October 01, 2019 04:06 pm David Mitchell Philadelphia – Frank Domino, M.D., has been delivering his "Top 10 Updates in Evidence-based Medicine" at the AAFP's annual meeting for 15 years. Due to demand, the popular session has been a mainstage event the past three years.
This time around, Domino delved into some sensitive issues, including one, he said, that had the potential to divide his audience.
"Kale is dangerous," Domino said during his presentation Sept. 27 at the Family Medicine Experience. "No one likes kale. You put it in a smoothie, and it turns it green."
Taste and appearance aside, Domino -- as usual -- had evidence on his side. The nonprofit Environmental Working Group named kale to its annual "Dirty Dozen" list,(www.ewg.org) which highlights pesticides in produce. According to that organization, 90% of the pesticide kale is exposed to remains after the food has been washed.
"This is a really good reason to skip kale," said Domino, who is editor-in-chief of The 5-Minute Clinical Consult,(www.amazon.com) and editor of the Evidence Based Practice Updates blog.(www.ebpupdate.com)
In other food news, Domino pointed to a Lancet study(www.thelancet.com) that found diet may be responsible for 20% of deaths worldwide. North America leads the world in consumption of processed meat, trans fat and sugar-sweetened beverages.
"Encourage patients not to buy processed foods like deli meat," said Domino, a professor and director of predoctoral education in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School in Worcester. "There are many things that are safer and healthier. This data tells me it's our job to tell people about how to eat."
Not all the food news was bad. Domino was critical of a BMJ study(www.bmj.com) that questioned the value of eating breakfast based on the likelihood of gaining weight. However, the only foods included in the study were corn flakes and porridge.
"The study did not prove that breakfast is bad for you," said Domino, who acknowledged that his favorite breakfast is Cap'n Crunch, once a year on his birthday.
But wait, there's more.
A study in Nutrients(www.ncbi.nlm.nih.gov) found that moderate beer intake did not blunt the positive effects of 10-week, high-intensity interval training on the bodies of healthy young adults.
"If you exercise regularly, it's OK to have a beer," Domino said.
The United States had the highest maternal mortality rate in the Western world from 1990-2015(www.clinicalkey.com) at 26.4 per 100,000, compared to 9.2 per 100,000 in the United Kingdom, which had the next highest rate of more than a dozen countries studied.
Domino said that although the prevalence of risk factors such as hemorrhage and hypertensive disorder has fallen drastically since 1990, that of other factors -- including cardiovascular disease, homicide and suicide -- has increased. And while the U.S. maternal mortality rate has steadily increased, California's rate -- which had been higher than the U.S. average at 16.9 per 100,000 in 2006 -- plummeted to 7.3 per 100,000 in 2013, according to a report released in 2018.(www.cdph.ca.gov)
Domino said a number of factors could improve mortality rates, including extended postpartum care, increased screening for mental health and chronic disease, and improved community resources.
The World Health Organization this year released guidelines on physical activity and sleep for children younger than 5 years old.(apps.who.int) One of the recommendations was for children ages 3 to 4 to get 180 minutes of physical activity per day and no more than 60 minutes of screen time.
"Talk to parents about different ways to engage children," Domino said.
Domino highlighted a Pediatrics study(pediatrics.aappublications.org) published in April that said parents and young children were more engaged during the reading of print books compared to electronic books. He then asked how many physicians in the audience participated in Reach Out and Read,(www.reachoutandread.org) which encourages physicians to talk to parents about the importance of reading to children and provides families with books. Numerous hands shot into the air.
"If you don't, you should," said Domino, who also pointed out that implementing the program can meet American Board of Family Medicine requirements(www.reachoutandread.org) for quality improvement projects. "Get them in your office."
Suicide is the second-leading cause of death among youths ages 10 to 18, and Domino offered some sobering statistics on the topic. The suicide rate(jamanetwork.com) in girls ages 15 to 19 has doubled in recent years, while the rate in girls ages 10 to 14 tripled.
"I lost a pediatric patient last year," Domino said. "It still haunts me."
Domino said that in 2017, 26,000 of 39,000 gun-related deaths in the United States were suicides.(www.nytimes.com) He said physicians should ask patients who acknowledge having suicidal thoughts how they would kill themselves and if they have guns in their home. He also said physicians should ask parents who are gun owners if they keep their guns locked and unloaded.
Not all the pediatric news was bad.
"Great news!" Domino said. "Autism is still not caused by MMR. We need to remind families of that. Nothing has changed."
The question of vaccines and autism had already been settled in the medical community, but a March study in the Annals of Internal Medicine(annals.org) confirmed that the measles, mumps and rubella vaccine does not increase the risk for autism, and there was no increased risk in children whose siblings had autism.
A December article in JAMA(jamanetwork.com) found that in-flight medical emergencies occur in roughly one per 604 flights. That adds up quickly considering there are more than 44,000 flights a day in the United States alone, according to the Federal Aviation Administration. The article was accompanied by resources on how to manage specific issues -- such as stroke, seizure and allergic reaction -- on a plane.
"If you travel by plane, this is a great thing to keep in your bag," Domino said of the resources.
Domino recommended a couple of free online tools: the Absolute CVD Risk/Benefit Calculator(chd.bestsciencemedicine.com) and PREDICT: Prostate,(prostate.predict.nhs.uk) which is a new model to predict survival and guide treatment decisions in men with nonmetastatic prostate cancer.
"It takes five minutes," Domino said of the prostate cancer resource. "It's very helpful if a patient is unsure or if you are unsure."
Domino had two tips for treating type 2 diabetes.
A December study in Lancet Diabetes Endocrinology(www.ncbi.nlm.nih.gov) found that aggressive periodontitis treatment could lead to a 0.5% A1c reduction.
"Look in the patient's mouth and recommend regular dental checkups," he said.
Meanwhile, a January study in Diabetes Care(care.diabetesjournals.org) found that viscous fiber supplements improve conventional markers of glycemic control more than standard care alone and should be considered in the management of patients with type 2 diabetes.
According to the U.S. Preventive Services Task Force, only one in three patients at risk for HIV infection is receiving pre-exposure prophylaxis. Furthermore, Domino said some patients are erroneously taking the drug only the day before or the day after sexual activity.
"That's not safe," he said. "It needs to be taken every day to be effective. It's really important. If we can prevent one case of HIV, that's huge."
The U.S. teen birth rate has fallen(www.pewresearch.org) from 41.5 per 1,000 females ages 15 to 19 in 2008 to 17.4 per 1,000 in 2018. Additionally, the teen pregnancy rate hit a 40-year low last year, while the teen abortion rate of 10.6 per 1,000 is the lowest on record, according to the Pew Research Center.
"You should applaud yourselves," Domino said, adding that sex education programs in schools and access to affordable contraception have contributed to the declines.
Domino recommended joint mobilization and soft tissue techniques to treat plantar fasciitis based not only on a study published last year in The Foot(www.ncbi.nlm.nih.gov) but also on his own experience.
"When you're doing it, they moan," he said. "I have to keep my door open because … well, they love it. It's easy. My physical therapist friends taught me, and I've been doing it for a year."
He said the treatment is also easy to bill for.
Domino also recommended using tape or a navicular sling for improved arch support.
"People hobble in and they walk out pain-free," he said. "It takes five minutes, and anyone can learn it."
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