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Popular in Dental Public Health Sciences
This 16 page Class Notes was uploaded by Craig Sipes on Wednesday September 9, 2015. The Class Notes belongs to DPHS 510 at University of Washington taught by Peter Milgrom in Fall. Since its upload, it has received 19 views. For similar materials see /class/192625/dphs-510-university-of-washington in Dental Public Health Sciences at University of Washington.
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Date Created: 09/09/15
From Chapter 8 Knowledge Resources Finding Answers to Primary Care Questions Debra Ketchell Leilani St Anna Sherry Dodson Sarah Safranek Terry Ann Jankowski in Informatics for Primary Care Providers Edited by Norris Fuller TarczyHornoch Goldberg 900 am Your clinic day starts with a teenage girl whose blood sugars are elevated and insulin requirements are increased She reports that her weight is down You probe and discover she has been taking Mahuang for weight control You believe that the weight loss may not be worth the risk and recommend that she stop taking Mahuang until a followup visit in two weeks Before her next visit you will review the evidence on the safety of this herbal supplement for adolescent diabetics Natural Medicines is the best first source to answer our busy primary care providers question about use of Mahuang for weight loss and effects in a diabetic teenage patient Our provider searches for ma huang and retrieves a tabularized summary ofthe Ephedra the generic name Underthe heading interactions with diseases and conditions our provider reads that this substance many interfere with blood sugar control and may exacerbate high blood pressure and circulatory problems in people with diabetes Performing the same search in AltMedDex leads to an extensive evaluation of the literature on Mahaung with diabetes listed as the first contraindication Our provider contacts her teenage patient to insure that she has discontinued use ofthis product 920 am Your next patient is a 42yearold woman who has nearly finished her radiation for stage2 breast cancer with adjuvant chemotherapy She tells you that her family is planning a vacation in Belize to celebrate and asks if she should get a Hepatitis A vaccination and take any precautions for diarrhea To answer her concerns you need to determine any contraindications for HepA and considerations about travelers diarrhea specific to immunosuppressed patients Should you recommend a Hepatitis A vaccination for a woman completing adjuvant chemotherapy for Stage II breast cancer who will be traveling to Belize for a week s vacation What is your recommendation for preventive treatment oftravelers diarrhea Our provider links to CDC Travelers Health and finds the Health Information for Travelers to Mexico and Central America A map indicates that Belize and all Central America are at high risk for Hepatitis A A deeper link recommends HepA vaccine as safe for immunocompromised patients For the question about traveler s diarrhea she links to the Food and Water Precautions and Travelers Diarrhea Prevention section on the CDC site where it states that travelers are advised to pay meticulous attention to choice of food and beverage to help prevent travelers diarrhea However the CDC does not recommend the prophylactic use of antibiotics even for immunocompromised travelers because antibiotics may cause additional problems What are the latest recommendations for preventive treatment of travelers diarrhea Our provider returns to this question at the end of the day as more of her patients will be presenting in the next month before they travel to sunny vacation spots in Central and South America She searches Clinical Evidence and finds that empirical treatment with antibiotics shortens illness duration in adults with diarrhea acquired overseas and scans the discussion about nondrug preventive interventions antimalarial vaccines and antimalarial interventions in children and pregnant women Moving on to the Cochrane Library she finds a systematic review that concludes antibiotic treatment is effective in reducing the duration and severity of symptoms but carries the price of increased risk of side effects She turns to the CDC Travel Health source and searches for the new drug malarone and the new the fact sheet for health providers noting the most adverse effects 940 am A 74yearold man who is 4 weeks out from a right hip replacement presents with excruciating lower back pain of 36 hours duration He describes the pain as burning searing and unremitting You suspect infection but note that he has no fever and his rehabilitation has been progressing normally He denies dysuria falls or trauma to his hip or back Upon physical exam you note erythematous papules that follow the fifth lumbar sensory nerve distribution and you realize you need to refresh your memory as to the skin findings for herpes zoster while you send the patient for lab tests and hip xrays How would our primary care provider followup on her 74yearold patient with erythematous papules An all too common scenario is that the clinic s dermatology text is missing or doesn t contain sufficient color images to match the patient s presentation An electronic alternative is called Dermatology Atlas Online is available on the Web see Table 3 This atlas contains thousands of abnormal skin images Our provider searches for herpes zoster and retrieves 17 images that denote the natural history of shingles Using the zoom image feature she decides that several images match the appearance and distribution ofthis patient s erythematous papules With an initial diagnosis in mind she links to UpToDate or Habif s Clinical Dermatology in MD Consult and finds a good description of pathogenesis natural history and complications of shingles in an immuno competent patient 1000 am Next you see a 58yearold man with leftsided Bell s palsy of 36 hours duration You know that some physicians prescribe steroids and possibly antiviral medications but wonder whether there is evidence that this is any better than watchful waiting Is there evidence that prescribing an antiviral corticosteroid or both to a 58yearold man with left sided Bell s palsy is better than watchful waiting Our provider first searches the Cochrane Library and finds there are two protocols in progress but no completed reviews She moves on to Clinical Evidence and finds a succinct description ofthe evidence on drug therapy for Bell s palsy Specifically it states that while the combination of steroids and acyclovir and steroids alone have been used there is not yet adequate evidence to support drug therapy note Clinical Evidence summary evidence has changed since chapter was written 1020am Your next patient is a 72yearold woman with osteoarthritis of the knees accompanied by her daughter a lab tech from the hospital The daughter wants you to give her mother a prescription for one of the new COX2 inhibitors She has heard that they cause less GI bleeding Her mother is concerned that the new drugs will mean more out of pocket costs each month You want to do some research comparing coxibs with established NSAIDS with regard to GI bleeding and efficacy in pain control What about the 72yearold woman patient with osteoarthritis of the knees Our provider wants to do some research comparing coxibs with traditional NSAIDS comparing pain control and GI bleeding A TRIP search on cox inhibitors identifies and provides a direct link to a Bandolier review titled Cox2 Roundup Another click and our provider is perusing a review and comparison on the efficacy of Cox2 in acute and chronic pain and adverse effects as compared with NSAIDs Bandolier typically provides helpful tables such as the table of effectiveness of coxibs and analgesics in acute pain models To update this review our provider searches the PubMed Clinical Queries database for cox AND osteoarthritis which identifies some review articles published after the Bandolier review 1040am Next you see a 57yearold woman for a routine well woman exam She is currently on hormone replacement therapy HRT but expresses concern about the risk of breast cancer She has searched the Web and PubMed looking for information about the pros and cons of HRT although there is no family history of breast cancer and previous exams and mammograms were normal You agree that the medical literature is not definitive and recommend that she not discontinue therapy until you can email her a review ofthe best evidence based on her specific profile Is there an evidencebased review of the risks and bene ts for HR T Our provider searches for hit in UpToDate retrieving the ERTrisk of breast cancer section and then the more general ERT benefits and risks section If our provider has a PC in the exam room she could discuss this summary of evidence from the primary literature during the visit and print relevant sections for the patient to review and compare to the information she found when searching the web and PubMed Selected Med Director39s Library Tips of the Month Debbie sends a message to the medical director who distributes to many administrative types Tips use a clinical scenario written by Sherry Dodson to focus on an information resource Some of the answers might be outofdate but the topics are probably still useful February 2002 Case Knee pain in a 45 yo woman A 45 yo women presents to your office with right knee pain of one month39s duration She39d previously run cross country in college and continued distance running until a biker crashed into her on the Burke Gilman trail causing a right ACL injury requiring surgery 10 years prior She describes morning stiffness and crepitation and pain that is relieved with ibuprofen Physical exam reveals a tender medial joint with no swelling or palpable warmth Her family history is significant for osteoarthritis You send her for xrays and accompany your medical student to the call room to review the latest on treatment of osteoarthritis your current diagnosis Your medical student suggests using PrimeAnswers a new web site that she39d heard about during her last rotation PrimeAnswers can be accessed from the top of the Care Provider Toolkit or by going directly to the site at wwwprimeanswersorg Immediately you hone in on quotosteoarthritisquot one of 16 quotcommon conditionsquot and are taken to a page with therapy patient education and quotfast searchquot The medical student suggests that you look at PrimeEvidence for osteoarthritis In one fell swoop you39ve retrieved an evidence summary from Clinical Evidence a systematic review from eWJM and a topic review from Journal of Family Practice Applied Evidence not to mention a scripted search into UpToDate MD Consult and Micromedexl You print out the topic review quotEvaluation and treatment of the patient with osteoarthritisquot J Fam Pract 2001 Sep5097917 and thank your medical student as together you read over the place of medication exercise physical therapy and complementary medicine for osteoarthritis Just 4 clicks got you all the way to the full text of a recent evidencebased review The PrimeAnswers project come to you from the Health Sciences Library and is funded by a grant from the National Library of Medicine The site is designed to bring the best evidence to primary care providers at the point of care and we invite you to use the site and send your comments December 2001 Case Leg pain and a targeted skin lesion A 55 yo male with a history of uncontrolled type 1 diabetes presents to your office complaining of a painful skin lesion on his left leg and concern that he has cutaneous anthrax Questioning reveals that he39s had a 3 day history of fever currently 1007 and hasn39t felt like eating Examination of his left leg shows that his painful skin lesion is circumscribed and erythematous with a dusky grey center Although he39s very anxious about anthrax you39re not able to elicit a history of any kind of animal exposures or quotwhite powderquot exposures and he39s not employed by the postal service You step out ofthe examining room to try to locate a derm text and remember an email from your medical director announcing a new PrimeAnswers website available at the top of the Care Provider Toolkit A search for anthrax in the top left hand search box on PrimeAnswers httpwwwprimeanswersorg pulls up 4 hits including a topic review in NEJM NEJM39s is one ofthose journals that requires another logon and password from the Health Sciences Library hsluwashingtonedu but you already have the logon and password enter it and drill down to the section on cutaneous anthrax to read that those lesions are generally painless and much more edematous than what you39re seeing Not having found the derm book in your office you enter quotanthraxquot in the skin conditions section of PrimeAnswers homepage which you notice has two derm sources including Habif s Clinical Dermatology Upon viewing the image you page the ID Fellow and return to the examining room to assure your patient that his lesion is not characteristic of anthrax You send him down to the lab and ask him to return to your office after the lab tests Upon hearing the history the ID Fellow suggests that the lesion may be ecthyma gangrenosum caused by pseudomonas bacteremia with seeding of the skin You start the patient on a course of antibiotics and arrange for careful followup with lab tests results November 2001 Case Grayish Blue Skin Discoloration A 36 yo male presented to a primary care clinic with a two week history of grayish blue discoloration of his skin He was examined by a resident who noted a normal physical examination with clear equal breath sounds a regular heart rate of 94 without murmurs gallops or rubs and a normal head and neck exam except for the grayish blue discoloration of his skin His past medical history was signficant for a positive yme titre for which he39d been prescibed antibiotics while living in rural Pennsylvania two years prior Although the patient denied any valvular heart disease the resident ordered a blood gas which proved normal to rule out cyanotic heart disease Careful questioning by the resident did not reveal any other symptoms or history and the resident consulted the attending physician to help evaluate the patient After additional questioning they were finally able to solicit a history of ingestion of colloidal silver as a more quotnaturalquot substitute for the antibiotics prescribed for his Lyme disease Following the advice given on homeopathic web sites he had purchased and was ingesting 14 cup of colloidal silver 3 times per day The patient enthusiastically described the benefits of silver which he touted as a protective agent for anthrax and other biological weapons not to mention colds cancer and GI disorders The attending physcian and resident stepped out ofthe examining room and looked up colloidal silver on the Natural Medicines Comprehensive Database httpwwwnaturaldatabasecom from the Care Provider Toolkit Written by pharmacists physicians dieticians and pharmacologists the Natural Medicines Comprehensive Database provides practical and scientific data on natural medicines including all known adverse reactions Typing in quotcolloidal silverquot and arrowing quickly down to adverse reactions revealed the diagnosis of argyria and this description quotOral or topical use of colloidal silver can lead to argyria an irreversible bluish skin discolorationquot To help confirm their diagnosis they also wanted to find a picture of argyria and checked UpToDate MD Consult and the Dermatology Atlas Online with no luck Finally a PubMed MEDLINE search pulled up quotImages in clinical medicine Argyriaquot from N Engl J Med 1999 May 20340201554 The resident had obtained a password from HSLIC for online New England Journal of Medicine so they were able to study the online image The resident also showed his attending physician where he could request a password from the library using the Password Request Form httphealthlinkswashingtoneduhslformspasswordshtml from the HealthLinks Journals page httphealthlinkswashingtonedu39ournals Finally they returned to the patient39s examining room and advised him to stop taking colloidal silver and also arranged for a visit to the Dermatology Clinic to confirm their diagnosis October 2001 Case 25 yo male with upper body rash elevated LFT39s and lymphadenopathy A 25 year old man presents to an outside ER with a 3 day history of maculopapular rash on his shoulders neck and arms He had been started on dilantin 3 months prior for new onset seizure disorder The ER doc dc39d the dilantin switched him to carbamazepine and sent him home with benadryl His rash improved for about a day but he presented again to the ER with lymphadenopathy facial edema worsening rash over his entire body and slightly elevated LFT39s He was transferred to the Medicine Service at UWMC where some of the questions raised were could dilantin hypersensitivity present this far out was carbamazepine the correct drug to substitute for dilantin and is the rash consistent with dilantin hypersensitivity A quick check of dilantin hypersensitivity in Micromedex indicated that skin eruptions do occur in up to 10 of patients and they can occur up to 3 months after starting the drug The next question was whether to continue the carbamazepine A search for dilantin hypersensitivity in PubMed revealed two articles that were extremely helpful quotCrosssensitivity and the anticonvulsant hypersensitivity syndromequot from J Emergency Med 1999 MayJun1735036 did not have a UW icon on PubMed but was one ofthe 2000 other online journals available on HealthLinks You pull up the article from the Journals page on HealthLinks httphealthlinkswashingtonedujournalsl and read about the crosssensitivity of phenytoin carbamazepine and phenobarbital You then dc the carbamazepine and replace it with valproic acid quotDilantin hypersensitivity reactionquot Cutis 1996 Apr574223226 was not available online but you visit HSLIC when it opens at 7am and photocopy the article for your team The photos ofthe skin eruptions in the article are very similar to your patient39s skin findings The patient39s symptoms slowly resolve and he is discharged home on valproic acid In addition you vow to contact the outside ER and send followup to the patient39s primary care provider September 2001 Case Impacted wisdom teeth in a 26 yo female with MVP A 26 year old female patient presents to your office for routine followup care Her medical history is notable for asthma controlled with an inhaler and mitral valve prolapse MVP with no regurgitation or wall thickening She39s very concerned about her dentist39s recommendation that she have her asymptomatic impacted wisdom teeth pulled and wants to know your opinion According to your patient her dentist routinely advises wisdom tooth extraction to prevent future infection tooth crowding and possible malocclusion If she does have her teeth extracted will she need a course of antibiotics due to her MVP You quickly search a new onine tool Clinical Evidence on the Care Provider Toolkit httphealthlinkswashingtonedutooIkitscareproviderhtml and pull up a concise summary ofthe best available evidence on the prophylactic removal of impacted wisdom teeth quotWe found no RCTs on the effects of prophylactic removal of asymptomatic impacted wisdom teeth Nonrandomised studies provide no evidence of benefit Removal of lower wisdom teeth causes permanent numbness ofthe lower lip or tongue in about one in 200 peoplequot You print out the summary and hand it to your patient along with the references so she can discuss this with her dentist Clinical Evidence from BMJ Publishing is a unique new tool that has been called the quotfriendly front end of the Cochrane Libraryquot since it takes the Cochrane Library and other evidencebased sources and pulls them together in one place in a concise format The focal point ofthis resource is the selection of clinical questions ie what are the effects of prophylactic removal of wisdom teeth Treatment options are listed after each clinical question and the benefits and harms ofthe interventions are summarized You39ve heard that there are new AHA guidelines for infective endocarditis prophylaxis for patients with cardiac conditions but you need to refresh your memory a bit That evening you take a quick look at UpToDate which doesn39t quite have the details you need but quickly leads you to the original article in JAMA Prevention of bacterial endocarditis Recommendations by the American Heart Association JAMA1997 Jun 11 277221794801 Using the seach feature on HealthLinks you pull up the JAMA article fulltext and scan the section on moderate risk which has a lengthy discussion on which MVP patients might be at risk for IE as well as a detailed figure that helps you decide how to advise your patient June 2001 Case Perioperative risk in an 89 year old female with hip fracture A 89 year woman sustained a right femoral hip fracture while trying to make her bed Her past medical history is complicated by CAD Parkinson39s osteoarthritis and osteopenia A UWPN patient she came by ambulance to the ER Her MlNDscape record indicated that she39d had a stress thallium scan in 1999 showing ischemia and no infarction She and her PMD had chosen medical management and she was on a beta blocker as well as other meds The Orthopaedic Resident called the Medicine Resident to admit the patient and manage her until a decision could be made about the timing for hip replacement surgery A number of questions were raised by this case How much of an operative risk is this patient What39s the evidence for using betablockers to prevent a perioperative cardiac event The Medicine Team admitted the patient at 2am and went right to work finding answers to these questions A search for perioperative risk in the National Guidelines Clearinghouse httpwwwngcgovindexasp from the Care Provider Toolkit pulled up major recommendations from both the ACCAHA Guidelines and the ACP Guidelines done in 3996 The complete fulltext ofthese guidelines Circulation 1996 Mar 159361278 317 and Ann Intern Med 1997 Aug 15127431328 was retrieved from the Journals page on Healthlinks Since the guidelines did not rule her out as a surgical candidate but showed that she was at risk for a cardiac event the senior resident opted to search PubMed to find the evidence for using betablockers in such cases She searched PubMed iteratively and the search required some finesse using the MeSH Browser the Clipboard and the History features all ofwhich she39d learned from the Department39s Library Liaison Of the 8 current citations that were pulled up on the search 7 were available fulltext on HealthLinks indicated by the UW purple logo on the abstract These articles included RCT39s and a persuasive review article The case for betaadrenergic blockade as prophylaxis against perioperative cardiovascular morbidity and mortality Arch Surg 2001 Mar136328690 showing the benefit of betablockers in high risk patients The materials were attached to the patient39s chart and discussed with the Orthopaedic and Medicine Teams the next morning Interested in learning to search PubMed with finesse Contact HSLIC at hsluwashingtonedu or call 206 5433390 and we39ll put you in touch with your library liaison May 2001 Case Fungal Toenail Infection in Diabetic Woman A 60 year old type 2 diabetic woman presents to your office for routine followup care Your foot exam reveals what is suspicious for onychomycosis so for you and your accompanying medical student39s edification you need to find a derm atlas with color images for comparison The medical student is unsuccessful in finding the clinic39s derm textbook and turns to the HealthLinks Care Provider Toolkit where she finds the Dermatology Atlas Online A quick search on quotonychoquot retrieves a panel of 22 thumbnails color images for comparison Clicking the tab for differential diagnosis lists 12 other diagnostic possibilites with images The images confirm your suspicion and you obtain a specimen to send out to the lab and tell the patient that you39ll be calling with a laboratory diagnosis and treatment plan In the meantime you ask your student to research the efficacy cost and potential harms ofthe antifungals for nail infections Later in the day she presents a Cochrane Review on topical treatments for fungal infections of the skin and nails ofthe foot published in May 1999 a review article in the February 15th issue of American Family Physician and an evidence review comparing itraconazole and terbinafine in the Aug 2000 issue of the American Board of Family Practice Journal She printed all three from the online journals on HealthLinks She reports that while the older Cochrane study recommends with azoles first and then allylamines due to cost but these were in the UK that the AFP article recommends terbinafine as firstline therapy for most cases which also carries the least risk of drug interactions the other two antifungals carry an increased risk of hypoglycemia and finally that the ABFPJ drug review concludes there is no significant differences in safety tolerability and efficacy but that terbinafine appears to have a more preferable drug interaction profile and is more costeffective based on Red Book retail figures April 2001 Case Effectiveness of Cinnamon for Blood Glucose Control A 52 year old woman presents to your office with newly diagnosed type 2 diabetes and a number of questions about natural remedies for blood glucose control particularly the value of fenugreek seed glucomannan oat bran and cinnamon for blood glucose control She has done a lot of research and has a stack of photocopies but wants to know your opinion Further discussion reveals she is most interested in cinnamon Since cinnamon is not currently in your armamentarium you advise your patient to continue with her prescribed metformin exercise and diet plan and you will check into cinnamon for diabetes Later in the day you check the quotDrug Referencequot section ofthe Care Provider Toolkit from Mindscape and discover the Natural Medicines Comprehensive Database which is an evidencebased source for natural products including herbals and nutritional supplements You click on the link the quotloginquot button on the next page the library has subscribed for you and then the quotsearch databasequot You type quotcinnamonquot in the search box and retrieve two different forms cinnamon bark and cinnamon flower Choosing bark you find diabetes listed under interactions with diseases where it states quotThere is some concern that cinnamon bark might interfere with blood glucose control in patients with diabetes Some cinnamon constituents seem to increase blood glucose levels Ref 4 and others seem to lower blood glucose levels Ref 6657 So far the clinical significance ofthese effects in patients with diabetes is not known Tell patients with diabetes to use cinnamon products cautiously Suggest they monitor blood glucose levels more closely Dose adjustments to diabetes medications might be necessaryquot You take another two minutes to search quotcinnamon AND diabetes OR insulin OR glucosequot in PubMed retrieving 10 articles While all the articles are animal models the most recent is a review entitled quotInsulinlike biological activity of culinary and medicinal plant extracts in vitroquot from the Human Nutrition Research Center of the Dept of Agriculture published in the J Agric Food Chem March 2000 Happily you see there is a link to the 3page online article which you print in a very readable PDF format to scan over lunch This article indicates that cinnamon was the most effective botanical leading to increased insulin sensitivity March 2001 Case Fever confusion elevated LFT39s and mild urethritis in a 80 year old male on dilantin An 80 year male came to the ER with confusion fever a slightly elevated white count and mild urethritis His only medication at that time was dilantin which he was taking for seizures postmeningioma resection one year prior He was admitted to the hospital for presumed urinary tract infection and started on levofloxacin Two days into his hospital course he developed an abdominal rash levofloxacin was discontinued and he was started on ceftriaxon His lab tests were remarkable for mild transaminitis and eosinophilia When the rash didn39t improve by hospital day 4 and other tests were negative the senior resident reexamined the history and discovered that his patient had been switched from carbamazepine to dilantin six weeks prior to admission A quick check on Micromedex confirmed that phenytoin hypersensitivity often presents in this fashion Both his antibiotic and anticonvulsant were discontinued and the patient recovered uneventfully A quick search of quotphenytoin hypersensitivityquot limited to English articles on PubMed MEDLINE provides two review articles on diagnosis and management Both illustrate online journals that are not linked directly from the reference in PubMed but are linked from the HealthLinks Electronic Journals page J Am Board Fam Pract 2000 SepOct13536470 Anticonvulsant hypersensitivity syndrome Kennebeck GA Drug Saf 1999 Dec2 l 61489501 Anticonvulsant hypersensitivity syndrome incidence prevention and management Knowles SR Shapiro LE Shear NH February 2001 Question Funduscopic Exam for CML patient with headache A 31 year old CML patient with fever fatigue and abdominal pain comes to the ER at 1am on the advice of the Oncology Fellow The admitting Medicine resident and his intern complete a thorough physical exam which is fairly unremarkable Upon further questioning the patient mentions a slight headache prompting a funduscopic exam which reveals unilateral left eye edema Wondering if this was leukemic infiltration that would damage the patient39s sight our residents pull up MD Consult on the PC in the ER and search for quotleukemiaquot and quoteyequot The first reference is Yanoff39s Ophthalmology which includes a color image of leukemic retinal infiltrate that matches the funduscopic exam Based on this information the Ophthalmology Service is called to come in to do a further workup Continuing their search in MD Consult in the Journal Literature results our residents find a recent review article in Opthalmology Clinics of North America Management of systemic malignancies metastatic to the eye andlt orbit Gombos DS Ophthalmol Clin North Am 1999 Jun12222523 and jump to the quotpresenting signs and symptomsquot and quotworkupquot sections End of the Story 1 The patient39s sight is saved by radiation therapy that morning 2 The resident39s make a big impression at morning report January 2001 Question What are the adverse effects of a new antimalarial drug A 50 year old woman comes to your office as a new patient requesting malaria prophylaxis in preparation for a cruise to temperate and tropical South America She asks about malarone a new antimalarial recommended by friends This patient is quite well read and searches the web for health information She found an abstract to a recent Lancet article in PubMed describing comparing maladrone and mefloquine that indicates the newer drug has fewer side effects Reviewing her current medications you note that she is on telmisartan for hypertension You turn to your PC to find current information to discuss the benefits vs harm of this newly approved drug for malaria prevention antimalarial alternatives and any documented interactions with telmisartan From the HealthLinks Care Provider Toolkit you select CDC Travelers39Health and search for malarone The first quothitquot is the Oct 27th Information for Health Care Providers on Malarone for Malaria Treatment and Prophylaxis It says that malarone a combination of atovquone and proguanil hydrocloride was approved in the US in July 2000 for both treatment and prophylaxis of malaria It states that malarone is now one of three options the others are mefloquine or doxycycline for prevention of malaria when traveling to areas with chloroquineresistant P falciparum malariaquot and further that quotthe most common reported adverse effects were abdominal pain nausea vomiting and headache There is a linkto a Malaria Prevention article that notes protection as well as antimalarial drugs You print offthe information to give your patient You return to the Care Provider Toolkit select Micromedex and search for malarone to discover a clinical review highlighting malarone39s high effectiveness and low toxicity The major adverse reactions are listed rash nauseavomiting diarrhea headache fever insomnia asthenia pruritus anemia rare neutropenia rare hyponatremia elevated hepatic enzymes Since Micromedex includes European drug data you also find a UK monograph on malarone A review ofthe cautions and adverse reactions reveals no known cardiovascular effects or interaction with telmisartan As a doublecheck you also search for this antihypertensive and find no known drug interactions with antimalarials You do notice a contraindication with ephedra and warn your patient that she should not take Mahuang as it will diminish the effectiveness of telmisartan September 2000 Question Drug therapy for Bell39s Palsy A 58yearold woman presents to your office with 36 hours of Bell39s palsy on the left side of her face You must decide between an antiviral a corticosteroid the combination of both drugs orwatchful waiting You wonder what the evidence is for therapy You first try the Cochrane Library the gold standard for comprehensive systematic reviews Although there are two protocols with anticipated completion dates of 42000 there are currently no completed systematic revrews You jump to the new Clinical Evidence website register for the free trial and type quotBell39s Palsyquot in the search box Clinical Evidence succinctly describes the evidence to date and the quality of the studies on drug therapy for Bell39s Palsy Although the combination of steroids and acyclovir and steroids alone have been used according to Clincal Evidence there is not yet adequate evidence to support drug therapy Clinical Evidence is a book about evidence only without recommendation and judgment based on the assumption that the decision to apply evidence toward patient care rests with the clinician A product of BMJ Publishing with an impressive list of editors and authors Clinical Evidence summarizes RCTs and systematic reviews for relevance The organization simulates the types of questions that arise in patient care Updated every six months it now covers about 300 questions or conditions and most of the data relates to therapeutics Both benefits and harms are listed and the authors take pains to point out gaps in knowledge by indicating where evidence is lacking Clinical Evidence is not your usual textbook but rather a new breed of regularly updated evidence on August 2000 Question Acute Hepatic Failure and Possible Liver Transplant Your medical assistant flags you down with an urgent phone call from Gloria Newton whose family members have been long time patients Gloria frantically describes a phone call from the critical care unit of a university hospital in the Midwest where her son Matt is a graduate student Over the weekend Matt had been training for a marathon with a group of friends and collapsed unconscious His friends were able to get him to an emergency room where the initial diagnosis was exertional heat stroke The Midwest had been suffering from extreme heat and high humidity Gloria went on to explain that she and her husband were now told that Matt had acute liver failure as a result of the heat stroke and may need livertransplantation Although Matt had regained consciousness he was in the critical care unit and they39d made arrangements to fly emergently to be with their son Gloria blurted out a whole host of question including what is Matt39s prognosis what tests and procedures might be done which drugs might he receive and did you have anything about liver failure or liver transplantation that they could take with them to read on the plane You put Gloria on hold for a minute and try to find your nurse who is so helpful with patient education materials Your nurse is in with a patient so you pull up the Care Provider Toolkit on HealthLinks choose Micromedex Patient Leaflets and type in quotliver failurequot There are three excellent handouts that cover acute hepatic failure and its causes and treatment options including livertransplantation Typing in quotliver transplantationquot also produced three additional handouts covering general information inpatient care and discharge instructions all quite comprehensive and written for a lay audience You choose quotPrint Readyquot and produce documents on to which you type words of encouragement for Matt and the Newton family as well as your phone number and email in case they wish to keep in contact from the Midwest July 2000 Question Ruleout MI in a patient with newly diagnosed diabetes cultural communication issues A 43 year old male and recent immigrant from Mexico is brought to the ER for angina and admitted to the Cardiology Service for ruleout of MI Dr Pace a new fellow from Vermont sees the patient with an interpreter but feels the history is inadequate and the patient may not be expressing the problem due to lack of eye contact The lab work comes back notable for a blood glucose of 323 and Dr Pace returns to the patient to obtain a diabetic history Through the interpreter he discovers that the patient has controlled his diabetes for many years with herbal teas provided by his curandero Dr Pace knows he needs a better understanding of the cultural issues to help this patient and is referred to the Patient Education section ofthe HealthLinks Care Provider Toolkit He discovers Cultural Clues and EthnoMed ln Cultural Clues he clicks on Latino Scanning the twopage tip sheet he notes that Latino patients may seek medical care from curanderos or folk healers and understands that his patient39s lack of eye contact may actually be a show of respect Furthermore his patient could be passive during an illness Both Cultural Clues and EthnoMed are designed as practical tools to help busy clinicians communicate more effectively with patient of diverse cultures Cultural Clues currently offers a twopage tip sheet for Albanian Latino and Russian patients as PDF documents Vietnamese and Korean will be added soon The clues are developed by the a workgroup of the UWMC Patient and Family Education Committee EthnoMed provides more information on the culture and their beliefs and specific medical topics eg TB hepatitis breastfeeding and currently covers Amharic Eritrean Oromo Somali Tigrean Cambodian and Vietnamese EthnoMed also includes cultural pearls on crosscultural medicine and immigration issues The community profiles are developed with and reviewed by the members of the local ethnic organizations as a joint project of of Harborview Medical Center39s Community House Calls Program and the library May 2000 Question Is Mahuang a safe herbal for a dieting diabetic adolescent A17 year old diabetic adolescent presents to her primary care provider for routine diabetes care She mentions that she39s had higher blood sugars and that her insulin requirements have increased Upon further questioning she reveals that she39d been taking Mahuang an herbal preparation to help her with weight loss She asked if there might be a relationship between Mahuang and hyperglycemia and her PCP suggests that she discontinue the Mahuang until she can check its safety Entering the term quotcomplementaryquot on the top lefthand query box on HealthLinks led to a number of likely sources on the Complementary and Alternative Medicine page including two new resources the AltMedDex database in Micromedex and the Natural Medicines Comprehensive Database The PCP selects the Natural Medicines database Produced by pharmacists and physicians it is scientificallybased and updated daily Note Just click the login button on the first page ofthe database we39ve licensed it for you A search on quotmahuangquot retrieves an extensive monograph under the scientific name Ephedra and discusses possible interference with blood sugar control and circulatory problems in people with diabetes In addition there is information on alternative names eg Sea Grape Teamster39s Tea Yellow Astringent uses and dosages mechanisms of action and interactions with drugs diseases foods and other herbal meds Based on this monograph the PCP calls the young diabetic girl and advises that she permanently discontinue the use of Mahuang February 2000 Question Is hirudin dialyzable A quick thinking nephrologist searched PubMed Medline looking for information that might help his team manage an ICU patient who was hospitalized for renal failure complicated by deep venous thrombosis DVT She was initially treated with heparin but developed heparininduced thrombocytopenia Hirudin a new anticoagulant was the drug chosen to manage this patient39s DVT Unfortunately the patient had significant bleeding after a PEG tub was placed The hirudin was stopped but the bleeding persisted A PubMed search revealed two articles that might answer the question of whether hirudin was dialyzable One journal was available on site at Harborview Medical Center but the second journal Thrombosis and Haemostasis was not available at Harborview nor on the Journals39 page on Healthlinks The nephrologist called the Health Sciences Library stated the clinical urgency ofthe request and the article was pulled and faxed within minutes Based on the information provided in the two articles the drug was rapidly and successfully dialyzed using a method called continuous venovenous hemofiltration CVVH Bleeding stopped and the hirudin dose was adjusted FINDING BEST EVIDENCE AT THE POINT OF CARE Exercises Sarah Safranek wrote for the WRITE Workshop February 2 2002 Although written for use with PrimeAnswers topics work in separate resources Try the following practice searches using P 39 1 httpwwwDrimeanswersorg A patient presents with swelling of the parotid gland You can t remember offhand what the differential includes and you d like to quickly research etiologies to consider and how to work it up Resource MD Consult medical reference textbooks Search salivary gland and swelling Several times a week you see patients in your practice with osteoarthritis You would like to review the latest evidence on the ef cacy of treatments for this disease Resource PrimeEvidence fast search of select evidencebased documents You are treating a young man who got a wood chip in the eye while cutting his firewood On fluoroscein exam you diagnose a corneal abrasion You plan to patch the eye as you d been taught but the medical student working with you says she d read something saying that wasn t necessary but she can t remember where she read it Resource Up ToDate You d like to present your patient with the corneal abrasion a handout explaining what to expect Resource Patient Handouts AAFP or MD Consult Your patient an engineer with chronic hepatitis C of 5 years duration asymptomatic brings in a flyer describing an herbal preparation claiming to cure his illness You loo t e ingredients and see a list of six herbs schisandra astragalus Siberian ginseng pimpinella cochin ginger and alcazuz He wants to know if it is safe for him to try Resource Natural Medicines A family presents newly arrived from Guadalajara Mexico and you diagnose asthma in their 7year old daughter You want to give them some basic information to read about asthma Resources MD Consult and MEDLINEPIus under the Patient Education tab on PrimeAnswers Your patients a recently married couple plan to go on an extended photo safari to Kenya They want to know what travel immunizations and general advice you offer Resource Travel Health Destination Recommendations You have a pregnant patient near term and you want to know the ACOG guidelines for managing pregnancy after 40 weeks Resource Guidelines Search Search postdates and pregnancy 9 Finding papers about a particular topic x You have a 52 yearold breast cancer patient that you follow along with an oncologist You get a copy of a lab from his office reporting a tenfold increase in her CA 2729 marker and she asks you What is the significance of this Resource PubMed MEDLINE under the Reference tab on PrimeAnswers Search CA 2729 AND marker In your search results find the 2000 update of clinical practice guidelines ofthe American Society of Clinical Oncology Display the Abstract View of the article by clicking on the authors names Click on the purple UW link to get to the full text Note If you do not see a UW link in PubMed you may still find the article online on the Journals AZ list You want to find research articles on the efficacy of different types of knee braces for treating knee injuries and pain Resource PubMed Search knee AND braces To limit results to research articles redo your search using the PubMed Clinical Queries filter with the therapy and sensitivity options checked Try searching for Systematic Reviews on the same topic A Finding Evidence Online Exercises Resources discussed are found on the HealthLinks Care Provider Toolkit httphealthlinkswashingtonedutoolkitscare providerhtml or PrimeAnswers httpwwwprimeanswersorg for MEDEX 092002 1 FINDING PUBLISHED PAPERS a Finding papers about a particular topic using PubMed You have a 52 yearold breast cancer patient that you follow along with an oncologist You get a copy of a lab from his of ce reporting a tenfold increase in her CA 2729 marker and she asks you What does this mean Type CA 2729 AND marker in PubMed search box In your search results nd the 2000 update of clinical practice guidelines of the American Society of Clinical Oncology Display the Abstract View ofthe article by clicking on the authors names Click on the purple UW link to get to the full text of this article Alternate way to get to fulltext journals Go to Healthlinks Journals page then browse under or type Journal of Clinical Oncology in the journals search box b Finding a particular paper You just got out of a heated discussion with some obstetricians about whether ability to perform a csection within 30 minutes is a standard supported by evidence You remember reading some articles about this in the BMJ about a year ago and you want to show them to your OB colleagues Under Databases and FullText Journals rst section of Care Provider Toolkit find Core Primary Care Journals Click BMJ and select searcharchive Type caesarean section 30 minutes in the words in title or abstract box Click search Click on the Full text links for the articles that appear 2 EVIDENCEBASED CLINICAL REVIEWS An elderly patient presents from home with tachypnea and lowgrade temp clear mental status with history of chronic severe asthma On exam you hear wheezes and he is mildly hypoxic You are trying to decide among various dosage regimens of steroids for acute asthma exacerbations in hospitalized patients a Cochrane Library contains 1081 rigorouslydone complete reviews of clinical topics updated at intervals each based on a large literature search and strict assessment ofthe methodology used very high quality work Go to the fourth section of Care Provider Toolkit Evidencebased Medicine and Guidelines and select Cochrane Library When the log in page appears enter username uwash password trains Note above username and password are for today only From home if you are using UWICK or have the proxy server configured leave username and password blank and just click Enter Type corticosteroids AND asthma in the search window and click Enter Click Complete Reviews and results will be displayed 25 at a time Look forthe review Corticosteroids for Acute Severe Asthma in Hospitalized Patients b POEM s PatientOriented Evidence that Matters summaries of critically evaluated articles Many of your patients taking hormone replacement therapy wish to discuss the recent ndings on risks vs bene ts of hrt gt PrimeEvidence PrimeEvidence is a good way to find summaries such as JFP Clinical Inquiries and other diverse resources that aren t easily found by other means Type hormone replacement in the PrimeEvidence search box You are treating a young man who got a wood chip in the eye while cutting his rewood On uoroscein exam you diagnose a corneal abrasion You plan to patch the eye as you d been taught but the medical student working with you says she d read an evidence based review saying that wasn t necessary but she can t remember where she read it gt TRIP Care Provider Toolkit This free site simultaneously searches across 55 sites containing 23000 POEM s and related articles a link to it is listed on Healthlinks Care Provider Toolkit under Evidencebased Medicine and Guidelines Type corneal abrasion in the search box and click go look at the hits under Evidence Based Direct links four of which are criticallyevaluated metaanalyses of seven RCT s one individual review ofa RCT and three on use of steroids etc c Researching Natural and Herbal Medicines Your patient an engineer with chronic hepatitis C of 5 years duration asymptomatic brings in a yer describing an herbal preparation claiming to cure his illness You look at the ingredients and see a list of six herbs schisandra astragalus Siberian ginseng pimpinella cochin ginger and alcazuz He wants to know if it is safe for him to try Natural Medicines Comprehensive Database This is a library of several thousand monographs just about every natural medicine sold in the US written by Pharm D s who write Pharmacist s Letter and Prescriber s Letter based on evidencebased reviews of the research literature From PrimeAnswers type schisandra in the Search Natural Medicines box Click on SCHISANDRA in the list under HerbalSupplement Monograph to see the review 3 REFRESHER READING ABOUT A TOPIC A patient presents with swelling of the parotid gland You can t remember offhand what the differential includes and you d like to quickly research etiologies to consider and how to work it up a Up To Date subscription online textbook regularly updated type parotid gland b MD Consult Fortodays training session use User Name uwash4 Password hot Note password is for today only From home with UWICK or Proxy use individual login or click Open Generic Edition Search MDC Reference Books salivary AND gland AND swelling 4 PATIENT EDUCATION A family presents newly arrived from Guadalajara Mexico and you diagnose asthma in their 7yearold daughter You want to give them some basic information to read about asthma a MD Consult Click on the Patient Education tab on the PrimeAnswers website Type asthma in the search MD Consult box hit enter Look for asthma pediatric version which is available in Spanish b Try searching for handouts on asthma or other topics in MEDLINEPIus and AAFP
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