Identifying and managing gambling-related harms

The Supreme Court under Chief Justice John Roberts (the Roberts Court) has made several high-profile rulings affecting health care over the past two decades, including its 2012 decision that upheld the Affordable Care Act’s Medicaid expansion but made it optional for states and its 2022 decision that abortion was not a fundamental right protected by the US Constitution.

A less heralded ruling with health implications occurred in 2018, when the Roberts Court held that a prior federal law forbidding states to legalize sports betting was unconstitutional. This decision led to the rapid proliferation of online sports gambling platforms and their ubiquitous television advertisements. No longer do people need to travel to brick and mortar casinos to place bets on players or teams; now they can legally win and lose large sums through a variety of smartphone apps. 68 million Americans, or one in four adults, planned to wager an estimated $15.5 billion on the NCAA Division I basketball tournaments (March Madness) this year.

Expanded access to sports gambling has fueled a rise in the number of people affected by gambling disorder. Previously known as pathologic gambling, gambling disorder manifests as “impaired control over gambling, gambling taking precedence over other life interests, and the continuation or escalation of gambling despite negative consequences.” Young males are the demographic group most likely to have gambling disorder, and comorbid alcohol use disorder and depression are common. Although prevalence estimates in North America are low (1.5% of women, 2.7% of men), hazardous gambling—risky or compulsive gambling behavior that does not meet criteria for gambling disorder—is thought to be far more common, particularly in older adults with more leisure time.

A recent article in the BMJ summarized a National Institute for Health and Care Excellence (NICE) guideline on identification and management of gambling-related harms. Based on expert opinion and low-certainty evidence, NICE recommends that clinicians ask direct questions about gambling in patients with mental health concerns, alcohol or substance use disorders, housing or financial insecurity, justice involvement, and certain higher-risk professions (eg, active-duty military, veterans, sports professionals, people working in the gambling or financial industries). People with gambling disorder are at increased risk for self-harm and suicide attempts. Effective treatments include referral to self-help groups such as Gamblers Anonymous, group or individual cognitive behavioral therapy, motivational interviewing, and naltrexone. Psychology Today maintains a national directory of therapists with training in CBT for gambling disorder.

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This post first appeared on the AFP Community Blog.

Migraine headaches: diagnostic and treatment tips

A patient with a history of headaches is brought by ambulance to the emergency department for the abrupt onset of weakness and decreased sensation in their left arm and leg. A code stroke is called. Are these symptoms of an acute stroke or a stroke mimic, such as a hemiplegic migraine?

A retrospective analysis of characteristics of 15 consecutive years of code stroke cases at a hospital in Barcelona, Spain, found that patients who were ultimately diagnosed with migraine headache with aura (1.1%) were more likely to be younger, female, and have fewer vascular risk factors than patients with ischemic strokes. In addition, an initial NIH Stroke Scale of greater than 6 (odds ratio = 3.74) and a fibrinogen level of greater than 400 mg/dL (odds ratio = 2.98) distinguished strokes from migraine headaches.

An article on acute migraine headaches in the April 2025 issue of American Family Physician reviewed current treatment strategies for acute migraine headaches, which “account for … 3.6 million primary care visits annually and are the fifth most common reason for emergency department visits” in the United States. The POUND mnemonic (ie, pulsatile quality, one-day duration, unilateral headache, nausea or vomiting, disabling intensity) can help clinicians make the diagnosis of migraine in primary care, and the Migraine Disability Assessment (MIDAS) quantifies headache severity. Scores that indicate MIDAS grades III and IV should prompt clinicians to consider targeted migraine medications rather than simple analgesics.

Although several drug classes are effective for acute migraine, a 2024 systematic review and network meta-analysis of 137 randomized controlled trials (summarized in a POEM in the April 2025 issue of AFP) found that triptans produced greater pain relief at 2 hours and less use of rescue drugs in the first 2 to 24 hours than the newer and more expensive medications ubrogepant, rimegepant, and lasmiditan.

Clinical practice guidelines on the management of episodic migraine headache, including the 2023 US Veterans Affairs/Department of Defense guideline, preferentially recommend triptans for most patients. In March, the American College of Physicians released a pharmacologic treatment guideline that recommends adding a triptan in nonpregnant adults with moderate to severe migraines who have not responded to a nonsteroidal anti-inflammatory drug or acetaminophen. Triptans can cause vasospasm, so they are contraindicated in patients with coronary artery disease, cardiovascular disease, and peripheral artery disease and should not be used in combination with ergot alkaloids.

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This post first appeared on the AFP Community Blog.

For family medicine workforce, HHS reorganization plan receives a failing grade

Match Day on March 21, 2025 unfolded similarly to the National Resident Matching Program in previous years. My program successfully recruited a full class of 13 future interns from medical schools across the country, but family medicine as a whole, despite the typically rosy American Academy of Family Physicians news story, didn't even come close, with 15% of slots unfilled and a quarter of programs needing to enter the Supplemental Offer and Acceptance Program (SOAP, previously known as the "Scramble"). The sub-headline from a Medscape news article said it all: "Anesthesiology Still Hot, Family Medicine Is Not."

Before becoming a core faculty member at the Lancaster General Hospital Family Medicine Residency Program, I spent more than 15 years teaching in Georgetown's family medicine department. Part of my job was to encourage students' interest in primary care careers and mentor those who chose to enter family medicine. Out of a typical graduating class of 200 students, our largest family-medicine bound group was 15 (7.5%) and the smallest was 6 (3%). Most years, two or three times as many students matched into Anesthesiology or Orthopedic Surgery.

While I'm grateful for subspecialists who alleviate pain, rescue patients who are unable to breathe on their own, manage complicated fractures, and replace worn-out hips and knees, the gap between the number of family doctors we need and the number we have keeps getting wider. The number of visits to primary care physicians fell by 43% from 2010 to 2021 despite 7.4% growth in the U.S. population, and a near-doubling in outpatient visits to advanced practice providers (the majority of whom work in medical subspecialties) wasn't enough to make up for this deficit. Challenges in accessing timely primary care affect not only private practices and health systems, but also the publicly funded Veterans Affairs system.

How can we train more family physicians? A recent study in Family Medicine found that contrary to conventional wisdom, more graduating students switch in to family medicine from another specialty than switch out of it after intending on family medicine upon matriculation. (I'm an example of this pattern, having intended to become a pediatrician when I started medical school.) Although this doesn't diminish the importance of nurturing students who (like my wife) declare their interest in family medicine starting on day one, it seems to make representation on admissions committees less critical. Other proposals include streamlining pathways for international medical graduates to enter residency programs in fields with physician shortages.

A report funded by the Milbank Memorial Fund highlighted five states - Virginia, Rhode Island, Connecticut, Oklahoma, and California - that are or will be setting spending targets for primary care as a percentage of their overall health care spend in order to increase their supply of clinicians and give practices more of the resources they need to improve health outcomes. This is, to put it mildly, easier said than done, starting with how to define primary care, estimate the health care dollars flowing into it, and determine the optimal percentage of those dollars. And if you build it, will they come?

We can hope and pray that some combination of interventions in premed programs, medical school, residency, and financial compensation will build the primary care infrastructure that America needs and prevent our health outcomes from getting much worse than they already are. But we need more research to design and implement these efforts. Dr. Rochelle Walensky, who directed the Centers for Disease Control and Prevention (CDC) from 2021 to 2023, calls the current state of affairs an "evidence emergency":

There is no more urgent research need than addressing the health of the workforce that is charged primarily with caring for the people of its nation. And yet, there is neither a funding stream nor a cohesive research community to do so. An investment in the evaluation of initiatives to strengthen the physician workforce is critical, and such research should not be conducted in silos. Data must be shared and evidence compiled and then directly interpreted and acted on for program and policy decision making.

Foundations such as Milbank, the Kaiser Family Foundation, and the Commonwealth Fund can't support this work by themselves. This is where the federal government must step up. But the Trump administration's radical shrinking and restructuring of the Department of Health and Human Services (HHS), which decimated the workforces and research grant-issuing functions of the better-known National Institutes of Health and the CDC, has also vanished the agency responsible for supporting health services research. According to HHS, the Agency for Healthcare Research and Quality will be merged into an "Office of Strategy," and the Health Services and Resources Administration (HRSA), which supports the backbone of federally qualified health centers that provide primary care to 1 in 11 Americans, will be consolidated into RFK Jr.'s "Administration for a Healthy America." To use a professional football analogy, it's as if the general manager of the team with the league's worst record used their premium draft picks to select a bunch of recreational players who wouldn't have been drafted by any other team in the first place. Instant analysis: a failing grade for HHS.

What's new in osteoporosis screening and fracture prevention?

In the two years since publication of the latest American Family Physician review article on osteoporosis, new guidelines and research studies have enhanced management of this common condition. In early 2025, the U.S. Preventive Services Task Force (USPSTF) updated its recommendations on screening for osteoporosis. Although on the surface these are unchanged from the 2018 version—recommending screening in all women 65 years or older and postmenopausal women younger than 65 years at increased risk for an osteoporotic fracture and finding insufficient evidence to screen men—an accompanying editorial noted a small, but significant, difference.

Previously, the USPSTF defined increased risk by a threshold on the Fracture Risk Assessment Tool (FRAX) that corresponded to the 10-year fracture risk of an average 65-year-old White woman. However, evidence indicates that the predictive value of FRAX without bone mineral density is poor and inferior to simpler tools such as the Osteoporosis Self-Assessment Tool and the Osteoporosis Risk Assessment Instrument. In its updated recommendations, the USPSTF recommends only a “clinical risk assessment” and notes that if FRAX is used, it “does not intend that these 10-year risk levels be used as mechanistic thresholds” to decide who should undergo dual-energy absorptiometry screening.

A recent analysis of the performance of the Osteoporosis Self-Assessment Tool, Osteoporosis Risk Assessment Instrument, and the Osteoporosis Assessment of Risk tools in a subgroup of Women’s Health Initiative participants 50 to 64 years of age found that each had “fair to moderate discrimination” in identifying osteoporosis, with areas under the receiver operating characteristic curve of 0.633 to 0.663, with 1.0 being perfect and 0.5 being no better than chance.

Not only is it difficult to clinically predict osteoporosis risk, fragility fractures can occur in patients without osteoporosis. In January 2025, researchers published a randomized, placebo-controlled trial of an alternative strategy for reducing fractures: treating women in early menopause with antiresorptive therapy regardless of bone mineral density. There were 1,054 women 50 to 60 years of age with bone mineral density T-scores at the lumbar spine or hip from 0 to -2.5 at baseline assigned to one of three groups: zoledronate intravenous infusion at baseline and repeated at 5 years; zoledronate infusion at baseline, placebo at 5 years; and placebo infusions at baseline and at 5 years. After 10 years, new fractures had occurred in 11.1% of the placebo-placebo group, 6.6% of the zoledronate-placebo group, and 6.3% of the two dose zoledronate group. The relative risk of fractures in the two-dose zoledronate compared with the placebo-placebo group was 0.72, with a number needed to treat of 25 to prevent one fracture. The comparative benefits and cost effectiveness of this prevention strategy vs fracture risk assessment and treating women at increased risk remains to be seen.

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This post first appeared on the AFP Community Blog.

What's in a name?

The following is a guest post from my sister-in-law, Dr. Therese Duane, a trauma surgeon who is on a medical mission in Uganda. You can read more about the essential work she and her colleagues have been doing at Mercy Trips Healthcare Outreach.

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Taking poetic license from Shakespeare, I recently found myself contemplating the value attributed to names and titles as I prepared for my next mission trip. For so long, my focus had been achieving more of these—whether it be professor of surgery, program director, or chair of the department. Fortunately, in His goodness, God stripped them away and left me with what really mattered—the names of wife, mother, sister, daughter, aunt, niece, friend, Godmother and now Mom Mom.
#Perspective #LegacyOverLabels #AmericanCollegeofSurgeons

In my family, Mom Mom is the sobriquet of the matriarch instead of grandmother. It has always represented the woman in the generation whose strength kept the family together. I grew up in awe of my Mom Mom, my mother’s mom, who as the mother of eight, built a newspaper alongside my Pop Pop while raising diligent and devout children. My mother, my children’s Mom Mom, followed in her footsteps embodying the same fortitude. With my Dad, she raised seven children who learned determination and discipline through tough love at an early age. So, when our eldest daughter Alejandra—who joined our family 17 years ago as our au pair and quickly became our 5th child—had her first, I could not be prouder to strive to deserve the name of Mom Mom.
#BlendedFamily #ChosenFamily #MomMomMoments

Being Mom Mom began as we walked her pregnancy together with all the anxieties and anticipation culminating in the birth. After 38 hours of labor, multiple positions, four hours of pushing and me supporting her mostly by yelling “GET OUT” to the baby and suggesting things that her wonderful OB/GYN, @JaimeObst, politely told me, “They don’t do that anymore,” baby Bella was born! My own experience in childbirth had been very different—having 4 kids in less total time than it took her to have one—ahh the benefits of being on call the night before giving birth! Hence, Bella’s delivery was transformative for all of us. Ale recognized her inner strength and responsibility as a new mother and me the power and privilege of being a Mom Mom.
#WomensHealth #BirthStory #GenerationalStrength

So what does this have to do with a mission trip? It all has to do with prioritizing the roles we do have. Just one day after getting Ale settled at home, I left to serve the community at IntegrisHealth Baptist as an acute care surgeon for a week, came home for one day and then was off for a four-day band trip with my two youngest as chaperone and band doctor—to fulfill my other name as Mom. Grateful that my professional family supports my flexible work schedule, I can fulfill all my roles. Of course, none of it would be possible without an understanding husband holding down the fort. This wife was able to spend two days in four weeks at home before leaving to fulfill my privileged role as missionary.

#MissionWork #FaithInAction #MedicalMissions #MomLife #GratefulHeart

So perhaps Shakespeare had it right. The name or title does not matter in and of itself—what is more important is how you fulfill the role. Becoming a missionary has made me appreciate so much more all the titles I have that really matter, none of which include monetary value and yet are invaluable to the people they bless and to the God who made me for the purpose. In Uganda, I see women labor with no pain medicine and pushing through it with a stoicism that is humbling. I am grateful for what we have in the US and for the care my daughter and granddaughter received. Moreover, as a mother and now as a Mom Mom trying to emulate those who came before me by setting the example of unconditional support, I know my family are in the good hands of each other and more importantly of God.

#GlobalHealth #ServingOthers #MercyInAction #Gratitude #PurposeDriven

Hence, I had no qualms returning soon after Bella’s birth to the country where these strong people survive under harsh circumstances to do what I can to help them. Ultimately, as I have learned through this missionary work with Mercy Trips, kindness, compassion and generosity fulfill the ideals of the most important name of all which we each should embrace—Child of God.

#MomMom #LegacyOfLove #FaithFamilyMission #LivingYourPurpose

Measles, vaccine hesitancy, and the ACIP

As of March 27, 2025, 19 states had confirmed a total of 483 measles infections, with 444 cases associated with an ongoing outbreak in West Texas and New Mexico that began in late January. 70 people (14%) have been hospitalized for serious illnesses, and one child and one adult have died. For comparison, there were 285 cases of measles in the United States in 2024, and there have already been more reported cases than in all but two years since 2000. In a 2024 American Family Physician editorial, Dr. Doug Campos-Outcalt reviewed best practices for diagnosis and prevention of measles. Of note, “a person with measles is infectious 4 days before through 4 days after the appearance of the [erythematous, maculopapular] rash.”

Increasing vaccine hesitancy has depressed measles, mumps, and rubella (MMR) vaccination rates in the affected jurisdictions, making more people vulnerable to the highly contagious illness. Parents may refuse vaccinations for their children due to concerns about adverse effects, such as the repeatedly debunked myth that MMR increases the risk of autism. (Studies show a 4 in 10,000 risk of a febrile seizure after receiving MMR at 12 to 15 months of age, considerably lower than the risk associated with measles infection.) Although the American Academy of Family Physicians and the American Academy of Pediatrics discourage nonmedical exemptions from childhood immunizations required for daycare or school attendance, “philosophical” or religious exemption policies have been increasing in the United States. In West Virginia, where the last reported case of measles was in 2009, physician advocacy groups successfully petitioned the governor to veto a 2024 bill passed by the state legislature that would have allowed private and parochial schools to opt out of state immunization requirements.

Currently, infants 6 to 11 months of age are recommended to receive an early MMR dose before international travel. In a recent JAMA Viewpoint, former Centers for Disease Control and Prevention (CDC) director Rochelle Walensky, MD, MPH, and colleagues proposed “updating the existing recommendation for an additional early MMR dose to infants aged 6 to 11 months traveling to any region with increased probability of measles exposure, whether international or domestic.” Although several federal agencies play a role in vaccine development and use, the CDC’s Advisory Committee on Immunization Practices (ACIP) has been the authoritative source of vaccine recommendations since its formation in 1964. Members of this independent committee are required to disclose financial conflicts of interest and recuse themselves from deliberations and votes about a vaccine, its potential competitors, and any other products of the company that makes the vaccine. An investigation by the journal Science concluded that contrary to accusations by leaders of antivaccine groups such as Robert F. Kennedy, Jr., there was “no sign that [ACIP] vaccine advisors are beholden to industry.” After the ACIP’s February 2025 meeting was postponed for unclear reasons, the CDC has announced that the committee will meet next month. According to the Federal Register notice, the agenda includes recommendation votes on meningococcal vaccines, chikungunya vaccines, and RSV vaccines for adults, as well as “an update on the current [Texas/New Mexico] measles outbreak.”

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This post first appeared on the AFP Community Blog. More than 100 new measles cases have been reported in the U.S. since last week.