc is going to have time to sit down and discuss with the patient," said Dr. Prine, women’s health director of the Institute for Family Health in New York. "They’re trying to make a diagnosis and move the patient on. Here you often have a woman who’s already thinking about what color she’s going to paint the bedroom, or buying a baby crib, or a stroller. This feels like a tragic loss to her. It needs to be explained gently as a natural process and some time taken for understanding. Her partner also needs to hear that it wasn’t her fault or his fault. It wasn’t the sex they had, the snow she shoveled – all of the things that start to go through a woman’s mind to blame herself."

Risk factors for miscarriage include advanced age or very young age, having prior miscarriages, smoking, cocaine use, and fever or infection. Contrary to myth, air travel does not cause miscarriage, she continued, and blunt abdominal trauma, contraceptive use, exercise, the human papillomavirus vaccine, previous abortions, and sexual activity are also not to blame.

Options for miscarriage include expectant management, medication management, and an aspiration procedure. "The patient should be involved in the decision making here," Dr. Prine said at the annual meeting of the American Academy of Family Physicians. "When the women are involved, their mental health outcomes are better. Family physicians are best suited to work through these events with our patients."

The potential risks of expectant management are rare but include infection, the need for emergent uterine aspiration, and bleeding or the need for blood transfusion. The benefits of expectant management include "avoiding the risks, though rare, that can happen with instrumentation such as perforation, introducing infection, or bleeding from a procedure that’s done too vigorously," she noted.

Fever with a tender uterus is a contraindication for expectant management. Incomplete abortions are more likely to have successful expectant management than are fetal demises or anembryonic pregnancies (at day 49, a success rate of 91% vs. 76% and 66%, respectively). "There’s no outside limit for how long you can wait for expectant management," Dr. Prine said. "Usually the woman is not going to want to wait for weeks and weeks, and that becomes the patient-centered limiting factor. How heavy can the bleeding get before she should start to worry about it? If she’s bleeding through two pads an hour for 2 hours back to back, she should call us, though this is rare."

For medical management of an early pregnancy loss, a common protocol involves 800 mcg misoprostol administered vaginally or buccally and repeated in 24 hours if the abortion is incomplete, with vacuum aspiration on day 8 if still incomplete. "Alternative oral regimens cause more GI side effects," Dr. Prine said. Side effects of misoprostol are bleeding, cramping, fever and/or chills, nausea and vomiting, and diarrhea. Misoprostol treatment is safest when used 10 weeks or less after an ultrasound exam confirming the pregnancy loss. "Rule out ectopic pregnancy because the medical treatment for ectopic pregnancy differs from miscarriage treatment," she said. Testing may include an ultrasound, an rh factor screen, hematocrit assessment, and measurement of the serum human chorionic gonadotropin level.

If medical management is not working, "we can repeat the misoprostol again, or she can come into the office for an aspiration procedure," Dr. Prine said.

Sample clinical protocols, patient education sheets, and other resources for providing miscarriage care can be found here.

Dr. Prine said she had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – "It’s not your fault."

Family physicians should relay those words of assurance to patients who present to them with early pregnancy loss, according to Dr. Linda Prine.

"In busy emergency rooms, that’s rarely the kind of thing an ER doc is going to have time to sit down and discuss with the patient," said Dr. Prine, women’s health director of the Institute for Family Health in New York. "They’re trying to make a diagnosis and move the patient on. Here you often have a woman who’s already thinking about what color she’s going to paint the bedroom, or buying a baby crib, or a stroller. This feels like a tragic loss to her. It needs to be explained gently as a natural process and some time taken for understanding. Her partner also needs to hear that it wasn’t her fault or his fault. It wasn’t the sex they had, the snow she shoveled – all of the things that start to go through a woman’s mind to blame herself."

Risk factors for miscarriage include advanced age or very young age, having prior miscarriages, smoking, cocaine use, and fever or infection. Contrary to myth, air travel does not cause miscarriage, she continued, and blunt abdominal trauma, contraceptive use, exercise, the human papillomavirus vaccine, previous abortions, and sexual activity are also not to blame.

Options for miscarriage include expectant management, medication management, and an aspiration procedure. "The patient should be involved in the decision making here," Dr. Prine said at the annual meeting of the American Academy of Family Physicians. "When the women are involved, their mental health outcomes are better. Family physicians are best suited to work through these events with our patients."

The potential risks of expectant management are rare but include infection, the need for emergent uterine aspiration, and bleeding or the need for blood transfusion. The benefits of expectant management include "avoiding the risks, though rare, that can happen with instrumentation such as perforation, introducing infection, or bleeding from a procedure that’s done too vigorously," she noted.

Fever with a tender uterus is a contraindication for expectant management. Incomplete abortions are more likely to have successful expectant management than are fetal demises or anembryonic pregnancies (at day 49, a success rate of 91% vs. 76% and 66%, respectively). "There’s no outside limit for how long you can wait for expectant management," Dr. Prine said. "Usually the woman is not going to want to wait for weeks and weeks, and that becomes the patient-centered limiting factor. How heavy can the bleeding get before she should start to worry about it? If she’s bleeding through two pads an hour for 2 hours back to back, she should call us, though this is rare."

For medical management of an early pregnancy loss, a common protocol involves 800 mcg misoprostol administered vaginally or buccally and repeated in 24 hours if the abortion is incomplete, with vacuum aspiration on day 8 if still incomplete. "Alternative oral regimens cause more GI side effects," Dr. Prine said. Side effects of misoprostol are bleeding, cramping, fever and/or chills, nausea and vomiting, and diarrhea. Misoprostol treatment is safest when used 10 weeks or less after an ultrasound exam confirming the pregnancy loss. "Rule out ectopic pregnancy because the medical treatment for ectopic pregnancy differs from miscarriage treatment," she said. Testing may include an ultrasound, an rh factor screen, hematocrit assessment, and measurement of the serum human chorionic gonadotropin level.

If medical management is not working, "we can repeat the misoprostol again, or she can come into the office for an aspiration procedure," Dr. Prine said.

Sample clinical protocols, patient education sheets, and other resources for providing miscarriage care can be found here.

Dr. Prine said she had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – "It’s not your fault."

Family physicians should relay those words of assurance to patients who present to them with early pregnancy loss, according to Dr. Linda Prine.

"In busy emergency rooms, that’s rarely the kind of thing an ER doc is going to have time to sit down and discuss with the patient," said Dr. Prine, women’s health director of the Institute for Family Health in New York. "They’re trying to make a diagnosis and move the patient on. Here you often have a woman who’s already thinking about what color she’s going to paint the bedroom, or buying a baby crib, or a stroller. This feels like a tragic loss to her. It needs to be explained gently as a natural process and some time taken for understanding. Her partner also needs to hear that it wasn’t her fault or his fault. It wasn’t the sex they had, the snow she shoveled – all of the things that start to go through a woman’s mind to blame herself."

Risk factors for miscarriage include advanced age or very young age, having prior miscarriages, smoking, cocaine use, and fever or infection. Contrary to myth, air travel does not cause miscarriage, she continued, and blunt abdominal trauma, contraceptive use, exercise, the human papillomavirus vaccine, previous abortions, and sexual activity are also not to blame.

Options for miscarriage include expectant management, medication management, and an aspiration procedure. "The patient should be involved in the decision making here," Dr. Prine said at the annual meeting of the American Academy of Family Physicians. "When the women are involved, their mental health outcomes are better. Family physicians are best suited to work through these events with our patients."

The potential risks of expectant management are rare but include infection, the need for emergent uterine aspiration, and bleeding or the need for blood transfusion. The benefits of expectant management include "avoiding the risks, though rare, that can happen with instrumentation such as perforation, introducing infection, or bleeding from a procedure that’s done too vigorously," she noted.

Fever with a tender uterus is a contraindication for expectant management. Incomplete abortions are more likely to have successful expectant management than are fetal demises or anembryonic pregnancies (at day 49, a success rate of 91% vs. 76% and 66%, respectively). "There’s no outside limit for how long you can wait for expectant management," Dr. Prine said. "Usually the woman is not going to want to wait for weeks and weeks, and that becomes the patient-centered limiting factor. How heavy can the bleeding get before she should start to worry about it? If she’s bleeding through two pads an hour for 2 hours back to back, she should call us, though this is rare."

For medical management of an early pregnancy loss, a common protocol involves 800 mcg misoprostol administered vaginally or buccally and repeated in 24 hours if the abortion is incomplete, with vacuum aspiration on day 8 if still incomplete. "Alternative oral regimens cause more GI side effects," Dr. Prine said. Side effects of misoprostol are bleeding, cramping, fever and/or chills, nausea and vomiting, and diarrhea. Misoprostol treatment is safest when used 10 weeks or less after an ultrasound exam confirming the pregnancy loss. "Rule out ectopic pregnancy because the medical treatment for ectopic pregnancy differs from miscarriage treatment," she said. Testing may include an ultrasound, an rh factor screen, hematocrit assessment, and measurement of the serum human chorionic gonadotropin level.

If medical management is not working, "we can repeat the misoprostol again, or she can come into the office for an aspiration procedure," Dr. Prine said.

Sample clinical protocols, patient education sheets, and other resources for providing miscarriage care can be found here.

Dr. Prine said she had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – The American Academy of Family Physicians will push the federal government to ban on the sale of energy drinks – caffeinated beverages that come in fizzy cans or small twist-cap bottle syrups – to kids under 18 years old, following a vote to do so by its Congress of Delegates.

Pitched largely to kids, "energy drinks are dangerous to youth and can lead to dehydration, particularly when consumed with alcohol," a not uncommon practice among minors. The academy will also work with the Food and Drug Administration to oppose handing out free samples to kids and establish specific definitions of stimulant drinks.

©Alexander Mirokhin/Fotolia.com

Delegates were following the news reports of the harm done by these drinks, which have been associated with thousands of visits by minors to the emergency department, and some deaths, mostly among children who overindulged on energy drinks. The beverages typically contain perhaps 200 mg of caffeine – but sometimes much more – plus herbs and other ingredients added to boost stimulating effects. In comparison, a 16 oz. Starbuck’s coffee comes with a 330 mg caffeine bolus.

The American Academy of Pediatrics has already come out against the drinks, and a few states are considering bans on sales to those under age 18 years.

The problem in New York, though, where AAFP’s resolution originated, is that legislators "believe this is a federal issue, an FDA issue," said Vito Grasso, executive vice-president of the state’s AAFP chapter. Meanwhile, N.Y. doctors are seeing heart issues, hyperactivity, and exacerbations of asthma and other chronic conditions in children because of the drinks, Mr. Grasso said.

AAFP is likely to draft legislation to remind the FDA that it has jurisdiction in the matter and can demand that companies fully disclose what the drinks contain, but AAFP delegates agreed with their N.Y. colleagues that there’s already enough evidence to ban the drinks for kids.

The move was just 1 of more than 50 resolutions tackled by AAFP delegates. None matched the fireworks of 2012’s vote to support gay marriage, but delegates considered some controversial topics.

Gun violence was one of those. Attendees voted to name it "a significant public health problem" that needs "further research."

That wasn’t as light-footed as it sounds. Worried that scientific findings might be used to support firearm limits, gun interests have kept the federal government from funding gun violence studies for almost 20 years, AAFP board chair Dr. Jeffrey Cain explained later.

The de-facto ban was relaxed a bit after a troubled, assault-weapon–wielding 20-year-old killed his mother and murdered 20 kindergarten and first grade students, and six teachers and administrators trying to protect them, at Sandy Hook Elementary School in Newtown, Conn., in December 2012. Delegates decided it’s time to get behind federal dollars to find how to stop gun murder in the United States and generate the data needed to cut through the country’s indecision on gun access.

Delegates voted down, however, calls by delegates from Washington and Oregon for mandatory background checks and tracking of all gun sales and transfers; delegates decided the issues were too "divisive."

Gun violence "is now recognized by our Academy as an issue of public health," just like using seatbelts in cars. Beyond that, though, "our members’ political views span the full spectrum, like the citizens of America," Dr. Cain said.

Delegates also decided that AAFP’s current gun policy addresses the intent of the Northwest measures, including, as it does, opposition to civilian ownership of military assault weapons, backing of doctors’ rights to ask gun owners about firearm safety in their homes, and support of background checks to keep guns out of the hands of criminals and people with mental illness.

Other measures

Guns and energy drinks weren’t the only things on AAFP delegates’ minds.

The group, which decides academy legislative and policy priorities, tackled more than 50 resolutions. Among them, it directed the academy to do the following:

• Push for automated electronic defibrillators in high schools.

• Work to ensure that "relative value unit" compensation models aren’t used to shortchange family doctors’ paychecks.

• Allow family medicine residents to prescribe for Medicaid patients.

• Stop states from adding extra CME requirements beyond what boards require.

• Consider legislative fixes so doctors can keep their license protections when helping sports teams and disaster victims out of state.

Delegates also revisited gay marriage. Oklahoma wanted the academy to take a neutral position on the issue, arguing that, like abortion and gun control, the issue is too divisive for members and goes beyond the medical issues AAFP should focus on.

Delegates didn’t go for it: "To go back on what the Congress of Delegates decided last year would be to make a divisive issue only more contentious. The testimony and research by the American College of Obstetricians and Gynecologists made it clear that marriage is a key to the access to health care. The adoption of the proposed resolution would say that the AAFP no longer believes that civil marriage is a health issue. In the final analysis ... the Congress of Delegates did not adopt the resolution to support civil [same-gender] marriage, but to serve the health of our members, our patients, and our communities," wrote the resolution committee, winning the day.

Medical marijuana came up, too.

New York asked delegates to fight state approval of smoked cannabis, arguing that it’s the business of the FDA to regulate drugs, not state legislators and that smoking pot probably hurts the lungs. AAFP’s N.Y. members are working stop the Empire State from approving medical marijuana, and wanted the academy’s help.

After testimony about marijuana’s benefits for sick people, delegates decided to sidestep the issue and vote instead for AAFP research and "expressing concerns" about the safety of smoking it.

The academy was also directed to take a few steps on women’s health issues.

Among them, it will try to stop the Centers for Medicare & Medicaid Services from requiring abnormal pap smears before paying for HPV screening. The American Society for Colposcopy and Cervical Pathology wants doctors to screen high-risk women over age 29 years for HPV during routine Pap smears, whatever their prior results. Delegates voted that payment guidelines need to match those of experts. Also, AAFP will also now support IUDs as first-line contraceptives for most women, and work to end prior approval for FDA-cleared contraceptive devices. The Affordable Care Act requires their coverage, so requiring prior authorization doesn’t make any sense, California and Texas delegates said in their resolutions.

The academy is going to look into pushing for OTC birth control pills, as well, but delegates didn’t want it to support OTC access without more investigation. Some worried that insurance companies won’t cover OTC birth control, and others that women might "stop visiting their family physicians if they no longer had to rely on them for birth control prescriptions."

Putting the ‘primary’ back into primary care education

Medical schools were the subject of three strong resolutions from New Hampshire delegates tired of hearing about professors who shoot down primary care as a career option.

Delegates didn’t like that either and voted for AAFP to poll new residents about what medical school faculty said regarding family care, and to figure out how many medical school graduates go into primary care each year and how many are still at it 5 years later.

The big hammer, though, was a vote from delegates for the academy to consider a push to link medical school accreditation and CMS education reimbursements to the number of graduates who go into primary care.

A better way for rural EDs

The AAFP endorsed Comprehensive Advanced Life Support (CALS) training as "an appropriate advanced life support course for" rural physicians and will consider it as an alternative to Advanced Trauma Life Support (ATLS) for low-level state trauma designation.

That’s not a trivial decision for rural emergency departments (EDs), where a lone family physician, physician assistant, or nurse practitioner is on the hook to handle anything that comes through the door, without help from specialists.

CALS was designed in Minnesota 20 years ago to help providers in rural EDs do that. "Other ED courses focus on specific emergencies. We compressed them, eliminated the redundancies, and added psychiatric, neurologic, burn, and other emergencies the other courses don’t cover," said Dr. Paul Van Gorp, a family practitioner in Long Prairie, Minn., and CALS board chair.

"It’s been very successful. We’ve presented CALS in nine states and several countries; people who have taken it, many from remote places like Alaska, have wonderful things to say about it, but not every state recognizes CALS as an acceptable route to qualify as a level 3 or 4 trauma center," he said.

In most states, "the only route to trauma level designation is ATLS, but trauma is just a small part of what we see," he said.

AAFP’s recognition will add heft to efforts to get states to recognize CALS as an alternative.

The course has 2 days of scenario-based training, a half-day trauma module that meets requirements for state trauma designation, and a day-long benchmark skills lab. A sheep is killed in the lab, but "we recognize that there’re a lot of people opposed to us using animals in this way, so we developed" an alternative that "entirely uses mannequins as a substitute," Dr. Van Gorp said.

The course comes with an exhaustive electronic reference manual to freshen up when the ambulance calls in. It’s a reassuring resource in places where "you go through an emergency and get pretty comfortable with it, but don’t see it again for 5 years," he said.

[email protected]

SAN DIEGO – The American Academy of Family Physicians will push the federal government to ban on the sale of energy drinks – caffeinated beverages that come in fizzy cans or small twist-cap bottle syrups – to kids under 18 years old, following a vote to do so by its Congress of Delegates.

Pitched largely to kids, "energy drinks are dangerous to youth and can lead to dehydration, particularly when consumed with alcohol," a not uncommon practice among minors. The academy will also work with the Food and Drug Administration to oppose handing out free samples to kids and establish specific definitions of stimulant drinks.

©Alexander Mirokhin/Fotolia.com

Delegates were following the news reports of the harm done by these drinks, which have been associated with thousands of visits by minors to the emergency department, and some deaths, mostly among children who overindulged on energy drinks. The beverages typically contain perhaps 200 mg of caffeine – but sometimes much more – plus herbs and other ingredients added to boost stimulating effects. In comparison, a 16 oz. Starbuck’s coffee comes with a 330 mg caffeine bolus.

The American Academy of Pediatrics has already come out against the drinks, and a few states are considering bans on sales to those under age 18 years.

The problem in New York, though, where AAFP’s resolution originated, is that legislators "believe this is a federal issue, an FDA issue," said Vito Grasso, executive vice-president of the state’s AAFP chapter. Meanwhile, N.Y. doctors are seeing heart issues, hyperactivity, and exacerbations of asthma and other chronic conditions in children because of the drinks, Mr. Grasso said.

AAFP is likely to draft legislation to remind the FDA that it has jurisdiction in the matter and can demand that companies fully disclose what the drinks contain, but AAFP delegates agreed with their N.Y. colleagues that there’s already enough evidence to ban the drinks for kids.

The move was just 1 of more than 50 resolutions tackled by AAFP delegates. None matched the fireworks of 2012’s vote to support gay marriage, but delegates considered some controversial topics.

Gun violence was one of those. Attendees voted to name it "a significant public health problem" that needs "further research."

That wasn’t as light-footed as it sounds. Worried that scientific findings might be used to support firearm limits, gun interests have kept the federal government from funding gun violence studies for almost 20 years, AAFP board chair Dr. Jeffrey Cain explained later.

The de-facto ban was relaxed a bit after a troubled, assault-weapon–wielding 20-year-old killed his mother and murdered 20 kindergarten and first grade students, and six teachers and administrators trying to protect them, at Sandy Hook Elementary School in Newtown, Conn., in December 2012. Delegates decided it’s time to get behind federal dollars to find how to stop gun murder in the United States and generate the data needed to cut through the country’s indecision on gun access.

Delegates voted down, however, calls by delegates from Washington and Oregon for mandatory background checks and tracking of all gun sales and transfers; delegates decided the issues were too "divisive."

Gun violence "is now recognized by our Academy as an issue of public health," just like using seatbelts in cars. Beyond that, though, "our members’ political views span the full spectrum, like the citizens of America," Dr. Cain said.

Delegates also decided that AAFP’s current gun policy addresses the intent of the Northwest measures, including, as it does, opposition to civilian ownership of military assault weapons, backing of doctors’ rights to ask gun owners about firearm safety in their homes, and support of background checks to keep guns out of the hands of criminals and people with mental illness.

Other measures

Guns and energy drinks weren’t the only things on AAFP delegates’ minds.

The group, which decides academy legislative and policy priorities, tackled more than 50 resolutions. Among them, it directed the academy to do the following:

• Push for automated electronic defibrillators in high schools.

• Work to ensure that "relative value unit" compensation models aren’t used to shortchange family doctors’ paychecks.

• Allow family medicine residents to prescribe for Medicaid patients.

• Stop states from adding extra CME requirements beyond what boards require.

• Consider legislative fixes so doctors can keep their license protections when helping sports teams and disaster victims out of state.

Delegates also revisited gay marriage. Oklahoma wanted the academy to take a neutral position on the issue, arguing that, like abortion and gun control, the issue is too divisive for members and goes beyond the medical issues AAFP should focus on.

Delegates didn’t go for it: "To go back on what the Congress of Delegates decided last year would be to make a divisive issue only more contentious. The testimony and research by the American College of Obstetricians and Gynecologists made it clear that marriage is a key to the access to health care. The adoption of the proposed resolution would say that the AAFP no longer believes that civil marriage is a health issue. In the final analysis ... the Congress of Delegates did not adopt the resolution to support civil [same-gender] marriage, but to serve the health of our members, our patients, and our communities," wrote the resolution committee, winning the day.

Medical marijuana came up, too.

New York asked delegates to fight state approval of smoked cannabis, arguing that it’s the business of the FDA to regulate drugs, not state legislators and that smoking pot probably hurts the lungs. AAFP’s N.Y. members are working stop the Empire State from approving medical marijuana, and wanted the academy’s help.

After testimony about marijuana’s benefits for sick people, delegates decided to sidestep the issue and vote instead for AAFP research and "expressing concerns" about the safety of smoking it.

The academy was also directed to take a few steps on women’s health issues.

Among them, it will try to stop the Centers for Medicare & Medicaid Services from requiring abnormal pap smears before paying for HPV screening. The American Society for Colposcopy and Cervical Pathology wants doctors to screen high-risk women over age 29 years for HPV during routine Pap smears, whatever their prior results. Delegates voted that payment guidelines need to match those of experts. Also, AAFP will also now support IUDs as first-line contraceptives for most women, and work to end prior approval for FDA-cleared contraceptive devices. The Affordable Care Act requires their coverage, so requiring prior authorization doesn’t make any sense, California and Texas delegates said in their resolutions.

The academy is going to look into pushing for OTC birth control pills, as well, but delegates didn’t want it to support OTC access without more investigation. Some worried that insurance companies won’t cover OTC birth control, and others that women might "stop visiting their family physicians if they no longer had to rely on them for birth control prescriptions."

Putting the ‘primary’ back into primary care education

Medical schools were the subject of three strong resolutions from New Hampshire delegates tired of hearing about professors who shoot down primary care as a career option.

Delegates didn’t like that either and voted for AAFP to poll new residents about what medical school faculty said regarding family care, and to figure out how many medical school graduates go into primary care each year and how many are still at it 5 years later.

The big hammer, though, was a vote from delegates for the academy to consider a push to link medical school accreditation and CMS education reimbursements to the number of graduates who go into primary care.

A better way for rural EDs

The AAFP endorsed Comprehensive Advanced Life Support (CALS) training as "an appropriate advanced life support course for" rural physicians and will consider it as an alternative to Advanced Trauma Life Support (ATLS) for low-level state trauma designation.

That’s not a trivial decision for rural emergency departments (EDs), where a lone family physician, physician assistant, or nurse practitioner is on the hook to handle anything that comes through the door, without help from specialists.

CALS was designed in Minnesota 20 years ago to help providers in rural EDs do that. "Other ED courses focus on specific emergencies. We compressed them, eliminated the redundancies, and added psychiatric, neurologic, burn, and other emergencies the other courses don’t cover," said Dr. Paul Van Gorp, a family practitioner in Long Prairie, Minn., and CALS board chair.

"It’s been very successful. We’ve presented CALS in nine states and several countries; people who have taken it, many from remote places like Alaska, have wonderful things to say about it, but not every state recognizes CALS as an acceptable route to qualify as a level 3 or 4 trauma center," he said.

In most states, "the only route to trauma level designation is ATLS, but trauma is just a small part of what we see," he said.

AAFP’s recognition will add heft to efforts to get states to recognize CALS as an alternative.

The course has 2 days of scenario-based training, a half-day trauma module that meets requirements for state trauma designation, and a day-long benchmark skills lab. A sheep is killed in the lab, but "we recognize that there’re a lot of people opposed to us using animals in this way, so we developed" an alternative that "entirely uses mannequins as a substitute," Dr. Van Gorp said.

The course comes with an exhaustive electronic reference manual to freshen up when the ambulance calls in. It’s a reassuring resource in places where "you go through an emergency and get pretty comfortable with it, but don’t see it again for 5 years," he said.

[email protected]

SAN DIEGO – The American Academy of Family Physicians will push the federal government to ban on the sale of energy drinks – caffeinated beverages that come in fizzy cans or small twist-cap bottle syrups – to kids under 18 years old, following a vote to do so by its Congress of Delegates.

Pitched largely to kids, "energy drinks are dangerous to youth and can lead to dehydration, particularly when consumed with alcohol," a not uncommon practice among minors. The academy will also work with the Food and Drug Administration to oppose handing out free samples to kids and establish specific definitions of stimulant drinks.

©Alexander Mirokhin/Fotolia.com

Delegates were following the news reports of the harm done by these drinks, which have been associated with thousands of visits by minors to the emergency department, and some deaths, mostly among children who overindulged on energy drinks. The beverages typically contain perhaps 200 mg of caffeine – but sometimes much more – plus herbs and other ingredients added to boost stimulating effects. In comparison, a 16 oz. Starbuck’s coffee comes with a 330 mg caffeine bolus.

The American Academy of Pediatrics has already come out against the drinks, and a few states are considering bans on sales to those under age 18 years.

The problem in New York, though, where AAFP’s resolution originated, is that legislators "believe this is a federal issue, an FDA issue," said Vito Grasso, executive vice-president of the state’s AAFP chapter. Meanwhile, N.Y. doctors are seeing heart issues, hyperactivity, and exacerbations of asthma and other chronic conditions in children because of the drinks, Mr. Grasso said.

AAFP is likely to draft legislation to remind the FDA that it has jurisdiction in the matter and can demand that companies fully disclose what the drinks contain, but AAFP delegates agreed with their N.Y. colleagues that there’s already enough evidence to ban the drinks for kids.

The move was just 1 of more than 50 resolutions tackled by AAFP delegates. None matched the fireworks of 2012’s vote to support gay marriage, but delegates considered some controversial topics.

Gun violence was one of those. Attendees voted to name it "a significant public health problem" that needs "further research."

That wasn’t as light-footed as it sounds. Worried that scientific findings might be used to support firearm limits, gun interests have kept the federal government from funding gun violence studies for almost 20 years, AAFP board chair Dr. Jeffrey Cain explained later.

The de-facto ban was relaxed a bit after a troubled, assault-weapon–wielding 20-year-old killed his mother and murdered 20 kindergarten and first grade students, and six teachers and administrators trying to protect them, at Sandy Hook Elementary School in Newtown, Conn., in December 2012. Delegates decided it’s time to get behind federal dollars to find how to stop gun murder in the United States and generate the data needed to cut through the country’s indecision on gun access.

Delegates voted down, however, calls by delegates from Washington and Oregon for mandatory background checks and tracking of all gun sales and transfers; delegates decided the issues were too "divisive."

Gun violence "is now recognized by our Academy as an issue of public health," just like using seatbelts in cars. Beyond that, though, "our members’ political views span the full spectrum, like the citizens of America," Dr. Cain said.

Delegates also decided that AAFP’s current gun policy addresses the intent of the Northwest measures, including, as it does, opposition to civilian ownership of military assault weapons, backing of doctors’ rights to ask gun owners about firearm safety in their homes, and support of background checks to keep guns out of the hands of criminals and people with mental illness.

Other measures

Guns and energy drinks weren’t the only things on AAFP delegates’ minds.

The group, which decides academy legislative and policy priorities, tackled more than 50 resolutions. Among them, it directed the academy to do the following:

• Push for automated electronic defibrillators in high schools.

• Work to ensure that "relative value unit" compensation models aren’t used to shortchange family doctors’ paychecks.

• Allow family medicine residents to prescribe for Medicaid patients.

• Stop states from adding extra CME requirements beyond what boards require.

• Consider legislative fixes so doctors can keep their license protections when helping sports teams and disaster victims out of state.

Delegates also revisited gay marriage. Oklahoma wanted the academy to take a neutral position on the issue, arguing that, like abortion and gun control, the issue is too divisive for members and goes beyond the medical issues AAFP should focus on.

Delegates didn’t go for it: "To go back on what the Congress of Delegates decided last year would be to make a divisive issue only more contentious. The testimony and research by the American College of Obstetricians and Gynecologists made it clear that marriage is a key to the access to health care. The adoption of the proposed resolution would say that the AAFP no longer believes that civil marriage is a health issue. In the final analysis ... the Congress of Delegates did not adopt the resolution to support civil [same-gender] marriage, but to serve the health of our members, our patients, and our communities," wrote the resolution committee, winning the day.

Medical marijuana came up, too.

New York asked delegates to fight state approval of smoked cannabis, arguing that it’s the business of the FDA to regulate drugs, not state legislators and that smoking pot probably hurts the lungs. AAFP’s N.Y. members are working stop the Empire State from approving medical marijuana, and wanted the academy’s help.

After testimony about marijuana’s benefits for sick people, delegates decided to sidestep the issue and vote instead for AAFP research and "expressing concerns" about the safety of smoking it.

The academy was also directed to take a few steps on women’s health issues.

Among them, it will try to stop the Centers for Medicare & Medicaid Services from requiring abnormal pap smears before paying for HPV screening. The American Society for Colposcopy and Cervical Pathology wants doctors to screen high-risk women over age 29 years for HPV during routine Pap smears, whatever their prior results. Delegates voted that payment guidelines need to match those of experts. Also, AAFP will also now support IUDs as first-line contraceptives for most women, and work to end prior approval for FDA-cleared contraceptive devices. The Affordable Care Act requires their coverage, so requiring prior authorization doesn’t make any sense, California and Texas delegates said in their resolutions.

The academy is going to look into pushing for OTC birth control pills, as well, but delegates didn’t want it to support OTC access without more investigation. Some worried that insurance companies won’t cover OTC birth control, and others that women might "stop visiting their family physicians if they no longer had to rely on them for birth control prescriptions."

Putting the ‘primary’ back into primary care education

Medical schools were the subject of three strong resolutions from New Hampshire delegates tired of hearing about professors who shoot down primary care as a career option.

Delegates didn’t like that either and voted for AAFP to poll new residents about what medical school faculty said regarding family care, and to figure out how many medical school graduates go into primary care each year and how many are still at it 5 years later.

The big hammer, though, was a vote from delegates for the academy to consider a push to link medical school accreditation and CMS education reimbursements to the number of graduates who go into primary care.

A better way for rural EDs

The AAFP endorsed Comprehensive Advanced Life Support (CALS) training as "an appropriate advanced life support course for" rural physicians and will consider it as an alternative to Advanced Trauma Life Support (ATLS) for low-level state trauma designation.

That’s not a trivial decision for rural emergency departments (EDs), where a lone family physician, physician assistant, or nurse practitioner is on the hook to handle anything that comes through the door, without help from specialists.

CALS was designed in Minnesota 20 years ago to help providers in rural EDs do that. "Other ED courses focus on specific emergencies. We compressed them, eliminated the redundancies, and added psychiatric, neurologic, burn, and other emergencies the other courses don’t cover," said Dr. Paul Van Gorp, a family practitioner in Long Prairie, Minn., and CALS board chair.

"It’s been very successful. We’ve presented CALS in nine states and several countries; people who have taken it, many from remote places like Alaska, have wonderful things to say about it, but not every state recognizes CALS as an acceptable route to qualify as a level 3 or 4 trauma center," he said.

In most states, "the only route to trauma level designation is ATLS, but trauma is just a small part of what we see," he said.

AAFP’s recognition will add heft to efforts to get states to recognize CALS as an alternative.

The course has 2 days of scenario-based training, a half-day trauma module that meets requirements for state trauma designation, and a day-long benchmark skills lab. A sheep is killed in the lab, but "we recognize that there’re a lot of people opposed to us using animals in this way, so we developed" an alternative that "entirely uses mannequins as a substitute," Dr. Van Gorp said.

The course comes with an exhaustive electronic reference manual to freshen up when the ambulance calls in. It’s a reassuring resource in places where "you go through an emergency and get pretty comfortable with it, but don’t see it again for 5 years," he said.

[email protected]

SAN DIEGO – If you’re skeptical about the impact that you as a primary care provider can make on patients who seek assistance from you with weight loss, think again, advised Dr. Lindsay Botsford.

"You can really make a big difference in your office," Dr. Botsford, a family physician who practices in Sugar Land, Tex., said at the annual meeting of the American Academy of Family Physicians.

During her presentation, she spotlighted the success of Practice-Based Opportunities for Weight Reduction (POWER-UP), a 2-year randomized controlled trial of obesity treatment in the primary care setting. For the trial, 390 patients at six primary care practices were randomized to one of three interventions: usual care, which consisted of quarterly visits that included education about weight management; brief lifestyle counseling, which consisted of quarterly primary care visits combined with short monthly sessions with lifestyle coaches who instructed patients about behavioral control; and enhanced brief lifestyle counseling, which consisted of quarterly primary care visits combined with short monthly sessions with lifestyle coaches who instructed patients about behavioral control, plus meal replacements or orlistat or sibutramine to potentially increase weight loss (N. Engl. J. Med. 2011;365[2]:1969-79).

At the end of the second year, patients in the enhanced lifestyle counseling group lost an average of 4.6 kg, which exceeded the average weight loss experienced by patients in the brief lifestyle counseling and usual care groups (an average of 2.9 kg and 1.7 kg, respectively). The proportion of patients who achieved a weight loss of more than 5% at the end of the second year was also greatest in the enhanced lifestyle group (34.9% vs. 26% and 21.5% in the other two groups, respectively).

Some patients harbor sensitivity about their weight, so if they want to talk about the issue, Dr. Botsford recommended avoiding the term "obesity" and instead using terms such as "weight," "excess weight," "unhealthy body weight," and "BMI." She also recommended involving other members of the staff. For example, front desk staff can ask patients to fill out a fitness inventory and medical assistants can check BMI, measure waist circumference, and provide basic counseling advice about weight loss strategies such as keeping a food journal and portion control.

Regarding how patients perceive overweight physicians, Dr. Botsford noted, "In general, patients find overweight physicians less credible. I find that a little sad, but your view on the subject can influence patients. If you are not at your healthy weight, try to overcome this by sharing personal stories with them."

In counseling patients who express interest in losing weight, she said she begins with a 24-hour dietary recall and then reviews the U.S. Preventive Services Task Force’s "5 A’s" framework to create goals. The five A’s include assess (ask about or assess behavioral health risk[s] and factors affecting choice of behavior change goals); advise (give clear, specific, and personalized behavior change advice, including information about harms and benefits); agree (collaboratively select treatment goals and methods based on interest and willingness to change); assist (using behavior change techniques, help patient to acquire the skills, confidence, and social or environmental supports for behavior change, supplemented with medical treatments when needed); and arrange (schedule follow-up to provide ongoing assistance or support and to adjust the treatment plan as needed).

Other evidence-based counseling tips include recommending that patients avoid artificial sweetener, eating out of a bag, eating in front of the television, eating bread when dining out, and being mindful of liquid calorie intake. She also said she advises patients to stay hydrated, leave one-third of the portion on the plate when dining out, order "small" sizes when possible, and use small plates and bowls at home.

"Study after study has shown that low-calorie diets – 1,000-1,200 kcal/day for women and 1,200-1,600 kcal/day for men are the most successful for maintaining weight loss in the long term," Dr. Botsford said. "Adherence is a big thing when it comes to diets. The most common thing is that people stop. They can’t stick with it. Low glycemic load may help adherence. That’s still within the context of a low-calorie diet. There is certain evidence that having more fiber and more protein will make you feel fuller along the way, but in the end, a low-calorie diet is best."

Tools that can help patients keep a handle on food intake include the AAFP\'s initiative Americans in Motion Healthy Interventions and smartphone apps such as Lose It!, Calorie Counter and Diet Tracker by MyFitnessPal.com, healthfinder.gov, and Weight Watchers Mobile. "Exercise alone is better than nothing, but it only translates into a small weight loss," Dr. Botsford said. "However, exercise reduces blood pressure, triglycerides, and fasting glucose, and it decreases abdominal adipose tissue. To make the real difference you need exercise and diet. You also improve your strength, balance, and peak oxygen consumption. The more intense your exercise, [the more] you will increase your weight loss."

Medicare will reimburse for obesity counseling, but the patient’s BMI has to be greater than 30 kg/m²; the patient has to be competent and alert, and the counseling has to be done in a primary care setting or by the primary care provider. "Medicare will cover up to 22 visits in 12 months in a staged way," Dr. Botsford said, noting that the ICD-9 code for a BMI of 30 or more is G0447. "For the first month they’ll cover once a week. The only caveat is that you cannot bill for any other services on the same day as the visit for obesity counseling."

Dr. Botsford said she had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – If you’re skeptical about the impact that you as a primary care provider can make on patients who seek assistance from you with weight loss, think again, advised Dr. Lindsay Botsford.

"You can really make a big difference in your office," Dr. Botsford, a family physician who practices in Sugar Land, Tex., said at the annual meeting of the American Academy of Family Physicians.

During her presentation, she spotlighted the success of Practice-Based Opportunities for Weight Reduction (POWER-UP), a 2-year randomized controlled trial of obesity treatment in the primary care setting. For the trial, 390 patients at six primary care practices were randomized to one of three interventions: usual care, which consisted of quarterly visits that included education about weight management; brief lifestyle counseling, which consisted of quarterly primary care visits combined with short monthly sessions with lifestyle coaches who instructed patients about behavioral control; and enhanced brief lifestyle counseling, which consisted of quarterly primary care visits combined with short monthly sessions with lifestyle coaches who instructed patients about behavioral control, plus meal replacements or orlistat or sibutramine to potentially increase weight loss (N. Engl. J. Med. 2011;365[2]:1969-79).

At the end of the second year, patients in the enhanced lifestyle counseling group lost an average of 4.6 kg, which exceeded the average weight loss experienced by patients in the brief lifestyle counseling and usual care groups (an average of 2.9 kg and 1.7 kg, respectively). The proportion of patients who achieved a weight loss of more than 5% at the end of the second year was also greatest in the enhanced lifestyle group (34.9% vs. 26% and 21.5% in the other two groups, respectively).

Some patients harbor sensitivity about their weight, so if they want to talk about the issue, Dr. Botsford recommended avoiding the term "obesity" and instead using terms such as "weight," "excess weight," "unhealthy body weight," and "BMI." She also recommended involving other members of the staff. For example, front desk staff can ask patients to fill out a fitness inventory and medical assistants can check BMI, measure waist circumference, and provide basic counseling advice about weight loss strategies such as keeping a food journal and portion control.

Regarding how patients perceive overweight physicians, Dr. Botsford noted, "In general, patients find overweight physicians less credible. I find that a little sad, but your view on the subject can influence patients. If you are not at your healthy weight, try to overcome this by sharing personal stories with them."

In counseling patients who express interest in losing weight, she said she begins with a 24-hour dietary recall and then reviews the U.S. Preventive Services Task Force’s "5 A’s" framework to create goals. The five A’s include assess (ask about or assess behavioral health risk[s] and factors affecting choice of behavior change goals); advise (give clear, specific, and personalized behavior change advice, including information about harms and benefits); agree (collaboratively select treatment goals and methods based on interest and willingness to change); assist (using behavior change techniques, help patient to acquire the skills, confidence, and social or environmental supports for behavior change, supplemented with medical treatments when needed); and arrange (schedule follow-up to provide ongoing assistance or support and to adjust the treatment plan as needed).

Other evidence-based counseling tips include recommending that patients avoid artificial sweetener, eating out of a bag, eating in front of the television, eating bread when dining out, and being mindful of liquid calorie intake. She also said she advises patients to stay hydrated, leave one-third of the portion on the plate when dining out, order "small" sizes when possible, and use small plates and bowls at home.

"Study after study has shown that low-calorie diets – 1,000-1,200 kcal/day for women and 1,200-1,600 kcal/day for men are the most successful for maintaining weight loss in the long term," Dr. Botsford said. "Adherence is a big thing when it comes to diets. The most common thing is that people stop. They can’t stick with it. Low glycemic load may help adherence. That’s still within the context of a low-calorie diet. There is certain evidence that having more fiber and more protein will make you feel fuller along the way, but in the end, a low-calorie diet is best."

Tools that can help patients keep a handle on food intake include the AAFP\'s initiative Americans in Motion Healthy Interventions and smartphone apps such as Lose It!, Calorie Counter and Diet Tracker by MyFitnessPal.com, healthfinder.gov, and Weight Watchers Mobile. "Exercise alone is better than nothing, but it only translates into a small weight loss," Dr. Botsford said. "However, exercise reduces blood pressure, triglycerides, and fasting glucose, and it decreases abdominal adipose tissue. To make the real difference you need exercise and diet. You also improve your strength, balance, and peak oxygen consumption. The more intense your exercise, [the more] you will increase your weight loss."

Medicare will reimburse for obesity counseling, but the patient’s BMI has to be greater than 30 kg/m²; the patient has to be competent and alert, and the counseling has to be done in a primary care setting or by the primary care provider. "Medicare will cover up to 22 visits in 12 months in a staged way," Dr. Botsford said, noting that the ICD-9 code for a BMI of 30 or more is G0447. "For the first month they’ll cover once a week. The only caveat is that you cannot bill for any other services on the same day as the visit for obesity counseling."

Dr. Botsford said she had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – If you’re skeptical about the impact that you as a primary care provider can make on patients who seek assistance from you with weight loss, think again, advised Dr. Lindsay Botsford.

"You can really make a big difference in your office," Dr. Botsford, a family physician who practices in Sugar Land, Tex., said at the annual meeting of the American Academy of Family Physicians.

During her presentation, she spotlighted the success of Practice-Based Opportunities for Weight Reduction (POWER-UP), a 2-year randomized controlled trial of obesity treatment in the primary care setting. For the trial, 390 patients at six primary care practices were randomized to one of three interventions: usual care, which consisted of quarterly visits that included education about weight management; brief lifestyle counseling, which consisted of quarterly primary care visits combined with short monthly sessions with lifestyle coaches who instructed patients about behavioral control; and enhanced brief lifestyle counseling, which consisted of quarterly primary care visits combined with short monthly sessions with lifestyle coaches who instructed patients about behavioral control, plus meal replacements or orlistat or sibutramine to potentially increase weight loss (N. Engl. J. Med. 2011;365[2]:1969-79).

At the end of the second year, patients in the enhanced lifestyle counseling group lost an average of 4.6 kg, which exceeded the average weight loss experienced by patients in the brief lifestyle counseling and usual care groups (an average of 2.9 kg and 1.7 kg, respectively). The proportion of patients who achieved a weight loss of more than 5% at the end of the second year was also greatest in the enhanced lifestyle group (34.9% vs. 26% and 21.5% in the other two groups, respectively).

Some patients harbor sensitivity about their weight, so if they want to talk about the issue, Dr. Botsford recommended avoiding the term "obesity" and instead using terms such as "weight," "excess weight," "unhealthy body weight," and "BMI." She also recommended involving other members of the staff. For example, front desk staff can ask patients to fill out a fitness inventory and medical assistants can check BMI, measure waist circumference, and provide basic counseling advice about weight loss strategies such as keeping a food journal and portion control.

Regarding how patients perceive overweight physicians, Dr. Botsford noted, "In general, patients find overweight physicians less credible. I find that a little sad, but your view on the subject can influence patients. If you are not at your healthy weight, try to overcome this by sharing personal stories with them."

In counseling patients who express interest in losing weight, she said she begins with a 24-hour dietary recall and then reviews the U.S. Preventive Services Task Force’s "5 A’s" framework to create goals. The five A’s include assess (ask about or assess behavioral health risk[s] and factors affecting choice of behavior change goals); advise (give clear, specific, and personalized behavior change advice, including information about harms and benefits); agree (collaboratively select treatment goals and methods based on interest and willingness to change); assist (using behavior change techniques, help patient to acquire the skills, confidence, and social or environmental supports for behavior change, supplemented with medical treatments when needed); and arrange (schedule follow-up to provide ongoing assistance or support and to adjust the treatment plan as needed).

Other evidence-based counseling tips include recommending that patients avoid artificial sweetener, eating out of a bag, eating in front of the television, eating bread when dining out, and being mindful of liquid calorie intake. She also said she advises patients to stay hydrated, leave one-third of the portion on the plate when dining out, order "small" sizes when possible, and use small plates and bowls at home.

"Study after study has shown that low-calorie diets – 1,000-1,200 kcal/day for women and 1,200-1,600 kcal/day for men are the most successful for maintaining weight loss in the long term," Dr. Botsford said. "Adherence is a big thing when it comes to diets. The most common thing is that people stop. They can’t stick with it. Low glycemic load may help adherence. That’s still within the context of a low-calorie diet. There is certain evidence that having more fiber and more protein will make you feel fuller along the way, but in the end, a low-calorie diet is best."

Tools that can help patients keep a handle on food intake include the AAFP\'s initiative Americans in Motion Healthy Interventions and smartphone apps such as Lose It!, Calorie Counter and Diet Tracker by MyFitnessPal.com, healthfinder.gov, and Weight Watchers Mobile. "Exercise alone is better than nothing, but it only translates into a small weight loss," Dr. Botsford said. "However, exercise reduces blood pressure, triglycerides, and fasting glucose, and it decreases abdominal adipose tissue. To make the real difference you need exercise and diet. You also improve your strength, balance, and peak oxygen consumption. The more intense your exercise, [the more] you will increase your weight loss."

Medicare will reimburse for obesity counseling, but the patient’s BMI has to be greater than 30 kg/m²; the patient has to be competent and alert, and the counseling has to be done in a primary care setting or by the primary care provider. "Medicare will cover up to 22 visits in 12 months in a staged way," Dr. Botsford said, noting that the ICD-9 code for a BMI of 30 or more is G0447. "For the first month they’ll cover once a week. The only caveat is that you cannot bill for any other services on the same day as the visit for obesity counseling."

Dr. Botsford said she had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – If a patient presents to your office with hives triggered by contact with water, think aquagenic urticaria.

"Aquagenic urticaria is a very rare disorder, with only about 100 cases reported in the medical literature," Patrick Coleman, a second-year medical student at the Uniformed Services University of the Health Sciences, Bethesda, Md., said in an interview. "Water is the inciting trigger. It’s followed by a wheal and flare response within 10-13 minutes. Sometimes it’s associated with pruritus. If it’s left untreated, it can resolve within an hour."

Courtesy Dr. Robert P. Lennon

At the annual meeting of the American Academy of Family Physicians, Mr. Coleman and his colleagues discussed the case of a 24-year-old woman who presented to Dr. Robert P. Lennon at the department of family medicine at the U.S. Naval Hospital in Okinawa, Japan, with skin discoloration on her upper arms and legs, hives, and severe global pruritus after showering. Water challenge testing was positive, and the patient was successfully treated with a daily H₁ antihistamine.

The hallmark feature of aquagenic urticaria is that the reaction is independent of water temperature. "So whether the water is cold or hot, the reaction will still occur," Mr. Coleman said. The pathogenesis of the condition is unclear, but may involve histamine release from the degranulation of mast cells. "Our patient was treated with an H₁ antihistamine and she benefitted," said Mr. Coleman. "For other patients, the care may not be the same. You may need to try different antihistamines to see if they will control it."

In their poster, the researchers noted that urticarias affect 20% of people in the United States. Of these, 25% have urticarias that last more than 6 weeks. Only 10%-20% of urticarias have an identifiable trigger.

The researchers stated that they had no relevant financial disclosures.

[email protected]

SAN DIEGO – If a patient presents to your office with hives triggered by contact with water, think aquagenic urticaria.

"Aquagenic urticaria is a very rare disorder, with only about 100 cases reported in the medical literature," Patrick Coleman, a second-year medical student at the Uniformed Services University of the Health Sciences, Bethesda, Md., said in an interview. "Water is the inciting trigger. It’s followed by a wheal and flare response within 10-13 minutes. Sometimes it’s associated with pruritus. If it’s left untreated, it can resolve within an hour."

Courtesy Dr. Robert P. Lennon

At the annual meeting of the American Academy of Family Physicians, Mr. Coleman and his colleagues discussed the case of a 24-year-old woman who presented to Dr. Robert P. Lennon at the department of family medicine at the U.S. Naval Hospital in Okinawa, Japan, with skin discoloration on her upper arms and legs, hives, and severe global pruritus after showering. Water challenge testing was positive, and the patient was successfully treated with a daily H₁ antihistamine.

The hallmark feature of aquagenic urticaria is that the reaction is independent of water temperature. "So whether the water is cold or hot, the reaction will still occur," Mr. Coleman said. The pathogenesis of the condition is unclear, but may involve histamine release from the degranulation of mast cells. "Our patient was treated with an H₁ antihistamine and she benefitted," said Mr. Coleman. "For other patients, the care may not be the same. You may need to try different antihistamines to see if they will control it."

In their poster, the researchers noted that urticarias affect 20% of people in the United States. Of these, 25% have urticarias that last more than 6 weeks. Only 10%-20% of urticarias have an identifiable trigger.

The researchers stated that they had no relevant financial disclosures.

[email protected]

SAN DIEGO – If a patient presents to your office with hives triggered by contact with water, think aquagenic urticaria.

"Aquagenic urticaria is a very rare disorder, with only about 100 cases reported in the medical literature," Patrick Coleman, a second-year medical student at the Uniformed Services University of the Health Sciences, Bethesda, Md., said in an interview. "Water is the inciting trigger. It’s followed by a wheal and flare response within 10-13 minutes. Sometimes it’s associated with pruritus. If it’s left untreated, it can resolve within an hour."

Courtesy Dr. Robert P. Lennon

At the annual meeting of the American Academy of Family Physicians, Mr. Coleman and his colleagues discussed the case of a 24-year-old woman who presented to Dr. Robert P. Lennon at the department of family medicine at the U.S. Naval Hospital in Okinawa, Japan, with skin discoloration on her upper arms and legs, hives, and severe global pruritus after showering. Water challenge testing was positive, and the patient was successfully treated with a daily H₁ antihistamine.

The hallmark feature of aquagenic urticaria is that the reaction is independent of water temperature. "So whether the water is cold or hot, the reaction will still occur," Mr. Coleman said. The pathogenesis of the condition is unclear, but may involve histamine release from the degranulation of mast cells. "Our patient was treated with an H₁ antihistamine and she benefitted," said Mr. Coleman. "For other patients, the care may not be the same. You may need to try different antihistamines to see if they will control it."

In their poster, the researchers noted that urticarias affect 20% of people in the United States. Of these, 25% have urticarias that last more than 6 weeks. Only 10%-20% of urticarias have an identifiable trigger.

The researchers stated that they had no relevant financial disclosures.

[email protected]

SAN DIEGO – Family medicine residents reported that documentation time increased by about 16 minutes per patient encounter following implementation of an electronic health record system at two academic medical institutions in Southern California.

"We have learned about how electronic health records are going to improve our patient care and our efficiency in the clinic but not a lot of studies have explored how the implementation of an electronic health record at academic centers is going to impact resident education," Dr. Maisara Rahman said in an interview during a poster session at the annual meeting of the American Academy of Family Physicians.

Dr. Rahman and her associates surveyed 122 family medicine residents, attending physicians, and other clinical staff from Riverside County Regional Medical Center (RCRMC) and Pomona Valley Hospital Medical Center (PVHMC) to assess their perceptions about the adequacy of EHR training, the amount of time spent on documentation, and the effects of EHRs on patient care and resident education. Of the 122 people surveyed, 99 responded, for a response rate of 83%.

Dr. Rahman, in the department of family medicine at Loma Linda University and an attending physician in the department of family medicine at RCRMC, reported that there was an overall decrease in resident productivity at both academic institutions following implementation of the EHR: a 30% decrease at RCRMC and a 20% decrease at PVHMC. Overall, respondents indicated that EHR documentation took about 16 minutes longer to complete compared with documentation by paper chart (an average of 37 vs. 21 minutes, respectively.)

The residents also reported missing an average of two educational didactic lecture sessions per month in order to complete EHR notes. In addition to missing didactic lectures, residents from both institutions used an average of 45 minutes of personal time to complete notes for a typical half-day clinic. "That’s pretty significant," Dr. Rahman said. "Resident satisfaction with EHR implementation was highly correlated with whether the respondents had adequate EHR training. When we compared the residents from the two academic sites, we noticed that a lot of the RCRMC residents were not satisfied and were not happy with the system. They were less efficient and less productive in clinic, and it was correlated to the training hours. This is most likely related to RCRMC being a county facility and there are fewer resources to provide adequate EHR training for residents."

In their poster, the researchers concluded that as academic teaching hospitals implement EHRs to meet financial incentives for meaningful use, "it is imperative that these institutions customize and implement EHR systems that enhance and support resident education. EHR has a unique potential to become an educational tool if it is customized and developed for resident education. The traditional teaching methods in ambulatory clinics will need to adapt to a more innovative, technology-enhanced learning environment. Further research is needed to identify improved EHR systems that optimize and enhance residents’ education."

The researchers stated that they had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Family medicine residents reported that documentation time increased by about 16 minutes per patient encounter following implementation of an electronic health record system at two academic medical institutions in Southern California.

"We have learned about how electronic health records are going to improve our patient care and our efficiency in the clinic but not a lot of studies have explored how the implementation of an electronic health record at academic centers is going to impact resident education," Dr. Maisara Rahman said in an interview during a poster session at the annual meeting of the American Academy of Family Physicians.

Dr. Rahman and her associates surveyed 122 family medicine residents, attending physicians, and other clinical staff from Riverside County Regional Medical Center (RCRMC) and Pomona Valley Hospital Medical Center (PVHMC) to assess their perceptions about the adequacy of EHR training, the amount of time spent on documentation, and the effects of EHRs on patient care and resident education. Of the 122 people surveyed, 99 responded, for a response rate of 83%.

Dr. Rahman, in the department of family medicine at Loma Linda University and an attending physician in the department of family medicine at RCRMC, reported that there was an overall decrease in resident productivity at both academic institutions following implementation of the EHR: a 30% decrease at RCRMC and a 20% decrease at PVHMC. Overall, respondents indicated that EHR documentation took about 16 minutes longer to complete compared with documentation by paper chart (an average of 37 vs. 21 minutes, respectively.)

The residents also reported missing an average of two educational didactic lecture sessions per month in order to complete EHR notes. In addition to missing didactic lectures, residents from both institutions used an average of 45 minutes of personal time to complete notes for a typical half-day clinic. "That’s pretty significant," Dr. Rahman said. "Resident satisfaction with EHR implementation was highly correlated with whether the respondents had adequate EHR training. When we compared the residents from the two academic sites, we noticed that a lot of the RCRMC residents were not satisfied and were not happy with the system. They were less efficient and less productive in clinic, and it was correlated to the training hours. This is most likely related to RCRMC being a county facility and there are fewer resources to provide adequate EHR training for residents."

In their poster, the researchers concluded that as academic teaching hospitals implement EHRs to meet financial incentives for meaningful use, "it is imperative that these institutions customize and implement EHR systems that enhance and support resident education. EHR has a unique potential to become an educational tool if it is customized and developed for resident education. The traditional teaching methods in ambulatory clinics will need to adapt to a more innovative, technology-enhanced learning environment. Further research is needed to identify improved EHR systems that optimize and enhance residents’ education."

The researchers stated that they had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Family medicine residents reported that documentation time increased by about 16 minutes per patient encounter following implementation of an electronic health record system at two academic medical institutions in Southern California.

"We have learned about how electronic health records are going to improve our patient care and our efficiency in the clinic but not a lot of studies have explored how the implementation of an electronic health record at academic centers is going to impact resident education," Dr. Maisara Rahman said in an interview during a poster session at the annual meeting of the American Academy of Family Physicians.

Dr. Rahman and her associates surveyed 122 family medicine residents, attending physicians, and other clinical staff from Riverside County Regional Medical Center (RCRMC) and Pomona Valley Hospital Medical Center (PVHMC) to assess their perceptions about the adequacy of EHR training, the amount of time spent on documentation, and the effects of EHRs on patient care and resident education. Of the 122 people surveyed, 99 responded, for a response rate of 83%.

Dr. Rahman, in the department of family medicine at Loma Linda University and an attending physician in the department of family medicine at RCRMC, reported that there was an overall decrease in resident productivity at both academic institutions following implementation of the EHR: a 30% decrease at RCRMC and a 20% decrease at PVHMC. Overall, respondents indicated that EHR documentation took about 16 minutes longer to complete compared with documentation by paper chart (an average of 37 vs. 21 minutes, respectively.)

The residents also reported missing an average of two educational didactic lecture sessions per month in order to complete EHR notes. In addition to missing didactic lectures, residents from both institutions used an average of 45 minutes of personal time to complete notes for a typical half-day clinic. "That’s pretty significant," Dr. Rahman said. "Resident satisfaction with EHR implementation was highly correlated with whether the respondents had adequate EHR training. When we compared the residents from the two academic sites, we noticed that a lot of the RCRMC residents were not satisfied and were not happy with the system. They were less efficient and less productive in clinic, and it was correlated to the training hours. This is most likely related to RCRMC being a county facility and there are fewer resources to provide adequate EHR training for residents."

In their poster, the researchers concluded that as academic teaching hospitals implement EHRs to meet financial incentives for meaningful use, "it is imperative that these institutions customize and implement EHR systems that enhance and support resident education. EHR has a unique potential to become an educational tool if it is customized and developed for resident education. The traditional teaching methods in ambulatory clinics will need to adapt to a more innovative, technology-enhanced learning environment. Further research is needed to identify improved EHR systems that optimize and enhance residents’ education."

The researchers stated that they had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Use of a standardized checklist with information describing opiate therapy and the source of the patient’s chronic pain improved resident and faculty satisfaction with management of chronic pain patients, results from a single-center study found.

"The management of chronic pain is so different for each individual patient, but the unique thing about this checklist is that it’s standardized to an entire panel," Dr. Filza Akhtar said in an interview during a poster session at the annual meeting of the American Academy of Family Physicians. "It allows us to manage this panel of patients in a way that we feel gives us some control."

In an effort to increase compliance with the clinic opiate policy for family medicine resident patients with chronic pain, Dr. Akhtar and her associates in the department of family medicine at Oregon Health and Science University (OHSU), Portland, added a standardized checklist to the department’s existing electronic health records system (EHR) that contained elements of the clinic-wide chronic pain policy.

The checklist includes nine items: chronic pain source or diagnosis; pain contract date; last urine drug screen date; monthly medication dosage and fill number; functional goals such as activities of daily living and exercise; opiate abuse risk assessment; other modalities such as acupuncture, sauna, and massage; depression/bowel habits screening date; and statewide controlled substance registry query status and date.

The researchers surveyed family medicine residents before and after implementation of the checklist into the EHR to assess comfort and satisfaction with management of 132 adult patients with ongoing chronic pain conditions on their own panels who were seen during the 2011-2012 academic year. Family medicine faculty completed surveys to assess their comfort managing family medicine residents’ chronic pain patients when the residents were not available in clinic. The family medicine department at OHSU consists of 12 residents, 12 faculty physicians, and 8 advanced practice nurses/physician assistants.

On a 10-point Likert scale, residents’ comfort with managing their own patients receiving chronic opiates improved from a baseline average of 4.25 to 6.55 after implementation of the checklist. One survey participant noted that standardizing EHR and patient expectations regarding the use of chronic narcotics "greatly improved my happiness as a resident physician." Another survey participant commented that conversations in the exam room "were much easier with standardization in place. It also seemed to cut down on ‘doctor shopping’ at our clinic."

The faculty comfort with management of family medicine residents’ patients receiving chronic opiates also improved from a baseline of 4.73 to 5.69 after implementation of the checklist.

Another study author, Dr. Eric Chen, a family medicine resident at OHSU, acknowledged that trying to map out a course of care for patients receiving chronic opiates can be difficult. "It’s a very sensitive topic because it brings up a lot of charged views with new residents who come into a training program inheriting patients who are managed on these opioid regimens," he said. "This tool is used mainly as kind of a historical marker of what has been done. It can shape what [approach] the physician would like to take going forward."

The researchers stated that they had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Use of a standardized checklist with information describing opiate therapy and the source of the patient’s chronic pain improved resident and faculty satisfaction with management of chronic pain patients, results from a single-center study found.

"The management of chronic pain is so different for each individual patient, but the unique thing about this checklist is that it’s standardized to an entire panel," Dr. Filza Akhtar said in an interview during a poster session at the annual meeting of the American Academy of Family Physicians. "It allows us to manage this panel of patients in a way that we feel gives us some control."

In an effort to increase compliance with the clinic opiate policy for family medicine resident patients with chronic pain, Dr. Akhtar and her associates in the department of family medicine at Oregon Health and Science University (OHSU), Portland, added a standardized checklist to the department’s existing electronic health records system (EHR) that contained elements of the clinic-wide chronic pain policy.

The checklist includes nine items: chronic pain source or diagnosis; pain contract date; last urine drug screen date; monthly medication dosage and fill number; functional goals such as activities of daily living and exercise; opiate abuse risk assessment; other modalities such as acupuncture, sauna, and massage; depression/bowel habits screening date; and statewide controlled substance registry query status and date.

The researchers surveyed family medicine residents before and after implementation of the checklist into the EHR to assess comfort and satisfaction with management of 132 adult patients with ongoing chronic pain conditions on their own panels who were seen during the 2011-2012 academic year. Family medicine faculty completed surveys to assess their comfort managing family medicine residents’ chronic pain patients when the residents were not available in clinic. The family medicine department at OHSU consists of 12 residents, 12 faculty physicians, and 8 advanced practice nurses/physician assistants.

On a 10-point Likert scale, residents’ comfort with managing their own patients receiving chronic opiates improved from a baseline average of 4.25 to 6.55 after implementation of the checklist. One survey participant noted that standardizing EHR and patient expectations regarding the use of chronic narcotics "greatly improved my happiness as a resident physician." Another survey participant commented that conversations in the exam room "were much easier with standardization in place. It also seemed to cut down on ‘doctor shopping’ at our clinic."

The faculty comfort with management of family medicine residents’ patients receiving chronic opiates also improved from a baseline of 4.73 to 5.69 after implementation of the checklist.

Another study author, Dr. Eric Chen, a family medicine resident at OHSU, acknowledged that trying to map out a course of care for patients receiving chronic opiates can be difficult. "It’s a very sensitive topic because it brings up a lot of charged views with new residents who come into a training program inheriting patients who are managed on these opioid regimens," he said. "This tool is used mainly as kind of a historical marker of what has been done. It can shape what [approach] the physician would like to take going forward."

The researchers stated that they had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Use of a standardized checklist with information describing opiate therapy and the source of the patient’s chronic pain improved resident and faculty satisfaction with management of chronic pain patients, results from a single-center study found.

"The management of chronic pain is so different for each individual patient, but the unique thing about this checklist is that it’s standardized to an entire panel," Dr. Filza Akhtar said in an interview during a poster session at the annual meeting of the American Academy of Family Physicians. "It allows us to manage this panel of patients in a way that we feel gives us some control."

In an effort to increase compliance with the clinic opiate policy for family medicine resident patients with chronic pain, Dr. Akhtar and her associates in the department of family medicine at Oregon Health and Science University (OHSU), Portland, added a standardized checklist to the department’s existing electronic health records system (EHR) that contained elements of the clinic-wide chronic pain policy.

The checklist includes nine items: chronic pain source or diagnosis; pain contract date; last urine drug screen date; monthly medication dosage and fill number; functional goals such as activities of daily living and exercise; opiate abuse risk assessment; other modalities such as acupuncture, sauna, and massage; depression/bowel habits screening date; and statewide controlled substance registry query status and date.

The researchers surveyed family medicine residents before and after implementation of the checklist into the EHR to assess comfort and satisfaction with management of 132 adult patients with ongoing chronic pain conditions on their own panels who were seen during the 2011-2012 academic year. Family medicine faculty completed surveys to assess their comfort managing family medicine residents’ chronic pain patients when the residents were not available in clinic. The family medicine department at OHSU consists of 12 residents, 12 faculty physicians, and 8 advanced practice nurses/physician assistants.

On a 10-point Likert scale, residents’ comfort with managing their own patients receiving chronic opiates improved from a baseline average of 4.25 to 6.55 after implementation of the checklist. One survey participant noted that standardizing EHR and patient expectations regarding the use of chronic narcotics "greatly improved my happiness as a resident physician." Another survey participant commented that conversations in the exam room "were much easier with standardization in place. It also seemed to cut down on ‘doctor shopping’ at our clinic."

The faculty comfort with management of family medicine residents’ patients receiving chronic opiates also improved from a baseline of 4.73 to 5.69 after implementation of the checklist.

Another study author, Dr. Eric Chen, a family medicine resident at OHSU, acknowledged that trying to map out a course of care for patients receiving chronic opiates can be difficult. "It’s a very sensitive topic because it brings up a lot of charged views with new residents who come into a training program inheriting patients who are managed on these opioid regimens," he said. "This tool is used mainly as kind of a historical marker of what has been done. It can shape what [approach] the physician would like to take going forward."

The researchers stated that they had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – The next time you enter an exam room without first donning your white coat or name tag, you might consider backtracking to retrieve them.

According to a survey of patients presenting to a family medicine clinic, 51% hold some opinion about your attire. "Even if they don’t admit that they care about those things, patients are picking the options of having physicians wear a white coat and having a traditional look," study author Dr. Seema Tayal said in an interview during a poster session at the annual meeting of the American Academy of Family Physicians. "Traditional looks still matter."

©Lars Lindblad/Fotolia.com

For the study, Dr. Tayal, a third-year resident in the family medicine department at the Brooklyn (N.Y.) Hospital Center, and her associates set out to determine what effects exist between the patient’s perception of a physician’s physical appearance and the patient’s compliance with medical recommendations. They distributed anonymous questionnaires to 200 patients who presented to the practice.

More than half of respondents (59%) were between the ages of 18 and 50 years, while the remaining 41% were over age 51. The majority (69%) were female.

When asked, "Do you feel your decision to follow a physician’s advice is influenced by his/her gender?" 91% responded yes and 9% responded no.

When asked, "Do you feel your decision to follow a physician’s advice is influenced by his/her appearance?" 83% responded yes and 17% responded no.

When asked, "Do you feel your decision to follow a physician’s advice is influenced by his/her age?" 85% responded yes and 15% responded no.

When asked about the preference of a physician’s attire, 49% had no preference and 51% did. Among those who did have a preference, the appearance accessory rated as most desirable was a white coat (52%), followed by a name tag (41%), stethoscope (25%), a "clean" look (33%), scrubs (15%), dress pants (14%), a tie and dress shirt (12%), dress shoes (10%), cologne/perfume (8%), short hair (6%), and jewelry (4%).

In another part of the questionnaire, respondents were asked to choose the most professional-looking image from a set of six photographs depicting medical personnel, including one of Dr. Gregory House, the fictional physician played by actor Hugh Laurie on the "House" television series. The "winning" image depicted a clean-looking young female with short hair who wore a white coat and a stethoscope.

The researchers stated that they had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – The next time you enter an exam room without first donning your white coat or name tag, you might consider backtracking to retrieve them.

According to a survey of patients presenting to a family medicine clinic, 51% hold some opinion about your attire. "Even if they don’t admit that they care about those things, patients are picking the options of having physicians wear a white coat and having a traditional look," study author Dr. Seema Tayal said in an interview during a poster session at the annual meeting of the American Academy of Family Physicians. "Traditional looks still matter."

©Lars Lindblad/Fotolia.com

For the study, Dr. Tayal, a third-year resident in the family medicine department at the Brooklyn (N.Y.) Hospital Center, and her associates set out to determine what effects exist between the patient’s perception of a physician’s physical appearance and the patient’s compliance with medical recommendations. They distributed anonymous questionnaires to 200 patients who presented to the practice.

More than half of respondents (59%) were between the ages of 18 and 50 years, while the remaining 41% were over age 51. The majority (69%) were female.

When asked, "Do you feel your decision to follow a physician’s advice is influenced by his/her gender?" 91% responded yes and 9% responded no.

When asked, "Do you feel your decision to follow a physician’s advice is influenced by his/her appearance?" 83% responded yes and 17% responded no.

When asked, "Do you feel your decision to follow a physician’s advice is influenced by his/her age?" 85% responded yes and 15% responded no.

When asked about the preference of a physician’s attire, 49% had no preference and 51% did. Among those who did have a preference, the appearance accessory rated as most desirable was a white coat (52%), followed by a name tag (41%), stethoscope (25%), a "clean" look (33%), scrubs (15%), dress pants (14%), a tie and dress shirt (12%), dress shoes (10%), cologne/perfume (8%), short hair (6%), and jewelry (4%).

In another part of the questionnaire, respondents were asked to choose the most professional-looking image from a set of six photographs depicting medical personnel, including one of Dr. Gregory House, the fictional physician played by actor Hugh Laurie on the "House" television series. The "winning" image depicted a clean-looking young female with short hair who wore a white coat and a stethoscope.

The researchers stated that they had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – The next time you enter an exam room without first donning your white coat or name tag, you might consider backtracking to retrieve them.

According to a survey of patients presenting to a family medicine clinic, 51% hold some opinion about your attire. "Even if they don’t admit that they care about those things, patients are picking the options of having physicians wear a white coat and having a traditional look," study author Dr. Seema Tayal said in an interview during a poster session at the annual meeting of the American Academy of Family Physicians. "Traditional looks still matter."

©Lars Lindblad/Fotolia.com

For the study, Dr. Tayal, a third-year resident in the family medicine department at the Brooklyn (N.Y.) Hospital Center, and her associates set out to determine what effects exist between the patient’s perception of a physician’s physical appearance and the patient’s compliance with medical recommendations. They distributed anonymous questionnaires to 200 patients who presented to the practice.

More than half of respondents (59%) were between the ages of 18 and 50 years, while the remaining 41% were over age 51. The majority (69%) were female.

When asked, "Do you feel your decision to follow a physician’s advice is influenced by his/her gender?" 91% responded yes and 9% responded no.

When asked, "Do you feel your decision to follow a physician’s advice is influenced by his/her appearance?" 83% responded yes and 17% responded no.

When asked, "Do you feel your decision to follow a physician’s advice is influenced by his/her age?" 85% responded yes and 15% responded no.

When asked about the preference of a physician’s attire, 49% had no preference and 51% did. Among those who did have a preference, the appearance accessory rated as most desirable was a white coat (52%), followed by a name tag (41%), stethoscope (25%), a "clean" look (33%), scrubs (15%), dress pants (14%), a tie and dress shirt (12%), dress shoes (10%), cologne/perfume (8%), short hair (6%), and jewelry (4%).

In another part of the questionnaire, respondents were asked to choose the most professional-looking image from a set of six photographs depicting medical personnel, including one of Dr. Gregory House, the fictional physician played by actor Hugh Laurie on the "House" television series. The "winning" image depicted a clean-looking young female with short hair who wore a white coat and a stethoscope.

The researchers stated that they had no relevant financial conflicts to disclose.

[email protected]