Addressing Nutritional Gaps: Simple Steps for the Primary Care Provider.

Identify common shortfalls in the typical American diet. Address the link between poor diet quality and chronic disease. Identify patients at risk for vitamin deficiency and potential vitamin-drug interactions. Recognize patients with vitamin and mineral deficiencies. Partner with patients regarding selection and appropriate use of vitamin and mineral supplements to achieve recommended dietary allowances.

Helping Family Physicians Keep Up to Date: A Next Step in the Pursuit of Mastery.

The American Board of Family Medicine (ABFM) is exploring the development of an ABFM Journal Club as a part of its continuing certification portfolio. To benchmark this effort, we reviewed the journal article activities of 8 other American Board of Medical Specialties boards. This paper identifies the principles that will drive the design of the optional ABFM lifelong learning and self-assessment activity. Articles for consideration will be identified through an explicit structured search process. A National Journal Club Committee will choose the top 100 articles based on methodologic rigor, generalizability and relevance to family medicine, and potential to change practice. A postactivity assessment instrument will require mastery learning of new clinical findings and support deeper learning, with the goal of supporting personal physicians in keeping up to date and informing shared decision-making.

Hot Topics in Primary Care: The Cardiovascular Safety of Nonsteroidal Anti-Inflammatory Drugs: Putting the Evidence in Perspective.

The Vioxx Gastrointestinal Outcomes Research (VIGOR) trial, published in 2000, was the first to raise concerns that NSAIDs (specifically, the COX-2 selective inhibitor rofecoxib) might be associated with a higher risk for cardiovascular (CV) events. As discussed in this article, subsequent trials and meta-analyses have demonstrated a higher CV risk with use of not only COX-2 inhibitors (coxibs) but also certain tNSAIDs. These investigations have contributed to actions by the US Food and Drug Administration (FDA), most recently in July 2015, requiring strengthening of CV risk warnings on labels for all prescription and over-the-counter NSAIDs, despite evidence suggesting that differences in CV risk may exist among the NSAIDs.

Vaginitis: diagnosis and management.

Vaginitis is one of the most common ambulatory problems to occur in women. It is a disorder responsible for > 10% of visits made to providers of women's health care. Although vaginal infections are the most common cause, other considerations include cervicitis, a normal vaginal discharge, foreign-body vaginitis, contact vaginitis, atrophic vaginitis, and desquamative inflammatory vaginitis. The medical history and examination are an important source of clues to the underlying diagnosis. However, making a definitive diagnosis requires skillful performance of office laboratory procedures, including the vaginal pool wet mount examination, determination of the vaginal pH, and the whiff test. Vaginal and cervical cultures, nucleic acid tests, and point-of-care tests are available and may be required in selected patients. Once a specific diagnosis is made, effective therapy can be prescribed. Candida vaginitis is generally treated with either the vaginal administration of an imidazole or triazole antifungal agent or the prescription of oral fluconazole. Oral nitroimidazole agents, metronidazole or tinidazole, are the only effective treatments for trichomoniasis in the United States. Bacterial vaginosis, which has been linked to important gynecologic and pregnancy complications, can be treated with an available oral or topical agent containing either a nitroimidazole or clindamycin.

Should clinicians routinely determine rhinitis subtype on initial diagnosis and evaluation? A debate among experts.

Rhinitis is one of the most prevalent conditions affecting Americans today. Twenty to 40 million Americans (10%-30% of adults and up to 40% of children) are estimated to have allergic rhinitis. In recent decades, its prevalence in Western societies has increased dramatically, and studies from around the world are reporting similar trends. Although studies have traditionally reported a 3:1 ratio of allergic to nonallergic rhinitis, recent data suggest that as many as 87% of patients with rhinitis may have mixed rhinitis, a combination of both allergic and nonallergic rhinitis. Untreated or inappropriately managed rhinitis can significantly affect a patient's quality of life and ability to perform activities of daily living. It is often associated with concomitant conditions, such as fatigue, headache, sleep disturbance, cognitive impairment, and respiratory conditions, complicated by rhinitis, including asthma and sinusitis. It is a significant cause of morbidity, health care expenditure, reduced work productivity, and absences from school. According to the recently released updated practice parameters, The Diagnosis & Management of Rhinitis, rhinitis is characterized by the presence of one or more of the following nasal symptoms: Congestion, Rhinorrhea (anterior and posterior), Sneezing, Itching. Inflammation is normally associated with rhinitis, but certain subtypes of the disease, such as vasomotor (increasingly known as chronic idiopathic rhinitis) or nonallergic rhinitis and atrophic rhinitis, are not predominantly inflammatory. The diagnosis of rhinitis may appear to be a fairly straightforward undertaking; however, rhinitis is composed of numerous subtypes and etiologies, and differentiating them can be a challenge for primary care practitioners. Further complicating matters is the fact that many patients have both an allergic and a nonallergic component to their rhinitis. Whether or not identification of rhinitis subtype should be an integral component of initial diagnosis remains an area of controversy. While standard treatment for allergic and nonallergic rhinitis is often the same, certain subtypes of the disease do not respond well to the usual first-line treatments for allergic rhinitis. Identification of subtype, therefore, can potentially have important implications for treatment choice. In the following section, we present a discussion between 2 members of the Respiratory & Allergic Disease (RAD) Foundation, Thomas B. Casale, MD, and Michael S. Blaiss, MD. Drs. Casale and Blaiss debate the question, "Should clinicians routinely determine rhinitis subtype on initial diagnosis and evaluation?" Each expert was randomly assigned a position to take: Dr. Casale's views represent the "pro" argument while Dr. Blaiss was asked to speak to the "con" argument. The debate concludes with a synthesis of their arguments and final points, including important takeaway messages for the primary care practitioner.