Preventing CVD in Women: Common Questions and Answers.

Cardiovascular disease (CVD) is the most common cause of mortality in the United States. Women have unique risk factors for CVD, including pregnancy, hormones, autoimmune disorders, and psychological stress. Most risk calculators underestimate the risk of CVD in women; therefore, it is essential that physicians have a heightened awareness of risk-enhancing factors. A thorough history of adverse pregnancy conditions, hormonal factors, autoimmune diseases, and psychological stress, including adverse social determinants of health, should be documented in the electronic health record. A risk assessment using the Atherosclerotic Cardiovascular Disease Risk Calculator should be routinely performed, and those with borderline (5% to less than 7.5%) and intermediate (7.5% to less than 20%) risk should undergo lifestyle modification counseling and shared decision-making regarding the initiation of a statin, aspirin, or antihypertensive therapy. Women with gestational diabetes mellitus should be screened at four to 12 weeks postpartum with a two-hour oral glucose tolerance test, and, if normal, the test should be repeated every one to three years. Women with hypertensive disorders of pregnancy should be assessed within three months of delivery, and CVD risk assessment should occur annually thereafter. Because women with a history of adverse pregnancy conditions have higher rates of traditional CVD risk factors that emerge at younger ages, earlier and more frequent monitoring should be considered. Optimizing management of mood disorders, traditional CVD risk factors, and autoimmune diseases and considering the effects of social determinants of health are essential. Lifestyle modification counseling should include guidance to adhere to a plant-based diet that is mostly vegetables, fruits, legumes, nuts, whole grains, and fish; 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity exercise weekly; and tobacco cessation.

One year of COVID: primary care learning experiences in a health system.

Context: Patients and communities consider their primary care clinicians (PCC's) to be their most trusted source of information. During the first 12 months of the COVID pandemic, initially reliable, accurate information was scare, evolving, and at times conflicting. From testing, public health prevention, treatment, and vaccinations clinicians had to learn, apply, and convey this information honestly and openly. Objective: This was a survey of a health system's PCC's after the first year of the pandemic. The objective was to determine the clinical, educational, and advisory roles performed by PCC's and the sources of from which PCC's obtained the information necessary to fulfill these roles. Study Design: An intranet survey was sent to members of the system's primary care learning collaborative. Questions were multiple answer with options for open-ended answers. Setting: Large health system. Population: Learning collaborative membership consisting of physicians, nurse practitioners (NP), and physician assistants (PA). Instrument: Brief intranet survey. Outcome measures: Identify clinical and educational roles for PCC. Results: 192 surveys were sent; 109 responses; 72% physicians, 28% NP/PA. 25 unique clinical roles were identified. Most common: discuss vaccine (94%), work excuse/return to work (88%), outpatient care (87%), virtual assessment for COVID (74%). 14 unique educational or advisory roles were identified; the most common being teaching residents (45%) or students (42%), lecture/discussion on COVID (20%) or vaccines (22%) or advising community groups (18%). Sources of information related to COVID were diverse. When asked to identify the three most relied on sources, system (internal COVID website or disseminated by system) (83%), colleagues (34%), and consultants (33%), were the most common source. CME was the least relied upon (7%). Frequently the system utilized information from CDC, state/local health department information along with national organizations. Conclusions: During the pandemic, primary care clinicians provided a broad array of clinical services, and are a source of information for colleagues, patients, and communities. They rely on a broad array of sources for reliable information, mostly relationship-based, not formal CME. The trusted relationships primary care clinicians have with others throughout their communities was essential in promulgating accurate reliable information during the first year of the pandemic.

Kitchen Adequacy and Child Diet Quality in a Racially/Ethnically Diverse Sample.

This study examined kitchen adequacy in a racially/ethnically diverse low-income sample and associations with child diet quality. Families with children age five to seven years old (n = 150) from non-Hispanic white, non-Hispanic Black, Hispanic, Native American, Hmong, and Somali families were recruited through primary care clinics. More than 85% of families had 15 of the 20 kitchen items queried, indicating that the sample had adequate kitchen facilities. Only one item (a kitchen table) was associated with higher overall diet quality of children. In contrast, children living in households with can openers and measuring spoons consumed more sodium and added sugars, respectively.

Nonalcoholic Fatty Liver Disease: Common Questions and Answers on Diagnosis and Management.

Nonalcoholic fatty liver disease (NAFLD) is the most common form of liver disease in the United States, affecting up to 30% of adults. There are two forms of NAFLD: nonalcoholic fatty liver (NAFL), defined as 5% or greater hepatic steatosis without hepatocellular injury or fibrosis, and nonalcoholic steatohepatitis (NASH), defined as 5% or greater hepatic steatosis plus hepatocellular injury and inflammation, with or without fibrosis. Individuals with obesity are at highest risk of NAFLD. Other established risk factors include metabolic syndrome and type 2 diabetes mellitus. Although NAFLD is common and typically asymptomatic, screening is not currently recommended, even in high-risk patients. NAFLD should be suspected in patients with elevated liver enzymes or hepatic steatosis on abdominal imaging that are found incidentally. Once other causes, such as excessive alcohol use and hepatotoxic medications, are excluded in these patients, risk scores or elastography tests can be used to identify those who are likely to have fibrosis that will progress to cirrhosis. Liver biopsy should be considered for patients at increased risk of fibrosis and when other liver disorders cannot be excluded with noninvasive tests. Weight loss through diet and exercise is the primary treatment for NAFLD. Other treatments, such as bariatric surgery, vitamin E supplements, and pharmacologic therapy with thiazolidinediones or glucagon-like peptide-1 analogues, have shown potential benefit; however, data are limited, and these therapies are not considered routine treatments. NAFL typically follows an indolent course, whereas patients with NASH are at higher risk of death from cardiovascular disease, cancer, and end-stage liver disease.

Calling Your Aunt Bertha for Social Assets: Family Medicine and Social Determinants of Health.

PURPOSE: The sociopolitical determinants of health drive health outcomes and inequities in the United States. Primary care practices are, increasingly, expected by payers and policy makers to assess patients' social needs. Resource referral platforms provide physicians with information and referral systems for community resources. One commonly used platform is Aunt Bertha/Find Help (AB/FH). The American Academy of Family Physicians (AAFP) Neighborhood Navigator (NN) tool allows physicians and laypeople to search for resources using AB/FH. We sought to describe what users were searching for and to identify patterns to inform resource allocation. METHODS: This was a descriptive study of the AAFP's NN tool. Searches of NN were analyzed to describe what users were searching for. RESULTS: From 2018 to April 2022 there were 168 135 searches. The most common searches were for food and housing insecurity (22%, 21%) and health care referral (20.6%) with 22% more searches in the winter than the spring. There was a 119% increase in searches between 2018 and 2022, and a 47% increase in searches during the COVID-19 Pandemic. In the "Health" category the top 20 subcategories accounted for over 77% of searches. CONCLUSIONS: Family physicians and their patients use NN to search AB/FH for community resources to address adverse social determinants of health (SDOH). As expected, searches increased during the COVID-19 pandemic. This type of analysis may help individual clinicians, practices, and health systems prepare for the most common social needs of their patients. Social resource platforms might serve as a robust measure for primary care practice screening and referral for SDOH.

Development and Early Experience of a Primary Care Learning Collaborative in a Large Health Care System.

INTRODUCTION: Primary care clinicians are presented with hundreds of new clinical recommendations and guidelines. To consider practice change clinicians must identify relevant information and develop a contextual framework. Too much attention to information irrelevant to one's practice results in wasted resources. Too little results in care gaps. A small group of primary care clinicians in a large health system sought to address the problem of vetting new information and providing peer reviewed context. This was done by engaging colleagues across the system though a primary care learning collaborative. METHODS: The collaborative was a grass roots initiative between community and academic-based clinicians. They invited all the system's primary care clinicians to participate. They selected new recommendations or guidelines and used surveys as the principal communication instrument. Surveys shared practice experience and also invited members to give narrative feedback regarding their acceptance of variation in care relate to the topic. A description of the collaborative along with its development, processes, and evolution are discussed. Process changes to address needs during the COVID-19 pandemic including expanded information sharing was necessary. RESULTS: Collaborative membership reached across 5 states and included family medicine, internal medicine, and pediatrics. Members found involvement with the collaborative useful. Less variation in care was thought important for public health crises: the COVID pandemic and opioid epidemic. Greater practice variation was thought acceptable for adherence to multispecialty guidelines, such as diabetes, lipid management, and adult ADHD care. Process changes during the pandemic resulted in more communications between members to avoid practice gaps. CONCLUSION: An internet-based learning collaborative in a health system had good engagement from its members. Using novel methods, it was able to provide members with feedback related to the importance of new practice recommendations as perceived by their peers. Greater standardization was thought necessary when adopting measures to address public health crisis, and less necessary when addressing multispecialty guidelines. By employing a learning collaborative, this group was able to keep members interested and engaged. During the first year of the COVID pandemic the collaborative also served as a vehicle to share timely information.

Best uses of osteopathic manipulation.

With the growing number of DOs and the high utilization of osteopathic manipulative treatment (OMT), it is important for all physicians to understand the role OMT can play in the treatment of conditions ranging from low back pain to irritable bowel syndrome so that patients may be offered, or referred for, the treatment when appropriate.

Dementia: an evidence-based review of common presentations and family-based interventions.

The number of US older adults with dementia is expected to grow over the next several decades. For instance, the number of persons with Alzheimer disease is predicted to increase by 50% by 2030. Physicians commonly come into contact with patients who have dementia and, as such, need to understand its varied presentation. In the current review, the most common types of dementia, including Alzheimer disease, frontotemporal dementia, dementia due to vascular disease, and several others, are described. Characteristics and etiologic findings of cortical and subcortical dementias are differentiated, and cognitive profiles and symptoms of specific types of dementia are reviewed. An osteopathic approach to care, focusing on establishing a relationship with patients and their families, is also discussed.