Storylines of family medicine VII: family medicine across the lifespan.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VII: family medicine across the lifespan', authors address the following themes: 'Family medicine maternity care', 'Seeing children as patients brings joy to work', 'Family medicine and the care of adolescents', 'Reproductive healthcare across the lifespan', 'Men's health', 'Care of older adults', and 'Being with dying'. May readers appreciate the range of family medicine in these essays.

The Impact of Local Education and Resource Distribution on Maternal Health Behaviors.

INTRODUCTION: Community forum participants voted for an education and resource distribution program (using a baby box) to help reduce local infant mortality. Although multiple sites have implemented similar programs, there is limited peer-reviewed literature about outcomes. METHODS: A retrospective pre- and immediate post-survey design with an intervention (video and written education and resource distribution) in between was utilized with a follow-up survey. The primary research objectives were whether viewing educational videos led to change in self-reported likelihood of select maternal behaviors. Other objectives were whether demographic characteristics were associated with self-reported likelihood of behaviors, and to assess the actual self-reported postpartum behavior. RESULTS: Participants reported a change in likelihood in: asking a WIC counselor for help (p < 0.001); talking with a provider about substance use (p = 0.014), postpartum depression (p < 0.001) and birth control (p = 0.025); and using the baby box as a sleeping space (p < 0.01). After watching the educational videos, college-educated participants were significantly more likely than participants with high school education or less to report likelihood to breastfeed (p = 0.039). Over half of the participants (59.2%) in the follow-up survey reported breastfeeding most to all of the time, compared to 91.5% who reported they were more likely to breastfeed in the post-education survey. The proportion of participants at the follow-up survey who reported bed-sharing most or all of the time (5.7%) was lower than those participants who had said they were likely or very likely to bed-share in the post-education survey (11.3%). Although nearly all participants (98.6%) in the post-education survey reported that they were likely to use the baby box, at the postpartum follow-up, 39.1% reported actual use of the baby box. CONCLUSIONS FOR PRACTICE: The program positively impacted self-reported likelihood of several health behaviors. A community-driven approach to maternal education and resource distribution may be beneficial in other cities.

Impact of order entry alerts and modifications on doses of intravenous opioids dispensed during a national drug shortage.

PURPOSE: To address the intravenous (i.v.) opioid shortage, computer-based alerts and modifications were implemented over 2 phases beginning in August 2017 and February 2018, respectively. A study was conducted to assess the impact of these interventions on dispenses of intermittent doses of i.v. opioids during a national shortage. METHODS: A retrospective, single-center, pre- and postimplementation study was conducted to compare opioid dispenses from September 2017 through December 2017 (phase 1) and March 2018 through May 2018 (phase 2) with dispenses during the same time periods of the previous year (historical control periods). Dispense data for intermittent doses of i.v. fentanyl, hydromorphone, and morphine and select oral opioids were collected from automated dispensing cabinets (ADCs) located in nonprocedural areas. The primary endpoint was the percentage of total intermittent doses of i.v. and oral opioids that were dispensed for i.v. administration. A subanalysis accounting for unit type was conducted. Key secondary endpoints were the numbers of oral and i.v. opioid dispenses by month. RESULTS: The final analysis included data from 92 ADCs. The percentage of i.v. opioid dispenses significantly decreased, by 9.8% during phase 1 (P < 0.0001) and by 16.8% during phase 2 (P < 0.0001) compared to dispenses during the historical control periods. These decreases were significant across all unit types except pediatric units during phase 1. Average monthly dispenses of i.v. opioids were 49.9% and 74.2% fewer than dispenses during the historical control periods after the phase 1 and phase 2 implementations, respectively. CONCLUSION: Order entry alerts and modifications significantly decreased dispenses of intermittent doses of i.v. opioids during a national shortage, with demonstrated sustainability of decreases over 7 months.

Supporting Family Physician Maternity Care Providers.

Maternity care access in the United States is in crisis. The American Congress of Obstetrics and Gynecology projects that by 2030 there will be a nationwide shortage of 9,000 obstetrician-gynecologists (OB/GYNs). Midwives and OB/GYNs have been called upon to address this crisis, yet in underserved areas, family physicians are often providing a majority of this care. Family medicine maternity care, a natural fit for the discipline, has been on sharp decline in recent years for many reasons including difficulties cultivating interdisciplinary relationships, navigating privileging, developing and maintaining adequate volume/competency, and preventing burnout. In 2016 and 2017, workshops were held among family medicine educators with resultant recommendations for essential strategies to support family physician maternity care providers. This article summarizes these strategies, provides guidance, and highlights the role family physicians have in addressing maternity care access for the underserved as well as presenting innovative ideas to train and retain rural family physician maternity care providers.

A Decade of Progress toward Ending the Intensive Confinement of Farm Animals in the United States.

In this paper, the Humane Society of the United States (HSUS) farm animal protection work over the preceding decade is described from the perspective of the organization. Prior to 2002, there were few legal protections for animals on the farm, and in 2005, a new campaign at the HSUS began to advance state ballot initiatives throughout the country, with a decisive advancement in California (Proposition 2) that paved the way for further progress. Combining legislative work with undercover farm and slaughterhouse investigations, litigation and corporate engagement, the HSUS and fellow animal protection organizations have made substantial progress in transitioning the veal, pork and egg industries away from intensive confinement systems that keep the animals in cages and crates. Investigations have become an important tool for demonstrating widespread inhumane practices, building public support and convincing the retail sector to publish meaningful animal welfare policies. While federal legislation protecting animals on the farm stalled, there has been steady state-by-state progress, and this is complemented by major brands such as McDonald's and Walmart pledging to purchase only from suppliers using cage-free and crate-free animal housing systems. The evolution of societal expectations regarding animals has helped propel the recent wave of progress and may also be driven, in part, by the work of animal protection organizations.

Preparing Future Leaders: An Integrated Quality Improvement Residency Curriculum.

BACKGROUND AND OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) has recognized the importance of quality improvement (QI) training and requires that accredited residencies in all specialties demonstrate that residents are "integrated and actively participate in interdisciplinary clinical quality improvement and patient safety activities." However, competing demands in residency training may make this difficult to accomplish. The study's objective is to develop and evaluate a longitudinal curriculum that meets the ACGME requirement for QI and patient safety training and links to patient-centered medical home (PCMH) practices. METHODS: Residents in the Worcester Family Medicine Residency (WFMR) participated in a faculty-developed quality improvement curriculum that included web-based tutorials, quality improvement projects, and small-group sessions across all 3 years of residency. They completed self-evaluations of knowledge and use of curricular activities annually and at graduation, and comparisons were made between two graduating classes, as well as comparison of end of PGY2 to end of PGY3 for one class. RESULTS: Graduating residents who completed the full 3 years of the curriculum rated themselves as significantly more skilled in nine of 15 areas assessed at end of residency compared to after PGY2 and reported confidence in providing future leadership in a focus group. Five areas were also rated significantly higher than prior-year residents. CONCLUSIONS: Involving family medicine residents in a longitudinal curriculum with hands-on practice in implementing QI, patient safety, and chronic illness management activities that are inclusive of PCMH goals increased their self-perceived skills and leadership ability to implement these new and emerging evidence-based practices in primary care.

The Impacts of Climate Change Mitigation Strategies on Animal Welfare.

The objective of this review is to point out that the global dialog on reducing greenhouse gas emissions in animal agriculture has, thus far, not adequately considered animal welfare in proposed climate change mitigation strategies. Many suggested approaches for reducing emissions, most of which could generally be described as calls for the intensification of production, can have substantial effects on the animals. Given the growing world-wide awareness and concern for animal welfare, many of these approaches are not socially sustainable. This review identifies the main emission abatement strategies in the climate change literature that would negatively affect animal welfare and details the associated problems. Alternative strategies are also identified as possible solutions for animal welfare and climate change, and it is suggested that more attention be focused on these types of options when allocating resources, researching mitigation strategies, and making policy decisions on reducing emissions from animal agriculture.

Animal Welfare and Food Safety Aspects of Confining Broiler Chickens to Cages.

In most areas of the world, broiler chickens are raised in floor systems, but cage confinement is becoming more common. The welfare of broiler chickens in cages is affected by movement restriction, poor bone strength due to lack of exercise, and prevention of key behavioral patterns such as dustbathing and ground scratching. Cages for broiler chickens also have a long history of causing skin and leg conditions that could further compromise welfare, but a lack of controlled studies makes it difficult to draw conclusions about newer cage designs. Cage environments are usually stocked at a higher density than open floor systems, and the limited studies available suggest that caging may lead to increased levels of fear and stress in the birds. Further, birds reared on the floor appear less likely to harbor and shed Salmonella, as litter may serve as a seeding agent for competitive exclusion by other microorganisms. Cages for laying hens used in egg production have met with substantial opposition due to welfare concerns and caging broiler chickens will likely be subject to the same kinds of social disapproval.

Biodegradation of crude oil from the BP oil spill in the marsh sediments of southeast Louisiana, USA.

The significant challenges presented by the April 20, 2010 explosion, sinking, and subsequent oil spill of the Deepwater Horizon drilling platform in Canyon Block 252 about 52 miles southeast of Venice, LA, USA greatly impacted Louisiana's coastal ecosystem including the sea food industry, recreational fishing, and tourism. The short-term and long-term impact of this oil spill are significant, and the Deepwater Horizon spill is potentially both an economic and an ecological disaster. Microbes present in the water column and sediments have the potential to degrade the oil. Oil degradation could be enhanced by biostimulation method. The conventional approach to bioremediation of petroleum hydrocarbon is based on aerobic processes. Anaerobic bioremediation has been tested only in a very few cases and is still considered experimental. The currently practiced conventional in situ biorestoration of petroleum-contaminated soils and ground water relies on the supply of oxygen to the subsurface to enhance natural aerobic processes to remediate the contaminants. However, anaerobic microbial processes can be significant in oxygen-depleted subsurface environments and sediments that are contaminated with petroleum-based compounds such as oil-impacted marshes in Louisiana. The goal of this work was to identify the right conditions for the indigenous anaerobic bacteria present in the contaminated sites to enhance degradation of petroleum hydrocarbons. We evaluated the ability of microorganisms under a variety of electron acceptor conditions to degrade petroleum hydrocarbons. Researched microbial systems include sulfate-, nitrate-reducing bacteria, and fermenting bacteria. The results indicated that anaerobic bacteria are viable candidates for bioremediation. Enhanced biodegradation was attained under mixed electron acceptor conditions, where various electron-accepting anaerobes coexisted and aided in degrading complex petroleum hydrocarbon components of marsh sediments in the coastal Louisiana. Significant degradation of oil also occurred under sulfate-reducing and nitrate-reducing conditions.

A critical review of electrical water-bath stun systems for poultry slaughter and recent developments in alternative technologies.

Prior to slaughter, most farmed birds move through a constant-voltage, multiple-bird, electrical water-bath stun system. Using this system subjects live birds to stressful and painful shackling, and the potential exists for them to receive prestun electric shocks and induction of seizures while still conscious. The existing electrical water-bath stunner settings, particularly those used in U.S. slaughter plants, are not necessarily based on sound scientific data that they produce a consistent, immediate stun, and research indicates that they are not effective in all birds. Further, in multiple-bird, electrical water-bath systems, birds may miss the stunner completely. Evidence suggests that some birds may still be alive when they reach the scald vat. For these reasons, electrical water-bath systems are increasingly under scrutiny on nonhuman-animal welfare grounds. Controlled Atmosphere Killing (CAK), a promising alternative technology, uses gas mixtures to render birds unconscious. CAK systems that stun birds while they are still in their transport crates avoid many of the welfare problems associated with the live-hang process and electrical water-bath stunning.

Dystocia in nulliparous women.

Dystocia is common in nulliparous women and is responsible for more than 50 percent of primary cesarean deliveries. Because cesarean delivery rates continue to rise, physicians providing maternity care should be skilled in the diagnosis, management, and prevention of dystocia. If labor is not progressing, inadequate uterine contractions, fetal malposition, or cephalopelvic disproportion may be the cause. Before resorting to operative delivery for arrested labor, physicians should ensure that the patient has had adequate uterine contractions for four hours, using oxytocin infusion for augmentation as needed. For nulliparous women, high-dose oxytocin-infusion protocols for labor augmentation decrease the time to delivery compared with low-dose protocols without causing adverse outcomes. The second stage of labor can be permitted to continue for longer than traditional time limits if fetal monitoring is reassuring and there is progress in descent. Prevention of dystocia includes encouraging the use of trained labor support companions, deferring hospital admission until the active phase of labor when possible, avoiding elective labor induction before 41 weeks' gestation, and using epidural analgesia judiciously.

On this day of mothers and sons.

Telling a pregnant woman and her family about a fetal demise is one of the greatest challenges for maternity care clinicians. In this essay, the author reflects on such an encounter in her work as a community health center clinician, maternity care teacher, and mother herself.