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

Social Networking and Health Literacy

Amanda’s blog brought up a great question regarding health literacy and the use of social networking sites. If individuals are unable to comprehend information being given to them by health care provider’s, are social networking effective at improving patient outcomes? Leea, Arozullahb, & Choc (2004) explained that low health literacy may have adverse health effects by limiting patients’ ability to comprehend health information and follow written medical instructions, to communicate with physicians and other health care providers, and to negotiate the complexity of health care and obtain proper and timely care. With such a concern for an individual’s understanding of health information, a provider must utilize any option available to reach the patients in their care.

             It is important that healthcare providers understand all aspects of educating the individual including family and friends as well as utilizing technology. If utilizing advancements in technology to reach out and provide alternative options for patients to gather information and become health literate is what we are wanting as future providers. Leea, Arozullahb, & Choc (2004) stated that support in individuals’ social networks can improve their ability to acquire and understand medical information and to negotiate the health care system. Such social support and resources would be important for those with low health literacy in facilitating the establishment of healthful attitude and behavior and would improve the health status of patients in need.

            By intertwining social networking sites and healthcare there is a possibility to make a significant change in individual’s lives. Not only can an individual get support from family and friends, they can gather helpful information from their provider as well. Technology is creating another avenue for providers to establish support for patients.

           

Reference

Leea, S., Arozullahb, A., Choc, Y. (2004). Health literacy, social support, and health: a research   agenda. Social Science and Medicine, 58, 1309-1321

Health Literacy

Understanding patient health literacy is an essential part of our daily practice. Harrington (2012) published an article about improving health literacy. Immediately following the teaching of medical information during a healthcare encounter, 40%-80% of the information is forgotten (Harrington, 2012). Limited health literacy leads to poorer health status and quality of life, difficulty taking medications correctly, increased rates of hospitalizations, lower immunization rates, decreased health knowledge, and shorter life spans. The article discusses the importance of forming relationships with patients, and active listening. Through these methods mutual trust is built, inspiring patients to participate in their care. Understanding personal needs and motivations for change lead to relevant treatment plans. The article discusses improving health literacy through the following resources for providers:

http://www.cdc.gov/healthcommunication/Audience/index.html

The Centers for Disease Control and Prevention (CDC) website offers insights about moms, teens, tweens, baby boomers, older generations, and the Hispanic cultural. These resources describe insights into the patient population, facts about the group, targeted health communication, lifestyle trends, top concerns, health-related concerns, health behaviors and attitudes, media habits, and interests and hobbies. The information is helpful to improve communication between the provider and the patient population groups listed.

https://www.train.org/DesktopModules/eLearning/CourseDetails/CourseDetailsForm.aspx?tabid=62&CourseID=1010510

The public health foundation offers a free, 5 CEU credit course titled Effective Communication Tools for Healthcare Professionals 101. This is a self-paced course that teaches providers how to manage cultural barriers, bridge knowledge gaps, and correctly use tools for low English proficiency patients.

An additional website specific to Arizona:

http://healthliteracy.pharmacy.arizona.edu/index.html

Health Literacy of Arizona offers data, publications, training resources, assessment tools, patient resources, and techniques that can be used to improve health literacy and communication between providers and patients.

References

Centers for Disease Control and Prevention [CDC]. (2012). Gateway to health communication & social marketing practice. Retrieved from http://www.cdc.gov/healthcommunication/Audience/index.html

Harrington, C. C. (2012). How can you improve health literacy? Advance for NPs & PAs, 3(10), 15. Retrieved from www.advanceweb.com/NPPA

Health Literacy Arizona. (2011). Health literacy. Retrieved from http://healthliteracy.pharmacy.arizona.edu/index.html

Public Health Foundation. (2012). Effective communication tools for healthcare professionals 101 (with continuing education credits). Retrieved from https://www.train.org/DesktopModules/eLearning/CourseDetails/CourseDetailsForm.aspx?tabid=62&CourseID=1010510

Hi everyone;

        I just wanted to share this article that I recently read in "Contemporary OB/GYN."  The article actually relates to Assignment Three that is due this week.  It is amazing the different tools we will be using in the future to relate to our patients.  Kim (2012) suggests that "social media, defined as various forms of online and mobile electronic communication with user generated content, is having a transformative impact on society and the way we communicate on a daily basis" (p. 40).  It appears that social media will definitely be the tool to link our communication with not only our friends but also our provider.  According to the literature providers are only using social media sites like Facebook, Twitter, Linkediln, and YouTube for their own personal use until some barriers like liability and patient privacy can be resolved.
        Kim (2012) explains that "direct messaging through social media sites, rather than public posts, is one strategy to ensure privacy of communications" (p. 42).  It appears that in spite of the barriers patients are showing interest in social media for patient-provider communication.  Furthermore patients are  reporting their experiences regarding their own medical conditions.  For example a "recent study used Twitter, mobile apps, and podcasts to help empower patients in a behavioral weight-loss intervention" (Kim, 2012, p. 44).  There are also many other ways that social media is being used in health care.  For example "providers have become early adopters of social media as a form of marketing and communication with the public" (Kim, 2012, p. 44). 
        Overall "social media allows free or low-cost marketing, help build brand name recognition and personalize interactions by developing relationships online, and providers can enhance their brand attractiveness by building social capital through audience engagement" (Kim, 2012, p. 44).  It is obvious that  this particular area of technology is the wave of the future.  Furthermore "by embracing these new tools, providers can communicate better with patients and expand their message to reach larger populations" (Kim, 2012, p. 46). 

Reference:

Kim, D. S. (2012).  Harness social media, enhance your practice.  Contemporary OB/GYN, 57(7), 40-46.  Retrieved:  CONTEMPORARYOBGYN.NET

  

High-carbohydrate diet linked to Alzheimer's:

 

        I am not sure if any of you had the opportunity to read today's article in the Arizona Republic, but I would like to share my thoughts on this topic. A recent study conducted by a team of researchers from the Mayo Clinic indicated that a high carbohydrate diet might be linked to mild cognitive impairment (MCI).  Also that "sugars play a role in the development of MCI, which is often a precursor to Alzheimer's disease" (Lloyd, 2012, p. A1).  The research team did their study on 1,230 people between the ages of 70 to 89.  The individuals were asked to present a dietary log from the previous year.  After evaluating the dietary logs; the number of individuals that showed no sign of MCI were 940 and were asked to continue the study for 15 months more.  At the end of the four year study 200 out of the 940 were starting to present with MCI.  According to the author the study found that "compared with people who rank in the bottom 20 percent for carbohydrate consumption, those in the highest 20 percent had a 3.68 times greater risk of MCI" (Lloyd, 2012, p. A9). 

        As health care providers we are aware that a high carbohydrate diet can be unhealthy due to  carbohydrates affecting both glucose and insulin metabolism.  Some sugar is good because it fuels the brain but "high glucose levels  affect the brain's blood vessels and play a role in the development of beta amyloid plaques, proteins toxic to brain health that are found in the brains of people with Alzheimer's" (Lloyd, 2012, p. A9). 

        In doing my own literature search regarding carbohydrates linked to Alzheimer's, I found that a high carbohydrate diet can very likely be related to this devastating disease.  Seneff, Wainwright, and Mascitelli (2011) suggests that "an excess of dietary carbohydrates, particularly fructose, alongside a relative deficiency in dietary fats and cholesterol, may lead to the development of Alzheimer's disease" (p. 134).  Furthermore Seneff, Wainwright, and Mascitelli (2011) suggest that "a first step in the pathophysiology of the disease is represented by advanced glycation end-products in crucial plasma proteins concerned with fat, cholesterol, and oxygen transport.  This leads to cholesterol deficiency in neurons, which significantly impairs their ability to function" (p. 134).  Apparently over a length of time the "response leads to impaired glutamate signaling, increased oxidative damage, mitochondrial and lysosomal dysfunction, increase risk to microbial infection, and, ultimately, apoptosis.  Other neurodegenerative diseases share many properties with Alzheimer's disease, and may also be due in large part to this same underlying cause" (Seneff, Wainwright, & Mascitelli, 2011, p. 134). 

        I am not sure if  changing to a low carbohydrate diet is the answer to fixing MCI, which is a precursor to Alzheimer's disease but it is a topic that is vital to address.  "Epidemiological indicators suggest that the incidence of Alzheimer's disease in the U.S. and likely the Western world is currently increasing at an alarming rate and disproportionately with the increase in the aged population" (Seneff, Wainwright,  & Mascitelli, 2011, p.138).  It is obvious that this disease is  devastating, "in terms of both mental anguish and health care costs" (Seneff, Wainwright, & Mancitelli, 2011, p. 138).  As health care providers it is our responsibility to continue the study regarding the cause of this horrible disease and especially continue to educate our patients regarding a healthier diet.  

 

Reference:

 

Lloyd, J. (2012, October 19).  Study ties diets heavy in carbs to Alzheimer's.  The Arizona Republic.

Retrieved from http://www.azcentral.com

 

Seneff, S., Wainwright, G.,  & Mascitelli, L.  (2011).  Nutrition and Alzheimer's disease: The detrimental role of a high carbohydrate diet.  European Journal of Internal Medicine, 22, 134-140.

 

  

 

 

 





IOM Report 2012: Calling All Lifelong Learners

The Institute of Medicine (IOM) released its latest report last month on the healthcare system. While this may not be the most exciting thing you’ve heard all week, allow me to recast this bureaucratic, lengthy report in a much brighter light.

The report (which can be found here) is titled Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. I found the 5-page report brief to be incredibly informative, succinct, and relevant to what we are learning here in our DNP program, and to the challenges we face while participating in patient care. In essence, the report highlights the inefficiencies and lack of quality with which healthcare is currently delivered in this country, and sets out specific recommendations to produce a more adaptive and efficient system. Let me briefly discuss what I found to be the three essential components recommended for our current healthcare system.

A comprehensive use of technology. Using technology tools in healthcare, such as EHRs and patient portals, are no longer considered optional. In order to continuously and effectively adapt to the complex and changing system of healthcare—which is made up of complex and changing patients—we must utilize the affordable and convenient tools that are available to us. This means creating patient portals where patients and clinicians can share knowledge, resources, and other information. It means connecting with clinical databases that offer real-time clinical decision-making support. It also means capturing all data—including patient and financial outcomes—electronically, in order to continuously assess the healthcare processes and make changes more quickly.

Patients as an integral part of the healthcare team. Patient inclusion and empowerment is, thankfully, a growing trend in healthcare discussions. In this report, the IOM repeatedly references patients as being an essential part of the clinical decision making process. Treatment plans should be tailored to the individual needs and preferences of each individual patient. Patients should be encouraged to use patient portals for education, communication with providers, and sharing of data that can be used to evaluate patient reported outcomes. In response to the call for greater use of technology, it is even proposed that technology developers create digital tools that can further empower patients in managing their own care.

An open culture of learning. The cultural wisdom is clear and we all know it is true: The best experts in any field are the ones who are lifelong learners. The unending thirst for knowledge can be instilled in practitioners through their education programs, which should offer students the most current knowledge and skills in accessing, managing, and applying evidence for practice. However, the workplace culture is what must continue to support this quest for knowledge by offering a safe place for questioning, adapting, and collaborating. Healthcare leaders (which includes us) need to embody the qualities of respectfulness, transparency, and inquisitiveness in order to foster a culture of lifelong learning.

For there is only one constant in the complexity and chaos of healthcare: Change. 

[photo credit]