How best to diagnose and manage abdominal aortic aneurysms.

The evidence summarized here can help guide your approach to this life-threatening condition that often goes undetected until rupture.

The End of the X-waiver: Excitement, Apprehension, and Opportunity.

With the passage of the MAT act (Mainstreaming Addiction Treatment) and the MATE Act (Medication Training and Expansion), the Drug Enforcement Agency "X-waiver" program governing the office-based prescription of buprenorphine for opioid use disorder has been immediately eliminated. The move was championed by vocal organizations with a rightful concern about buprenorphine access but was opposed by most physicians. Nonetheless, buprenorphine can now be prescribed like any schedule 3 medication. Studies show that despite rising opioid overdoses, buprenorphine prescription increases have been slow to rise and are particularly absent in rural communities. The elimination of the X-waiver may theoretically improve buprenorphine prescribing rates for opioid use disorder in rural areas, by nurse practitioners and physician assistants, and by resident physicians in teaching programs. It may also help decrease discrimination against individuals with opioid use disorder in postacute-care settings like nursing homes, physical rehabilitation centers, and in prisons and jails. Concerns include the elimination of the only focused opioid use disorder education many physicians receive (X-waiver courses) and a literature base showing that interest, rather than the X-waiver itself, remains the biggest barrier to recruiting more buprenorphine prescribers. Concerns also exist over the harms of precipitated withdrawal when buprenorphine is initiated inappropriately. The change of the elimination of the X-waiver brings about a new opportunity for Family Medicine and its parent organizations to champion the inclusion of opioid use disorder treatment within the chronic disease care models well-known to our integrated care settings.

Subclinical hypothyroidism: Let the evidence be your guide.

Patient age, time of day, and supplement use influence screening results; repeat testing is advised. Avoid treating to improve mood, cognition, fatigue, or quality of life.

Common Issues in Prenatal Care: First Trimester Bleeding.

Vaginal bleeding in the first trimester is a common concern during pregnancy. The amount of bleeding and associated symptoms, such as nausea and vomiting, can be of prognostic value. Timely evaluation with vital signs, physical examination, laboratory tests (eg, Rh factor, hemoglobin and possibly progesterone levels), and pelvic ultrasound (US) can distinguish among viable pregnancy, nonviable pregnancy, intrauterine pregnancy (IUP) of uncertain viability, and pregnancy of unknown location. Serial pelvic US can be obtained in patients with IUP of uncertain viability after 11 to 14 days, and in pregnancy of unknown location in as little as 48 hours. Quantitative human chorionic gonadotropin (hCG) levels are of minimal clinical utility after IUP is visualized on US. Serial quantitative hCG levels should be measured in patients with pregnancy of unknown location. After an early pregnancy loss has been identified, as long as the patient is hemodynamically stable, options include expectant, medical, and surgical management. The treatment plan can be guided by shared decision-making. Ectopic pregnancy can be managed surgically via laparoscopy, medically with methotrexate, or expectantly (in certain circumstances). Progesterone for patients with early pregnancy bleeding and no history of miscarriage likely is of no benefit.

Common Issues in Prenatal Care: Gestational Diabetes.

Two screening approaches are used to detect gestational diabetes, the 1-step and 2-step methods. The 1-step method is diagnostic and consists of a 75-g, 2-hour oral glucose tolerance test (OGTT). The 2-step method consists of a 50-g, 1-hour glucose challenge test, followed by a 100-g, 3-hr OGTT if initial test results are positive. All pregnant patients should be screened for gestational diabetes between 24 and 28 weeks' gestation unless pregestational diabetes is present. Lifestyle modifications are fundamental to management, and most patients are able to control blood glucose levels with these alone. Persistent hyperglycemia should be managed with drugs. Currently, insulin is the only drug approved by the Food and Drug Administration (FDA) for gestational diabetes management. Metformin or glyburide can be reasonable alternatives. For patients who require drugs, antepartum fetal surveillance is recommended starting at 32 weeks' gestation. The American College of Obstetricians and Gynecologists (ACOG) recommends delivery at 39 0/7 to 40 6/7 weeks' gestation for patients with gestational diabetes controlled with diet alone. Earlier delivery is recommended for patients with gestational diabetes controlled with drugs, at 39 0/7 to 39 6/7 weeks' gestation. Patients with gestational diabetes are at increased risk of type 2 diabetes later in life. These patients should be screened for prediabetes and diabetes between 4 and 12 weeks postpartum with a 75-g, 2-hour OGTT. Postpartum patients with a normal OGTT result should be screened every 1 to 3 years thereafter.

Common Issues in Prenatal Care: Fetal Growth Restriction.

Fetal growth restriction (FGR) is defined as an ultrasound (US)-determined estimated fetal weight or abdominal circumference less than the 10th percentile according to a population level reference curve. FGR affects up to 10% of pregnancies. Fetuses with FGR are at increased risk of intrauterine mortality and, postnatally, neonatal intraventricular hemorrhage, necrotizing enterocolitis, respiratory distress, hypoglycemia, and suboptimal neurologic, behavioral, and cognitive development. In early-onset FGR (ie, less than 32 weeks' gestation), a detailed US examination is recommended. When FGR is accompanied by polyhydramnios and/or fetal anomalies, genetic testing should be obtained, including chromosomal microarray analysis. The timing of delivery strategy should be based on the severity of growth restriction and findings on fetal tests of well-being (eg, nonstress testing, umbilical artery Doppler velocimetry). No routine prevention strategies are recommended. However, it has been shown that daily low-dose aspirin (ie, 81 mg/day) reduces the risk of FGR when taken by patients with a high risk of preeclampsia.

Common Issues in Prenatal Care: Antepartum Fetal Surveillance.

Patients at increased risk of stillbirth should be assessed with antepartum fetal surveillance (AFS) tests at regular intervals. In general, AFS should begin at the gestational age at which delivery would be considered. Most surveillance tests are performed weekly, but more frequent testing should be considered for patients with high-risk conditions. AFS tests include fetal movement monitoring, nonstress test, contraction stress test, biophysical profile, and modified biophysical profile. Umbilical artery Doppler velocimetry is used in the setting of fetal growth restriction. Abnormal test results should prompt additional assessment and consideration of delivery. Normal test results can provide reassurance about fetal well-being, but cannot predict the likelihood of acute incidents, such as placental abruption and umbilical cord infarction.

An FP's guide to identifying-and treating-postpartum depression.

Certain risk factors and this screening tool can help you identify patients at risk. Cognitive behavioral therapy and SSRIs can provide relief.

Scope of Practice and Location of 3- Versus 4-Year Family Medicine Residency Graduates.

BACKGROUND AND OBJECTIVES: The John Peter Smith (JPS) Family Medicine Residency Program participated in two national experiments: Preparing the Personal Physician for Practice (P4, 2007-2012) and the Length of Training Pilot, which began in 2013. In these experiments, JPS created optional integrated 4-year areas of emphasis (AOE). The objective of this study was to examine the career outcomes of JPS graduates differentiated by those who completed a 4-year AOE, versus traditional fourth-year fellowship, vs 3-year only. METHODS: We surveyed each graduate who started residency from 2007-2016 on their scope of practice. We also searched each graduate via Google to identify each of their practice sites and ascertain their status as a Health Professional Shortage Area (HPSA) or Medically Underserved Area for primary care (MUA-P). RESULTS: Of the 220 residents who entered the program as interns, 70 completed an integrated AOE (31.8%), 54 completed 3 years of training with a traditional fourth-year fellowship (24.5%, 40 at JPS, 14 at another location), and 93 completed only 3 years of training (42.3%). The overall percentage of JPS graduates who work in the United States (n=201) in HPSAs or MUA-Ps is similar to national numbers (45.3% vs 43.5% for HPSAs, 35.3% vs 33.3% for MUA-Ps). Graduates of a JPS integrated AOE track were more likely to work in a HPSA or MUA-P than other graduates (81.4% vs 38.5% traditional fellowship vs 45.6% 3-year only, P<.001; US practice sites only). Graduates of sports medicine fellowships were particularly less likely to work in HPSAs/MUA-Ps than other graduates (26.1%). Graduates of integrated AOEs provided much broader scopes of cognitive and procedural services than fellowship or 3-year graduates. CONCLUSIONS: In JPS graduates, 4 years of training with an integrated AOE had a large association with serving vulnerable populations, and providing broader cognitive and procedural services.

Labor Dystocia in Nulliparous Women.

Dystocia (abnormally slow or protracted labor) accounts for 25% to 55% of primary cesarean deliveries. The latent phase of labor begins with onset of regular, painful contractions and continues until 6 cm of cervical dilation. Current recommendations are to avoid admission to labor and delivery during the latent phase, assuming maternal/fetal status is reassuring. The active phase begins at 6 cm. An arrested active phase is defined as more than four hours without cervical change despite rupture of membranes and adequate contractions and more than six hours of no cervical change without adequate contractions. Managing a protracted active phase includes oxytocin augmentation with or without amniotomy. The second stage of labor begins at complete cervical dilation and continues to delivery. This stage is considered protracted if it lasts three hours or more in nulliparous patients without an epidural or four hours or more in nulliparous patients with an epidural. Primary interventions for a protracted second stage include use of oxytocin and manual rotation if the fetus is in the occiput posterior position. When contractions or pushing is inadequate, vacuum or forceps delivery may be needed. Effective measures for preventing dystocia and subsequent cesarean delivery include avoiding admission during latent labor, providing cervical ripening agents for induction in patients with an unfavorable cervix, encouraging the use of continuous labor support (e.g., a doula), walking or upright positioning in the first stage, and not diagnosing failed induction during the latent phase until oxytocin has been given for 12 to 18 hours after membrane rupture. Elective induction at 39 weeks' gestation in low-risk nulliparous patients may reduce the risk of cesarean delivery.

Fetal Aneuploidy: Screening and Diagnostic Testing.

Aneuploidy is the presence of one or more extra chromosomes or the absence of one or more chromosomes. The risk of fetal aneuploidy rises with increasing maternal age. Because fetal aneuploidy can affect any pregnancy, all pregnant women should be offered screening. First-trimester combined screening performed between 10 and 13 weeks' gestation detects 82% to 87% of trisomy 21 (Down syndrome) cases. Second-trimester serum quadruple screening performed between 15 and 22 weeks' gestation detects 81% of trisomy 21 cases. Combinations of these tests include integrated or serum integrated, stepwise sequential, and contingent sequential screenings, all of which improve detection rates compared with each test alone. Fetal cell-free DNA testing (noninvasive prenatal testing) performed at or after 10 weeks' gestation detects more than 99% of trisomy 21 cases, with a lower false-positive rate than traditional first- or second-trimester screening methods. Fetal cell-free DNA testing has similar detection rates in high- and low-risk populations but has lower positive predictive values in younger women. It may be performed as primary screening or as a follow-up test to abnormal findings on first- or second-trimester screenings. Second-trimester ultrasonography has limited utility in aneuploidy screening in women who have already been screened with a first- or second-trimester serum test. Diagnostic tests following a positive screening result include chorionic villus sampling performed between 10 and 13 weeks' gestation or amniocentesis performed after 15 weeks' gestation.

Maternity Care Update: Prenatal Care and Specific Conditions.

Early initiation of prenatal care is associated with improved health outcomes for women and newborns. An essential element of prenatal care is determining the estimated due date, ideally using a first-trimester ultrasound. Laboratory tests should be obtained to screen for conditions that can affect pregnancy. Routine immunizations for all pregnant women include influenza vaccine; tetanus toxoid, reduced diphtheria, acellular pertussis (Tdap) vaccine. All women should be screened for gestational diabetes mellitus in midpregnancy. Women with risk factors also should be screened in the first trimester. Aspirin (ie, 60 to 150 mg/day) starting at 12 to 16 weeks reduces the risk of preeclampsia for women at high risk. Chronic medical conditions should be managed according to guidelines to promote optimal control. Women with such conditions may require testing in the late third trimester. Induction of labor may be offered to these women before 41 weeks, based on the condition and relative risks and benefits of continued pregnancy. Women without maternal or fetal indications should not be offered elective delivery before 39 weeks, but should be offered induction at 41 weeks with a recommendation for delivery before 42 weeks.

Maternity Care Update: Labor and Delivery.

Labor is defined as contractions with cervical change and active labor starts when the cervix is dilated 6 cm. Updated labor curves and definitions should be used to define labor dystocia. Oxytocin and amniotomy have important roles in the management of labor dystocia. Structured intermittent fetal monitoring should be considered for women with low-risk pregnancies but continuous electronic fetal monitoring still is used most commonly. Moderate fetal heart rate variability is the most reliable marker of fetal well-being. Epidural analgesia is used in more than half of all births in the United States. It is not associated with an increase in the rate of cesarean deliveries but is associated with a longer second stage of labor. Interventions that may reduce the need for cesarean delivery include use of the new definitions of labor dystocia, a trial of manual rotation of occiput posterior presentations, use of cervical ripening agents for induction of labor with an unfavorable cervix, and encouragement of women with previous cesarean deliveries to attempt vaginal delivery.

Maternity Care Update: Preconception Care.

Family physicians are in a unique position to ensure that women receive preconception care. The Centers for Disease Control and Prevention, the American College of Obstetricians and Gynecologists, and the American Academy of Family Physicians recommend preconception care for all women, but particularly for women with comorbid conditions such as obesity, diabetes, and chronic hypertension. Family physicians should ask all women of reproductive age who are at risk of unintended pregnancy if they desire pregnancy within the next year and, based on this answer, provide counseling on contraception or preconception care. Given that more than half of all pregnancies in the United States are unplanned, all women of reproductive age should be prescribed at least 400 mcg/day of folic acid. They also should be counseled to modify risk factors such as smoking, alcohol use, overweight and obesity, and travel to countries where Zika virus infection is endemic. Women with significant chronic conditions should be counseled to achieve optimum control of their conditions before conception. Long-term treatment of such conditions with drugs should be reviewed and modified to prevent potentially teratogenic effects after the risks and benefits of continuing the drugs are considered.

Maternity Care Update: Postpartum Care.

Family physicians are uniquely situated to play a major role in postpartum care. Postpartum issues that should be monitored and addressed include reproductive and contraceptive planning, breastfeeding counseling and support, and maternal mental health. All women should be screened for postpartum depression using a validated tool at the postpartum visit and/or at well-child visits. Patients with positive screening results should be offered support and treatment. Women are more likely to breastfeed if they are provided with breastfeeding support and counseling routinely during the prenatal and postpartum periods. All women should be asked about their reproductive life plans, counseled about potential risks associated with short and prolonged interpregnancy intervals, and offered contraception.

Vitamin D Screening and Supplementation in Community-Dwelling Adults: Common Questions and Answers.

Measurement of vitamin D levels and supplementation with oral vitamin D have become commonplace, although clinical trials have not demonstrated health benefits. The usefulness of serum 25-hydroxyvitamin D levels to assess adequate exposure to vitamin D is hampered by variations in measurement technique and precision. Serum levels less than 12 ng per mL reflect inadequate vitamin D intake for bone health. Levels greater than 20 ng per mL are adequate for 97.5% of the population. Routine vitamin D supplementation does not prolong life, decrease the incidence of cancer or cardiovascular disease, or decrease fracture rates. Screening asymptomatic individuals for vitamin D deficiency and treating those considered to be deficient do not reduce the risk of cancer, type 2 diabetes mellitus, or death in community-dwelling adults, or fractures in persons not at high risk of fractures. Randomized controlled trials of vitamin D supplementation in the treatment of depression, fatigue, osteoarthritis, and chronic pain show no benefit, even in persons with low levels at baseline.