Folic acid for the prevention of neural tube defects

In 1992, the U.S. Public Health Service recommended that women of childbearing age take folate supplements to reduce the incidence of neural tube defects, which occur in about 1 in 1000 pregnancies. Subsequently, the Food and Drug Administration began requiring that enriched grain products be fortified with folic acid. Ten years later, the incidence of neural tube defects had declined, though there was little change in the percentage of women of childbearing age (25-30%) who reported taking folate supplements on a regular basis, as AFP reported in a Clinical Brief. A more recent study conducted in Canada found that 22% of women of childbearing age have red blood cell folate concentrations that are considered suboptimal for neural tube defect prevention.

The December 15th issue of AFP features the U.S. Preventive Service Task Force's updated recommendation statement on folic acid for the prevention of neural tube defects, along with a Putting Prevention Into Practice case study. Recognizing that a substantial proportion of pregnancies are unplanned, the USPSTF gives an "A" grade to the recommendation that "all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 mcg) of folic acid." (You can find more information about preconception and prenatal issues in AFP's Prenatal Care collection.)

USPSTF recommendations are written for primary care clinicians, but it is relatively rare for patients to present specifically for preconception care visits, where they can receive education about the need to take folic acid supplements. What alternative strategies does your practice use to inform patients about these and other important preventive health needs, such as healthy eating and exercise, that wouldn't necessarily bring them into the office?

Avoiding the perils of plagiarism

About a year ago, a primary care supplement sponsored by a prominent physician specialty organization arrived at my home address. The topic of the supplement was a professional interest of mine; in fact, I had published an original paper on the subject in a leading research journal the year before. Skimming the introduction to the first article, I felt a deja-vu sensation. Not only had I read these words before, I was pretty sure that I had actually written them. Indeed, comparing the text to my paper, the first three paragraphs were virtually identical, with only a few words changed here and there, and no citation.

The December 15th Inside AFP column reviews how to avoid the perils of plagiarism in medical and other publications. Plagiarism is a term that means different things to different people, but AFP's policies are that 1) wording should be paraphrased in such a way as to make it your own; 2) verbatim wording should be enclosed in quotation marks; 3) original sources should be cited for any wording or concepts taken from them.

As the Inside AFP column notes (direct quotation, crediting the source): "You can expose yourself to accusations of plagiarism by using another's words, even with proper attribution, if they are too close in form or content to the original source. This is a matter of degree, and sometimes is a judgment call, but it's best to err on the side of caution and make the phrasing your own." But if I were to rewrite this quoted passage along the lines of the following, I would be guilty of what is sometimes called the "too-perfect paraphrase":

You can open yourself up to accusations of plagiarism by using someone else's words, even with proper citation, if they are too close in form or content to the original. This is a matter of degree, and subject to interpretation, but it's best to err on the side of caution and make the words your own.

Even if the proper citation was included, this passage would still be considered plagiarism.

AFP's editors use the internationally recognized Committee on Publication Ethics guidelines for addressing claims of possible plagiarism in our pages. We carefully consider concerns raised by editors and readers and contact the authors for full explanations before taking any actions. Since plagiarism is a serious matter that can have professional and personal consequences, we strongly encourage prospective authors to contact us with questions or clarifications prior to submitting manuscripts for consideration.

Antibiotics for acute bronchitis: just don't do it

In 1998, AFP published an article on acute bronchitis that pointed out the discrepancy between usual practice and evidence demonstrating the lack of effectiveness of prescribing antibiotics for this condition:

Although many authorities have argued that antibiotics have no role in the treatment of acute bronchitis, these agents remain the predominant therapy offered to patients. Primary care physicians in the United States have treated acute bronchitis with a wide range of antibiotics even though scant evidence exists that antibiotics offer any significant advantage over placebo.

Twelve years later, it appears that little has changed. According to an updated review of the diagnosis and treatment of acute bronchitis by Ross Albert, MD, PhD in AFP's December 1st issue,

Because of the risk of antibiotic resistance and of Clostridium difficile infection in the community, antibiotics should not be routinely used in the treatment of acute bronchitis, especially in younger patients in whom pertussis is not suspected. Although 90 percent of bronchitis infections are caused by viruses, approximately two thirds of patients in the United States diagnosed with the disease are treated with antibiotics. ... Clinical data support that antibiotics do not significantly change the course of acute bronchitis, and may provide only minimal benefit compared with the risk of antibiotic use itself.

If the evidence has been this clear for so long, why do family physicians continue to prescribe antibiotics for patients with acute bronchitis? The usual explanations are that 1) patients expect to receive antibiotics; and 2) prescribing an antibiotic takes less time than talking the patient out of the prescription. However, Dr. Albert's article also observes that "studies have shown that the duration of office visits for acute respiratory infection is unchanged or only one minute longer when antibiotics are not prescribed." To help AFP's readers better manage patients' expectations, the article contains a handy table of communication strategies that clinicians can use to avoid unnecessary and potentially harmful antibiotic prescriptions.

Close-ups: bringing the patient perspective to AFP

In 2007, AFP introduced a new regular feature called "Close-ups: A Patient's Perspective." In an editorial explaining the rationale for Close-ups, which includes a patient's story in his or her own words, a photo of the patient, and a brief clinician commentary, Associate Deputy Editor Caroline Wellbery, MD wrote:

Physicians live in a health care environment that continually raises difficult issues, many of them of a magnitude that transcends our personal practices: uninsured patients, a fragmented health care system, epidemics of obesity and lung disease, the threat of bioterrorism, contentious issues such as abortion, and rising health care costs. For anyone overwhelmed by contemporary health care developments, going back to our roots—meaningful, healing relationships with the people and communities we care for—might put our daily practice into perspective. Close-ups offers an intimate, personal reminder of this most important task.

"The Blood Sugar Diaries" in the December 1st issue of AFP relates the fears of a man with type 2 diabetes when he is told by his physician that he will need to use insulin. Explaining that several close relatives suffered serious complications or death shortly after starting insulin, the man says: "These are the reasons why I told my doctor 'no way' when she told me that I needed insulin. I didn't want to end up like my family members. I didn't want to go on dialysis, lose my leg, go blind, or die." These sentences speak volumes about the need for family physicians not only to provide patient education to patients with chronic conditions, but to explore existing beliefs regarding health and to meet patients where they are.

You can find a collection of previously published Close-Ups at http://www.aafp.org/afp/closeups. We welcome new submissions from patients and clinicians. Guidelines for contributing to this feature can be found in our Authors' Guide.

Preventing cervical cancer with HPV vaccine

Human papillomaviruses (HPV) are the subject of the cover article of AFP's November 15th issue, authored by Drs. Gregory Juckett and Holly Hartman-Adams from the West Virginia University Robert C. Byrd Health Sciences Center School of Medicine. While "low risk" HPV types 6 and 11 cause up to 95 percent of genital warts, "high risk" HPV types 16 and 18 cause the majority of cervical cancers. In recognition of these risks, the American College of Obstetricians and Gynecologists recently recommended that women older than 30 years receive high-risk HPV DNA testing in addition to cytology for cervical cancer screening.

Previous issues of AFP reviewed the efficacy of the quadrivalent HPV recombinant vaccine and recommendations for its administration by the American Cancer Society and the CDC's Advisory Committee on Immunization Practices. HPV vaccine is only the second cancer-preventing vaccine, after hepatitis B vaccine (which prevents liver cancer). However, Drs. Juckett and Hartman-Adams observe in their article that implementing HPV vaccine recommendations has been challenging:

Controversy about HPV vaccination involves its high cost (approximately $150 per injection), uncertain duration of protection, and concerns that it provides tacit approval of sexual activity and a false sense of security. In addition, the necessity of vaccinating girls as young as nine to 11 years, before they become sexually active, unsettles many parents. There has been criticism for aggressive marketing of HPV vaccine to older women already exposed to HPV, while less attention has been given to the subpopulations at highest risk.

AAFP News Now recently reported that HPV vaccination rates in 2009 varied widely from state to state, with 44.3 percent of teenage girls nationally having received at least one dose and 26.7 percent having completed the 3-dose series. Just last week, a U.S. Food and Drug Administration advisory committee meeting reviewed the evidence that HPV vaccination prevents anal cancer in men who have sex with men. How the committee's reported decision to approve HPV vaccine for this indication will affect future national recommendations for vaccination in males remains to be seen.

How has the availability of HPV vaccine affected your practice? What approach do you take in discussions with adolescents and parents? We would love to hear about your experiences.

Asthma management: a stepwise approach

The November 15th issue of AFP features an updated clinical review of medical therapies for asthma, based on the 2007 Expert Panel Report of the National Asthma Education and Prevention Program (NAEPP). This review recommends a "stepwise approach" for asthma management in patients 12 years and older, depending on the severity of asthma and response to first-line medications. Persons with intermittent symptoms may use an inhaled short-acting beta-agonist as needed; older children and adults with persistent asthma generally require daily inhaled corticosteroids, and possibly additional medications.

Another component of effective management is the use of written asthma action plans for patients to monitor asthma control outside of planned office visits and to take physician-approved steps to address worsening symptoms. The article includes examples of asthma action plans for children and adults, as well as a link to a short video about asthma action plans on Familydoctor.org.

For information about related clinical issues such as the role of allergens in asthma, treatment of asthma in young children, managing acute exacerbations, and practice-level approaches to planned asthma care, you can consult our AFP By Topic collection.

Telephone triage for suspected influenza

Although the Centers for Disease Control and Prevention's weekly flu tracking report showed "low" influenza activity in the U.S. as of the publication date of AFP's November 1, 2010 issue, we know that it is only a matter of time before family physicians' offices are filled with patients either seeking the vaccine or presenting with symptoms of an acute infection. Accordingly, this issue contains several key resources for managing influenza, including a focused clinical review of testing and treatment; a Tip on the effectiveness and limitations of oseltamivir (Tamiflu) for reducing flu duration in children; and an updated influenza management guide from the University of California at San Francisco's Department of Family and Community Medicine. The guide suggests using "telephone triage" to reduce office visits that can potentially transmit influenza to other patients and staff:

Telephone triage can assess severity of symptoms and identify patients at risk of complications who would benefit from expedited access to antiviral medications, which can then be prescribed by telephone or fax. This approach provides timely access to treatment while reducing waiting room exposures. Conversely, if telephone triage identifies concerning symptoms that would require outpatient or emergency department evaluation, this can be arranged and expedited.

For additional information about best practices and a sample protocol for telephone triage, you can refer to a previous editorial by Jonathan L. Temte, MD, PhD. This editorial and other up-to-date resources, including the CDC's 2010-11 vaccination guidelines, are all included in AFP's Influenza Topic Collection. Finally, you can also click on the CDC's Flu.Gov widget, located on the lower right border of this blog, for updates and alerts throughout the influenza season.