2018 Family Medicine Experience

FPs Flock to Domino's Annual Evidence-based Update

October 16, 2018, 03:50 pm David Mitchell New Orleans – Near the beginning of his main-stage presentation Oct. 12 during the Family Medicine Experience, Frank Domino, M.D., asked if anyone in attendance had taken music lessons as a child.

In a vast ballroom packed with physicians, hundreds of hands shot into the air.

"That's most of us," Domino said. "Next time you see your parents, tell them thank you. If Mom and Dad hadn't made you play the clarinet, you might be a lawyer, for God's sake."

Domino was referring to a study published earlier this year in Frontiers in Neuroscience that found that children who took music lessons had improved inhibition, planning and verbal intelligence compared to their peers who did not have such lessons.

A professor of family medicine and community health at the University of Massachusetts Medical School, Domino has been presenting the "Top Ten Updates in Evidence-Based Medicine" for years at the AAFP's annual meeting. The session has proved so popular that it moved from a standard meeting room to the main stage last year at FMX in San Antonio. Domino's up-to-date information combined with humorous insights once again drew a big crowd in "The Big Easy."

Frank Domino, M.D., speaks during the 2018 FMX

^{Frank Domino, M.D., delivers updates on evidence-based medicine during the 2018 Family Medicine Experience in New Orleans. Domino, a professor of family medicine and community health at the University of Massachusetts Medical School, was the Oct. 12 main-stage speaker for the event.}

Domino, who also is editor-in-chief of The 5-Minute Clinical Consult and host of the Frankly Speaking About Family Medicine podcast,(www.pri-med.com) said he aimed to give his peers "changes you can start making Monday when you get back to your office," but added that they should "be skeptical because it might change again tomorrow."

The "single biggest change in my practice this year," said Domino, stemmed from a Mayo Clinic Proceedings article that said up to 94 percent of patients who self-report penicillin allergy test negative for the allergy.

That's significant, he said, because an actual allergy limits physicians' options when treating conditions such as methicillin-resistant Staphylococcus aureus or Clostridium difficile.

"Send them for testing," Domino said. "Every single patient I have sent for allergy testing has turned out to be nonallergic."

Story Highlights

Children in Peril

During his presentation, Domino pointed out some sad realities for U.S. youth. According to a Health Affairs report, the United States has poorer outcomes than other developed nations despite higher per capita spending on children's health care. Part of the problem is that American children are more than 80 times more likely to die from gun homicide than their peers in other countries.

Domino also highlighted an April Pediatrics article that found that adolescents and young adults who survived initial self-harm were at significantly elevated risk for suicide and thus require followup care.

"It's heartbreaking," he said. "After they've had an attempt, bring them back every month. You might be the adult figure that prevents them from a second attempt."

Prostate Cancer

Domino called the updated recommendation from the U.S. Preventive Services Task Force (USPSTF) regarding prostate cancer screening "unfortunate."

In 2012, the USPSTF and the AAFP recommended against prostate-specific antigen (PSA)-based screening for all men. In May, the task force issued a "C" recommendation for men ages 55-69, saying the decision to undergo periodic PSA-based screening should be individualized. The AAFP also issued a "C" recommendation, but it used different language from that of the task force to emphasize that PSA-based screening should not be done routinely.

Domino broke it down this way: If 1,000 men have PSA-based screening, 240 will get a positive result that may indicate cancer. One hundred will have cancer confirmed by biopsy, while more than half of the 240 will have false-positives.

Of the 100, 80 will choose surgery or radiation. Of those, three will avoid cancer spreading to other organs, and one or two will avoid death from prostate cancer. Meanwhile, 60 or more of the 80 will suffer complications related to impotence or incontinence, and five will still die from prostate cancer.

"Share that data with your patients," Domino said. "It's shocking how many people will say, 'No way.'"

Aspirin

It wasn't a good year for aspirin. A study in The New England Journal of Medicine found that the medication did not provide significant improvements in outcomes related to cardiovascular disease or all-cause mortality, and it actually caused worse outcomes related to cancer and hemorrhage. Studies published in The Lancet and The New England Journal of Medicine found aspirin to be of no benefit in primary prevention of cardiovascular events in certain patient populations.

It's worth noting that the AAFP and USPSTF have "B" recommendations for the use of aspirin as primary prevention in adults aged 50-59 who are at an increased risk for CVD and a low risk of bleeding.

Social Determinants of Health

An article in Preventive Medicine Reports found three risks that make adult patients more likely to be high-cost utilizers of health care: psychiatric diagnosis, financial stressors and adverse childhood experiences.

Domino said resources related to health equity and social determinants of health that are included in the AAFP's The EveryONE project can help. In particular, he emphasized Neighborhood Navigator, which can help identify local resources related to things such as food, housing and legal assistance. Domino demonstrated by plugging in his own ZIP code and finding more than 1,300 resources within a 15-mile radius of his practice.

Pain

A study in Anesthesia & Analgesia found that possession of unused opioid medications was reported by 73 percent of patients who had stopped opioid therapy at one-month followup appointments and by 34 percent of patients at six-month followup. At the same time, more than 90 percent of patients acknowledged unsafe storage and failure to dispose of opioids.

Domino said physicians can link patients to drug take-back programs, and he also noted that medications can be flushed or even thrown in the trash with coffee grounds.

One American dies every 12.5 minutes due to drug overdose. Domino pointed out that Surgeon General Jerome Adams, M.D, M.P.H., has urged more Americans to carry naloxone and added that a two-pack of the medication costs less than $100.

"It's incumbent upon us to protect our patients," Domino said.

Obesity

One in three U.S. adults suffers from nonalcoholic fatty liver disease, said Domino, who briefly reviewed several options for treatment, including exercise, diet, medication and surgery. He highlighted in more detail a study in Nutrition that found that patients who consumed 35 grams of fiber a day and limited protein to 0.8 grams a day per kilogram of body weight lost an average of 4.4 pounds in 12 weeks.

Domino said he suggests patients use a combination of bran cereal, fiber gummy supplements and psyllium powder that adds up to 33 grams a day.

"Even if they don't lose weight, they're going to have an amazing bowel movement," said Domino, who noted that psyllium has also been shown to help lower hemoglobin A1c levels.

Here are a few more highlights from Domino's presentation:

A July study in JAMA Pediatrics found that infants who had early introduction of solid foods woke less frequently at night and slept an average of 16.6 minutes longer. Domino noted that recommendations call for infants to be exclusively breastfed for at least six months but said the study was worth remembering in severe cases when the child and/or parents are suffering due to inadequate sleep.
Based on information released by manufacturer GlaxoSmithKline (GSK), Domino said Shingrix, the zoster vaccine released last year, is "amazing." According to GSK, the vaccine is 97 percent effective in patients aged 50-69 up to four years after vaccination.
A review of 16 studies in Respirology linked fast food to asthma. That makes it "a very unhappy meal," Domino quipped.
A study in JAMA Internal Medicine found that initial blood pressure readings are elevated in nearly 40 percent of visits, but when checked a second time, 50 percent of patients were within the normal range.
More than 30 states still have gag rules that limit what pharmacists can tell patients about the costs of medications unless patients specifically ask. "Tell your patients to ask the pharmacist if there's a cheaper alternative," Domino said.

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Additional Resources
2018 AAFP Family Medicine Experience: Day Three

2018 AAFP Family Medicine Experience: Day Two

2018 AAFP Family Medicine Experience: Day One

2018 Congress of Delegates: Day Three

2018 Congress of Delegates: Day Two

2018 Congress of Delegates: Day One