Appropriate Antibiotic Use

Did you know that November 12-18 was national Get Smart About Antibiotics Week? According to the CDC, the Institute of Medicine has declared antibiotic resistance a key threat to health in the United States. They propose decreasing the inappropriate use of antibiotics as the main solution (CDC, 2010).

According to the CDC website (found here) the campaign aims to reduce the rate of rise of antibiotic resistance by:

1.      promoting adherence to appropriate prescribing guidelines among providers,

2.      decreasing demand for antibiotics for viral upper respiratory infections among healthy adults and parents of young children, and

3.      increasing adherence to prescribed antibiotics for upper respiratory infections.

 

On Sunday November 18^th the Arizona Republic published an article (Painter, 2012) citing data from the Center for Disease Dynamics, Economics & Policy (CDDEP). (Find more information about the recent CDDEP report and related media coverage here.) The data shows that while antibiotic use is decreasing across the nation (down 17% from 1999-2010), some Southeastern states have decreased their use very little and could be posing a threat to others across the nation. According to the article, a recent Pew study indicates that 79% of adults know they can harm their own health by taking unneeded antibiotics but only 47% know they could harm others including family and community members by spreading antibiotic resistant organisms.

 

So, what influence do we as healthcare providers have in antibiotic resistance?

1.      We need to ensure that we are prescribing antibiotics only when clinically indicated,

2.      educate our patients about the appropriate use of antibiotics, and

3.      provide thorough patient education about the importance of taking antibiotics as prescribed.

 

References

Center for Disease Control and Prevention. (2010). About the get smart campaign. Retrieved

from http://www.cdc.gov/getsmart/campaign-materials/about-campaign.html

Painter, K. (2012, November 18). Study tracks U.S. antibiotic use. The Arizona Republic, p. A25.

End of Life Communication

It is important as a primary care provider to have effective communication skills for quality health 

 management. Communication skills come from experience in the classroom and in the practice setting 

 spending time talking with patients and gaining confidence in the art of communication. It is just as important 

 that providers have effective skills at discussing end of life care for patients and their loved ones. Learning 

 this vital skill allows the patient and loved ones have a full understanding of the diseases process and the 

 stages to the process of dying. According to Metzger, August, Srinivasan, Liao & Meyskens (2008) primary care providers form the backbone of an integrated team by providing an unbiased medical perspective, providing continuity during a stressful disease course, supporting patients and their families through emotional ups and downs, negotiating or mediating decisions, monitoring for complications, and providing perspective on the illness.

            Providing guidance for patients and their loved ones during end of life care needs to be viewed as a special gift that providers are allowed to be a part of.  Developing the skills needed to be an effective communicator needs to be honed by the practitioner. Han, Keranen, Lescisin & Arnold (2005) stated that no educational intervention has yet been devised to allow residents to learn and demonstrate communication skills with actual seriously ill patients in real clinical settings, although several experts argue that this would be ideal. In addition, skill development requires practice; educational interventions that simply increase knowledge may not necessarily lead to improved action. According to the JAMA (2000) physical care is expectedly crucial, but is only one component of total care. Whereas physicians tend to focus on physical aspects, patients and families tend to view the end of life with broader psychosocial and spiritual meaning, shaped by a lifetime of experiences. In addition, providers should recognize that there is no one definition of a good death and quality care at the end of life is highly individual and should be achieved through a process of shared decision making and clear communication that acknowledges the values and preferences of patients and their families.

            Provider’s patients and loved ones all play a critical role in creating the experience at the end of life. As our experience on death and dying expands, further research is needed to define our role during the period of the dying process and provide quality end of life care. The challenge for providers is to understand the feelings of patients and loved ones and  be effective at communicating the disease processes and permit a variety of expressions for a good death for everyone involved.

Reference

Han, P., Keranen, L., Lescisin, D & Arnold, R. (2005). The Palliative Care Clinical Evaluation      Exercise (CEX): An Experience-Based Intervention for Teaching End-o-Life Communication Skills. Academic Medicine: 80(7), 669-676

Metzger, Q., August, K., Srinivasan, M., Liao, S & Meyskens, F. (2008). End-of-  Life Care:        Guidelines for Patient-Centered Communication. American family Physician, 77(2) Steinhauser, K., Christakis, N., Clipp, E., McNeilly, M., McIntyre, L., Tulsky, J. (2000). Factors Considered Important at the End of Life by Patients, Family, Physicians, and Other Care Providers. The Journal; Of the American Medical Association, 284(19), 2476-2482. doi:10.1001/jama.284.19.2476

Theophylline: What you need to know

         As a future Adult Nurse Practitioner, I am seeing the effects of chronic disease on the human body. One disease I encounter every time I am working on my residency hours is chronic obstructive pulmonary disease (COPD). COPD is progressive disease that basically blocks airflow as you exhale making it harder for the individual to breathe. One medicine that is a common treatment for COPD is Theophylline. The main action of Theophylline is to relax bronchial smooth muscle to help the individual breathe easier. But there are other effects on the body such as increased heart rate, blood pressure and central nervous stimulation. Theophylline is absorbed orally and metabolized by the liver and the half life is 3-15 hours normally. This medication should be used with caution in individuals with arrhythmias, peptic ulcers, hyperthyroidism, hypertension, alcoholism, GERD, and impaired hepatic function. Almost every patient come in contact with deals with one or more of these conditions.

            Besides the drug warnings, there are different drug interactions with theophylline practitioners need to be aware of. Several of the common drugs that inhibit or increase the effects of theophylline are ciprofloxacin, ketoconazole, erythromycin, and rofecoxib. The drugs that are an  inducer or they decrease in the effects of theophylline are phenytoin, carbamazepine and rifampin. It is very important as a healthcare provider to monitor for Drug toxicity. Therapeutic range for an individual is 10-20 mcg/ml and toxic levels are >20. When a patient presents with nausea, vomiting, and tachycardia and are found to be on Theophylline, the practitioner should check levels as a differential diagnosis. The treatment for Theophylline toxicity is treatment with a short acting beta blocker and monitor for arrhythmias.

Reference

Semla, T., Beizer, J., Higbee, M. (2008). Geriatric Dosage Handbook (13^th ed.). Hudson,   OH,Lexicomp

The Study Drug

They call her “Addy”, and she’s become known on college campuses as the steroid of academics. She’s frequently sold to students in libraries when they just need a boost to stay up late studying for their big exam the next morning. She’s requested at college health centers by students who answer “yes” to questions about distractibility and trouble concentrating. And then she’s blamed for students’ demise when they are carted off to jail after being discovered as controlled substance dealers.

Addy is Adderall, a well-known stimulant used in the treatment of attention deficit hyperactivity disorder (ADHD). While there are many other brands and types of stimulants—such as Ritalin, Concerta, and Vyvanse—Adderall seems to be the favorite of college students who are looking for an edge in a fiercely competitive academic world.

The problem? Stimulants are not candy, or smart drugs (as they’re often referred to), and on top of being controlled substances, they can have serious effects on those who are not meant to take them. Stimulants can raise blood pressure and heart rate and can cause severe moodiness and depression in those who do not have ADHD.

I bring this up because a recent segment on NBC’s Rock Center with Brian Williams caught my eye, featuring an ambitious Columbia University student who became caught up in the Addy craze. You can watch the video here.

As a psychiatric nurse practitioner student in the student health center on ASU’s downtown campus, I am keen to the many student requests for stimulants for their supposed ADHD that is affecting their school performance. Now, I want to make it clear that many of these students actually do have ADHD, and may not have been diagnosed before due to denial on the part of their parents. Or they have been successfully treated for years and just need to continue their treatment on campus. However, I suspect that there are many others who have heard about the wonder study drug and have been coached on what to say so that they can convince the provider (sometimes me) that they have diagnosable symptoms of ADHD.

The unfortunate reality, given the current state of our neurobiology advancements, is that we cannot diagnose ADHD definitively with any type of biological data. As psychiatric providers, we essentially conduct a comprehensive psychiatric interview with a thorough history, and then may supplement with an ADHD rating scale. But savvy college students—or any patients, for that matter—will know what they need to say and fill out on the rating scales in order to win an ADHD diagnosis.

So while there is no current way to diagnose ADHD with 100% accuracy and weed out every fraudulent request, it is advantageous to at least become more aware of college students’ (and others’) tactics, while also refreshing our knowledge on the DSM-IV-TR criteria for ADHD.

The symptomatology of ADHD is split up into two categories: inattention and hyperactivity/impulsivity. Patients can be diagnosed with either ADHD combined type (meeting full criteria in both categories), ADHD inattentive type (meeting inattention criteria only), or ADHD hyperactive-impulsive type (meeting the latter criteria only). Diagnosable criteria require the patient reporting at least 6 symptoms from either or both symptom categories.

There are a few key points here. First, symptoms must have persisted for at least 6 months. Also, symptoms must be causing interference in functioning in at least two areas of life, such as socially and academically. And finally, at least some symptoms must have been present before the age of 7. That is the kicker. While some patients may be savvy enough to know about this criterion, many will not, and this may be where we can really hone in on the critical assessment.

While I see a lot of ADHD complaints as a psychiatric provider, I am well aware that all nurse practitioners encounter these complaints in a variety of settings. My advice is to be vigilant of patients seeking a “smart drug” or “study drug”, and perform a comprehensive assessment guided by the current DSM-IV-TR every time. Your license and your patients’ well being depends on it. 

[photo credit]

Recurrent Bacterial Vaginosis

 

        In my fourth blog, I would like to share information regarding the recurrences of Bacterial Vaginosis.  This infection generally originates in the female genital tract.  It was amazing that this week, I treated four patients daily with recurrent Bacteria Vaginosis (BV).  It is my understanding that the exact cause of the onset of this vaginal infection is still unknown.  The literature suggest that "it is associated with a reduction in lactobacilli (LB) and hydrogen peroxide production, a rise in the vaginal pH, and the overgrowth of BV associated organisms" (Wilson, 2004, p. 8).  Furthermore this infection is known to increase other risk factors like acquiring the Human Immunodeficiency Virus (HIV), associated with complications in pregnancy, and may have a direct connection with the pathogenesis of pelvic inflammatory disease.

        There are many unanswered questions regarding whether recurrent episodes of BV is the outcome of re-infection or due to a relapse.  According to the literature, if the condition is created by re-infection is it due to the type of pathogens and is it associated to behavior of the female or her male sexual partner?  If the infection is due to a relapse than what generates the disturbance of the flora?  As health care providers, we are aware that there are some predisposing factors linked to BV like douching, smoking, the use of an Intrauterine Device, younger age, and black ethnicity but the precise process for the beginning of BV is still a mystery.

        The literature suggests that BV may also be associated with sexual behavior, a recent change of sexual partner, and multiple partners.  Whatever the case maybe it is important to have therapeutic options for the prevention of recurrent BV.  Wilson (2004) suggests that "probably the ideal way of managing recurrent BV would be to tackle all aspects of the interrelation by replacing the lactobacilli, at the same time maintaining the vaginal pH at 4.5, and if necessary also adding in prophylactic treatment to control overgrowth of bacteria" (p. 11).  Hopefully by following these therapeutic options there will be a cure for the recurrences of BV.

 

Reference

Wilson, J. (2004).  Managing recurrent bacterial vaginosis.  Sex Transmitted Infection Journal, 80,

 

        8-11.  doi: 10.1136/sti.2002.002733 

 











More on supplements…

            Many people believe that a daily multivitamin is harmless and may even help prevent chronic diseases, including cancer. According to Martinez, Jacobs, Baron, Marshall, and Byers (2012) about half of all adults in the U.S. take supplements. But just how helpful are multivitamins? In 2009 a study was conducted to evaluate the impact of multivitamin use on cancer risk and cardiovascular disease in women participating in the Women’s Health Initiative study. After following the patients for eight years, multivitamin use was found to have little to no influence on risk of common cancers, cardiovascular disease, or total mortality in postmenopausal women (Neuhouser et al, 2009). This and many other studies have resulted in inconclusive evidence that there is a benefit to daily supplementation for purposes other than nutritional deficiencies (Martinez et al., 2012). As a result of the lack of current scientific evidence, federal dietary guidelines and the American Cancer Society recommend a well balanced diet with plenty of fruits and vegetables (Rabin, 2012). The provider that I work with advises his patients that they can continue to take daily multivitamins if they choose, but as long as they are eating a well-balanced diet, this is not necessary.

However, a recently published study to evaluate the use of multivitamins for the prevention of cancer in men followed male physicians over the age of 50 for about eleven years and found that daily multivitamin use decreased the incidence of cancer by 8% (Gaziano et al., 2012). Interestingly multivitamin use did not impact the incidence of prostate cancer, the most common cancer in men. However, as when evaluating all types of evidence, one should ask if the results can be generalized to the population as a whole. Upon further analysis, this study was conducted on a population of well-educated male physicians who are overall less racially and ethnically diverse and had far fewer smokers than in the general population. Additionally, the study was specific to the formulation of Centrum Silver provided to the patients in the study. Thus, this study can be a building block for additional research, but the use of daily multivitamins is not an evidence-based practice at this time.

 

References

Gaziano, J. M., Sesso, H. D., Bubes, V., Smith, J. P., MacFadyen, J., Schvartz, M., … Buring, J. E. (2012). Journal of the American Medical Association, 308(18), E1-E10. doi: 10.1001/jama.2012.14641

Martinez, M. E., Jacobs, E. T., Baron, J. A., Marshall, J. R., & Byers, T. (2012). Dietary supplements and cancer prevention: Balancing potential benefits against proven harms. Journal of the National Cancer Institute, 104(10), 732-739. doi: 10.1093/jnci/djs195

Neuhouser, M. L., Wassertheil-Smoller, S., Thomson, C., Aragaki, A., Anderson, G. L., Manson, J. E., … Prentice, R. L. (2009). Mutlivitamin use and risk on cancer and cardiovascular disease in Women’s Health Initiative cohorts. Archives of Internal Medicine, 169(3), 294-304

Rabin, R. C. (2012, October 22). Curbing the enthusiasm on daily multivitamins. The New York Times. Retrieved from http://well.blogs.nytimes.com/2012/10/22/curbing-the-enthusiasm-on-daily-multivitamins/?ref=health

To supplement or not to supplement?

            In my clinical setting I see quite a few elderly patients for annual wellness exams. Many of these patients have osteopenia or osteoporosis and take calcium supplements. These supplements include calcium-only supplements and combination supplements containing both calcium and vitamin D. For years healthcare providers have been recommending these supplements without fail. However, the provider I work with has recently changed his recommendations in light of a new study indicating calcium supplementation may increase the risk for having a myocardial infarction (MI). Earlier this year an article (which can be found here) was published that looked at the relationship between dietary and supplemental calcium intake with myocardial infarction, stroke risk, and overall cardiovascular mortality. The study findings indicated that when compared with those who did not use any supplements, those who used calcium supplements had a statistically significant increased risk for having a MI. This risk was even more pronounced for patients who used calcium-only supplements versus those who took calcium with another supplement. No elevated heart attack risk with was found with intake of dietary calcium (Li, Kaaks, Linseisen, & Rohrmann, 2012). No associations were found between calcium intake of either type and stroke risk or overall cardiovascular mortality. In light of these findings, the provider I work with now recommends completely discontinuing calcium-only supplements. If the patient is taking calcium with vitamin D he advises them of the potential increased MI risk and if they are able to take calcium in their diet he advises them to eat a diet high in calcium and continue vitamin D-only supplementation. Just some food for thought.

 

References

Li, K., Kaaks, R., Linseisen, J., & Rohrmann, S. (2012). Association of dietary calcium intake and calcium supplementation with myocardial infarction and stroke risk and overall cardiovascular mortality in the Heidelberg cohort of the European prospective investigation into cancer and nutrition study (EPIC-Heidelberg). Heart, 98, 920-925. doi: 10.1136/heartjnl-2011-301345

New Pap smear Guidelines from The American College of Obstetricians and Gynecologists

On October 22, 2012 the American College of Obstetricians and Gynecologists released a new recommendation for cervical cancer screening. In the U. S. over the last 30 years, Pap smear testing has significantly lowered rates of cervical cancer. Cervical cancer is caused by high risk strains of the Human Papilloma Virus (HPV). However, most of the HPV strains are transient and do not progress to cervical cancer. The immune system will typically clear these transient strains of HPV in about eight months.

The recommendation states women younger than 21 years should not be screened for cervical cancer regardless of the sexual experience history. Women between the ages of 21-29 years old should be screened once every 3 years if the result of the Pap smear is negative. Women between the ages of 30-65 should be screened using co-testing (Pap smear combined with HPV testing) every five years, if both tests are negative. Cervical cancer screening should be discontinued for women older than 65 years if they have no history of cervical cancer or if the Pap results were negative the past 3 consecutive times. Women who have had a hysterectomy with removal of the cervix, with no history of gynecological cancer, should no longer be screened. Any woman with a history of dysplasia will follow different guidelines until resolved, then they will return to routine testing recommendations. It is important to keep in mind that women with a history of cervical cancer, who are HIV positive, immunocompromised, or were exposed to DES should not follow routine cervical cancer screening guidelines; they must follow more frequent screening.

Here is the video link to explain the new recommendations: http://youtu.be/tzk-wKXiCQU

Reference

The American College of Obstetricians and Gynecologists [ACOG]. (2012). Ob-gyns recommend women wait 3 to 5 years between pap tests. Retrieved from http://www.acog.org/About_ACOG/News_Room/News_Releases/2012/Ob-Gyns_Recommend_Women_Wait_3_to_5_Years_Between_Pap_Tests