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					                                                                         What to tell patients who eat butter
                                                     Fall 2003           and bacon?’- “The Atkins diet.”
                                                                         “Two recent reports from the        was significantly decreased at       strong enough to change the recom-
                                                                         New England Journal of Medi-        six months. The question was         mendations about using or not using
                                                                         cine have provided some             raised as to whether the im-         the Atkins diet, nor to recommend the
                                                                         much-anticipated clinical data      provements in the lipid profile      Atkins diet over any other dietary ap-
                                                                         on the controversial low-           and other cardiovascular             proach to weight loss, but the findings
                                                                         carbohydrate, high-protein,         markers seen with the Atkins         suggest that lowering the carbohydrate
                                                                         high-fat Atkins diet. Both          diet is due to the weight loss       content of one’s diet may be a viable
                                                                         studies found that after six        connected to the diet itself, or     alternative for obese patients.”
                                                                         months, obese patients lost         to the actual content of the
                                                                                                                                                  (Women’s Health in Primary Care,
                                                                         more weight on the Atkins diet      diet. The two recent controlled
                                                                                                                                                  July 2003)
                                                                         than on a standard low-fat regi-    trials concluded that the an-
TEXAS DEPARTMENT OF HEALTH, PUBLIC HEALTH REGION 1




                                                                         men. In one study, for exam-        swer is the content of the diet,
                                                                         ple, the reduction in body          since weight loss is similar
                                                                         weight after six months was         with other diets. Another con-
                                                                         twice as great with the Atkins      cern regarding the diet has
                                                                         diet (7.0% versus 3.2%), al-        been the long-term safety of
                                                                         though the difference was           the diet, which has yet to be
                                                                         smaller and no longer statisti-     determined. Studies have
                                                                         cally significant at 12 months      provided only short-term data,
                                                                         (4.4% versus 2.5%). Perhaps         up to one year. One expected
                                                                         the biggest surprise, however,      long-term concern that has not
                                                                         was that the Atkins diet had a      ended up being a concern is
                                                     Literature Review




                                                                         positive impact on high-density     an increase in cholesterol.
                                                                         lipoprotein (HDL) levels in one     So, what to tell patients eating
                                                     Women’s Health




                                                                         study, and on triglyceride lev-     butter and bacon? According
                                                                         els in both studies. Moreover,      to the author, the trials look-
                                                                         in one trial insulin sensitivity    ing at short-term data is not




                                                                         Introduction of a new prehypertension category
                                                                         The Seventh Report of the Joint     has introduced a prehypertension
                                                                         National Committee on Preven-       category encompassing a BP in
                                                                         tion, Detection, Evaluation, and    the range of 120-139/80-89.
                                                                         Treatment of High Blood Pres-       Patients with prehypertensive dis-
                                                                         sure (JNC 7) will soon introduce    ease have double the risk for pro-
                                                                         a new prehypertension category.     gression to hypertension com-
                                                                         Six years ago, high-normal was      pared with normotensive persons.
                                                                         redefined as a BP in the 130-       (Women’s Health in Primary Care,
                                                                         139/85-89 range. JNC 7 has          July 2003)
                                                                         defined “normal” as a BP below
                                                                         120/80; in addition, the JNC 7


                                                                          New Hypertension Guidelines                       A bruise versus ischemia: how to tell?
                                                                                                                            When assessing a patient’s extremity following
                                                                         Normal              S <120    D <80                an injury or trauma, and not knowing if the
                                                                         Prehypertension     S 120-139 D 80-89              discoloration is due to bruising or poor circula-
                                                                         Stage 1                                            tion, apply pressure to the area with the tip of
                                                                         Hypertension        S 140-159 D 90-99              your thumb. If the discoloration blanches, it is
                                                                         Stage 2                                            ischemia. (Clinician Reviews, August 2003)
                                                                         Hypertension        S >160         D>100
Helping the client to choose the right method
of birth control for them
The following questions                                              daily at approximately the          quick return to fertility? (If yes, pills, patch, or
should be posed to                                                   same time each day? Are you         ring recommended) Have you completed your
each woman consider-                                                 available for quarterly clinic      family and you therefore are seeking a con-
ing the use of a hormo-                                              visits for hormonal injections?     traceptive method to use until you reach
nal method of birth                                                  Are you comfortable applying a      menopause? (If yes, pills, patch, or IUD recom-
control. The answers                                                 patch on a weekly basis, or         mended) Are you breast-feeding? (Most pro-
might also help to rule                                              inserting a vaginal ring each       gestin-only methods are appropriate) Are
out some specific                                                    month? Are you just entering        monthly periods important to you? (If yes, pills,
methods. These                                                       your reproductive years and         patch, ring recommended. Depo or the LNG-IUD
questions could also                                                 wish to delay childbearing for      is not appropriate). Are you very concerned
be printed in a ques-                                                at least a decade? (If yes, IUD     about potential weight gain, or do you have a
tionnaire and used                                                   is recommended) Would you           history of being overweight or obese? (If yes,
prior to a discussion                                                like to avoid thinking about        Depo may not be appropriate) Do you have
with the clinician.                                                  contraception at all for the next   medical concerns that might be addressed by
                                                                     few years? (If yes, IUD is recom-   hormonal contraception? Acne– use low
What led you to choose                                                                                   androgenic pills; painful period– pills, Depo,
                                                                     mended) Are you seeking a
your current method?                                                                                     ring, or patch recommended; Sickle cell
                                                                     short-duration method to
Do you still require that                                                                                anemia– Depo recommended; Seizure dis-
                                                                     space your children? (If yes,
desired effect? Can                                                                                      order– Depo recommended. (Women’s
                                                    pills, patch or ring recommended) Do you
you remember to consistently take a BC pill                                                              Health Care, May/June 2003)
                                                    want a birth-control method that affords a


Which herbs are taken most often and
for what reason?
In a recent survey, respondents identified the top 10     Chondroitin for arthritis
herbals or other supplements used, and the reasons        Creatine to increase athletic performance
they took those products. The results were:               Saw Palmetto to maintain prostate health
Ginseng for energy                                        Herbal supplements were taken by 14% of respon-
Ginkgo for memory improvement                             dents, in most instances by middle-aged adults of
Garlic for atherosclerosis                                both sexes. Creatine was most likely to be used by
Glucosamine for arthritis                                 younger men. Glucosamine and saw palmetto
Saint John’s Wort for depression                          were popular choices among older men, and Ginko
Echinacea for cold symptoms/ immune system boost          was favored by older women. (Clinician News,
Lecithin to lower one’s cholesterol                       March 2002)




Missed appointments
“Patients who miss appointments are the             notes for every entry should be when the             of on a specific date, for example, such as
most common source of lawsuits by noncom-           patient was instructed to return, as well as         a family planning patient to return in three
pliant patients. Usually, these patients testify    under what                                                         months, it would be beneficial
that the clinician failed to schedule a return      circumstances the                                                  to chart that time frame and
visit or did not explain to them the importance     patient is to return                                               include that the patient will
of the return visit for follow-up.” Documenta-      prior to that ap-                                                  have the responsibility to call
tion of the return appointment in the chart         pointment. If the                                                  in three months to make the
obviously reduces this risk. Editor’s note: A       patient is to return                                               appointment. (The Clinical
memorable legal workshop several years ago          within a certain                                                   Advisor, August 2003)
advised that the last sentence in the progress      time frame instead


Page 2                                                                                                   WO M E N ’S H E A L T H L I T E R A T U R E R E V I E W
Common sense reminders about the face and oral exam
The “sun-touched” areas of the face (the             noted. Traumatic ecchymosis or petechiae             healthy patient. Burning mouth syndrome
forehead, tops of the ears, nose and lips)           at the junction of the hard and soft palates         (lesion-free), usually affecting the tongue, is
are most likely to have sustained damage             may signify forced oral sex. Primary syphi-          mostly idiopathic, but is occasionally associ-
due to ultraviolet ray exposure, and are most        lis should also be considered as a possible          ated with iron or folate deficiency glossitis,
vulnerable to basal cell and squamous cell           cause of oral ulceration.                            xerostomia from medications or other
carcinoma. All suspicious lesions should be                                                               sources, or diabetes. In some patients, un-
                                                     Leukoplakia, or a white patch lesion, is a
biopsied. Does your routine exam specifi-                                                                 derlying depression, fear of cancer, or other
                                                     thickened, keratinized mucosal layer with-
cally cover these areas? Do you make a                                                                    psychosomatic components may be sus-
                                                     out other pathologic findings on biopsy.
conscious effort to inspect each of these                                                                 pected. An exact cause or cure is elusive.
                                                     Biopsy is the only adequate way to investi-
areas? The most important focus of oral                                                                   Oral cancer is the 6th most common cancer
                                                     gate leukoplakia. Leukoplakia must be dis-
inspection is the tongue, whose underside                                                                 in US men and 4th among African-American
                                                     tinguished from oral candidiasis, which can
and lateral borders are the most common                                                                   men. More than 90% of all oral cancers are
                                                     be wiped away. Since progression to oral
sites for oral cancers. The floor of the                                                                  squamous cell carcinomas. 75% of oral can-
                                                     cancer occurs in up to 33% of cases, leu-
mouth is the second most common location                                                                  cers are caused by tobacco and alcohol use.
                                                     koplakia should be considered premalig-
for oral cancers, and should be inspected                                                                 While oral cancer is usually slow growing,
                                                     nant and watched carefully, even after a
visually and digitally. Oral cancer is typically                                                          60% are well advanced at the time they are
                                                     normal initial biopsy. Though considered
spongy, possibly ulcerated, and likely to                                                                 detected. Any oral lesion that is present
                                                     idiopathic, leuloplakia is associated with
bleed when manipulated. Firm or fixed le-                                                                 longer than 3 weeks should be considered
                                                     advanced age, alcohol abuse, smoking,
sions should be biopsied. The hard palate                                                                 highly suspicious and should be referred.
                                                     oral tobacco use, and frictional irritation.
should be inspected and palpated. History
                                                     Black hairy tongue is not normally seen in a         (Clinician Reviews, August 2003)
of trauma (e.g. ”pizza burn”) should be



Portion Distortions
“The history of how food portion size got out      size of familiar items in comparison to food        in the world’s devel-
of control began in the 1980s, when a fast-        portions. A light bulb equals one serving of        oping countries, and
food restaurant created a ‘value meal’ con-        raw vegetables, and a deck of cards equals a        portion size, without
cept. For just a little more money, the hungry     three-ounce serving of meat. A nail polish          question, is a real
customer could get more food. Every other          container equals two tablespoons of salad           issue.”
fast-food establishment followed the trend.        dressing, and a dime is equal to seven shelled
There are also sneaky ‘disproportions’ por-        sunflower seeds. Lastly, a tennis ball is equal     (World Practitioner
                                                   to one cup of rice, potatoes, or pasta. A half-     World News, May
tions. For example, a large no-butter movie
theater popcorn (sounds healthy) based on fat      cup of pasta is one serving, so serving size        2003)
and calories, should serve ten people. One         would be half of a tennis ball. Another known
easy guide to portion control is to take the       fact is that Americans are the heaviest people
                                                                                                             Legal perspective to
                                                                                                              informed consent

Cervix length predicts preterm birth                                                                   In order to sustain a claim of lack of informed
                                                                                                       consent, a patient must prove two things:
                        “Cervical length of          with a cervical length of less than 25 mm         (1) that a piece of critical information was miss-
                        less than 25 mm at 16        on a single mid-trimester sonogram were           ing from the discussion; and (2) that if she had
                        to 18 weeks’ gesta-          more than three times as likely to deliver        known that particular piece of information, she
                        tion, as determined by       pre-term, while those whose cervixes              would not have consented. It is not standard of
                        endovaginal ultra-           were less than 25 mm on serial sono-
                                                                                                       care to describe every complication ever known
                        sound, is a strong           grams were four and one half times as
                                                                                                       or imagined, but, what a reasonable person
                        predictor of spontane-       likely to deliver early. Identifying a risk for
                        ous birth before 35          cervical incompentency in mid-trimester           would need to know. If the patient’s complaint is
                        weeks in women with          allows for intervention with such strate-         that the piece of information missing is one that
                        a history of spontane-       gies as cerclage, according to the authors        a reasonable person would need to know, it is
                        ous pre-term delivery,       of the study.” (Contemporary OB/GYN,              hard to overcome an allegation of lack of in-
                        according to a recent        January 2002)                                     formed consent. (Contemporary Ob/GYN, Janu-
observational study. Among 183 women, those                                                            ary 2002)

                                                                                                                                                   Page 3
            Publication #
                                                                                 ~ Interesting Tidbits~
             50-10873
                                                        Sex differences in the predictability of chronic headaches and the risk of stroke:
                                                        Chronic headaches increase the risk of stroke about fourfold in men, but not in women. Al-
                                                        though women suffer from chronic headaches twice as often as men, men with headaches
   TEXAS DEPARTMENT OF HEALTH,
      PUBLIC HEALTH REGION 1                            have a substantially higher risk of having a stroke. The study hypothesizes that headache
                                                        etiology may differ between the sexes, with vascular causes playing a greater role in men.
             300 Victory Drive
                                                        The pneumococcal vaccine update: The May issue of the New England Journal of Medi-
              P.O. Box 60968                            cine suggests that the pneumonia vaccine may be useful only against certain types of pneu-
                 WTA&M                                  monia. A recent study found that the vaccine decreased the risk of pneumococcal bactere-
                                                        mia by 44%; however, vaccinated patients had a slightly increased risk of hospitalization for
        Phone: 806-655-7151                             pneumonia, and vaccination did not influence the risks of outpatient and community-
                                                        acquired pneumonia.
          Fax: 806-655-7159
  Email: jamie.moore@tdh.state.tx.us                    Sex differences in tearing an ACL: Females involved in sports that require jumping and
    sheila.rhodes@tdh.state.tx.us                       pivoting (such as basketball) are up to eight times more likely than males participating in the
                                                        same sport to rupture the anterior cruciate ligament (ACL). In women, maximal internal
                                                        rotations of the leg are 16% and 27% greater in the passive and active muscle states, re-
          Editor: Jamie L. Moore,                       spectively, than they are in men; women also have an 18% smaller voluntary increase in
               RNC, WHCNP                               torsional stiffness of the knee than male athletes. Women are also less able than men to
                                                        protect their knee ligaments by stiffening their muscles during pivoting maneuvers than
            Contributing Editor:                        men.
          Sheila Rhodes, RNC, PNP
                                                        Tidbits from Women’s Health in Primary Care, July 2003 edition




                                                                              Epilepsy Onset
       New Cervical Screening                                                     Linked                          Genetics–
                                                                               to Menarche                        Androgen Insensitivity
           Guidelines
If cervical cancer is caught while still localized, the five-year survival   In girls, the risk that an initial   Androgen insensitivity syndrome
rate is 92%. Still, the disease claimed the lives of 4,100 American          epileptic episode will occur is      can be complete, partial, or mild,
women in 2003. Most cases of cervical cancer develop in women                highest around the time of           but in all three disorders the individ-
who have never had a pap smear, or who have not had one in the               menarche. In studies, epi-           ual will have either a lessened abil-
past 5 years. Other cases of cervical cancer develop in women                lepsy began the year of men-         ity or a total inability to respond to
who did not receive adequate follow-up after an abnormal pap test            arche in 17% of patients, ver-       testosterone. While individuals af-
result. The US Preventive Services Task Force (USPSTF) has pre-              sus 5.5% that would be ex-           fected by any of the three disorders
sented new recommendations regarding who should be screened                  pected by chance. Seizures           are genetically males, those with
and how often. According to the new guidelines, screening need not           began within two years of            complete insensitivity will, to all the
begin until three years after the onset of sexual activity or until the      menarche (either before or           world, look like females. They show
age of 21, whichever one comes first (prior was age 18 or with the           after) in 38% of patients, ver-      bilateral testes, female external
onset of sexual activity, whichever one came first). The USPSTF              sus 22% expected. In sub-            genitalia, and a blindly ending va-
also recommends the interval between routine pap smears be                   jects in whom seizures had           gina. The testes of those affected
every three years after 2-3 normal screens, and the age to stop
                                                                             begun three or more years            are usually normal in size and may
screening is age 65 if they have had a recent normal pap and are
                                                                             before menarche, 29% experi-         be located in various places; in the
not at increased risk for cervical cancer. According to the American
Cancer Society, pap smears should take place until age 70.
                                                                             enced seizure exacerbation           abdomen, inguinal canal, labia, or
According to the USPSTF there is insufficient evidence for or                during perimenarche.                 anywhere along the path of embry-
against liquid based cytology. While liquid-based cytology may be            (Women’s                             onic testicular descent. Although it
more sensitive, the cost is considerably more, and it may have a             Health in                            is eventually necessary to remove
lower specificity. The cost effectiveness of liquid-based cytology           Primary                              the testes, it is acceptable to leave
would be justified only at three-year intervals or longer. The               Care,                                them in until puberty.
USPSTF also states there is insufficient evidence for or against             April                                (Contemporary OB/GYN, November
HPV testing as a primary screening tool for cervical cancer.                 2003)                                2001)
(Women’s Health in Primary Care, April 2003)

				
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