Spring 2019 (April-June) by Missouri Academy of Family Physicians

FP SPRING 2019

MISSOURI FAMILY PHYSICIAN VOLUME 38, ISSUE 2

Men's & Women's Health EVERYDAY HEALTH & WELLNESS TOPICS

MISSOURI ACADEMY OF FAMILY PHYSICIANS

1 SMFM show me c3m.5e0 Family Medicine

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FP MISSOURI FAMILY PHYSICIAN

EXECUTIVE COMMISSION

BOARD CHAIR Mark Schabbing, MD (Perryville) PRESIDENT Sarah Cole, DO, FAAFP (St. Louis) PRESIDENT-ELECT Jamie Ulbrich, MD, FAAFP (Marshall) VICE PRESIDENT John Paulson, MD, PhD, FAAFP (Joplin) SECRETARY/TREASURER Lisa Mayes, DO (Macon)

BOARD OF DIRECTORS

CONTENTS 6 MEN'S & WOMEN'S HEALTH: EVERYDAY HEALTH & WELLNESS TOPICS 4 President's Column Opening remarks

DISTRICT 1 DIRECTOR John Burroughs, MD (Kansas City) ALTERNATE Jared Dirks, MD (Kansas City) DISTRICT 2 DIRECTOR Robert Schneider, DO (Kirksville) ALTERNATE Brooks Beal, DO (Kirksville) DISTRICT 3 DIRECTOR Emily Doucette, MD, FAAFP (St. Louis) DIRECTOR Kara Mayes, MD (St. Louis) ALTERNATE Dawn Davis, MD (St. Louis) DISTRICT 4 DIRECTOR Jennifer Scheer, MD, FAAFP (Gerald) ALTERNATE Kristin Weidle, MD (Washington) DISTRICT 5 DIRECTOR Natalie Long, MD (Columbia) ALTERNATE Vacant DISTRICT 6 DIRECTOR David Pulliam, DO, FAAFP (Higginsville) ALTERNATE Carrie Peecher, DO (Marshall) DISTRICT 7 DIRECTOR Wael Mourad, MD, FAAFP (Kansas City) DIRECTOR Afsheen Patel, MD (Kansas City) ALTERNATE Beth Rosemergey, DO, FAAFP (Kansas City) DISTRICT 8 DIRECTOR Kurt Bravata, MD (Buffalo) ALTERNATE Vacant DISTRICT 9 DIRECTOR Patricia Benoist, MD, FAAFP (Houston) ALTERNATE Vacant DISTRICT 10 DIRECTOR Deanne Siemer, MD (Jackson) ALTERNATE Vicki Roberts, MD, FAAFP (Cape Girardeau) DIRECTOR AT LARGE Jacob Shepherd, MD (Grain Valley)

5 Members Promote Family Medicine to Legislators

RESIDENT DIRECTORS

45 Membership Census Results

Ann Lottes, MD, SLU Misty Todd, MD, UMC (Alternate)

STUDENT DIRECTORS Mimi Liu, SLU Morgan Dresvyannikov, UMKC (Alternate)

AAFP DELEGATES Todd Shaffer, MD, MBA, FAAFP, Delegate Keith Ratcliff, MD, FAAFP, Alternate Delegate Kate Lichtenberg, DO, MPH, FAAFP, Alternate Delegate Peter Koopman, MD, FAAFP, Alternate Delegate

MAFP STAFF EXECUTIVE DIRECTOR Kathy Pabst, MBA, CAE COMMUNICATIONS & EDUCATION MANAGER Sarah Mengwasser MEMBERSHIP & PROGRAMS COORDINATOR Becki Hughes The information contained in Missouri Family Physician is for information purposes only. The Missouri Academy of Family Physicians assumes no liability or responsibility for any inaccurate, delayed or incomplete information, nor for any actions taken in reliance thereon. The information contained has been provided by the individual/organization stated. The opinion expressed in each article(s) is the opinion of its author(s) and does not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no responsibility for the opinion expressed thereon.

Missouri Academy of Family Physicians, 722 West High Street Jefferson City, MO 65101 p. 573.635.0830 • f. 573.635.0148 mo-afp.org • office@mo-afp.org

A recap of 2019 Advocacy Day

6 Men's & Women's Health

Everyday health and wellness topics you may deal with when treating your patients

19 MAFP App Review

The latest apps reviewed for you

41 Member Opinion Piece

Dr. Kurt Bravata on 'Life: The most fundamental human right'

43 Match Results

2019 main residency match is the largest on record

44 Legislative Report

A report from MAFP governmental consultants

46 Members in the News Recognizing our MAFP members DONT FORGET

TO PAY YOUR

DUES MARK YOUR CALENDAR Show Me Family Medicine Conference June 21-22, 2019 Margaritaville Lake Resort Osage Beach, Missouri ANNUAL BUSINESS MEETING June 22, 2019 Margaritaville Lake Resort 11:45 am-1:45 pm (Parasol I)

Family Medicine Transition Conference June 7-8, 2019 Marriot Hotel Country Club Plaza Kansas City, Missouri Annual Fall Conference November 8-9, 2019 Big Cedar Lodge Ridgedale, Missouri MO-AFP.ORG 3

PRESIDENT'S COLUMN

M Sarah Cole, DO, FAAFP MAFP President

AFP has received compliments lately for its journal’s new look and relevant content. I want to thank its contributing authors and MAFP staff for their expertise and energy in making it so! This issue, dedicated to men’s and women’s health, highlights the similarities and differences of health care based on biological sex and gender. To further explore those similarities and differences, we must continue to ensure inclusion of women in clinical trials. Not until 1993 did the National Institutes of Health require its funded researchers to include women in clinical studies and analyze results by sex or gender. In the same year, the Food and Drug Administration stopped excluding women of childbearing potential from early phase drug trials. Prior to 1993, clinical research primarily was conducted on men, leaving women and their family physicians with little or no information as to whether these medical interventions were safe or effective for them.

Despite improvement over the past 25 years, more progress is needed to assess the impact of sex and gender on health."

For example, readers may remember the Physician’s Health Study showed aspirin every other day reduced risk of myocardial infarction in men aged 50 years and older while potentially increasing risk of stroke. That study, published in 1989, was comprised only of male subjects. For the following 16 years, family physicians may have recommended, on the basis of that study, that their female

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

patients take an aspirin every other day for primary prevention of cardiovascular disease. Not until 2005 did the Women’s Health Study show the converse to be true – aspirin every other day reduces risk of stroke in women aged 65 years and older without reducing risk of heart attack. Since 1993, more women have been included in research in cardiovascular disease, breast cancer, and cervical cancer, but little progress has been made in other areas that affect women such as: 1.) cancers other than breast or cervical; 2.) maternal morbidity and mortality; 3.) autoimmune diseases; and 4.) alcohol or drug addiction. A 2011 Institute of Medicine report found both inadequate enforcement of the requirement for representative numbers of women to be included in clinical trials; and also inadequate reporting of results on women. Several subspecialty reviews show that while most studies now recruit both women and men, fewer than 25 percent of investigators report intention to analyze results by sex or gender. Even most preclinical laboratory studies continue to use only male animals as test subjects. Despite improvement over the past 25 years, more progress is needed to assess the impact of sex and gender on health. For many community family physicians, one way to incorporate this into daily practice may be to ask industry representatives whether the trials they describe to you: • Recruit both sexes • Report the number of participants by sex or gender • Report differences in results by sex or gender. As family physicians, we can help educate policymakers and advocate researchers to improve parity in inclusion so we can best care for both the men and the women we serve.

SAVE THE DATE

Advocacy Day 2020 February 17-18, 2020

MEMBERS PROMOTE FAMILY MEDICINE TO LEGISLATORS

his year’s MAFP Advocacy Day, February 18-19, drew participation from over 35 family physicians from all four corners of the state. Our diverse membership was represented by rural physicians, physicians in underserved areas, residents, students, urban physicians, family medicine faculty, direct primary care physicians, and many others. Our message was loud and clear, family medicine is the foundation to improving patient health care outcomes…period. The event began Monday evening with a detailed review of our priority legislation. This is an informal opportunity to learn more about proposed legislation and MAFP’s position. Tuesday, white coats were seen in the halls of the capitol as members met with over 15 senators and 25 representatives. At the last minute, Kristin Weidle, MD, Washington, Missouri, served as the Doctor of the Day. Legislator's schedules were full with committee hearings, floor debate, and appointments with constituents. Many of our attendees were introduced to, and met their legislators on the chamber floor. A brief meeting was then held to educate our elected leaders about family medicine. Each legislator received a summary document which described our priority bills and issues, including, but not limited to: primary care investment, scope of practice expansion, patient safety, and of course, a prescription drug monitoring program…maybe this year will be the last year a bill will be introduced, as it will hopefully pass before the bell rings on May 17. Advocacy Day is one day out of the session that an organized event is held for family physicians; but it’s not the only day you can come to Jefferson City. The legislative week begins on Mondays around noon, and ends on Thursdays at noon. The MAFP staff and governmental consultants are ready to help you meet with your legislators at your convenience. We will arrange your appointments and attend your appointment with you, if you choose. You are the expert and your message may be what it takes to help legislators better understand why family physicians are the key to better health outcomes in Missouri.

Board of Directors meeting recap The day wrapped up with your MAFP Board of Directors meeting. This year’s meeting covered updates from the officers about their participation on your behalf at national and state meetings. The Member Services Commission presented guidelines for three new awards: Distinguished Service Award, Outstanding Resident of the Year Award, and Exemplary Teaching Award. Look for more information on these awards in the Show Me State Update, the next issue of the Missouri Family Physician, and on the MAFP website. The Missouri Transition Conference for Family Medicine Residents and Students will be held in Kansas City on June 7 and 8. MAFP, along with the Missouri Chapter of the American Academy of Pediatrics, is hosting a meeting to discuss the need for a Missouri immunization coalition. Several board members also volunteered to represent Missouri at this year’s Family Medicine Advocacy Summit in Washington, DC.

Advocacy Day was wellorganized and a good learning experience for how the system works."

MO-AFP.ORG 5

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

Men's & Women's

HEALTH Men and women are alike in many ways. However, there are important biological and behavioral differences between the two genders. They face different, yet many of the same health issues. The following articles touch on just a few of the everyday health concerns you may deal with when treating your patients.

MO-AFP.ORG 7

A MISSOURI FAMILY PHYSICIAN

SAVED

even years ago, at age 46, I wanted to attend Bartle Scout reservation as an adult leader. To get into camp, I needed a health form signed by my family physician, Dr. James D’Angelo. He wisely declined my fax request for a signature and required me to get a physical, which included getting a PSA test. I had no idea what a prostate was, nor did we talk about the merits of a PSA test, but thank God my doc was on top of this. Shortly after, my doc called to let me know that my PSA was elevated

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

to 19. He said it may be nothing, but to play it safe he needed me to see a urologist. That’s when my prostate cancer education and journey started. A biopsy found Gleason 9 aggressive prostate cancer. I had no symptoms, so if my doc hadn’t ordered that PSA test, it’s unlikely that you would be reading this story. Up to this point in my life, I had been taking my health for granted, overweight, poor diet, not working out, and smoking cigarettes. After lighting up outside of a cancer center, it hit me like a ton of bricks, it was time to make serious changes! I was a

MY LIFE single dad to a 13-year-old son and this wasn’t just about me. I had to beat it! The motivation was an unstoppable force, and my drive for better health was unrelenting. Shortly thereafter, I met a cancer exercise specialist who had statistics indicating that if you exercised and cleaned up your diet it was possible to cut reoccurrence rates in half. I did every single thing she said and dropped her an e-mail to say thanks. Her response was, "That was just step one." I realized that working out and eating well were about the only things within my control at this point, and it helped me both physically and mentally. My sister suggested I join her and her daughter in an organized walk. This wasn’t anything I had done before, so of course I said yes. In fact, it was actually a marathon, but we were just going to walk a part of it. When it started, they were fast walking which I didn’t feel comfortable doing, so I said I’d run for a little, then rest so we could meet back up. I started running and before long I was tracking alongside a group lead by a full marathon pacer, and they kept encouraging me. I never looked back and completed my first half marathon without taking a single break. On my journey, I met a few other survivors. We leaned on each other and eventually launched the Prostate Network. We found that supporting each other made us all stronger and better equipped to handle the roller coaster of living with prostate cancer. Beyond our meetings, we made a public plea to our community to invite us to share our stories. This would allow us to let other survivors know we had a place for them; and to begin to fill what we found was a massive gap on men’s health. It has now been over five years we have been sending survivors with educational materials into our community to educate men on the importance of seeing their family physicians. We advise

them to find out if they have a family history, which indicates an increased risk, and need to be screened earlier and more aggressively. Since many men keep this disease a secret, as was the case with my family, we tell them to inquire about their family health history. We also tell men to stack the deck in their favors by eating good and exercising. A significant amount of cancers are due to nongenetic factors, so we believe encouraging healthy lifestyles will keep our club as small as possible.

Currently, 29.5 million American men are living with prostate cancer." Family physicians, we’re doing our part in getting men to come see you, so please do your part and encourage screening. We like to say, "It’s not what you know that will get you, but what you don’t." Thank you for all you're doing in helping the men of Missouri live long, healthy, happy lives. Steve Hentzen is a prostate cancer survivor and chairman and a co-founder of the Prostate Network. He is a member of the Kansas Cancer Partnership and Missouri Cancer Consortium, and a member of the Patient Advisory Board at the University of Kansas Cancer Center where he volunteers his time and capabilities. Steve is a recipient of the Harry Pinchot Award by the Prostate Cancer Research Institute, and is a seven-year prostate cancer survivor who had a radical prostatectomy at age 46 followed by IMRT radiation one year later.

MO-AFP.ORG 9

DEPRESSION IN WOMEN

’ve got a great life. I’ve got everything I could want. Why am I not happy?” The question, at an office visit 30 years ago, startled me. I had known “Chantal” for a few years, caring for her and her children. Indeed, this beautiful, confident French woman had it all. She had married an American at a young age and moved to an upscale California community. Her children were great kids, the oldest on the cusp of adulthood. Her husband was successful and loving, Thomas C. Bent, MD, FAAFP if, perhaps, a bit dull. From the outside, she had everything a woman could want. I didn’t know what to say. Thomas C. Bent, MD, FAAFP, “I want an adventure, I want to fall in love again.” is a volunteer physician at She then began to cry quietly. A moment later, she Laguna Beach Community looked at me with surprise and embarrassment. Clinic, following a long career “I don’t know what came over me. I’ve never said in community and academic anything like this to anyone.” She was back in control. family medicine. He is past Everything was perfect again. president of the California AFP. My attempts to open the conversation again at subsequent visits were politely averted. Our professional relationship remained warm and positive, but I always felt I missed an opportunity with Chantal. A few years later I left my private group practice for academics and community medicine; Chantal and I lost touch. Depression strikes all ages, all genders, all social backgrounds. Peak age of onset is between 20 and 40 years. Women are twice as likely to suffer depression as men. A family history of depression increases the risk up to threefold. Marital status is also a risk factor. Married/partnered women are more likely to be depressed than singles, while single men are more likely to be depressed than married/partnered men. Family physicians are the best clinicians to recognize and treat depression. Unfortunately, we don’t always make an accurate diagnosis. Barriers to accurate diagnosis and treatment can be patient-based, physician-based, systems-based, or a combination of all these factors. The result is that up to two-thirds of patients may not receive appropriate care. Patient-based barriers to care are numerous. Few women present to their family physician specifically requesting care for depression. Most visits are for health maintenance or somatic complaints. Women are reluctant to share their symptoms … often because of denial, embarrassment, feeling they are weak of character, or this is the life they deserve. Cultural issues can also prevent women from discussing their emotions. 10

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

Presenting complaints in depressed patients include fatigue, malaise, headaches, vague abdominal, back or joint pain, and GI and GYN complaints. Clues that we need to screen our patients for depression may be found in phrases, usually last-minute doorknob disclosures, such as, “Could you prescribe some vitamins for me?” “By the way, could you give me something to help me sleep?” “I need something for stress” “Can you order a hormone test?” “I want you to test me for everything” and “I don’t know what’s wrong with me.” These phrases should trigger further questioning or an additional appointment. The US Preventive Services Task Force (USPSTF) recommends screening adults for depression in clinical settings that have systems in place to assure diagnosis, effective treatment and follow up.

Depression strikes all ages, all genders, all social backgrounds. Peak age of onset is between 20 and 40 years. Women are twice as likely to suffer depression as men."

Yet we know time, or lack thereof, for screening, diagnosis, and treatment is the most significant system-based barrier to care. When we hear or see the hints triggering the need to do further investigation, we are usually near or at minute 27 of our 15-minute appointment. Scheduling systems may not allow flexibility of longer appointments. Scheduling staff may automatically deflect mental health complaints to another clinician or another facility altogether. Insurance may have very limited benefits for mental health services. Formularies may require certain medications be written only by psychiatrists. Counselling services may not exist at all or be unavailable in the patient’s preferred language for care. Physician-based barriers to appropriate care include lack of knowledge or experience in diagnosis and management of depression, discomfort with discussing mental health issues, or the need for relentless pursuit of a physical cause for every somatic symptom. The lack of biomarkers for the diagnosis of

depression can contribute to physician uncertainty and reluctance. Fortunately, we now have access to a number of screening tools that are easy to administer and can partially quantify patients’ symptoms and severity. The simplest tool is the two-question test, endorsed by the USPSTF. 2 • Over the past two weeks, have you ever felt down, depressed, or hopeless? • Over the past two weeks, have you felt little pleasure or interest in doing things? This tool has 96 percent sensitivity and 57 percent specificity. Once a diagnosis of depression is established, a complete social history is critical. Women are particularly vulnerable to poor socio-economic circumstance and abusive relationships. A depressed woman may have limited resources and options to leave a toxic relationship, especially when children are involved. Extending your office-based systems

to link with shelters and social services is an important intervention. Having a handout in the exam room with contact information for shelters can be very valuable.

Suicide risk is another uncomfortable, but essential, conversation. Risk factors include hopelessness, advanced age, living alone, prior attempts, substance abuse, chronic medical illness, psychosis, and having access to the means to suicide. Data also show that women of Caucasian race commit suicide at a higher level than other racial groups. Treatment for depression is based in both pharmacology and psychotherapy. Cognitive Behavioral Therapy (CBT) and pharmacology each have a greater than 50 percent efficacy in resolution of symptoms. Combined therapy yields an 85 percent success rate. Psychotherapy has a very low side effect profile, proven efficacy and the enduring nature of therapeutic gains. However, treatment is time consuming, may take longer to achieve results and can be expensive for many patients. The National Guidelines Clearinghouse recommends that psychotherapy may be as effective as medication in the treatment of mild to moderate depression and should be considered, especially in patients who prefer to avoid medication. The benefit of the therapeutic alliance between the family physician and the patient cannot be overstated.

Many patients tell me of improvement of symptoms earlier than expected after initiating an SSRI. Having a diagnosis, a treatment plan, and the care and concern of her physician is an important therapeutic modality for her treatment. Brief counselling, using CBT or motivational interviewing, can be used in the family medicine setting, especially when other resources are not available to patients. “I don’t really see the point of treating my Hepatis, or of living much longer.” Betty arrived at my community clinic practice in a state of anger, confusion and despair. She had been erroneously diagnosed as having HIV and was referred to our clinic for care. A review of her records and repeat labs quickly confirmed a false positive screen with a negative confirmation and viral load. My work up also confirmed active Hepatitis C, which she had known about and avoided treatment. Her life could not have been more different than Chantal’s. A series of bad decisions and bad luck had left her broke, homeless and alone. She was ashamed of herself and her circumstance and did not see any hope for the future. My news that she did not have HIV gave me some credibility and trust. She consented to depression screening and reluctantly began treatment. With a slow but steady response she felt she had the energy and hope to pursue Hep C treatment. At a recent visit, we celebrated her one-year follow-up results, showing her Hep C is cured. She is in a modest apartment she loves, is connecting with people, and looking forward to social activities. “I love my life.” Major depression is a chronic medical condition that can be successfully treated. Family physicians are uniquely qualified to effectively care for the biological, psychological and social needs of our patients. References: 1. Stephen Stahl, M.D., Ph.D. Essential Psychopharmacology of Depression and Bipolar Disorder, Cambridge University Press, 2000:6; 2. https://www.uspreventiveservicestaskforce.org/Page/ Document/UpdateSummaryFinal/depression-in-adultsscreening1; 3. Pignone MP et al. Ann Intern Med.2002;136:765-776; 4. Sadock et al. Synopsis of Psychiatry. Philadelphia, PA: Lippincott Williams and Wilkins; 2003:913-4; 5. Keller et al. N Engl J Med. 2000;342:1462; 6. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2943776/; 7. https://www.ncbi.nlm.nih.gov/pubmed/8857869

MO-AFP.ORG 11

THE ADULT WELL-MALE EXAMINATION

T Joel J. Heidelbaugh, MD, FAAFP, FACG Joel J. Heidelbaugh, MD, FAAFP, FACG, is a clinical professor in the departments of family medicine and urology at the University of Michigan Medical School.

he adult well-male examination should provide evidence-based guidance toward the promotion of optimal health and well-being. The medical history should focus on tobacco and alcohol use, risk of human immunodeficiency virus and other sexually transmitted infections, and diet and exercise habits. The physical examination should include blood pressure screening, and height and weight measurements to calculate body mass index. Lipid screening is performed in men 40 to 75 years of age; there is insufficient evidence for screening younger men. One-time screening ultrasonography for detection of abdominal aortic aneurysm is recommended in men 65 to 75 years of age who have ever smoked. Screening for prostate cancer using prostate-specific antigen testing in men 55 to 69 years of age should be individualized using shared decision making. Screening for colorectal cancer should begin at 50 years of age for average-risk men and continue until at least 75 years of age. Screening options include fecal immunochemical testing, colonoscopy, or computed tomography colonography. Lung cancer screening using low-dose computed tomography is recommended in men 55 to 80 years of age who have at least a 30-pack-year smoking history and currently smoke or have quit within the past 15 years. Immunizations should be updated according to guidelines from the Advisory Committee on Immunization Practices. The goals of the adult well-male examination are to provide evidence-based guidance toward the promotion of optimal health and well-being, to screen for, and potentially prevent, premature morbidity and mortality from chronic diseases, and to provide age-appropriate cancer screening and immunizations. Most primary care guidelines come from the US Preventive Services Task Force (USPSTF) and have been adopted by the American Academy of Family Physicians (AAFP).1,2 Some subspecialty guidelines offer additional guidance but may have conflicting recommendations. Currently, there is no accepted guideline for frequency of adult wellmale examinations, although many private health insurance plans and Medicare recommend annual examinations. In 2007, men 15 to 65 years of age were significantly less likely than women to seek preventive

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

care services from a primary care physician (15% vs. 44% of total visits, respectively).3 In 2000, one in three men reported not having a primary care physician, compared with one in five women.4 No data are available on the impact of the Patient Protection and Affordable Care Act. The life expectancy of US men in 2015 was 76.3 years, a slight decrease from previous averages, and five years lower than that of women.5 Table 1 (To view tables, please visit www.aafp.org/ afp/2018/1215/p729.html) includes Centers for Disease Control and Prevention statistics related to men’s health and well-being.6 History For the evaluation of men, the patient history should be comprised of medical and surgical histories, current medications, and allergies. Family history relevant to the risk of chronic diseases and cancer should also be included. Social history should focus on lifestyle risks that contribute to premature morbidity and mortality, including substance use, risk of human immunodeficiency virus and other sexually transmitted infections (STIs), and diet and exercise habits. Evaluation of men with Medicare should also include gait stability, their ability to achieve activities of daily living, and depression screening. Screening for Lifestyle Table 2 (To view tables, please visit www.aafp.org/ afp/2018/1215/p729.html) summarizes screening guidelines for lifestyle and mental health risks in men.7–21 Tobacco and Substance Use Men should be asked about tobacco and alcohol use at every visit.7,8 The USPSTF found insufficient evidence to recommend for or against screening for illicit drug use9; however, the National Institute on Drug Abuse recommends screening for nonmedical prescription drug use and other illicit drug use.10 Clinicians can use recommended counseling approaches such as the five A’s (ask, advise, assess, assist, and arrange), the CAGE questionnaire, or motivational interviewing.8,22 Sexually Transmitted Infections Men with risk factors, including men with multiple sex partners, men who engage in unprotected sex, and men who have sex with men, should be

screened for STIs.11,12,23 There is good evidence of increased yield from routine screening for human immunodeficiency virus infection in persons who report no individual risk factors but are seen in highrisk or high-prevalence clinical settings, including STI clinics, correctional facilities, homeless shelters, tuberculosis clinics, clinics serving men who have sex with men, and adolescent health clinics that have a high prevalence of STIs. However, all men should be offered screening.13 One study concluded that counseling patients about the use of condoms is likely to benefit some patients at STI clinics and minimize the risk of infection transmission, although it is unlikely to benefit men who have sex with men.24 The costeffectiveness of implementing behavioral counseling in STI programs is unclear, but feasibility would be improved if behavioral counseling were implemented in the context of other prevention efforts. Depression Men should be screened for depression using the two-item Patient Health Questionnaire (PHQ; http:// www.commonwealthfund.org/usr_doc/PHQ2.pdf). If results of the PHQ-2 are positive, the patient should be further evaluated using the PHQ-9 (https://www. phqscreeners.com/sites/g/files/g10049256/f/201412/ PHQ-9_English.pdf).17 Screening for Chronic Conditions Table 3 (To view tables, please visit www.aafp.org/ afp/2018/1215/p729.html) summarizes screening guidelines for chronic conditions in men.18,25â&#x20AC;&#x201C;40 Cardiovascular Risk Components of the adult well-male examination include blood pressure screening and height and weight measurements to calculate body mass index (BMI).18,25 Hypertension: Men should be screened for high blood pressure.25 When treatment decisions are being made, blood pressure should be considered with global risk of cardiovascular disease (CVD); smoking status; presence of diabetes mellitus, dyslipidemia, or obesity; physical activity level; age; and sex.25 Hypertension (defined as a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher by the Eighth Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [JNC-8]) can be diagnosed after two or more elevated readings are obtained on at least two visits over a period of one to several weeks.28 Recent guidelines recommend a cutoff for stage 1 hypertension of 130 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic 41; however, the AAFP continues to support the cutoff

recommended by the JNC-8.26,42 Evidence supports ambulatory blood pressure monitoring as the reference standard for confirming elevated office blood pressure measurements to avoid misdiagnosis and overtreatment of persons with isolated clinic hypertension (white coat hypertension).29 The ASCVD (Atherosclerotic Cardiovascular Disease) Risk Estimator (available at http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/ calculate/estimate/) can be used to determine the 10-year risk of cardiovascular events or stroke in men 40 to 79 years of age. Obesity: Height and weight measurements should be obtained at every visit to calculate BMI.18 An abdominal (waist) circumference greater than 40 inches is associated with an increased risk of type 2 diabetes, dyslipidemia, hypertension, and CVD in men with a BMI of 25 to 35 kg per m2.43 In persons with a BMI of 35 kg per m2 or greater, determination of waist circumference has limited additional value in the prediction of CVD risk.43 In Asian and black men, waist circumference and other measures such as waist-to-height ratio may be better indicators of CVD risk than BMI because BMI does not adequately account for differences in visceral fat distribution.43 Diabetes: Among men 20 years and older, more than 15 million have diabetes and approximately 44.5 million have prediabetes.44 Diabetes is considered a CVD risk equivalent because diabetes-related comorbidity with other risk factors leads to a higher risk of CVD within 10 years.31 The American Diabetes Association defines diabetes as an A1C level of 6.5% or higher; fasting plasma glucose concentration of 126 mg per dL (7.0 mmol per L) or greater; plasma glucose concentration of 200 mg per dL (11.1 mmol per L) or greater two hours after a 75-g oral glucose load; and a random plasma glucose concentration of 200 mg per dL or greater in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis (e.g., polyuria, polydipsia, polyphagia).32 Dyslipidemia: The USPSTF recommends lipid screening in men 40 to 75 years of age; a risk calculator is then used to determine the need for treatment.33 The optimal interval for screening is uncertain.33 Notably, the USPSTF found insufficient evidence to recommend for or against screening in any risk group younger than 40 years.33 Risk factors for CVD include elevated low-density lipoprotein cholesterol, history of CVD or noncoronary atherosclerosis, diabetes, smoking, hypertension, obesity, and family history of CVD before 50 years of age in male relatives or before 60 years of age in female relatives.33,34 Fasting lipoprotein profile is the preferred screening test for dyslipidemia.33,34 For nonfasting samples, total cholesterol and high-density lipoprotein cholesterol MO-AFP.ORG 13

measurements are recommended and are sufficient for calculating 10-year cardiovascular risk using most calculators.45,46 Abdominal Aortic Aneurysm: The USPSTF recommends one-time screening ultrasonography for detection of abdominal aortic aneurysm in men 65 to 75 years of age who have ever smoked.35 Randomized trials show that the benefits of screening and surgical repair in this high-risk group outweigh potential harms.35 The pooled prevalence of abdominal aortic aneurysm is 4.4%.47 The mortality rate after dissection and rupture approaches 80% for men who reach the hospital and 50% for men who undergo emergent surgical repair.48 Smoking is the risk factor most strongly associated with abdominal aortic aneurysm (odds ratio = 5.07) and accounts for 75% of all aneurysms 4 cm or greater.49 Other risk factors include hypertension, dyslipidemia, family history, and atherosclerosis. A meta-analysis determined that a well-functioning screening program would reduce abdominal aortic aneurysm–related mortality by at least 45%; the number needed to screen to prevent one rupture is 238.50 Osteoporosis The USPSTF found insufficient evidence to recommend for or against screening men for osteoporosis, given that the relative benefits and harms of therapy for osteoporosis in men have not been determined.36 Although evidence for screening is lacking, men most likely to benefit from screening would have a 10-year risk of osteoporotic fracture equal to or greater than that of a 65-year-old white woman with no additional risk factors.36 For men, major risk factors include increasing age, white race, and family history. The National Osteoporosis Foundation recommends bone mineral density testing for all men 70 years or older and men 50 to 69 years of age with risk factors (e.g., frailty, low BMI).37 The USPSTF found insufficient evidence to recommend for or against calcium and vitamin D supplementation to prevent fractures.51 Chronic Obstuctive Pulmonary Disease The USPSTF recommends against screening adults for chronic obstructive pulmonary disease (COPD) using spirometry.38 Men with COPD, including those with mild or moderate illness, benefit from smoking cessation and annual influenza vaccination. Moderate evidence suggests that influenza vaccination reduces COPD exacerbations.38

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

Hepatitis C Screening for hepatitis C should be offered to men at high risk of infection. Adults born between 1945 and 1965 should be offered one-time screening.39 Cancer Screening Table 4 (To view tables, please visit https://www. aafp.org/afp/2018/1215/p729.html) summarizes screening guidelines for cancer in men.52–61 Testicular Cancer The USPSTF recommends against screening asymptomatic men for testicular cancer. Because the incidence of testicular cancer is very low and treatment is often effective even in advanced stages, the benefits of earlier detection are minimal and likely outweighed by the harms of false-positive results and unnecessary workup for benign conditions.52 Skin Cancer The USPSTF concludes that there is insufficient evidence to assess the benefits vs. harms of a wholebody skin examination performed by a primary care clinician for the early detection of skin cancer in men. It concludes that there is also insufficient evidence to assess the benefits vs. harms of counseling patients about performing self-examinations.53,54 Prostate Cancer Screening for prostate cancer in primary care is controversial because it is widely believed that screening has resulted in overdiagnosis and overtreatment of clinically insignificant cancers. An editorial on prostate cancer screening was published in American Family Physician (available at https:// www.aafp.org/afp/2018/1015/p478.html). Previous USPSTF recommendations argued against screening for prostate cancer with prostate-specific antigen testing because of possible harms, based on data from the European Randomized Study of Screening for Prostate Cancer and the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial.62 Current USPSTF and AAFP guidelines align with American Urological Association guidelines in recommending a discussion of benefits vs. risks of screening for men 55 to 69 years of age and using a shared decision-making approach; screening decisions should be individualized based on risk factors (i.e., family history, black race) and take into account the patient’s values and preferences.55,56,63 The USPSTF and AAFP recommend against prostate-specific antigen screening for prostate cancer in men 70 years and older.55,56

Although not recommended by the USPSTF, expert opinion from the American Urological Association and data from an uncontrolled trial suggest that prostate cancer screening should combine the digital rectal examination and prostate-specific antigen test, which improves detection compared with either test alone (positive predictive value = 18% and 45%, respectively).56,64 Colorectal Cancer Screening for colorectal cancer should begin at 50 years of age for average-risk men and continue until at least 75 years of age.57 Colonoscopy is increasingly becoming the test of choice for colorectal cancer screening in primary care, yet there are no randomized controlled trials comparing colonoscopy, flexible sigmoidoscopy, and fecal occult blood testing (FOBT) with a definable outcome of cancer-specific or all-cause mortality.57,65,66 Fecal immunochemical testing has greater sensitivity and specificity compared with guaiac-based FOBT.67 Fecal DNA testing has not proved more accurate than FOBT or fecal immunochemical testing and has more falsepositive results than FOBT (16% vs. 5%).68 Computed tomography colonography may result in harms from low-dose ionizing radiation exposure or identification of extracolonic findings.69 Lung Cancer Lung cancer is the third most common cancer and the leading cause of preventable cancer-related death in the United States.70 Smoking is the most important risk factor for lung cancer, accounting for approximately 85% of cases.71 The USPSTF recommends annual screening for lung cancer with low-dose computed tomography in adults 55 to 80 years of age who have at least a 30-pack-year smoking history and currently smoke or have quit within the past 15 years,59,72 whereas the AAFP concludes that the evidence is insufficient to recommend for or against screening.60 Physicians should be aware of the high rate of false-positives with low-dose computed tomography screening; more than one-half of patients require additional testing and tracking, of which only 1.5% receive a lung cancer diagnosis.73 Screening should be discontinued once a patient has not smoked for 15 years or if a patient develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.59

Immunizations The Advisory Committee on Immunization Practices (ACIP) strongly encourages annual influenza vaccination for all adults, with the high-dose preparation recommended for those older than 65 years. ACIP recommends a single tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination, regardless of when the last tetanus and diphtheria toxoids (Td) booster was given.74 A vaccine series does not need to be restarted, even if a long period has passed between doses, although immunity may need to be verified via serologic testing.74 Full ACIP vaccine recommendations are available at https://www.cdc.gov/vaccines/schedules/ hcp/imz/adult.html. This article updates a previous article on this topic by Heidelbaugh and Tortorello.75 Data References: I performed a bibliographic search of select men’s health topics highlighting USPSTF guidelines, the Cochrane Database of Systematic Reviews, Essential Evidence Plus, the American Urological Association, the Agency for Healthcare Research and Quality, DynaMed, and the National Guideline Clearinghouse database. I searched Medline using the terms men’s health, guidelines, evidence-based, hypertension, hyperlipidemia, obesity, diabetes mellitus, abdominal aortic aneurysm, osteoporosis, prostate cancer, colorectal cancer, lung cancer, testicular cancer, skin cancer, sexually transmitted diseases/infections, and immunizations. Original research studies cited within these guidelines were reviewed. Search dates: September through November 2017. (See complete list of sources at https://www.aafp.org/afp/2018/1215/ p729.html) AAFP News, [December 2018]. © American Academy of Family Physicians

MO-AFP.ORG 15

EATING DISORDERS

AN UNDER-DETECTED AND UNDER-TREATED SERIOUS MENTAL ILLNESS IN MISSOURI

Ellen Fitzsimmons-Craft, PhD, LP Ellen Fitzsimmons-Craft, PhD, LP, is a licensed clinical psychologist and assistant professor of Psychiatry at Washington School of Medicine. She serves as executive director of the Missouri Eating Disorder Council’s 360 Program, their training initiative. Her work aims to disseminate evidencebased interventions for eating disorders from research to practice, as well as extend treatments in ways that will reach the large number of people in need of clinical care, but who are not receiving services.

ating disorders (EDs), which include the diagnoses of anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified feeding or eating disorder (OSFED), and unspecified feeding or eating disorder (UFED), are serious mental illnesses associated with high medical and psychiatric comorbidity, poor quality of life, and high mortality (Klump et al., 2009). Mortality from AN is the highest of all mental illnesses, and EDs rank as the 12th leading cause of disability in young women in high-income nations (Hoek, 2016). Although EDs are more prevalent in women vs. men, the clinical prevalence of EDs in men has been rising in recent decades, perhaps due to greater recognition that EDs do not discriminate (Raevuori, Keski-Rahkonen, & Hoek, 2014). Epidemiological studies find the rate ratios of lifetime prevalence for AN in males vs. females to be 1:3-1:12 and 1:3-1:18 for BN. In BED, the male to female rate ratio is more equal, ranging from 1:2-1:6 (Raevuori et al., 2014). Indeed, EDs affect individuals from every socioeconomic status, race, ethnicity, and gender, with approximately 10% of the population affected by an ED at some point in their lifetime (Schaumberg et al., 2017). This translates to over 600,000 Missourians struggling with a serious ED over the course of their lives. Delayed or inadequate treatment results in poorer prognosis and greater relapse (American Psychiatric Association, 2006), underscoring the need for early identification and evidence-based treatment. Indeed, full recovery from an ED is not only possible, but probable, with appropriate care (Schaumberg et al., 2017). However, the statistics regarding receipt of ED treatment are dire, with less than 20% of those with EDs receiving treatment (Kazdin, FitzsimmonsCraft, & Wilfley, 2017). A majority of individuals who receive treatment for an ED are first seen by their primary care physician (Dickerson et al., 2011; Striegel-Moore et al., 2008), but one study indicated that 92% of frontline medical providers (e.g., general practice physicians and nurse practitioners) believed they had missed an ED diagnosis (Linville, Benton, O’Neil, & Sturm, 2010).

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

Further, when individuals with EDs receive care, evidence-based treatment is rarely used (Cooper & Bailey-Straebler, 2015; Fairburn & Wilson, 2013; Lilienfeld et al., 2013). This underscores two current, major gaps: 1) the gap between the large number of people in need of clinical care for EDs and those actually receiving services (i.e., the treatment gap); and 2) the gap between what is known about effective treatment for EDs and what is actually provided to patients who receive care. (i.e., the research-practice gap). Evidence-based treatment for EDs, based on an integrated care model, is currently only available in two Missouri cities, St. Louis and Kansas City, creating a hardship for rural Missourians to access high-quality care. Rural Missourians must not only have the resources to travel for treatment but must also have the means to pay for treatment (approximately $2500/day), as these treatment centers are, for the most part, considered out of network on insurance plans. There are currently no Medicaid beds in Missouri for ED treatment. As such, the vast majority of Missourians with EDs do not have access to treatment providers trained in evidence-based practices for EDs, resulting in poorer prognosis, greater relapse, higher costs, and increased risk of serious complications such as cardiovascular problems and death. The Missouri Eating Disorders Council (MOEDC), a division of the Missouri Department of Mental Health, is comprised of 23 stakeholders from across the state dedicated to increasing awareness of and access to treatment for EDs. These individuals represent mental health organizations, ED clinics, universities, government, patients, and carers. In response to the current gaps in the treatment of EDs in Missouri, the MOEDC has established the first state-wide training initiative in the nation, “MOEDC 360,”, focusing on training providers in the screening, diagnosis, and treatment of EDs, with a particular emphasis on community mental health center providers. Through this program, the MOEDC has made evidence-based, multidisciplinary ED treatment available in one area in rural Missouri (i.e., Ozark Center in Joplin) and has successfully trained 200+ providers throughout

Although EDs are more prevalent in women vs. men, the clinical prevalence of EDs in men has been rising in recent decades, perhaps due to greater recognition that EDs do not discriminate."

Missouri in evidence-based approaches. The MOEDC has also made all of our trainings available online, including a webinar that was conducted specifically for primary care providers and a training in the medical management of EDs. To learn more about MOEDC 360 or to gain access to MOEDC 360 online training opportunities, please visit the MOEDC website at www.moedc.org. For additional information or to express interest in establishing a multidisciplinary ED treatment team at your community mental health center or obtaining inperson training, please email Dr. Ellen FitzsimmonsCraft, executive director of the MOEDC 360 Program, at: fitzsimmonse@wustl.edu References: American Psychiatric Association. (2006). Treatment of patients with eating disorders, American Psychiatric Association. American Journal of Psychiatry, 163, 4. Cooper, Z., & Bailey-Straebler, S. (2015). Disseminating evidence-based psychological treatments for eating disorders. Current Psychiatry Reports, 17, 12. Dickerson, J. F., DeBar, L., Perrin, N. A., Lynch, F., Wilson, G. T., Rosselli, F., ... & Striegel‐Moore, R. H. (2011). Health‐service use in women with binge eating disorders. International Journal of Eating Disorders, 44, 524-530. Fairburn, C. G., & Wilson, G. T. (2013). The dissemination and implementation of psychological treatments: Problems and solutions. International Journal of Eating Disorders, 46, 516-521.

Hoek, H. W. (2016). Review of the worldwide epidemiology of eating disorders. Current Opinion in Psychiatry, 29, 336-339. Kazdin, A. E., Fitzsimmons‐Craft, E. E., & Wilfley, D. E. (2017). Addressing critical gaps in the treatment of eating disorders. International Journal of Eating Disorders, 50, 170-189. Klump, K. L., Bulik, C. M., Kaye, W. H., Treasure, J., & Tyson, E. (2009). Academy for Eating Disorders position paper: Eating disorders are serious mental illnesses. International Journal of Eating Disorders, 42, 97-103. Lilienfeld, S. O., Ritschel, L. A., Lynn, S. J., Brown, A. P., Cautin, R. L., & Latzman, R. D. (2013). The research– practice gap: Bridging the schism between eating disorder researchers and practitioners. International Journal of Eating Disorders, 46, 386-394. Linville, D., Benton, A., O'Neil, M., & Sturm, K. (2010). Medical providers' screening, training and intervention practices for eating disorders. Eating Disorders, 18, 110131. Raevuori, A., Keski-Rahkonen, A., & Hoek, H. W. (2014). A review of eating disorders in males. Current Opinion in Psychiatry, 27, 426-430. Schaumberg, K., Welch, E., Breithaupt, L., Hübel, C., Baker, J. H., Munn‐Chernoff, M. A., ... & Hardaway, A. J. (2017). The science behind the Academy for Eating Disorders' Nine Truths About Eating Disorders. European Eating Disorders Review, 25, 432-450. Striegel-Moore, R. H., DeBar, L., Wilson, G. T., Dickerson, J., Rosselli, F., Perrin, N., ... & Kraemer, H. C. (2008). Health services use in eating disorders. Psychological Medicine, 38, 1465-1474. MO-AFP.ORG 17

FP S & VASECTOMIES:

HELP YOUR PATIENTS MAKE A 'SNIP' DECISION

John Cullen, MD, FAAFP AAFP President John S. Cullen, MD, FAAFP, a family physician in Valdez, Alaska, has practiced the full scope of family medicine in a rural community of 4,000 people in Alaska for the past 25 years. Cullen works in a small group practice and is director of emergency medical services at Providence Valdez Medical Center. He has been actively involved in residency and medical student teaching for more than 20 years, providing comprehensive training in rural health care.

'd like to address a disparity regarding family planning. Guys, it is time to step up to the plate. I'm talking vasectomy here, and family physicians are ideally positioned to provide this service. I was interviewed last year about why more men don't get vasectomies. (huffingtonpost.com) My response was that they do here in Valdez, Alaska. I live in a remote community in a state known as the last frontier, and the men here are tough. They have to be. (So are the women, but that's a different post.) The reality is that in our community, most women don't get their tubes tied; the men do. There are exceptions. We perform elective tubal ligations during cesarean sections and offer the full range of reversible contraception. But for permanent birth control, I always recommend vasectomy. It is easier to perform than tubal ligation, ablation or hysteroscopic tubal occlusion and does not entail major surgery. I can do this procedure in my office in about 20 minutes. I discuss it during prenatal visits and as part of discharge planning after a delivery. I have donated many vasectomies to fundraising auctions over the years. I started with Ducks Unlimited, an organization that is effective in wetlands preservation. I offered a vasectomy that was auctioned with the tagline "Make sure you're shooting blanks." It raised a ridiculous amount of money. I've offered vasectomies through other local charities since then, and we found that adding a catchy phrase helps get people's attention. For example, the line for the local museum auction was "Your sperm-producing days are history." I realized that these campaigns were a true success when the winner of one auction started jumping up and down with his arms raised over his head in a victory dance. At another amusing event, the wife of an auctioneer started bidding. The auctioneer came in the next day. For every vasectomy I donated, I had multiple other procedures scheduled by the same patients and families. It was a good loss leader. I charge half the rate of a urologist because I really want my male patients to step up.

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

I learned how to perform vasectomies from a no-scalpel vasectomy course offered by the AAFP many years ago. It is an easy procedure that requires some specialized instruments. I use a local anesthetic with oral narcotic and a benzodiazepine. I don't use clips, preferring the technique outlined in the AAFP course, which has a low complication rate and excellent evidence as to its safety and efficacy.

Nationally, women are three times more likely to undergo a sterilization procedure than men, (ncbi.nlm.nih.gov) but men can, and should, take responsibility for their own fertility."

I practice in a small town, so I would know if there were problems or unintended pregnancies. Instead, my biggest concern is that for some reason, men often try some heroic adventure the day after their vasectomy. I had one patient ride a snow machine across the Valdez Glacier. Another took a glacier rescue class and spent the day jumping into crevasses while wearing a harness. I use these as examples of what men should not do when I advise them to sit at home and watch TV for the next several days. Nationally, women are three times more likely to undergo a sterilization procedure than men, (ncbi.nlm.nih.gov) but men can, and should, take responsibility for their own fertility. There are financial and professional benefits for us to provide this service, as well. It is an easy procedure with little significant risk, and family physicians, by the nature of our practice, can promote its use. It is time for men to step up. AAFP News, [November 2018]. ÂŠ American Academy of Family Physicians

MAFP App Review featured app

MyFitnessPal Overall Rating: 4/5 MyFitnessPal App

Going into the New Year with a lot of our patients focusing on New Year’s Resolutions we decided to review an app that is medical, but is also used for personal fitness goals. MyFitnessPal is one of the best known fitness apps available through Apple and Google Play. It gives you the ability to track your exercise, food, water, and weight all in one place.

Pros

• Ability to track workouts and track your weight goals over a period of time. • This app is setup like an organized live journal that can be used to input each thing you eat and the types of workouts and calorie output. • It also has the ability to scan in foods from the store to help you calculate the nutrition value of what you are eating. • This app also gives you the ability to track your water intake and exercise routine. • The Premium app gives you additional functions: Nutrient dashboard, food analysis to analyze the type of nutrition you care about the most, and downloadable CSV files that track your progress.

Cons

• The free version doesn’t allow you to calculate net carbs and lacks a lot of the functionality of the premium version. • This is a fairly expensive app on the subscription model. • It seems to be a better calorie counter than a carb counter which make it difficult to for patients using other diet types. The premium version may be a good solution for this but it’s pricey.

Price

• Free version available without full functionality of the premium version. • Premium Version is $49.99 per year or $9.99 per month. • There is a one-month free trial of the premium app available.

How to Download

• Search MyFitnessPal in the Apple or Google store. Reviewed by: Jacob Shepherd, MD MAFP Director at Large

MO-AFP.ORG 19

M AT E R N A L B E N E F I T S O F BREASTFEEDING

Sarah Calhoun, MD, IBCLC Sarah Calhoun, MD, IBCLC, is assistant professor of Clinical Family and Community Medicine at the University of Missouri School of Medicine.

reastfeeding has both short- and long-term health benefits for the mother and child. Several organizations support breastfeeding and have written policies regarding breastfeeding exclusivity and duration. The World Health Organization (WHO) recommends exclusive breastfeeding for the first six months of life, and continuing breastfeeding with complementary foods until at least two years of age.1 The American Academy of Pediatrics and the American Academy of Family Physicians have similar recommendations regarding exclusive breastfeeding, but recommend breastfeeding continue with complementary foods until one year of age, or longer as mutually desired by the mother and infant.2,3 Most people know that breastfeeding has many health benefits for infants, but we often forget that breastfeeding has many benefits for mothers as well. The Breastfeeding Report Card from the Centers for Disease Control and Prevention (CDC) was last updated in 2015.4 82.3% of infants born in Missouri in 2015 were ever breastfed, which includes infants who received one or more breastfeeds. At six months of age, 57.8% were breastfed. By 12 months of age, the percentage of infants breastfed fell to 33.1%. We do not meet any of the CDC’s Healthy People 2020 goals for ever breastfed (83.2%), breastfed at six months (60.6%), and breastfed at one year (34.1%).4 In 2015, Acta Pædiatrica published a systematic review and meta-analysis of breastfeeding and maternal health outcomes.5 Investigators reviewed 163 prospective/retrospective cohort and casecontrol studies, randomized controlled trials, and quasi-experimental trials along with systematic reviews. Long-term health outcomes included risk of breast cancer, ovarian cancer, osteoporosis, and type 2 diabetes with breastfeeding. Ninetyeight studies evaluated the association between ever breastfeeding and the risk of breast cancer. Women who ever breastfed had a 22% reduction of the risk of breast cancer compared with those who never breastfed (OR 0.78; 95% CI, 0.74-0.82).

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

Women who breastfed for over 12 months had a 26% decreased risk of breast cancer compared to those who never breastfed (OR 0.74; 95% CI, 0.690.79). When breastfeeding lasted for more than 12 months, there was a lower risk of breast cancer as compared to those who breastfed for shorter periods of time.5

Most people know that breastfeeding has many health benefits for infants, but we often forget that breastfeeding has many benefits for mothers as well."

Results from 41 studies were pooled to assess breastfeeding and ovarian cancer risk. Mothers who ever breastfed had a 30% risk reduction for ovarian cancer, when compared to mothers who never breastfed (OR 0.70; 95% CI, 0.64-0.77). The largest risk reduction was seen in women who had a lifetime breastfeeding duration longer than 12 months. These women had a 37% decreased risk of ovarian cancer, when compared to mothers who never breastfed (OR 0.63; 95% CI, 0.56-0.71).5 There were no new studies found regarding type 2 diabetes since a systematic review by Aune et al. in 2013 (N=273,961). This systematic review of six prospective cohort, case-cohort, and nested case-control studies found through a dose-response analysis that women with a longer duration of lifetime breastfeeding compared to women with a shorter duration of lifetime breastfeeding had a 32% lower risk of type 2 diabetes (RR 0.68; 95% CI, 0.57-0.82).6 For each additional 12 months of breastfeeding, there was a 9% relative risk reduction of developing type 2 diabetes.6 The Women’s Health Initiative cohort study (N=139,000) found that women who

breastfed for 12 to 23 months during their lifetime had a decreased risk of diabetes (OR 0.74; 95% CI, 0.65-0.84).2 Short-term health outcomes examined in the systematic review in Acta Pædiatrica included lactational amenorrhea, postpartum depression, and postpartum weight change. Twelve studies evaluated lactational amenorrhea and breastfeeding. Women who were exclusively or predominantly breastfeeding at six months postpartum were 23% more likely to have lactational amenorrhea than those who were not breastfeeding (RR 1.23; 95% CI, 1.07-1.41).5 Lactational amenorrhea results in increased spacing between children.2 Women with postpartum depression had a 1.25 times greater risk of having stopped breastfeeding as compared to women who did not have postpartum depression at that same point in time after delivery (95% CI, 1.03-1.52).7 Women who did not breastfeed have a higher risk of postpartum depression.2 There does not appear to be an association between breastfeeding and postpartum weight loss,5 although studies have conflicting results due to confounding factors including baseline BMI, ethnicity, diet, and activity.2 Breastfeeding is associated with other benefits that may not be as well known. The Nurses’ Health Study (N=121,700) found that in women whose lifetime breastfeeding exceeded 12 months, the relative risk of rheumatoid arthritis was 0.8 compared to women whose lifetime breastfeeding was less than 12 months (95% CI, 0.8-1.0). If lifetime breastfeeding exceeded 24 months, the relative risk of rheumatoid arthritis decreased to 0.5 (95% CI, 0.3-0.8).2 The large Women’s Health Initiative found that women whose lifetime breastfeeding duration was 12 to 23 months had a reduced risk of hypertension (OR 0.88, p <0.001).8 The risks for hyperlipidemia (OR 0.81, p <0.001) and cardiovascular disease (OR 0.91, p=0.008) were decreased as well.8 There are no known maternal harms to breastfeeding, including the risk of osteoporosis.

Even though calcium and bone metabolism is altered during pregnancy and lactation, there is no conclusive evidence that breastfeeding affects osteoporosis risk.5 Family physicians have a unique role to support the mother-infant dyad. Short-term benefits of breastfeeding include decreased postpartum bleeding, lactational amenorrhea, increased spacing between children, and decreased risk of postpartum depression. Long-term maternal benefits include a reduced risk of breast and ovarian cancers, type 2 diabetes, rheumatoid arthritis, hypertension, hyperlipidemia, and cardiovascular disease. Due to the many health benefits of breastfeeding to both the mother and the infant, family physicians should encourage and support breastfeeding unless it is contraindicated. References 1. World Health Organization UNICEF, Innocenti Declaration on the Protection, Promotion, and Support of Breastfeeding. 1990. http://www.unicef.org/programme/ breastfeeding/innocenti.htm 2. Breastfeeding and the Use of Human Milk. Pediatrics. 2012;129(3):827-841. 3. Breastfeeding, Family Physicians Supporting (Position Paper). AAFP Home. https://www.aafp.org/about/ policies/all/breastfeeding-support.html. Published May 17, 2017. Accessed March 6, 2019. 4. Breastfeeding Report Card | Breastfeeding | CDC. Centers for Disease Control and Prevention. https://www. cdc.gov/breastfeeding/data/reportcard.htm. Published August 20, 2018. Accessed March 6, 2019. 5. Chowdhury R, Sinha B, Sankar MJ, et al. Breastfeeding and maternal health outcomes: a systematic review and meta-analysis. Acta Pædiatrica. 2015;104:96-113. 6. Aune D, Norat T, Romundstad P, Vatten LJ. Breastfeeding and the maternal risk of type 2 diabetes: a systemic review and dose-response meta-analysis of cohort studies. Nutrition, Metabolism, & Cardiovascular Disease. 2014;24:107-115. 7. Henderson JJ, Evans SR, Straton JA, Priest SR, Hagan R. Impact of postnatal depression on breastfeeding duration. Birth. 2003;30(3):175-180. 8. Schwarz EB, Ray RM, Stuebe AM, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstetrics and Gynecology. 2009;113(5):974982.

MO-AFP.ORG 21

STUMBLING ONTO CANCER: AV O I D I N G O V E R D I A G N O S I S O F R E N A L CELL CARCINOMA

r. Baker's voice was obviously hoarse on the phone. He called the office because he had been hoarse for six weeks—although he felt well otherwise. An ear, nose, and throat doctor examined Mr. Baker a few days later, removed a small tumor from his vocal cord, and the hoarseness promptly resolved. That would have been the end of the story, H. Gilbert Welch, MD, MPH except someone along the way had ordered chest radiography. The chest radiograph image was interpreted as abnormal, possibly showing H. Gilbert Welch, MD, MPH, a widened mediastinum. The recommended is a general internist in course of action was computed tomography (CT) Thetford, Vermont, and was of the chest. The chest CT scan revealed a normal a professor of medicine at Dartmouth for 28 years. He is mediastinum, a normal chest, and a 5-cm renal the author of "Less Medicine, mass compatible with renal cell carcinoma. More Health: 7 Assumptions Some doctors might argue that Mr. Baker That Drive Too Much Medical should have had chest radiography as part of the Care" evaluation for his hoarseness given his history of smoking and the possibility of lung cancer affecting the recurrent laryngeal nerve. I would counter that once we had found the cancer responsible for Mr. Baker's hoarseness, we did not need to go looking for a second cancer. Others might argue he should be screened for lung cancer anyway, but that's a different story altogether. A long-term follow-up study of the Mayo Lung Project has shown no reduction in lung cancer mortality from chest radiography,1 and the question of whether the benefits of CT screening outweigh its harms is still the subject of considerable debate.2,3 So, Mr. Baker called complaining of hoarseness and was given a diagnosis of kidney cancer. One had absolutely nothing to do with the other; it was just dumb luck. But was it good luck or bad luck? Whenever I tell this story to clinical audiences, I always get the same response—laughter. They aren't laughing at Mr. Baker's diagnosis, they are laughing because they have experienced similar episodes and have faced a similar quandary.

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

Remarkably, as pointed out in Gray and Harris's review of renal cell carcinoma in this issue of American Family Physician,4 some version of this story is now responsible for more than one-half of kidney cancer diagnoses.

This is not an epidemic of disease, this is an epidemic of diagnosis." You can see the effect in our national cancer statistics. Since the advent of cross-sectional imaging in the 1970s, the incidence of kidney cancer has more than doubled in the United States5 (Figure 1).6 The figure also shows that no corresponding change in kidney cancer mortality rates has occurred. The rising incidence and stable underlying (true) disease burden are a clear-cut case of cancer overdiagnosis: the detection of disease not destined to cause clinical illness or death.7,8 Further evidence of a stable underlying disease burden is evident in the stable rate at which patients first present with metastatic disease. This is not an epidemic of disease, this is an epidemic of diagnosis. It is not the result of a purposeful screening effort, it is the result of unintended incidental detection—a side effect of the increasing use of cross-sectional imaging. Some doctors order more CT scans than others. Similarly, the chance of being scanned is higher in some geographic regions than others. My colleagues and I found that Medicare beneficiaries residing in high scanning regions faced a higher risk of nephrectomy—undoubtedly reflecting increased incidental detection of kidney masses (Figure 2).5 The BMJ's Richard Lehman summed it up succinctly in his journal review blog, “More CTs, fewer kidneys.”9 Mr. Baker's urologist recommended a nephrectomy based on data that apparently

buttressed her case. Because of early detection, the five-year survival rate for kidney cancer at that time had risen from 34% in 1950 to 62%. The current five-year survival rate is 75%.6 The five-year survival rate is rising, yet mortality is stable? How can that be right? It turns out that the combined effect of lead time (www.youtube.com/watch?v=ngHB1DzP5xc) and overdiagnosis bias (www.youtube.com/watch?v=s7QNhE59s9Q) can be very powerful. My colleagues and I investigated changes in five-year survival rates over time for 20 solid tumors. We found that increased survival was not associated with lower mortality but instead was associated with rising incidence.10 In other words, as we find more disease, the typical patient appears to do better. Mr. Baker and I made a shared decision not to pursue surgery; however, he did undergo more CT scans. Sometimes the mass seemed to grow a bit, sometimes it seemed to shrink. About a decade later, he died of pneumonia. An autopsy showed that he had renal cell carcinoma even though he had never developed symptoms of kidney cancer, and the cancer never spread beyond his kidney. He was overdiagnosed. I learned a great deal from Mr. Baker. Not all cancers invariably progress. Survival statistics can be very misleading, and comparisons across time and place are more reflective of diagnostic practice than the benefit of therapy. Imaging—and testing in general—has real downsides, such as stumbling onto things you wish you had not. That is why we all need to test wisely and weigh the risks and benefits of diagnostic imaging.11 We will all stumble occasionally, and when we do, it is important to remember that sometimes the right thing to do is nothing. References 1. Marcus PM, Bergstralh EJ, Fagerstrom RM, et al. Lung cancer mortality in the Mayo Lung Project: impact of extended follow-up. J Natl Cancer Inst. 2000;92(16):1308–1316. 2. U.S. Preventive Services Task Force. Lung cancer: screening. December 2013. https://www. uspreventiveservicestaskforce.org/Page/ Document/RecommendationStatementFinal/ lung-cancer-screening. Accessed October 13, 2018. 3. American Academy of Family Physicians. Clinical preventive service recommendation. Lung cancer. 2013. https://www.aafp.org/patient-care/ clinical-recommendations/all/lung-cancer.html. Accessed October 13, 2018. 4. Gray RE, Harris GT. Renal cell carcinoma: diagnosis and management. Am Fam Physician. 2019;99(3):179–184. 5. Welch HG, Skinner JS, Schroeck FR, Zhou W, Black WC. Regional variation of computed tomographic imaging in the United States and the risk of nephrectomy. JAMA Intern Med. 2018;178(2):221–227. 6. National Cancer Institute. Cancer stat facts: kidney and renal pelvis cancer. https://seer.cancer. gov/statfacts/html/kidrp.html. Accessed October 13, 2018. 7. Welch HG, Black WC. Overdiagnosis in cancer. J Natl Cancer Inst. 2010;102(9):605– 613. 8. Davies L, Petitti DB, Martin L, Woo M, Lin JS. Defining, estimating, and communicating overdiagnosis in cancer screening. Ann Intern Med. 2018;169(1):36–43. 9. thebmjopinion. Richard Lehman's journal review—2 January, 2018. https://blogs.bmj.com/bmj/2018/01/02/ richard-lehmans-journal-review-2-january-2018/. Accessed October 13, 2018. 10. Welch HG, Schwartz LM, Woloshin S. Are increasing 5-year survival rates evidence of success against cancer? JAMA. 2000;283(22):2975–2978. 11. Crownover BK, Bepko JL. Appropriate and safe use of diagnostic imaging. Am Fam Physician. 2013;87(7):494–501. AAFP News, [February 2019]. © American Academy of Family Physicians

Figure 1

Figure 2

MO-AFP.ORG 23

A N U N E X P E C T E D C AU S E O F A B D O M I N A L PA I N IN PREGNANCY A CASE REPORT ABSTRACT

Chase Beliles, MD Chase Beliles, MD, recently graduated from his residency at University of Missouri Family Medicine in Columbia, Missouri, and is currently practicing family medicine at Prime Care-Graves Gilbert Clinic in his hometown of Bowling Green, Kentucky.

Laura Morris, MD, MSPH, FAAFP Laura Morris, MD, MSPH, FAAFP, is associate professor of Family & Community Medicine at the University of Missouri in Columbia, Missouri. She is the medical director of Maternity Care for the department. 24

Background: Spontaneous forniceal rupture is an uncommon complication of pregnancy. Though rare, it can be life threatening. The clinical presentation can often delay diagnosis as more common pathologies are typically first considered and ruled out. Case Presentation: 28 year old G3P2 female presented to the Emergency Department with several days of right flank pain and new onset abdominal pain. Initial workup and ultrasound imaging demonstrated hydronephrosis and raised concern for appendicitis or ovarian torsion. More advanced imaging showed forniceal rupture of the right kidney. Urology was consulted and the patient was monitored and managed conservatively without surgical intervention. Symptoms improved and she went on to deliver a viable male infant at 41 weeks gestation. Following delivery, hydronephrosis resolved and the renal parenchyma healed appropriately without placement of ureteral stent. Conclusion: Hydronephrosis during pregnancy is common, present in 90% of patients by the third trimester. Dilation of the right ureter is more likely given anatomic compression by the gravid uterus and iliac vessels. A possible, although rare, sequelae of hydronephrosis is spontaneous rupture of the renal parenchyma or collecting system. Diagnosis of rupture is often delayed given the clinical appearance of more common diseases such as appendicitis. Based on the site of the rupture and the patientâ&#x20AC;&#x2122;s clinical stability, management can range from conservative follow up to complete nephrectomy.

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

CASE

A 28 year old Gravida 3, Para 2 at 26 weeks gestation presented to the obstetrics emergency triage with new right flank pain intermittently present for the past three days. Exacerbating factors included standing and bearing weight or prolonged sitting. Alleviating factors included acetaminophen and rest. Pain was localized in right flank at the mid-axillary line with some radiation into her pelvis and leg. Exam was remarkable for costovertebral angle tenderness on the right side as well as walking with a slight right-sided limp. Reassuring findings included vital signs within normal limits and normal lower extremity strength and sensation. Fetal monitoring showed moderate variability and accelerations present with no decelerations. Urinalysis was negative. The patient received acetaminophen 1,000 mg along with a heating pad to the affected area with subsequent improvement of her pain. She was discharged with a diagnosis of suspected piriformis syndrome and referred to see an outpatient Physical Medicine & Rehabilitation consultant. The patient returned to the triage unit on the following evening with similar symptoms, but additionally complaining of abdominal pain. Acetaminophen was no longer helpful. On exam, there was similar costovertebral angle tenderness accompanied by abdominal tenderness in the right upper quadrant. Fetal monitoring remained reassuring. Repeat urinalysis was positive for ketones. The patient received an intravenous fluid bolus and muscle relaxers for pain. She was admitted for further workup of her right flank and abdominal pain. Vital signs on admission were stable. Laboratory analyses were significant for a leukocytosis of 12.28x10(9)/L and hemoglobin of 11.4g/dL. However, this was deemed normal physiologic changes of pregnancy. A glucose level of 53 mg/dL

was likely secondary to anorexia due to pain, which appropriately responded to intravenous glucose supplementation.

The image on the left shows the patientâ&#x20AC;&#x2122;s significant degree of hydronephrosis experienced in the right kidney. The image on the right shows the perinephric fluid collection surrounding the right kidney, raising concern for a forniceal rupture.

Renal ultrasound showed a normal left kidney with right hydronephrosis and a small amount of ascites. Subsequent abdominal ultrasound could not visualize the appendix but did show a discrepancy of ovarian size. MRI was recommended for further evaluation to rule out appendicitis or ovarian torsion. MRI was suggestive of forniceal rupture of right kidney secondary to hydronephrosis. Both ovaries, as well as the appendix, were visualized and normal in appearance. Urology was consulted. Our patient was monitored with serial exams without surgical intervention. She was discharged on hospital day six with outpatient urology follow up. At 41 weeks, she delivered a viable male infant with subsequent resolution of hydronephrosis and healing of forniceal rupture at a postpartum urology visit with a follow up renal ultrasound.

DISCUSSION

Spontaneous rupture of the renal parenchyma or collecting system typically occurs in a kidney with prior pathology.1 Predisposing factors include renal cysts, renal tumors, history of chronic infection, abscess, or obstruction.1 A retrospective review of 108 cases of forniceal rupture diagnosed by CT revealed that ureteric stones caused 74% of cases, followed by extrinsic ureteral compression from malignancy at 8%.2 Forniceal rupture occurs due to a buildup of pressure in the renal collecting system leading to hydronephrosis, and eventually exceeds the tensile strength of the system, causing rupture. Rupture can occur in the collection system or in the renal parenchyma.

Spontaneous rupture of a healthy kidney without any identifiable predisposing event is rare. Only 35 cases of spontaneous rupture during pregnancy had been reported, published in a 2013 case report.3 Spontaneous cases exclude recent ureteric instrumentation, surgery, external trauma, kidney lesions, stone, or external compression.4 Our patient had no hematuria or signs of nephrolithiasis on ultrasound. Ultrasound found only hydronephrosis with otherwise unremarkable kidneys, therefore meeting criteria for spontaneous rupture. Physiologic and anatomic factors of pregnancy can predispose patient to this rare complication of hydronephrosis. Hydronephrosis is actually quite commonly observed during pregnancy and typically does not result in symptomatic consequences. It begins early in pregnancy, around six to ten weeks gestation, and is seen in 90% of pregnant patients by the third trimester.5 The right kidney and collecting system is often more affected than the left due to compression of ureter and common iliac vessels at the pelvic brim by the gravid uterus.5 Hormonal changes such as an increase in prostaglandins and progesterone reduce smooth muscle tone in the collecting system leading to decreased ureteral peristalsis. Interestingly, the condition is rarely seen in non upright mammals even when these subjects were given high doses of hormones,5 making the condition likely anatomical in nature. The clinical presentation of this condition mimics several more common disorders, often making diagnosis difficult and delayed. Patients typically present with abdominal and or flank pain. The typical differential diagnosis list includes appendicitis, cholecystitis, or nephrolithiasis.6 Patients may receive unwarranted intravenous antibiotics or surgical appendectomy of a healthy appendix.6 Forniceal rupture is typically found along with a perinephric fluid collection during imaging. MRI can differentiate a urinoma from a more clinically serious hematoma through interpretation of signal intensity on T1 and T2 weighted images.7 Management of forniceal rupture has evolved. Prior to 1980, the few reported cases of spontaneous forniceal rupture during pregnancy were all managed with nephrectomy.8 A 1980 case report established that renal salvage was possible, and utilized a nephrostomy tube until delivery; however, authors recommended surgical exploration during pregnancy once the diagnosis of forniceal rupture was made.8 MO-AFP.ORG 25

A recent observational prospective study showed that these patients could likely be managed conservatively if their case was uncomplicated.9 Intervention was limited to complicated cases or cases with a large urinoma (>100mL3). Urinomas of this size were often managed with placement of a double J ureteral stent to prevent further accumulation.9 Stents are typically changed every four to six weeks during pregnancy and patients receive prophylactic antibiotics until delivery, when stents can then be removed.4 An important treatment consideration is the site of rupture. Rupture of the renal collecting system and rupture of the renal parenchyma can lead to stark differences in clinical sequelae. A rupture of the renal parenchyma itself is much more severe than a rupture in the collecting system. As noted in a 1956 case report, parenchymal rupture can quickly lead to massive hemorrhage and even exsanguination.10 Parenchymal rupture necessitates exploratory surgery and potentially partial or complete nephrectomy to control the bleeding if needed.1,4 Rupture of the renal collecting system is often much less complicated and can be managed conservatively, such as in our patient’s case, or with a double J ureteral stent. It is important to consider the patient’s clinical picture and site of rupture as the main factors to guide treatment.

CONCLUSION

Hydronephrosis during pregnancy is common, present in 90% of patients by the third trimester. Dilation is more likely found in the right ureter given anatomic compression by the gravid uterus and iliac vessels. A possible although very rare sequelae of hydronephrosis is spontaneous rupture of the renal parenchyma or collecting system. Diagnosis of rupture is often delayed given the clinical appearance of more common diseases such as appendicitis. Based on the site of the rupture and the patient’s clinical stability, management can range from conservative follow up to complete nephrectomy.

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

References 1. Van Winter J, Ogburn P, Engen D, Webb M. Spontaneous Renal Rupture During Pregnancy. Mayo Clin Proc 66:179-182, 1991 2. Gershman, B., Kulkarni, N., Sahani, D. V. and Eisner, B. H. Causes of renal forniceal rupture. BJU International, 108: 1909-1911, 2011 3. Hanson B, Tabbarah, R. “Preterm Delivery in the Setting of Left Calyceal Rupture.” Case Reports in Obstetrics and Gynecology 2015 (2015): 906073. PMC. Web. 10 May 2018. 4. Roshni Upputalla, Robert M. Moore, and Belinda Jim, “Spontaneous Forniceal Rupture in Pregnancy,” Case Reports in Nephrology, vol. 2015, Article ID 379061, 3 pages, 2015. 5. Osterling J, Besinger R, Brendler C. Spontaneous Rupture of the Renal Collecting System During Pregnancy: Successful Management With a Temporary Ureteral Catheter. The Journal of Urology 140:588-590, 1988 6. Nabi G, Sundeep D, Dogra, Ambika. Spontaneous rupture of hydronephrotic solitary functioning kidney during pregnancy. International Urology and Nephrology 33:453-456, 2001 7. Hwang S, Park Y, Lee C, Jung Y. Spontaneous Rupture of Hydronephrotic Kidney During Pregnancy: Value of Serial Sonography. Journal of Clinical Ultrasound 28:358-360, 2000 8. Middleton A, Middleton G, Dean L. Spontaneous Renal Rupture In Pregnancy. Urology 15:60-63, 1980 9. Al-mujaljhem AG, Aziz MS, Sultan MF, Al-maghraby AM, Al-shazly MA. Spontaneous forniceal rupture: Can it be treated conservatively?. Urol Ann 9:41-44, 2017. 10. Chamblin WD, Marine WC. Massive retroperitoneal hemorrhage complicating pregnancy. Am. J. Obstet. Gynecol. 72:680-682. 1956

L O W E R U R I N A R Y T R AC T S Y M P T O M S : HOW TO APPROACH AN ENL ARGED PROSTATE

ower urinary tract symptoms (LUTS) are a common complaint among aging males, and thus a common problem encountered by the primary physician. Although there may be other etiologies, these symptoms are often attributed to prostatic enlargement. Due to this common association, multiple terms have been used to describe this syndrome and are sometimes used interchangeably, although there may be subtle differences LUTS refers to the symptoms themselves and includes symptoms related to storage of urine, voiding or post-void symptoms. Common storage symptoms can include urinary frequency, urgency, nocturia or incontinence. Voiding symptoms consists of slow/weak stream, difficulty starting stream (hesitancy), intermittent stream, the need to strain to void or dysuria. Post-void symptoms occur after urination and include post-void dribbling or a sensation of incomplete bladder emptying. Other related terms include benign prostatic enlargement (BPE), benign prostatic hyperplasia (BPH), benign prostatic obstruction (BPO), and bladder outlet obstruction (BOO). BPE is made based on the finding of an enlarged prostate with or without obstruction and related symptoms, while BPH is a histologic diagnosis based on evidence of stromal and/or epithelial hyperplasia of the prostate. BOO, on the other hand, is a urologic diagnosis made upon proving obstruction of the bladder outlet; BPO is a subset of BOO specifically referring to obstruction due to compression of the prostatic urethra. The prostate is an exocrine gland of the male reproductive system. The prostate functions to secrete a slightly alkaline fluid to protect sperm cells from the acidic environment of the vagina. Prostatic fluid accounts for roughly 30% of the volume of semen. With aging, the gland tends to enlarge. The cause of BPH is not well understood. Several hypotheses exist, but it is likely due to a multifactorial process. It is thought that

testosterone and dihydrotestosterone (DHT) play at least a permissive rule, as castrated boys do not go on to develop BPH. It is also suspected that failure of spermatic venous drainage may play a role by causing backflow into the prostatic venous drainage and resultant exposure of the prostate to high concentrations of androgens. Regardless, the connection between aging and BPH is well established with enlargement starting as early as 30 years old. Clinical studies conducted over the past 60 years have found that histologic evidence of BPH is present in 50% of 60 year old men, and 80% of 80 year old men. Of those with histologic BPH, approximately 50% will go on to become symptomatic. Knowing how to evaluate and treat this common disease is an essential part of the armamentarium for the primary physician. This is crucial not only for managing patientâ&#x20AC;&#x2122;s symptoms and quality of life, but preventing the deleterious consequences of prolonged, untreated obstruction. Useful information to obtain during history includes the patientâ&#x20AC;&#x2122;s prior genitourinary history. A history of urethral trauma, urethritis or instrumentation could predispose to urethral stricture. Underlying neurologic disease may suggest a neurogenic bladder and certain medications may decrease bladder contractility (e.g. anticholinergic agents) or increase outflow resistance (e.g. sympathomimetics). Any of these may mimic or aggravate BPH related LUTS. The quality and severity of symptoms should also be assessed. Patients should be asked about their specific symptoms to identify a predominance of storage, voiding or post-void symptoms. The degree of bother should also be asked. The AUA symptom index is a validated questionnaire that may be useful for objectively quantifying this information. For patients who complain predominantly of nocturia, a frequency/ volume diary may be useful. Physical examination should include a digital rectal exam (DRE) to evaluate for prostate size, symmetry, nodularity or tenderness. Rectal

Katie Murray, DO Katie Murray, DO, is assistant professor at the University of Missouri Department of Surgery-Urology Division. She is the medical director of Urological Oncology at Ellis Fishcel Cancer Center in Columbia, Missouri.

MO-AFP.ORG 27

sphincter tone can also be tested at this time, which may indicate a neurologic etiology of symptoms if abnormal. A normal prostate is about the size of a walnut and should be smooth, firm and non-tender. Significant asymmetry or the presence of a nodule may suggest malignancy, while marked tenderness can point to prostatitis. Urinalysis should also be obtained to evaluate for infection or hematuria. Prostate specific antigen (PSA) should be checked for patients with a greater than 10-year life expectancy and if a diagnosis of cancer may affect management. Once the patient has been thoroughly evaluated, the next step is determining management options. In the patient with little or no bother, reassurance and follow up is appropriate. In symptomatic patients, approximately 50% will worsen, while 30% will remain stable and 20% will actually improve without intervention. For those who do report significant bother, modifiable factors such as drugs and fluid intake should be adjusted, and medical therapy is appropriate. In choosing the approach to medical management, we must take into consideration the patientâ&#x20AC;&#x2122;s symptom profile, as well as physical and laboratory findings. Overactive bladder (OAB) symptoms include urinary frequency, urgency, urge incontinence and nocturia, while BOO symptoms include weak stream, hesitancy, intermittent stream, straining to void and sensation of incomplete emptying. A regimen of antimuscarinics and alpha blockers should be considered for those with mixed OAB and BOO symptoms. Antimuscarinic agents work on the bladder by inhibiting detrusor contraction. While this may be useful for treating OAB, it should be noted that this carries an increased risk of urinary retention. Alpha-blockers work by acting on the alpha-1A adreno receptors in the prostatic stroma, as well as the alpha-1D receptors at the bladder neck to reduce smooth muscle tone and relieve obstruction. For patients with a large prostate on exam and/ or an elevated PSA, treatment with an alpha blocker, 5-alpha reductase inhibitor (5-ARI), or a combination may be appropriate. For those with predominantly BOO symptoms, small prostate and lower PSA, an alpha blocker should be used. 5-alpha reductase inhibitors work by blocking the enzyme 5-alpha reductase, which converts testosterone to (DHT). Reduction of DHT in the prostate leads to apoptosis, atrophy, and ultimately shrinkage. This results in an approximately 50% decrease in PSA at six months of treatment. However, due to their mode of action, 5-ARI can take longer to have significant symptom improvement compared to alpha blockers. 28

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

Studies have shown that both alpha blockers and 5-ARI alone are superior to placebo in decreasing symptoms and preventing progression of symptoms. Furthermore, the combination is more effective than either agent alone, but at the cost of increased side effects. Alpha blockers can cause orthostatic hypotension, dizziness, fatigue, nasal congestion, retrograde ejaculation and floppy iris syndrome. 5-ARIs can result in fatigue and gynecomastia, as well as sexual dysfunction manifested by erectile dysfunction, decreased libido and decreased ejaculate. If patients' symptoms are not well controlled despite medical therapy, or they are unwilling or unable to tolerate medications, they should be referred to a urologist for further evaluation and discussion of surgical management. Prolonged, untreated urinary obstruction can have other consequences as previously mentioned; these should also prompt urologic referral. Due to obstruction, patients may develop hydronephrosis and renal insufficiency, urinary stasis causing bladder stones or recurrent urinary tract infection, and detrusor weakness or failure. All of these except detrusor weakness are indications for surgical intervention for BPH, as well as refractory urinary retention or recurrent gross hematuria. Other findings during evaluation that warrant a urology referral include an elevated PSA, abnormal DRE concerning for malignancy, or hematuria. Microscopic hematuria is defined as >3 red blood cells per high power field on urinalysis and gross hematuria is the presence of blood in the urine visible to the naked eye. Both should prompt a urologic evaluation in the absence of an obvious benign cause. Microscopic hematuria cannot be diagnosed on dipstick alone, thus an abnormal dipstick should prompt a formal microscopic urinalysis. Known or suspected BPH should not prevent further workup of hematuria as this may be the result of more serious disease, including bladder cancer. Overall, BPH and its associated LUTS affect a large portion of the aging male population. This is a problem that will be frequently encountered by nearly all primary care physicians. Due to this, familiarity in the evaluation and management of BPH is essential. The history and physical are paramount, but can be aided by the use of urinalysis or PSA testing. Objective questionnaires may be useful in monitoring symptom progression and assessing bother. Lifestyle modification is helpful in many cases, but medical therapy is well established and should be guided by the clinical presentation. Treatment can have significant effects on quality of life, as well as preventing detrimental outcomes of obstruction.

Saint Louis University School of Medicine establishing Addiction Medicine Fellowship beginning July 1, 2019 Addiction Medicine (ADM) involves the prevention, screening, diagnosis, treatment, and recovery of/from substance use disorders. Care is provided to patients across the lifespan by physicians and interprofessional teams in diverse areas including clinical medicine, public health, education, and research. Completion of the fellowship grants a physician the ability to sit for the American Board of Medical Specialties (ABMS) board exam in Addiction Medicine. Saint Louis University's fellowship is unique and designed to provide knowledge and skills, among multiple specialties, in both ambulatory care and inpatient settings and the associated transitions of care.

In addition to continuity practice in the fellow's own specialty, core rotations include: Family Medicine Inpatient Service at SSM Health St. Mary's Hospital Psychiatry Inpatient Service at SSM Health Saint Louis University Hospital Inpatient and Outpatient Services with the WISH Center (Women and Infant Substance Health) at SSM St. Mary's Hospital Consultation on Substance Use Disorders and Pain Management at the SLU Family Medicine Residency at Family Care Health Center Ambulatory Care and Telehealth Care at Assisted Recovery Centers of America (ARCA) The SLU Addiction Medicine Fellowship is now accepting applications. Board-certified/board-eligible physicians of all specialties are eligible to apply to this one-year ACGME-approved fellowship. Interested Applicants should contact Fred Rottnek, MD, at: fred.rottnek@health.slu.edu Additional information can be found at: https://www.slu.edu/medicine/family-medicine/addiction-medicine.php

MO-AFP.ORG 29

I N F L A M M AT I O N I N FA M I LY M E D I C I N E : THE KEY TO CHRONIC DISEASE MANAGEMENT IN MEN AND WOMEN

Jenny Powell, MD, FAAFP Jenny Powell MD, FAAFP, is the sole physician-owner of Direct Primary Care Clinics, LLC in Osage Beach and Lebanon, Missouri, and president of the Missouri Chapter of the AAPS.

isease prevention and wellness is the responsibility of family physicians, and our patients not only look to us for guidance, but will be more likely to enact change in their lifestyle when we can properly address cause and effect. Many are concerned about cancer, heart disease, or Alzheimer’s disease, especially when a family member or friend experiences such a devastating disease, but aren’t sure what they need to do to prevent it. The inflammatory process is essential to survival, and a normally functioning immune response is critical. Many anti-inflammatory treatments can lead to a weakened immune response, so it is best to prevent the development of disease processes that necessitate the utilization of these immune responsedampening therapies. Chronic low-dose exposures to inflammatory agents have been indicated in a wide variety of chronic disease states. Our environment and culture are overrun with such inflammatory exposures. It is vital that today’s family physicians are aware of the causes of the inflammatory response and how to address it. To what kind of everyday exposures are our patients subject, and what steps might they take to prevent the possible end results? Let’s look at the underlying problem. What kind of chronic disease processes have been linked to multiple low-dose exposure to inflammatory agents? The more common chronic diseases linked to inflammation include cancer, obesity, atherosclerosis, diabetes mellitus/metabolic syndrome, and GERD, but Alzheimer’s Disease, Parkinson’s Disease (and Parkinsonism), autoimmune diseases, including inflammatory bowel diseases and pulmonary fibrosis, have also been attributed. We all remember the “classic” signs and symptoms of inflammation: “calor, dolor, rubor and tumor” or heat, pain, redness and

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swelling. But hypertension is also an inflammatory disease process, so elevated blood pressure is another indication of inflammation. End-organ damage caused by prolonged hypertension may be added to the list. External inflammatory processes are far easier to identify than internal processes. But family physicians must have a high suspicion for chronic inflammation, especially when pain and tenderness are involved. While C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) can be indicators of inflammation, as so may an elevated white count (WBC), low-levels of inflammation may be present with all normal values, so laboratories are not necessarily helpful in identifying exposure. Not surprisingly, a thorough history will provide you with the highest suspicion for inflammatory exposure. A health questionnaire is a good time-saver, as a social history alone is not sufficient. In addition to asking about smoking and other environmental exposures (heavy metals, diesel emissions, cleaning products, aerosolized chemicals including paint) one needs to ask about foods, drinks and other ingested substances. Ask about bowel movements and urination and ask if they feel hot when others feel fine. Ask about water intake and sleep quality (difficulty falling asleep, staying asleep, ease in getting back to sleep when awakened, and ask what awakens them). What are some of the causative agents? The long list includes tobacco – smoked or chewed; processed meat, grain-finished meats and their fats: processed foods (bagged, cannned or dried – I usually tell patients if it has more than two or three ingredients and/or a bunch of chemical names or comes in a box, bag or can – it’s probably processed); enriched flours and products made with same; alcohol; caffeine; sugars/sweeteners; vegetable or certain other oils; corn starch, meal, or products; a diet low in fiber and/or low in vegetables and fruits;

bacterial/viral/parasitic infections, and yet, also antibiotics/ antivirals/antifungals/anti-parasitics; NSAIDs and steroids (conversely) and long-term use of oral contraceptives or other hormones. The gut is the epicenter of the immune system, so an abnormal inflammatory response within the gut flora can lead to more than inflammatory bowel disease. NSAIDs can enact change within the intestinal mucosa. GERD agents can alter the pH of the gut and therefore are theorized to encourage change in flora, a cascade effect which may affect the inflammatory response (turning it on or turning it off). Environmental factors include silica dust, solvents, hydrazines (used in making plastics/rubber/textiles/ herbicides/dyes), mercury and other heavy metals. And then, there’s ANY oxidative stress to consider. Besides living in a bubble, what CAN your patient do? Avoiding known causative agents as much as possible is key but it helps to give some positive advice, too. A plantbased, “good” fat diet is an anti-inflammatory lifestyle that should be encouraged. This relies heavily on fruits and vegetables, especially those grown without herbicide or pesticide applications if the flesh is eaten. Whole non-GMO grains such as oats, quinoa, and barley are preferred over enriched flours, especially wheat and corn meal; one should also avoid ALL corn-derived products (corn syrup/starch, dextrose). Stick with nut flours such as almond, hazelnut, chestnut, cashew, macadamia flours; also, coconut, rice flour, tapioca flour, spelt, and amaranth flours are less inflammatory in nature. Avoid refined sugar, maltose and sucralose, and artificial sweeteners such as aspartame and saccharine. Better sweetener options are pure maple syrup, stevia, honey and coconut sugar; the absolute best sweetener for an antiinflammatory diet, however, is fruit. Good fats include avocado (and avocado oil), extra virgin olive oil (and be careful – there are knock-offs out there that are not true olive oil), and coconut oil. Nut and seed butters are good, such as almond and cashew, as well as sunflower butter. As with all processed foods, however, one must be careful to read labels as there may be more in your product than “cashews,” for instance. Protein choices for an anti-inflammatory diet include eggs, lentils, beans, tofu, salmon (other fish are good too, but not as good as the salmon!), seafood, wild venison, chickpeas, and tempeh. If one eats eggs, chicken, or turkey remember that “you are what you eat eats too,” as Michael Pollan, the author of “In Defense of Food” and “Omnivore’s Dilemma,” puts it. You want to try to avoid grain-fed meats

as much as possible, and this includes the eggs of grain-fed chickens. According to an article published in 2014 in the Journal of Clinical & Cellular Immunology (“Chronic Diseases Caused by Chronic Inflammation Require Chronic Treatment: Antiinflammatory Role of Dietary Spices” by Sahdeo Prasad and Bharat B. Aggarwal) there are several better spices to use in cooking that can have an anti-inflammatory effect. These too may be surprising, as their list includes anise, parsley, chili, turmeric, clove, fenugreek, cinnamon, cardamom, kokum, soy, ginger, black pepper, Asian ginger, hops and black cumin. What are some other good treatments to consider, and some reading resources for my patients and me? High-quality anti-oxidants have been shown to slow down progression of Alzheimer’s Disease, so they should also be helpful in preventing other inflammatory diseases. Medicinal mushrooms, in particular Lingzhi/Red Reishi, are adaptogens, and have amazing results in a variety of disease processes, including cancers. Traditional Chinese medicine recognizes inflammation, especially manifested by sharp pain, as a blockage of Qi, or energy flow, and acupuncture - also an adaptogenic treatment – is helpful getting the Qi to flow properly. Moderate exercise, such as Tai Chi or Qi Gong are anti-inflammatory in nature. Good quality sleep is important in prevention of ALL chronic disease states, and an anti-inflammatory diet is helpful in multiple ways to contribute to good sleep quality. Meditation and prayer are also helpful adjuncts to incorporate. And don’t forget drinking plenty of good fresh water (preferably not bottled in plastic). A book that I often loan out to patients is “The Complete Anti-Inflammatory Diet for Beginners,” by Dorothy Calimeris and Lulu Cook, RDN. I already mentioned Micheal Pollan’s book “In Defense of Food,” which is an excellent read, but there is an abbreviated version titled “Food Rules” that gives such helpful hints as “don’t eat anything

your great-grandmother would not have recognized as food,” “avoid food products containing

ingredients that a third grader can’t pronounce,” and, one of my favorites, “shop the peripheries of the supermarket and stay out of the middle.” This small book, while not specifically geared toward an anti-inflammatory diet, makes a good patient handout for general common-sense eating. Lastly, your example is one of the best treatments. If you can follow an anti-inflammatory lifestyle, you will better enable your patients to do the same.

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ADDRESSING THE INCREASED INCIDENCE O F C O M M O N S E X UA L LY T R A NThe S MAmerican I T T E DOsteopathic I N F E C T IAssociation O N S (AOA

protect itself and the published authors again STIs in the United States include genital herpes, HIV, and human papilloma virus. In publications. article candetailing be read 2017, the Centers for Disease Control and This Prevention released a report a surge in in the chlamydia, gonorrhea, and syphilis infections in the United States. The authors summarize current trends and discuss epidemiologic factors, disease burden, and patient care. It is important to be aware of the recent increases in these three STIs and to be prepared to screen for, diagnose, and manage these infections and their complications.

John Paulson, MD, PhD, FAAFP, KCUMB

Mianna Armstrong, MS, OMS IV, KCUMB

Megan McMurray, MS, OMS IV, KCUMB

t least 16 sexually transmitted infections (STIs) are commonly found in the United States: anogenital warts, bacterial vaginosis, chlamydia, gonorrhea, genital herpes (herpes simplex virus [HSV]), HIV, human papillomavirus (HPV), granuloma inguinale, lymphogranuloma venereum, Mycoplasma genitalium, pubic lice, scabies, syphilis, trichomonas vaginalis, viral hepatitis, and vulvovaginal candidiasis.1 In September 2017, the Centers for Disease Control and Prevention (CDC) released a report that identified a surge in STIs, specifically, chlamydia, gonorrhea, and syphilis (Chlamydia trachomatis, Neisseria gonorrhoeae, and Treponema pallidum, respectively).2 The surge in the incidence of chlamydia, gonorrhea, and syphilis in the United States has reached a cumulative all-time high.2 In 2016, more than two million new cases of these three STIs were reported in the United States, setting a record for the second year in a row.2 Of note, these three infections, along with HIV, are the only STIs with federally funded control programs and are therefore reportable conditions.2 The majority of new STIs diagnosed in 2016 were chlamydial, with 1.6 million newly diagnosed chlamydia infectionsâ&#x20AC;&#x201D;a 4.7% increase in incidence from 2015.2 Chlamydia infection rates are highest among young females aged 15 to 24 years but are also increasing among men. Also, 470,000

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

new cases of gonorrhea were diagnosed in 2016. Compared with 2015, gonorrhea cases rose 22.2% among men and 13.8% among women in 2016.2 The CDC reported 28,000 cases of primary and secondary syphilis in 2016, an increase of 18% from 2015. Most cases (88.9%) were seen in men, with a 14.7% increase from 2015. Men who have sex with men (MSM) accounted for 80.6% of male cases, and 47.0% of MSM cases were also HIV positive. Although men make up the majority of syphilis cases, rates in women have more than doubled since 2012. In that time, cases of congenital syphilis rose 86.9% (8.4 cases per 100,000 live births in 2012 compared with 15.7 cases per 100,000 live births in 2016). There were 628 cases of congenital syphilis reported in 2016, including 41 deaths among newborns.2 The increase in gonorrhea and syphilis infections represents a sharp shift from previous trends. In 2009, the rate of gonorrhea cases reached a historic low of 98.1 cases per 100,000 population. Seven years later, the rate increased by almost 150%.2 In 2000 and 2001, syphilis was reportedly close to elimination in the United States, with rates at their lowest since reporting began in 1941.2 The rates of other common STIs in the United States have either declined or remained stable, including chancroid, HPV, HSV, and trichomonas.2 However, their rates are often difficult to track, as most are not reportable conditions.2 Human papilloma virus is the most common STI in the United States; however, the introduction of HPV

A) copyrights all issues of its publications to nst unauthorized use of the contents of those vaccines has resulted in a significantly decreased prevalence in With the increase in the three aforementioned STIs, there the postvaccine era (2009-2012) compared with the prevaccine is a paradoxical decrease in funds available for STI screening. print version of Family Physician magazine. era (2003-2006), particularly in females aged 14 to 24 years. State and local STI programs continue to have budget cuts, 2

Rates of HSV are difficult to measure, as HSV is often subclinical and may never be formally diagnosed.2 The prevalence of HSV2 has decreased when comparing 1988-1994 and 2007-2010 rates.2 Orolabial HSV-1 cases are declining in adolescents aged 14 to 19; however, genital HSV-1 cases may be increasing, owing to a variety of factors.2 Trichomonas vaginalis rates also seem to have remained stable since the 1990s.2 New diagnoses of HIV have been steadily declining, with a rate of 12.3 individuals per 100,000 population in 2016 compared with 13.5 in 2011.3

Increased Rates of Clamydia, Gonorrhea, and Syphilis Possible explanations for the increased incidence in chlamydia, gonorrhea, and syphilis include improved technology, which may contribute to the number of cases reported. Before 2002, diagnostic testing for chlamydia and gonorrhea was performed via culture. Bacterial culture presented significant difficulty with maintaining viability of organisms during transport, as well as difficulty with test standardization, high costs, and relative insensitivity of the test. This lack of efficacy prompted the development of nonculture tests, including enzyme immunoassays, direct fluorescent antibody tests, and nucleic acid hybridization tests. However, each of these tests failed to detect a significant number of infections. The development of nucleic acid amplification tests resulted in a new criterion standard for chlamydia and gonorrhea testing, as it is 20% to 35% more sensitive than the preceding nonculture tests.4 Another contributing factor may be the low prevalence of condom use.5 Every five years, the CDC performs a national survey asking men and women aged 15 to 44 years whether they used a condom during their most recent sexual intercourse in the past 12 months. A 2017 report comparing data from the 2006-2010 survey with data from the 2011-2015 survey found that the percentage of women who used a condom decreased from 25.3% to 23.8% over time, and the percentage of men remained stable (33.1% vs 33.7%).5 Condom use rates of 23.8% and 33.7% are alarmingly low given their established role in preventing the spread of STIs.

with 52% of programs being cut and 21 clinics closing in 2012.2 Fortunately, funding for STI prevention has increased. The fiscal year 2019 budget acknowledges the recent increase in chlamydia, gonorrhea, and syphilis and includes $152 million to fund the surveillance, prevention, and control of STIs. This is a $1 million increase from the amount allocated in the fiscal year 2018 budget.6 Another potential explanation for the increased rates is poor sexual history taking and STI screening by health care professionals. The failure to detect STIs early could result in further propagation and spread of infections, as well as more long-term complications of these infections. A 2005 survey7 of US medical schools and fourth-year medical students revealed that only 55.4% of schools surveyed had a sexual health curriculum. When asked about their comfort level in taking a sexual history, the students were most likely to be comfortable with patients aged 15 to 24 years (91%) and 25 to 50 years (93%) than with patients aged 10 to 14 years (57%), 51 to 75 years (67%) or older than 75 years (50%).7 The students were also given case scenarios and asked whether they would screen each patient for chlamydia. Most students correctly chose to screen a 31-year-old pregnant woman (94%) and a sexually active 20-year-old woman (74%).7 Forty-seven percent said that they would screen a 20-year-old man who had oral sex with another man.7 This information indicates room for growth in sexual health education in medical school, including sexual history taking and STI screening. Epidemiology Although chlamydia, gonorrhea, and syphilis can all be managed with antibiotics, dire consequences can result when these STIs are left undiagnosed and untreated. Infertility, ectopic pregnancy, stillbirth in infants, potentially fatal neurologic and cardiovascular complications, and increased risk for HIV transmission are potential medical complications that can result from untreated infections. Additionally, the stigmatization of subgroups of people in the United States who are disproportionately infected is of concern, including the MSM MO-AFP.ORG 33

population, African Americans, and American Indians/Alaska Natives.2 Antimicrobial resistance of N gonorrhoeae is a growing concern in the medical community. Between 2013 and 2016, the rate of azithromycin resistance increased from 0.6% to 3.6%.2 Within 10 years, cephalosporin-resistant N gonorrhoeae could cause an estimated 75,000 additional cases of pelvic inflammatory disease, 15,000 cases of epididymitis, and 222 cases of HIV, which would cost $235 million in direct medical costs.8 Financially, the rise in STIs is of great concern. In 2016, the total lifetime direct medical cost of treating eight of the most common STIs contracted in a single year was $15.6 billion. This figure included $516.7 million for chlamydia, $162.1 million for gonorrhea, and $39.3 million for syphilis.9 Due to inflation and the increase in cases in the past 10 years, these numbers will likely continue to rise.

who have sex with men should be screened for chlamydia, gonorrhea, and syphilis at least annually (every 3 to 6 months if at increased risk), regardless of condom use. (See CDC Diagnosis and Treatment Guidelines for STI's table on page 35) HIV-Positive Patients Sexually active males and females who are HIV positive should be screened for chlamydia, gonorrhea, and syphilis at their first HIV evaluation and at least annually thereafter.

The American Osteopathic Association (AO and Treatment protect itself and Diagnosis the published authors agai The Table outlines the CDC’s diagnosis and treatment guidelines. Partners should be publications. This article can be in the encouraged to seek evaluation and toread discuss

Screening Guidelines In 2015, the CDC published their STD screening and treatment guidelines.1 In general, these guidelines have the following screening recommendations. Female Patients All nonpregnant sexually active female patients younger than 25 years should be screened for chlamydia and gonorrhea. Women older than 25 years and at increased risk for infection may also be screened. Patients with a diagnosis of chlamydia or gonorrhea should be rescreened three months after treatment is completed. There are currently no guidelines for screening nonpregnant females for syphilis. All pregnant patients younger than 25 years (or >25 years and at increased risk) should be screened for chlamydia and gonorrhea at the first prenatal visit, with repeated chlamydia screening in the third trimester. Pregnant patients with a chlamydia diagnosis should be rescreened three to four weeks after treatment and again three months later. Pregnant patients with a gonorrhea diagnosis should be rescreened three months after treatment. All pregnant patients should be screened for syphilis at the first prenatal visit, with repeated screening early in the third trimester and at delivery if at high risk. Male Patients Male patients should be screened for chlamydia if they are located in high prevalence clinical settings or are part of a population with a high burden of infection, regardless of age. Men 34

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

screening for other STIs with a health care professional. The American College of Obstetricians and Gynecologists advocates for expedited partner therapy as a method of preventing gonorrhea and chlamydia reinfection when a patient’s partners are unable or unwilling to seek medical care. Expedited partner therapy should only occur after a health care professional has assessed the risk of intimate partner violence associated with partner notification.10 Expedited partner therapy is currently prohibited in two states (Kentucky and South Carolina) and limited in seven states (Alabama, Delaware, Kansas, Oklahoma, New Jersey, South Dakota, and Virginia) and Puerto Rico.11

Patient Care and Education Physicians and medical students have a duty to educate themselves and their patients about STIs. Familiarization with the prevention, screening, diagnosis, and treatment guidelines for STIs is essential. But it is also important to recognize the variety of STI presentations and the multitude of both acute and chronic complications that occur with unrecognized or untreated cases. The National Coalition for Sexual Health recommends that a sexual history be taken for all teenagers and adults at least annually.12 Topics to consider addressing include the five Ps: partners, practices, past STI, protection, and pregnancy prevention. When taking a sexual history, physicians should use neutral terms (eg, partner) and avoid making assumptions about a patient’s sexual behaviors, sexual orientation, or gender identity.12 Sources of additional STI training and education include the National Network of STD Clinical Prevention Training Centers13 and the CDC.14 Cardea

Services has a sexual history–taking toolkit, which includes a comfort scale self-assessment, sample history forms, and a pocket guide.15 Advocating for funding for affordable STI screening and treatment programs at the state or national level is important, particularly for patients in underserved areas. Additionally, advocating for expansion of expedited partner therapy would be of benefit to potential infected partners and would help reduce the spread of STIs. Conclusion The rates of chlamydia, gonorrhea, and syphilis infections are alarmingly high. These STIs can cause grave medical consequences for affected persons, especially when the STIs are undiagnosed and untreated. It is imperative that health care professionals perform thorough sexual histories, be familiar with STI presentations, enact routine screening for STIs in sexually active patients, and provide patient education. By remaining proficient in the current diagnosis and treatment guidelines and committing to continuing education, they can play a role in reversing this alarming trend in the United States.

OA) copyrights all issues of its publications to inst unauthorized use of the contents of those e print version of Family Physician magazine.

References 1. Sexually Transmitted Diseases Treatment Guidelines, 2015 [published correction appears in MMWR Recomm Rep. 2015;64(33):924]. MMWR Recomm Rep. 2015;64(RR-03):1-137; 2. 2016 Sexually Transmitted Diseases Surveillance. Atlanta, GA: Centers for Disease Control and Prevention; 2017. https://www.cdc. gov/std/stats16/toc.htm. Accessed October 9, 2017; 3. HIV Surveillance Report, 2016. Vol 28. Atlanta, GA: Centers for Disease Control and Prevention. 2017. https://www.cdc.gov/hiv/ pdf /library/reports/surveillance/cdc-hiv-surveillance-report-2016-vol-28.pdf. Accessed December 2, 2017; 4. Papp JR, Schachter J, Gaydos CA, Van Der Pol B. Recommendations for the Laboratory-Based Detection of Chlamydia trachomatis and Neisseria gonorrhoeae — 2014. MMWR Recomm Rep. 2014;63 (RR02):1-19. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4047970/. Accessed December 2, 2017; 5. Copen CE. Condom use during sexual intercourse among women and men aged 15-44 in the United States: 2011-2015 National Survey of Family Growth. Natl Health Stat Report. 2017;(105):1-18; 6. Putting America’s Health First: FY 2019 President’s Budget for HHS. Washington, DC: US Dept of Health & Human Services; 2018. https://www. hhs.gov/sites/default/files/fy-2019-budget-in-brief.pdf. Accessed June 22, 2019; 7. Malhotra S, Khurshid A, Hendricks KA, Mann JR. Medical school sexual health curriculum and training in the United States. J Natl Med Assoc. 2008;100(9):10971106. doi:10.1016/s0027-9684 (15)31452-8; 8. Antibiotic Resistance Threats in the United States, 2013. Atlanta, GA: Centers for Disease Control and Prevention; 2013. https://www.cdc. gov/drugresistance/pdf/ar-threats-2013-508.pdf. Accessed October 9, 2017; 9. Owusu-Edusei K Jr, Chesson HW, Gift TL, et al. The estimated direct medical cost of selected sexually transmitted infections in the United States, 2008. Sex Transm Dis. 2013;40(3):197-201. doi:10.1097/ olq.0b013e318285c6d2; 10. Committee Opinion No. 632: expedited partner therapy in themanagement of gonorrhea and chlamydial infection. Obstet Gynecol. 2015;125(6):1526-1528. doi:10.1097/01.AOG.0000466366.67312.8c; 11. Sexually transmitted diseases (STDs): legal status of expeditedpartner therapy (EPT). Centers for Disease Control and Prevention website. https://www.cdc. gov/std/EPT/legal/default.htm. Accessed October 9, 2017; 12. Delivering recommended preventive sexual health services. NationalCoalition for Sexual Health website. https://nationalcoalitionforsexual health.org/tools/for-healthcare-providers/asset/ DeliveringRecommended-Preventive-SH-Services.pdf. Accessed October 9, 2017; 13. Sexual Health eLearning Module. National Network of STD ClinicalPrevention Training Centers. http://courses.nnptc.org/STICK.html.Accessed October 9, 2017; 14. Sexually transmitted diseases (STDs): training. Centers for Disease Control and Prevention website. https://www.cdc.gov/std/training / default.htm. Accessed October 9, 2017; 15. Sexual history-taking toolkit. CARDEA website. http://www. cardeaservices.org/ resourcecenter/sexual-history-taking-toolkit. Accessed October 9, 2017. © 2018 American Osteopathic Association MO-AFP.ORG 35

W H AT S H O U L D P H YS I C I A N S B E T E L L I N G PAT I E N T S ABOUT EXERCISE?

Brady Fleshman, MD Brady Fleshman, MD, is a chief resident physician for the University of Missouri Family and Community Medicine Department. He will be starting a Primary Care Sports Medicine Fellowship at University of Kentucky in July 2019.

Background familiar patient comes to see you for a wellness exam. Their body mass index (BMI) is 35 and steadily climbing over the past five years. When reviewing the patient’s social history, you inquire about an exercise routine, and the patient admits to not having one. In the limited time available for counseling, what evidence-based recommendations from you will have the greatest impact on their patient-oriented outcomes? Discussing exercise with patients is often an overlooked and underappreciated part of a clinic visit. The Centers for Disease Control and Prevention (CDC) report the prevalence of obesity in adults in the United States, defined as a BMI of 30 or greater, was 39.8% in 2016.1 Hispanic and non-Hispanic black patients had the highest ageadjusted prevalence.1 By increasing amounts of moderate-to-vigorous physical activity, not only was there a reduction in the risk of death, but also a reduced risk of heart disease, stroke, hypertension, type 2 diabetes, dementia, depression, postpartum depression, falls with injuries among the elderly, and eight types of cancer.2 While patients often come to the doctor expecting advice focused on weight loss goals rather than exercise goals, it may not necessarily be the best advice we can give. Fatness vs. Fitness Meta-analyses in 2005 and 2009 concluded that obesity independently increases mortality and decreasing cardiorespiratory fitness (CRF) independently increases mortality.3,4 However, determining which variable is “more important” is controversial. A 2014 meta-analysis, Fitness vs. Fatness on All-Cause Mortality: A Meta-Analysis, included 10 studies (N=92,986, 83.8% males) with a mean follow-up of 8 to 16 years.5 Patients fell into six basic groups: fit-normal weight (control group), unfit-normal weight, fit-overweight,

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

unfit-overweight, fit-obese, and unfit-obese.5 CRF is determined by VO2 max testing, which is the maximum amount of oxygen that an individual can utilize during intense aerobic exercise.5 This is considered the gold standard for determining CRF because muscles need oxygen for prolonged exercise. Normal weight is defined as a BMI less than 25, overweight is a BMI of 25 to 29.9, and obese is a BMI of 30 or greater.5 In the normal weight category, researchers found that unfit individuals had twice the risk of all-cause mortality compared to the fit individuals (See Table 1). In the overweight category, unfit individuals had more than doubled the risk of mortality compared to fit-normal weight patients, but those individuals who were fit-overweight did not have an elevated risk. All-cause mortality risk was more than doubled for unfit-obese patients compared to fit-normal weight patients, but not for the fit-obese group. Additionally, fit-overweight and fit-obese individuals had a similar mortality risk as their fit-normal weight counterparts. The risk of death appears to be more dependent more upon fitness (i.e. CRF level) than on BMI.5 Obesity and respiratory fitness (CRF) are known risk factors for cardiovascular disease (CVD) mortality. However, the magnitude of the relationship remains under debate. A 2018 metaanalysis included nine studies (N=137,406, 98.6% male) with a mean follow-up of 8 to 20 years and it included the same six groups as the previous meta-analysis. A majority of the studies included in the previously mentioned 2014 meta-analyses are also included in this meta-analysis focusing on cardiovascular disease mortality. In this study, unfit-normal weight and unfit-overweight patients had double the risk of CVD mortality (See Table 1). Unfit-obese patients had triple the risk of CVD mortality. Fit-overweight and fit-obese patients had a much lower risk of cardiovascular mortality. Elevated BMI was associated with CVD mortality, but being fit greatly reduced this risk in overweight and obese individuals. Again, low CRF is a stronger

Evidence is overwhelming about the benefits of exercise. Unfortunately, it is often forgotten or overlooked by busy doctors when patients come into the clinic for preventative visits or annual exams."

predictor of CVD mortality risk than BMI.6 One limitation of these meta-analyses is the lack of female patients. While these studies were conducted largely in a male population, the conclusions should be encouraging to all male and female patients who exercise regularly. These studies show that patients of all weights can experience significant health benefits by maintaining a moderate level of CRF by participating regularly in aerobic physical activity.5,6 American Heart Association Recommendations The American Heart Association (AHA) recently updated their recommendations after the Physical Activity Guidelines for Americans, 2nd edition was released in 2018. An advisory committee chosen by the United States Department of Health and Human Services used systematic reviews to address 38 research questions and 104 sub-questions to develop the current guidelines. The key recommendations identified in the nearly 800-page report include: • Adults should participate in 150 to 300 minutes a week of moderate-intensity or 75 to

150 minutes a week of vigorous-intensity aerobic activity. • Additional health benefits are gained by engaging in physical activity beyond 300 minutes of moderate-intensity physical activity a week. • Adults should include muscle-strengthening activities on two or more days a week. • Adults should move more and sit less throughout the day. Almost 80 percent of adults do not meet both the aerobic and muscle-strengthening recommendations and only about 50 percent meet the aerobic physical activity guidelines.7 This lack of activity is linked to $117 billion in annual health care costs and about 10 percent of premature mortality.7 There are numerous immediate and long-term benefits associated with physical activity. Immediate benefits include reduced anxiety, reduced blood pressure, improved quality of sleep (reduced sleep onset, increased REM sleep) and increased insulin sensitivity.2 As previously mentioned, long-term benefits include prevention of eight types of cancer (breast, colon, bladder, endometrium, esophagus, kidney, stomach,

Table 1: Fitness versus Fatness on All-Cause Mortality and Cardiovascular Disease Mortality

Unfit-Normal weight Unfit-Overweight Unfit-Obese Fit-Overweight

All-Cause Mortality Hazard Ratio5 Unfit Individuals* 2.42 (1.96-2.99), P=.002 2.14 (1.77-2.58), P=.024 2.46 (1.92-3.14), P=.001 Fit Individuals* 1.13 (1.000-1.27), P=.069

Fit-Obese 1.21 (0.95-1.52), P=.010 *Compared to Fit-Normal weight individuals

CVD Mortality Hazard Ratio6

2.18 (1.89-2.52), P=.000 2.39 (1.83-3.13), P=.000 3.10 (2.36-4.07), P=.000 1.25 (1.07-1.46), P=.005 1.42 (1.01-1.98), P=.041

and lung) and a reduced risk of dementia, falls, heart disease, stroke, hypertension, type 2 diabetes, and allcause mortality.2 Evidence shows that the majority of mortality risk reduction was achieved by those who performed 500 to 1,000 metabolic equivalent of task (MET)-minutes per week of physical activity.2 By definition, moderateintensity activity requires 3.0 to less than 6.0 METs.2 This approximately equates to 150 to 300 minutes of moderate-intensity exercise. Examples of moderateintensity exercise include brisk walking (at least 3.0 mph), bicycling slower than 10 mph, tennis (doubles), water aerobics or recreational swimming, gardening, and active yoga. Vigorous-intensity activities require 6.0 or more METs.2 This requires approximately twice the energy expenditure compared to moderate-intensity activities. Therefore, the time required to perform 500 to 1,000 MET-minutes of vigorous activity is about half that of moderate-intensity physical activities; hence, the recommendation of 75 to 150 minutes of vigorousintensity physical activity.2 Some examples include jogging or running (at least 4.5 mph), bicycling faster than 10 mph, tennis (singles), swimming laps, and highintensity interval training. A person doing moderateintensity aerobic activity can talk, but not sing, during the activity. With vigorous-intensity activity, a person cannot say more than a few words without pausing for a breath. The 2018 physical activity guidelines found that exercise of any duration contributes to the total amount that day.2 Muscle strengthening also has major benefits. It provides reductions in blood pressure equivalent to aerobic activities, and when combined with balance training, it reduces the risk of falls and injuries from falls in our geriatric patients. Muscle strengthening exercises focusing on all major muscle groups performed on two or three nonconsecutive days per week has the most evidence of support. It is recommended to do at least one set of 8 to 12 repetitions for all major muscle groups.2 The final recommendation, which is new for the 2018 guidelines, simply instructs patients to move more and sit less.2 A meta-analysis of 16 prospective cohort studies and more than one million participants compared daily sitting time and physical activity (measured in MET-hours per week).8 Daily sitting time, even those sitting greater than eight hours per day, did not increase all-cause mortality in the most active quartile of physical activity (greater than 35.5 METhours per week or 60-75 minutes per day of moderateintensity physical activity) (HR=1.04; 95% CI 0.99-1.10).8 Thus, high levels of physical activity eliminated the increased risk of death associated with high sitting time.8 The significantly highest risk of mortality occurred in patients sitting greater than eight hours per day and in 38

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

the least active quartile (less than 2.5 MET-hours per week or less than five minutes per day of moderateintensity activity) (HR 1.59; 95% CI, 1.52-1.66).8 This provides further evidence of the benefits of physical activity, particularly for those who have prolonged and unavoidable periods of sitting at work or school.8 Conclusion Evidence is overwhelming about the benefits of exercise. Unfortunately, it is often forgotten or overlooked by busy doctors when patients come into the clinic for preventative visits or annual exams. Allcause mortality and cardiovascular disease mortality are significantly reduced in individuals with high levels of fitness, regardless of their BMI.5,6 As physicians, maybe we should take more initiative to include this evidence in our daily conversations and focus on increasing aerobic physical activity rather than just losing weight. Next time a patient comes in for a wellness examination, consider using the AHA recommendations as a guide to increase their physical activity. References 1. Hales CM, Carroll MD, Fryar CD, Ogden CL. (2017). Prevalence of obesity among adults and youth: United States, 2015â&#x20AC;&#x201C;2016. NCHS data brief, no 288. Hyattsville, MD: National Center for Health Statistics. 2. 2018 Physical Activity Guidelines Advisory Committee. (2018). 2018 Physical Activity Guidelines Advisory Committee Scientific Report. Washington, DC: U.S. Department of Health and Human Services. https://health.gov/paguidelines/secondedition/report/pdf/PAG_Advisory_Committee_Report.pdf 3. Kodama S, Saito K, Tanaka S, et al. (2009). Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: A meta-analysis. JAMA,301(19), 2024-2035. doi:10.1001/ jama.2009.681 4. McGee DL. (2005). Body mass index and mortality: a meta-analysis based on person-level data from twenty-six observational studies. Ann Epidemiol,15(2), 87-97. 5. Barry VW, Baruth M, Beets MW, Durstine JL, Liu J, Blair SN. (2014). Fitness vs. fatness on all-cause mortality: A metaanalysis. Progress in Cardiovascular Diseases,56, 382-390. doi:10.1016/j.pcad.2013.09.002 6. Barry VW, Caputo JL, Kang M. (2018). The joint association of fitness and fatness on cardiovascular disease mortality: A meta-analysis. Progress in Cardiovascular Diseases,61, 136141. doi:10.1016/j.pcad.2018.07.004 7. U.S. Department of Health and Human Services. (2018). Physical Activity Guidelines for Americans, 2nd edition. Washington, DC: U.S. Department of Health and Human Services. https://health.gov/paguidelines/second-edition/pdf/ Physical_Activity_Guidelines_2nd_edition.pdf 8. Ekelund U, Steene-Johannessen J, Brown WJ, et al. (2016). Does physical activity attenuate, or even eliminate, the detrimental association of sitting time with mortality? A harmonised meta-analysis of data from more than 1 million men and women. The Lancet,388(10051), 1302-1310. doi:10.1016/s0140-6736(16)30370-1

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LIFE

THE MOST FUNDAMENTAL HUMAN RIGHT MEMBER OPINION PIECE

Kurt Bravata, MD Kurt Bravata, MD, is a family physician and addictionoligist practicing in Southwest Missouri. He is a member of the MAFP Board of Directors and is an active contributor to the MAFP Family Physician Magazine and the AAFP Fresh Perspectives Blog.

believe most people would agree that life is the most fundamental human right. Consequently, one would also have to concede that the preservation of life is the most basic duty of a physician. Because of this, we find ourselves in a precarious and complex dilemma when it comes to abortion rights. At face value, a naive outsider who is unfamiliar with the politically charged semantics of this debate might think it only logical that to be a physician, the widely accepted physician mandate to "first do no harm" would automatically require that one fall on the side of being Prolife. But, many would quickly respond by saying, "It isn't this simple. Not by far." Although it is a common misconception that the phrase 'Primum non nocere' is part of the now rarely required Hippocratic Oath, it does allude to the concept and also provides a clear admonition against abortion. So, here is the conundrum we face. The politics of the day constantly demand that we pick sides. Activists from both fronts demand our attention and allegiance. Meanwhile, we are engaged daily in a battle to maintain the health and longevity of our patients, ever keenly aware of the delicate balance

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

between life and death. As family physicians, we more than most, are there all along the way to provide comprehensive medical care from the day of conception and the first cry of life, until the moment our patients take their last breath. Many of us are as comfortable providing contraception, prenatal care, and delivery as we are palliative and hospice services. Life is our profession, family is our passion, and death is a familiar adversarial companion. Since Roe v. Wade, abortion has been treated as an unfortunate necessity and last resort. Almost 25 years ago, Bill and Hillary Clinton famously endorsed a Pro-choice policy that abortion is a “fundamental constitutional right” that should be “safe, legal, and rare.” Now, with the advent of new liberalized late term abortion bills in New York and Virginia, we are at a new inflection point. Are we about to make abortion risky, encouraged, and common? Although many family physicians have accepted the need to make early termination of unwanted or high risk pregnancy available, I believe that few would be comfortable moving to what is essentially an abortion on demand model that removes the limitations of best practice medical guidelines and legal restrictions. However, the New York

MEMBER OPINION PIECE DEFINITIONS: BECAUSE WORDS MATTER Life - Noun: The condition that distinguishes animals and plants from inorganic matter, including the capacity for growth, reproduction, functional activity, and continual change preceding death. The existence of an individual human being or animal. (https://en.oxforddictionaries.com/definition/life)

Physician - Noun: A person qualified to practice medicine, especially one who specializes in diagnosis and medical treatment as distinct from surgery. A person who cures moral or spiritual ills; a healer. (https://en.oxforddictionaries.com/definition/physician)

Human - Adjective: Relating to or characteristic of humankind. Of or characteristic of people as opposed to God or animals or machines, especially in being susceptible to weaknesses. Showing the better qualities of humankind, such as kindness. Of or belonging to the genus Homo (as in Homo sapiens). (https://en.oxforddictionaries.com/definition/human)

Family - Noun: A group consisting of two parents and their children living together as a unit. A group of people related by blood or marriage. The children of a person or couple being discussed. (https://en.oxforddictionaries.com/definition/family)

Reproductive Health Act (Senate Bill S240, which became law on 1/22/19) and Virginia House Bill 2491 expand the scope of abortion practices to the furthest extreme, essentially eliminating all existing precautionary measures that would in any way delay or interfere with a woman’s progression from the contemplation stage to the act of pregnancy termination. These bills drastically reduce the requirements of maternal education and informed consent. Additionally, their vague language regarding late term abortions opens the door to more liberal use of controversial techniques such as the dilation and evacuation (D&E) procedure. Furthermore, the New York law expands the definition of who can legally perform an abortion to nurse practitioners, physician assistants, and midwives. So, is this the new model for abortion in America? Are we willing to take this monumental and precarious leap as physicians and a nation as a whole? Gallup Poll July 2018 A Gallup poll released July 12, just before Trump introduced Kavanaugh as his nominee, found that 64 percent of Americans want Roe v. Wade to stand. In a separate poll from May, Gallup found that 79 percent of Americans think abortion should be legal under certain circumstances (50 percent) or under all circumstances (29 percent). In a follow-up question to the “certain circumstances” group, most respondents said it should be legal “‘only in a few’ rather than ‘most’ circumstances.” This distinction is important. For example, a separate series of Gallup questions found support for legal abortion ranging widely depending on circumstances: from as low as 20 percent during the third trimester if the woman does not want the child for any reason to 83 percent during the first trimester if the woman’s life is in danger. https://www.washingtonpost.com/news/ fact-checker/wp/2018/07/19/whos-in-favorof-abortion/?noredirect=on&utm_term=. df5b71596f70

Traditionally, physicians have been able to unite under the concept that abortion may be indicated in the first trimester if the pregnancy is unwanted, is the product of incest or rape, or if the fetus is expected to be non-viable due to a severely mutagenic intrauterine malady. During its early years, the AMA actually advocated strongly against abortion rights, but in the 1970s they joined the British Medical Association in supporting a woman's right to choose. The AAFP followed suite providing legally protected medical services for first trimester termination of pregnancy. But, where do we go from here?

When we choose life, only then can liberty and the pursuit of happiness be possible."

On Friday, April 27th, 2018, Governor Kelly Reynolds of Iowa, signed the country’s most restrictive abortion law, Senate File 359, which went into effect on July 1, 2018, but was later struck down by Iowa’s Supreme Court. This heartbeat bill, as it is called, attempted to ban most abortions after a fetal heartbeat is detected, and was the strictest of its kind, sparking other states to follow suite. There are a total of 20 states which have passed heart beat bills, including Tennessee House Bill 77, Georgia House Bill 481, and Mississippi Senate Bill 2116, just to name a few. On February 27th, 2019, Missouri joined these states by passing their own fetal heartbeat legislation, House Bill 126. In the last two years, the election of a Republican president and the confirmation of two conservative chief justices has sparked fears amongst the Pro-choice community that Roe v. Wade will be overturned. This fear may be unfounded, since it is highly unlikely that Congress or the Supreme

AMA Position on Abortion

Code of Medical Ethics Opinion 4.2.7

The Principles of Medical Ethics of the AMA do not prohibit a physician from performing an abortion in accordance with good medical practice and under circumstances that do not violate the law. https://www.ama-assn. org/delivering-care/ethics/ abortion

MO-AFP.ORG 41

MEMBER OPINION PIECE

Court would produce legal injunctions that would reverse the mountains of case precedent on abortion in the US, nor abridge a woman's right to choose. However, it's certainly conceivable that these bodies could step in to halt a trend that proposes to move the goal post from pro-choice, to pro-abortion, a position that the World Health Organization seems to have embraced. Mystery of life passage by Chief Justice Kennedy "At the heart of liberty is the right to define oneâ&#x20AC;&#x2122;s own concept of existence, of meaning, of the universe, and of the mystery of human life. Beliefs about these matters could not define the attributes of personhood were they formed under compulsion of the State." Planned Parenthood of Southeastern Pa. v. Casey, 505 U. S. 833, 851 (1992). https://www.law.cornell.edu/wex/ quotation/%5Bfield_short_title-raw%5D_25

With all the political and legislative pressure being introduced into the abortion debate, I think it is reasonable that we ask ourselves as physicians if we are being unduly influenced by outside forces rather than sound medical judgement. Is it really best practice to expand our comfort zones and treatment protocols to meet societal demands, or should we pause to contemplate the scientific and social implications that result when we risk cheapening the value of human life? Where will it end if we as physicians lose our historically cherished role as the conservators of human life? How we triage the value of a human life matters, especially for the most vulnerable and voiceless. The future for humanity can be either bright or terribly bleak, depending on which path we take. History will judge us by whether or not we protected life as the most fundamental human right. When we choose life, only then can liberty and the pursuit of happiness be possible.

AAFP Position Statements on Reproductive Decisions Reproductive Decisions The American Academy of Family Physicians (AAFP) encourages all family physicians to provide patient education on contraceptive options at every available opportunity to avoid unintended pregnancies. In the event of an unintended pregnancy, family physicians should educate patients about all options. If a patient desires termination of their pregnancy or adoption, family physicians should provide resources to facilitate those services. If a family physician's moral or ethical beliefs conflict with the ability to provide the requested resources or education, the family physician should ask a colleague to provide this information in a timely fashion rather than omit it. Additionally, the AAFP encourages family physicians to stay informed of all state and federal laws as they apply to reproductive health. (1989) (2017 COD) https://www.aafp.org/about/ policies/all/reproductive-decisions.html Coverage for Reproductive Decisions The American Academy of Family Physicians endorses the principle that women receiving health care paid for through health plans funded by state or federal governments who have coverage for continuing a pregnancy also should have coverage for ending a pregnancy. (2017 December BOD) https://www.aafp.org/about/policies/all/reproductive-decisionscoverage. html Preconception Care Preconception care is primary care, and providing quality preconception care is the responsibility of all primary care providers. Successful implementation requires transforming care delivery and making preconception care based on the best available evidence routine. The AAFP encourages members to follow these evidencebased recommendations to incorporate preconception care into all routine primary care visits and supports membersâ&#x20AC;&#x2122; efforts to improve maternal and fetal outcomes. https://www.aafp.org/about/policies/all/ preconception-care.html Reproductive and Maternity Health Services The American Academy of Family Physicians (AAFP) supports a woman's access to reproductive and maternity health services and opposes nonevidence-based restrictions on medical care and the provision of such services. The AAFP believes maternity and reproductive health services are essential to general health care and should be covered under all insurance plans. (2014 COD) (2018 COD) https://www.aafp.org/about/policies/all/ reproductivehealth-services.html Training in Reproductive Health Decisions The American Academy of Family Physicians supports the concept that no physician or other health professional shall be required to perform any act which violates personally held moral principles. The AAFP recommends that medical students and family medicine residents be trained in counseling and referral skills regarding all options available to pregnant women. The AAFP supports provision of opportunities for residents to have access to supervised, expert training in management techniques and procedures pertaining to reproductive health and decisions commensurate with the scope of their anticipated future practices. (1995) (2015 COD) https://www.aafp.org/about/policies/all/reproductive-training.html

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

2019 MAIN RESIDENCY MATCH L ARGEST ON RECORD

he 2019 Main Residency Match is the largest in NRMP history. A record-high 38,376 applicants submitted program choices for 35,185 positions, the most ever offered in the Match. The number of available first-year (PGY-1) positions rose to 32,194, an increase of 1,962 (6.5%) over 2018. The influx of positions is due, in part, to the increased numbers of osteopathic programs that joined the Main Residency Match as a result of the ongoing transition to a single accreditation system for graduate medical education programs.

Marc Propst and family pose for a picture after his match to University of Missouri-Columbia.

Primary Care Of the 32,194 first-year positions offered in the Match, 15,946 were in the primary care specialties of Family Medicine, Internal Medicine, Internal Medicine â&#x20AC;&#x201C; Pediatrics, Internal Medicine â&#x20AC;&#x201C; Primary, Pediatrics, and Pediatrics â&#x20AC;&#x201C; Primary, a 7.8 percent increase over the number offered in 2018. Of those, 15,355 (96.3%) were filled and 7,272 (45.6%) were filled by U.S. allopathic seniors. Internal Medicine programs offered 8,116 categorical positions, 574 more than in 2018; 7,892 (97.2%) positions filled, and 3,366 (41.5%) filled with US allopathic seniors. The percentage of Internal Medicine categorical positions filled by US allopathic seniors has declined every year since 2015. Family Medicine programs offered 4,107 positions, 478 more than in 2018; 3,827 (93.2%) positions filled, and 1,601 (39.0%) filled with US allopathic seniors. This year was the first year since 2009 that the number of US allopathic seniors matching to Family Medicine has decreased; however, a record number 986 osteopathic students and graduates matched in Family Medicine, accounting for 25.8 percent of all applicants who matched to the specialty. Pediatrics programs offered 2,847 categorial positions, 79 more than in 2018; 2,778 (97.6%) filled, and 1,715 (60.2%) filled with US allopathic seniors. The percentage of U.S. allopathic seniors matching to Pediatrics has declined every year since 2015. Reference: nrmp.org

Mercy residents on a tour of Busch Stadium.

MO-AFP.ORG 43

2019 LEGISLATIVE SESSION UNDERWAY RJ Scherr and Associates, MAFP governmental consultants

The Missouri Academy of Family Physicians has been very busy this session both on offense and defense. As this column is published in the Missouri Family Physician, we will have about one month remaining in this session set to adjourn on May 17, 2019 at 6:00 pm. To date, we are tracking over 120 bills on both the House and Senate sides that cover prior authorization, scope of practice (NP, AP, PA, Paramedic Practitioner, Athletic Trainers, etc.), MoHealthNet, insurance, PDMP, patient safety, and more. There have been almost 2,000 bills and resolutions introduced in both chambers that have been reviewed by Randy Scherr and Brian Bernskoetter, MAFP’s governmental consultants. And, we have testified at over 15 hearings on priority legislation. Primary Care Investment The MAFP is very excited to be supporting legislation filed on your behalf called the “Primary Care Transparency Act”. This legislation is simple in its concept but very important in its effect. The proposal creates a uniform definition of what constitutes primary care spending and requires insurers to disclose the percentage they spend on those services. The proposal was filed on both the House of Representatives as House Bill 879 and in the Senate as Senate Bill 417. MAFP believes this is an important first step to prioritize primary care as the bedrock on which our entire healthcare foundation rests. MAFP Board Chair, Mark Schabbing, MD, testified in the House Health and Mental Health Committee to express our support of this bill in March. If you haven’t already contacted your legislator to express your support for these bills, please do so today. Prior Authorization – SB 298 As you know, prior authorization is a major source of physician fatigue. It’s also a major point of contention with the insurance lobby. This year, we are very pleased to be working with every healthcare provider interest in the capitol to fight for reasonable reforms to the prior authorization process to keep insurers from keeping your patients from the care they need and from your office wasting valuable time jumping through hoops with insurers.

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

Pharmacist Prescribing The concept of a pharmacist prescribing either birth control or tobacco cessation drugs have both been advanced this year. The proponents regard this as a solution to access issues and in some limited regards, it certainly could be but, in most instances, you are trading one “access” issue for another. MAFP believes that if these drugs are safe enough for pharmacists to give out without a doctor’s evaluation, assessment, and prescription then they should be available without a pharmacist’s “prescription” as well. Scope of Practice Nurse Practitioners: The perennial fight of scope of practice issues are alive and well this session. Our nurse colleagues are supporting a few different measures but the basic thrust is to define either at the Board of Nursing or in statute what is their scope of practice. The takeaway from this fight is simple…nurses are more actively engaged with their legislators, and until our members express their thoughts through direct contact with legislators, this will be a circumstance where we fight for the best possible outcome instead of defeating these measures outright. Paramedic Practitioner (HB 907): In addition to the nurses, Missouri was the first state to create an “assistant physician” mid-level provider. We are at it again this year with legislation introduced to create a new license for a “paramedic practitioner” who would complete an educational curriculum similar to a physician assistant to be eligible for licensure. Assistant Physician (HB 710): Legislation introduced would create a pathway to licensure for assistant physicians, and create collaborative practice arrangements between assistant physicians and nurse practitioners. No activity has occurred yet on this bill, but it is on our radar. Take Action Most importantly, for every piece of legislation that we track, we need you! Other professions actively engage in contacting legislators on their priority bills. Legislators listen to their constituents - you take care of them, their family, friends, and neighbors. They want to hear from you…it can be as simple as you sending an email to support or oppose a bill, or including a justification for your position. You are a resource to them!

MISSOURI MEMBERSHIP CENSUS RESULTS Which of the following best describes your employment/professional situation? n % Full-time (at least 35 hours/week) 625 88.0% Part-time 69 9.7% Fully retired 9 1.3% Not in the workforce for other reasons 7 1.0% Total 710 100.0% Indicate the percentage of time which you spend in each of the following professional roles: Mean Median Clinical practice/patient care and related tasks 84.4 95.0 Administration or managerial tasks (not directly related to patient care) 11.1 5.0 Research 1.6 0.0 Teaching 6.8 0.0 Who is your primary employer? You (self-employed, majority practice owner, independent contractor, etc.) Physicians group (single- or multi-specialty) University-owned (public or private) clinic or hospital Private for-profit hospital or health system Private non-profit hospital or health system Managed care organization or insurance company Federal, state, or local government, community board, etc. (not including universities) Locum tenens group/staffing organization Other Total

n 110 131 61 73 244 5

% 16.0% 19.1% 8.9% 10.6% 35.5% 0.7%

38 7 18 687

5.5% 1.0% 2.6% 100.0%

Please indicate all physician specialties represented at your primary location: n % Family Medicine 662 93.1% General internal medicine 193 27.1% Pediatrics 127 17.9% Obstetrics/gynecology 111 15.6% Emergency medicine 78 11.0% Other specialties 148 20.8% Which of the following types of clinical services do you personally provide?: n % Adolescent medicine 569 80.0% Care of infants and children 536 75.4% Chronic care management 570 80.2% Emergency care 238 33.5% Geriatric medicine 554 77.9% Hospice/palliative care 279 39.2% Inpatient care 271 38.1% Intensive care 139 19.5% Obstetrics 102 14.3% Occupational medicine 181 25.5% Newborn/nursery care 202 28.4% Sleep medicine 52 7.3% Sports medicine 280 39.4% Urgent care 369 51.9% None selected 18 2.5%

MO-AFP.ORG 45

MEMBERS IN THE NEWS Puckett Awarded Physician of the Year by MSACOFP

Starrett Awarded $1,000 Scholarship by MSACOFP

Justin Puckett, DO, FACOFP, a family physician at Complete Family Medicine in Kirksville, Missouri, was recently awarded the 2019 Osteopathic Family Physician of the Year Award by the Missouri Society of the American College of Osteopathic Family Physicians (MSACOFP). Dr. Puckett was honored at a ceremony on January 25 at the Hilton Garden Inn in Independence, Missouri, during the 2019 MSACOFP Winter Family Medicine Update. The prestigious award is given to an osteopathic family physician who exemplifies the principles of osteopathic family medicine via outstanding accomplishments and service for the betterment of the osteopathic profession.

James Starrett, DO, was recently awarded a $1,000 scholarship from the Missouri Society of the American College of Osteopathic Family Physicians. (MSACOFP). Dr. Starrett was honored at a ceremony on January 26 at the Hilton Garden Inn in Independence, Missouri during the 2019 MSACOFP Winter Family Medicine Update. The prestigious award is given to an osteopathic family medicine resident who has demonstrated leadership skills in medical school and in residency and is committed to practice family medicine in Missouri after completion of his/her residency training.

2019 SLAFP Installation Dinner The St. Louis Chapter held their Installation ceremony on January 13, 2019 at Rosalita's Cantina in Des Peres, Missouri. Congratulations and best wishes to all!

2019 President, Christopher Blanner, MD, (left) with 2018 Greater St. Louis Community Health Award recipient, Beth Zimmer, MD, and 2018 President, Lauren Wilfling, DO.

Zweig

2019 SLAFP Board and Officers: Back Row, L-R: Drs. Kara Mayes, Lauren Wilfling, Nick Moore, Christian Verry, Daniel Herleth, Andrea Otto, Kanika Turner, Dawn Davis and Matt Breeden. Front Row, L-R: Drs. Laura Covert, TinaRose Trost, Christopher Blanner and Katy Lui. Not pictured: Dr. William Manard.

Potts Serves 46th Year as Physician of the Day

Donald Potts, MD, (right) is pictured with Jeff Howell, MSMA Director of Government Relations. Dr. Potts visited the Missouri State Capitol in March for his 46th year as Physician of the Day. Potts was Appointed Interim Dean the first Physician of the Day Steven Zweig, MD, professor and chair of the Department of Family and Community in 1973. Thank you, Dr. Potts, Medicine, has been named interim dean at the University of Missouri School of for your tradition of service to Medicine effective April 1, 2019. “Building on the success of those who have come family medicine! before me, I will do my best to advance the mission of the School of Medicine: to improve the health of all people, especially Missourians, through exemplary education, research and patient-centered care,” Zweig said. “We will do so with the work of the outstanding faculty, staff and students of the medical school; our vital partnership with MU Health Care; and the collaboration of our colleagues on the MU campus and beyond.”

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2019

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