Domino Examines Past Year in Research, Looks Into the Future

Doubled Risks

Beginning his slides with a study of nicotine and cannabis use in pregnancy, Domino said the numbers showed that some adverse outcomes occurred at about twice the rate they had with patients using neither substance. Preterm births went from 6.6% for nonusers to 12.2% in cannabis users and 12% in nicotine users. Pregnant patients using both substances experienced double the rate of maternal morbidity.

Fortified with this data, he said, family physicians should help their pregnant patients “try to not do those things.”

Culture Club

Reminding the audience about the rapid development of children’s sinuses beginning when they’re about 2, Domino ran through what he called a “refreshing” update on pediatric sinusitis.

A study looking at “grubby, skunky nose discharge,” he said, found that the color of that mucus did not predict treatment efficacy and that only patients whose cultures revealed pathogens benefited from an antibiotic. Which antibiotic, though? Amoxicillin, he said.

Meanwhile, adults and their long-formed, sometimes long-suffering sinuses benefit from saline, Domino said, citing research published in August.

The Hardest-working Inhibitors in Show Business

While Ozempic and other glucagon-like peptide-1 receptor agonists developed to treat diabetes have grabbed headlines for their off-label use as weight-loss drugs, especially among celebrities, Domino noted the stalwart benefits of sodium-glucose cotransporter 2 inhibitors. Encouraging recent findings about SGLT-2 drugs, staples against type 2 diabetes, he said, include,

• increased regression of nonalcoholic fatty liver disease and lower risk of adverse liver-related outcomes;
• decreases in major adverse cardiovascular events and risk of hospitalization and death; and
• lower risk of all-cause mortality, cardiac death and hospitalization for heart failure among diabetic patients who are frail or age 65 or older.

“I love these drugs,” he said. “They’re really, really quite remarkable.”

Domino also reported that a “great randomized” look at the 5:2 diet (two days of eating about 500 calories for every five days of eating normally), compared with two days a week of high-intensity interval and resistance training, had yielded promising results in both test groups, including a regression of type 2 diabetes.

Food ‘Makes the World Better’ …

Domino quoted his mother to soften a stark message about the importance of childhood nutrition.  

According to National Survey of Children’s Health results published this past March (with nationwide responses from primary caregivers of one child per home ages 0-17 years), 5.42 % of children experienced low food security, and 7.4 % were exposed to violence. The findings suggest, Domino said, that food insecurity increases the risk of exposure to violence by a factor of five. (He also reminded his audience that higher BMI doesn’t necessarily correlate to food security.)

“And that 5.42% — I bet the real number of food-insecure children is at least twice that number,” he said, adding that Indigenous and Black children are more likely to experience or witness violence when food insecure than white children.

Domino urged family physicians to ask about their patients’ food security and touted the AAFP’s Neighborhood Navigator tool. The EveryONE Project innovation, he said, “covers the country and is the backbone of whatever (data) you’re using.”

… But Cut the Juice Loose

“On this one, Mom was wrong,” Domino said, showing an orange juice carton on the screen to summon a bygone era when squeezing oranges was thought to pump up well-being. “Even one serving is too much. One glass of juice increases BMI,” he said, citing a study of fruit juice on health outcomes in children and adults. (He then earned a laugh by citing another authority: himself. “Now, some apple cider, heated on a cold night with a little amaretto, does make a good hot toddy.”)

Fruit, however, is still a boon to health.

“This huge study, a systematic review, found that increasing fruit intake by the equivalent of half an apple had a big positive impact on weight and BMI,” Domino said. Better yet, “the study associated high fruit intake with lower obesity.”

Omega-3 Supplements Are Fishy

Or, as Domino put it, “baloney.” Though fish-oil pills, marketed as helpful to cardiovascular health, remain popular with consumers, “there’s no data showing they’re beneficial,” he said. “Just friggin’ eat some fish. Twice a week, eat some fish. And don’t give up your omelets.”

Ages of Anxiety

Recounting a story he said had hit very close to home for him, Domino talked about a patient whose teenage daughter had become sad and withdrawn. The patient helped his daughter seek psychiatric consultations and appointments, but her condition didn’t improve. She died by suicide.

“The number of teen girls who reported feeling persistently sad or hopeless increased dramatically from 2011 to 2021,” Domino said. CDC data show that number — one among several alarming mental health statistics in the report — reached almost 60% in the survey’s most recent year.

“Young people are struggling to find meaning in life. ER visits for self-harm are up. We’re seeing way more girls than boys, and even suicide attempts and suicides among children ages 8 to 12. This is a bit of an epidemic. It’s incumbent on us to try to look at it.

“And adults are not doing great,” Domino said, noting three groups at higher suicide risk (veterans, LGBTQ+ people and those ages 44-64). “We’re spending more and more time alone and on social media. The average adult spends more than two hours a day on social media. I don’t know that we can resolve this, but we need to be aware and try to intervene when we can. The 988 line and the Trevor Project are great things to display in your office.”

Think Positive

“Like doughnuts, cookies call my name,” Domino said. “They could be 100 years old, something I got on an airplane in 1982 — I will still snoop around and try to find them.”

Here he lingered on a family recipe for anise cookies that solved a longstanding bug — terminal dryness — with that heap of soft cheese. He said he, too, used that distinctly American excuse: “One cookie is not really going to make a difference.”

This has a name: delayed discounting. “It’s when I put off what my future self wants to be for some immediate gratification,” Domino said.

“How can we stop this irrational hiding of our goals? Well, a systematic review says to envision your future self to improve obesity outcomes. Envision reaching your goal. Not just tomorrow but a year from tomorrow, 10 years from tomorrow. This episodic future thinking decreased BMI. You can incorporate this into your counsel to patients: ‘Imagine yourself tomorrow.’ It’s a great psychological ploy when you are trying to change behavior.”

Relatedly, Domino said a study pointed to the advantages of a “pro-social” approach to combating vaccine hesitancy, suggesting that a patient picture the positive effects on family, friends and neighbors of getting a flu shot or other vaccine.

“You can say, ‘Look, I know you don’t want this, but it will help everyone around you. It might help that person in the grocery store who has health issues you don’t know about.’ If we frame it as ‘This is not just for you but for everyone in your world,’ most people are good and compassionate souls and they’ll follow along.”

AI? Aye!

Domino asked for a show of hands from those using artificial intelligence in clinical practice. Many went up. (A new AAFP survey about AI use, announced earlier at FMX, also is looking for a robust show of hands by Nov. 4.)

“Good,” he said. “Wonderful.”

He then went over what he called his “simple process” for using AI-powered search, which he predicted would continue to improve — and benefit family physicians..

“To use AI effectively, you can’t ask just one question,” he explained. “You need to ask at least three if not four questions, and they should be open-ended, clinical questions.”

Domino illustrated this by showing the results when he asked an AI search engine, “What is the value of statins for primary prevention?”

“I reviewed the answers and the references, then asked a follow-up to refine the first answer: ‘What is the optimal age to start a statin for primary prevention?’ Then I asked for a counter: ‘What are the downsides to using a statin for primary prevention?’

“Finally, I asked it to think like a specialist and answer the questions again.”

AI, Domino said, is a strong tool for family physicians who want to improve their quality of life by reclaiming time.

“Your time is valuable, so value it,” he said, to loud, grateful applause.