Early Age at Menopause Linked to Angina Post MI

http://cme.medscape.com/viewarticle/727317?src=cmemp&uac=97984HK

News Author: Emma Hitt, PhD
CME Author: Laurie Barclay, MD

CME Released: 08/24/2010; Valid for credit through 08/24/2011

August 24, 2010 — Women who have an early menopause, at 40 years or younger, are at higher risk for angina after a myocardial infarction (MI) vs women who experience menopause at 50 years or older, new research suggests.

Susmita Parashar, MD, with Emory University, in Atlanta, Georgia, and colleagues reported their findings in the July 21 online issue of Menopause: The Journal of The North American Menopause Society.

According to the researchers, women who experience early menopause may be at risk for cardiovascular disease morbidity and mortality because of a deprivation of estrogen after menopause; however, "no descriptions of its prognostic importance among women with known coronary heart disease have been reported," which may help in the risk stratification and management of this patient group.

In addition, the study authors note that angina symptom-driven care for women accounts for most costs associated with care in women with coronary heart disease.

In the current study, 493 women were interviewed by telephone 1 year after discharge from the hospital for MI on aspects of behavioral, treatment, and health status measures. Mean age at menopause (AAM) was 45.2 ± 7.8 years.

Participants were classified by AAM: 40 years or younger, 41 to 49 years, and 50 years or older. The researchers then determined whether age predicted 1-year post-MI angina and severity of angina while taking into account pre-MI angina, demographics, comorbidities, MI severity, and quality of care.

Of the women, 132 (26.8%) experienced early menopause at 40 years or younger. These women were more often smokers but otherwise had similar comorbidities and characteristics as women experiencing later menopause both before and after MI.

However, the rate of 1-year angina in women with an AAM of 40 years or younger (32.4%) was double that of women with an AAM of 50 years or older (12.2%) in a multivariable analysis (relative risk, 2.09; 95% confidence interval [CI], 1.38 - 3.17), as was the severity of angina (odds ratio, 2.65; 95% CI, 1.34 - 5.22 for a higher severity level).

"Early menopause is a significant predictor of angina at 1 year after MI, independent of comorbidities, MI severity, and quality of care," Dr. Parashar and colleagues conclude.

According to the researchers, deprivation of endogenous estrogen may increase the extent of vascular inflammation, endothelial and microvascular dysfunction, and coagulation abnormalities; and decrease arterial compliance, all of which could cause angina in the setting of coronary artery disease.

"A simple, inexpensive, and easily administered question regarding age at menopause may help identify high-risk women and guide efforts toward improving treatments and quality of life of post-MI women," they suggest.

Cardiovascular Therapeutics and Cardiovascular Outcomes funded the data collection and analysis of the Prospective Registry Evaluating Myocardial Infarction: Events and Recovery Study. This study was also supported by the Emory University General Clinical Research Center (National Institutes of Health [NIH]) and by an NIH grant. Dr. Parashar is supported by Mentored Clinical Scientist Development Award. Coauthor Viola Vaccarino, MD, PhD, is supported by a grant. Coauthor Kimberly J. Reid, MS, is supported through an NIH grant. The remaining study authors have disclosed no relevant financial relationships.

Menopause. Published online July 21, 2010. Abstract

regards, taniafdi ^_^

New Journals

Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome.

Clopidogrel with or without Omeprazole in Coronary Artery Disease.

Microflora, Helminths, and the Immune System — Who Controls Whom?

Rapid Molecular Detection of Tuberculosis and Rifampin Resistance.

Basophils and Nephritis in Lupus.

Erythropoietic Response and Outcomes in Kidney Disease and Type 2 Diabetes.

Calcium Kidney Stones.

Risk of Cardiovascular Disease in Patients with Nonalcoholic Fatty Liver Disease.

Fondaparinux for the Treatment of Superficial-Vein Thrombosis in the Legs.

Traumatic Brain Injury — Football, Warfare, and Long-Term Effects.

A Randomized Trial of Tai Chi for Fibromyalgia.

Treating Cancer by Targeting the Immune System.

Emergency Treatment of Asthma.

regards, taniafdi ^_^

Eating Green Leafy Vegetables May Lower Risk for Type 2 Diabetes

http://cme.medscape.com/viewarticle/727501?src=cmemp&uac=97984HK

News Author: Laurie Barclay, MD
CME Author: Charles P. Vega, MD

CME Released: 08/26/2010; Valid for credit through 08/26/2011

August 26, 2010 — Eating green leafy vegetables may lower the risk for type 2 diabetes, according to the results of a systematic review and meta-analysis reported in the August 20 issue of the BMJ.

"High intake of fruit and vegetables has been associated with a reduced incidence of cancer and cardiovascular disease," write Patrice Carter, from University of Leicester, in Leicester, United Kingdom, and colleagues. "Diabetes is a strong independent risk factor for cardiovascular disease, and often the conditions exist together, sharing common modifiable risk factors. As yet no firm conclusions have been made as to whether increasing intake of fruit and vegetables can decrease the risk of type 2 diabetes itself, given the abundance of conflicting evidence within the literature."

To determine the independent effects of fruit and vegetable consumption on the incidence of type 2 diabetes, the reviewers searched MEDLINE, EMBASE, CINAHL, British Nursing Index, and the Cochrane Library for terms involving diabetes, prediabetes, fruit, and vegetables. They also asked experts about their opinions and searched bibliographies of retrieved articles. Inclusion criteria were prospective cohort studies with an independent measure of intake of fruit, vegetables, or fruit and vegetables, as well as data on the incidence of type 2 diabetes.

Of 6 studies meeting selection criteria, enrolling a total of more than 220,000 participants, 4 studies also provided separate data regarding intake of green leafy vegetables. Greater consumption of green leafy vegetables was associated with a 14% reduction in the risk for type 2 diabetes (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.77 - 0.97; P = .01), based on summary estimates.

Increasing intake of vegetables, fruit, or fruit and vegetables combined did not significantly reduce the risk for type 2 diabetes.

"Increasing daily intake of green leafy vegetables could significantly reduce the risk of type 2 diabetes and should be investigated further," the study authors write.

Limitations of this meta-analysis include difficulties in determining dietary intake, significant heterogeneity among the included studies, and unmeasured confounding. In addition, only a small number of studies were included in the meta-analysis, which may have prevented detecting a benefit of combined fruit and vegetable consumption for reducing type 2 diabetes risk.

"Our results support the evidence that 'foods' rather than isolated components such as antioxidants are beneficial for health," the study authors conclude. "Results from several supplement trials have produced disappointing results for prevention of disease, in contrast with epidemiological evidence. Further investigation is warranted to understand the mechanisms involved in the proposed relation between green leafy vegetables and risk of type 2 diabetes."

In an accompanying editorial, Jim Mann, from the University of Otago in Otago, New Zealand, and Dagfinn Aune, from Imperial College London, in London, United Kingdom, warn that increasing overall fruit and vegetable intake should still be emphasized. However, dietary recommendations for 5 portions of fruit and vegetables should certainly include green leafy vegetables.

"The meta-analysis suggests that an additional one and a half UK portions (roughly 120 g) daily of green leafy vegetables (for example, cabbage, brussel sprouts, broccoli, cauliflower, and spinach) has the potential to reduce the risk of diabetes by 14% independently of any effect of weight loss," Drs. Mann and Aune write. "Although it may be reasonable to draw attention to the potential benefits of green leafy vegetables, which could be incorporated as one of the five recommended portions of fruit and vegetables a day, we must be careful that the message of increasing overall fruit and vegetable intake is not lost in a plethora of magic bullets. The findings are also a useful reminder to clinicians that giving dietary advice may be just as beneficial, if not more so, than prescribing drugs to patients at risk of chronic disease."

The Cardiovascular Research Department, University of Leicester, funded this study. All members of the research team are either employees of the University of Leicester or the University Hospitals of Leicester NHS Trust, with ongoing support from the National Institute of Health Research (NIHR)-CLAHRC. Two of the study authors have received grants from the NIHR for studies on the prevention of type 2 diabetes. Drs. Mann and Aune have disclosed no relevant financial relationships.

BMJ. 2010;341:c4229. Published online August 20, 2010.

regards, taniafdi ^_^

Fish Oil, Monounsaturated Fats May Be Helpful in Metabolic Syndrome

http://cme.medscape.com/viewarticle/727500?src=cmemp&uac=97984HK

News Author: Laurie Barclay, MD
CME Author: Charles P. Vega, MD

CME Released: 08/26/2010; Valid for credit through 08/26/2011

August 26, 2010 — Postprandial lipoprotein abnormalities associated with metabolic syndrome can be attenuated with a low-fat, high-complex carbohydrate (LFHCC) diet supplemented with intake of long-chain (n-3) fatty acids, according to the results of a multicenter, parallel, randomized controlled trial reported in the September issue of the Journal of Nutrition.

"Dietary fat intake plays a critical role in the development of metabolic syndrome (MetS)," write Yolanda Jiménez-Gómez, from University of Córdoba in Córdoba, Spain, and colleagues. "This study addressed the hypothesis that dietary fat quantity and quality may differentially modulate postprandial lipoprotein metabolism in MetS patients."

As part of the LIPGENE study, patients with metabolic syndrome were randomly assigned to 1 of 4 diets for 12 weeks each: (1) a high-saturated fatty acid diet (38% energy from fat, 16% energy as saturated fatty acid); (2) a high-monounsaturated fatty acid (MUFA) diet (38% energy from fat, 20% energy as MUFA); (3) an LFHCC diet (28% energy from fat) supplemented with 1.24 g/day of long-chain (n-3) polyunsaturated fatty acids (ratio, 1.4 eicosapentaenoic acid:1 docosahexaenoic acid); or (4) an LFHCC diet with a placebo supplement (1.24 g/day of high-oleic sunflower-seed oil).

Before and after the dietary intervention, patients underwent a fat challenge with the same fat composition as the diets, as well as determination of postprandial total cholesterol, triglycerides (TG), apolipoprotein B, apolipoprotein B-48, apolipoprotein A-I, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, retinyl palmitate, and apolipoprotein B in TG-rich lipoproteins (TRL; large and small).

Compared with the high-saturated fatty acid group and the LFHCC group, the high MUFA group had earlier and faster postintervention clearance of postprandial TG (P < .001) and large TRL-TG (P = .009). Compared with the other diet groups, the LFHCC (n-3) group had a lower postprandial TG concentration (P < .001).

Compared with preintervention values, participants following the LFHCC diet had increase in postintervention postprandial area under the curve for TG (P = .04), large TRL-TG (P = .01), TRL cholesterol (P < .001), TRL-retinyl palmitate (P = .001), and TRL-apolipoprotein B (P = .002). In contrast, however, participants following the LFHCC (n-3) diet long term did not have augmented postprandial TG and TRL metabolism.

"[P]ostprandial abnormalities associated with MetS can be attenuated with LFHCC (n-3) and HMUFA diets," the study authors write. "The adverse postprandial TG-raising effects of long-term LFHCC diets may be avoided by concomitant LC (n-3) PUFA [polyunsaturated fatty acid] supplementation to weight-stable MetS patients."

Limitations of this study include difficulty in ensuring complete adherence to dietary instructions, mild adverse effects associated with consumption of long-chain (n-3) polyunsaturated fatty acid capsules in some patients with metabolic syndrome, use of long-chain (n-3) polyunsaturated fatty acid capsules instead of increased fish consumption, and duration limited to 12 weeks.

"Our data suggest that long-term intake of an isocaloric, low-fat, high-carbohydrate diet supplemented with LC [long-chain] (n-3) PUFA and MUFA-rich diets have beneficial effects on postprandial lipoprotein response in patients with MetS," the study authors conclude. "On the other hand, the addition of LC (n-3) PUFA to a LFHCC diet may normalize the adverse postprandial lipoprotein effects produced by this diet. Importantly, both diets were effective exclusive of weight loss, which is highly pertinent given the pandemic of obesity-induced MetS that will occur in Europe and North America over the next 20–30 y due to excessive weight gain."

This study was supported in part by FEDER, Fondo Social Europeo, the EU Sixth Framework Food Safety & Quality Programme, Consejería de Salud, Consejería de Innovación, Proyecto de investigación de excelencia, Junta de Andalucía, the Spanish Ministry of Education and Science, and the Spanish Ministry of Science and Innovation (CIBER Fisiopatología de la Obesidad y Nutrición is an initiative of ISCIII). Intervention Foods were supplied by Unilever Best Foods. The study authors have disclosed no relevant financial relationships.

J Nutrition. 2010;140:1595-1601.

regards, taniafdi ^_^

Cannabis Use Associated With Superior Cognition in Some Persons With Schizophrenia

Caroline Helwick

August 29, 2010 (Amsterdam, The Netherlands) — Although the use of cannabis is believed to heighten the risk for schizophrenia and psychotic episodes, a meta-analysis of existing data and a new study suggest these associations may be even more complex than previously thought.

At the 23rd European College of Neuropsychopharmacology Congress, Murat Yücel, PhD, and colleagues from the University of Melbourne in Australia reported that patients with schizophrenia having a history of cannabis use had superior neuropsychological functioning compared with nonusers. The conclusion was drawn from their meta-analysis of 10 studies involving 572 patients with schizophrenia, but the investigators emphasized this does not imply neuroprotection.

Furthermore, from their own study of 85 individuals with first-episode psychosis (FEP), they found that regular users of cannabis performed better on tests of visual memory, working memory, and executive functioning. In addition, patients who began using cannabis by the age of 16 years (ie, early users) had less neuropsychological impairment than patients who began using cannabis later.

"Patients with schizophrenia generally use more cannabis than the general population, and there must be a reason. As researchers, we are interested in what that association is about," Dr. Yücel told Medscape Medical News. "Our key finding is that the relationship between cannabis and psychosis is complex. In healthy persons, heavy or long-term use of cannabis has negative effects on cognition and memory, but in psychosis the relationship is apparently not as clear."

The findings of both the meta-analysis and experimental data together indicate that the use of cannabis in established schizophrenia and also in FEP is associated with better cognitive performance than the lack of using cannabis, although this does not indicate that it is neuroprotective, he said. The investigators believe that the subgroup of cannabis users may be characterized by better underlying cognition function and perhaps only developed schizophrenia after exposure to cannabis.

Global Cognition Index Better With Cannabis Use

In the meta-analysis, neuropsychological variables were grouped according to the 6 cognitive domains of the Measurement and Treatment Research to Improve Cognition in Schizophrenia battery. A global cognition index was calculated by averaging effect sizes from each domain for each study.

Patients with a history of cannabis use were found to have superior neuropsychological functioning. The finding was largely driven by studies that included patients with a lifetime history of cannabis use rather than current or recent use. In 1 study, greater frequency of cannabis use was associated with better cognitive performance. Overall, earlier starting age of cannabis use (16 years or younger) was associated with superior cognitive performance compared with later use, Dr. Yucel reported.

"We found that patients with a history of cannabis use had superior neuropsychological functioning, with an average effect size of 0.50 across all the cognitive domains investigated," he said.

The mean weighted effect size associated with lifetime cannabis use was 0.55 (P = .001) for global cognition, 0.65 (P = .001) for processing speed, and 0.64 (P = .003) for working memory.

New Data in FEP

In the second study, 85 FEP patients were compared with 43 healthy non–cannabis-using controls with FEP. Regular use was defined as at least 2 years of use and use of at least 2 g per week. None of the FEP cannabis users had ever used cannabis regularly (ie, weekly for at least 12 months). Healthy controls had no current or past history of illicit substance abuse or dependence.

Relative to controls, FEP cannabis users displayed only selective neuropsychological impairments, whereas FEP nonusers displayed generalized deficits. When the 2 clinical groups were directly compared, the cannabis users performed better on tests of visual memory, working memory, and executive functioning. Patients with early-onset cannabis use had less neuropsychological impairment than patients with later onset of use. The early cannabis users were younger than the later-onset users but did not differ in duration or monthly quantity of cannabis use, diagnosis, treatment, or antipsychotic levels, he added.

The investigators speculated that age of onset of cannabis use as a moderator of the association between cannabis and psychotic illness may be related to the effects of cannabis on the developing brain. "We contend that the association between better cognitive performance and cannabis use is driven by a subgroup of ‘neurocognitively less impaired' patients who only develop psychosis after early initiation into cannabis use. As such, early cannabis use may be an independent risk factor for the development of psychosis," he said.

"In other words, cannabis is potentially tipping some persons over the edge, maybe in combination with a genetic predisposition. We wonder if, in the absence of cannabis, they may not have developed the illness," he added.

The investigators are following up the patients and will soon have 10-year data on approximately 80% of the cohort.

"It will be important to see the long-term data," commented Richard Tranter, MBChB, consultant psychiatrist at the North West Wales NHS Trust, Bangor, United Kingdom, who said he was intrigued by these findings. "A large body of data is suggesting that cannabis can be an important predisposing factor for schizophrenia. The current study suggests, however, there may be a group that is different—who, if they are exposed to cannabis, may sustain damage perhaps because of some elementary factors in the brain, but if you get them off cannabis they may be fine. The other possibility is that cannabis is actually having a positive effect. We will have to wait for the 10-year data to determine this."

The study author and Dr. Tranter have disclosed no relevant financial relationships.

23rd European College of Neuropsychopharmacology (ECNP) Congress: Abstract P.3.a.005. Presented August 29, 2010.

http://www.medscape.com/viewarticle/727681?src=mp&spon=25&uac=97984HK

regards, taniafdi ^_^

Resources for Choosing a Medical Specialty

Joel Schofer, MD, Emergency Medicine, 12:15AM Sep 1, 2010

There was a lot of interest in my post about Emergency Medicine (EM) and all of its pluses and minuses.  While I find it difficult to comment on fields other than EM, there are some other resources that exist for those interested in finding out about various medical specialties.

I know it is old fashioned, but there are a few books I'd recommend if you are up in the air over your specialty choice.  First, I'd check out Iserson's Getting into a Residency: A Guide for Medical Students by Kenneth Iserson, MD (Galen Press, Ltd.; 7th edition, July 10, 2006).  It discusses all of the medical specialties, their training programs, and the process needed to get where you wan to go.  I found it to be invaluable during my medical school and residency selection process.

Second, I'd check out The Ultimate Guide to Choosing a Medical Specialty by Brian Freeman, MD (McGraw-Hill Medical; 2 edition, May 2, 2007).  It contains chapters on all the medical specialties that are written by residents.  Sort of an inside view from those who are in the trenches.  It also covers the residency application process.

Finally, if Emergency Medicine is your goal, you can check out my own book.  It is called Rules of the Road for Medical Students: The Guide for a Career in Emergency Medicine.  It is a complete guide to becoming an Emergency Physician, covering all aspects from what EM is like to having a fulfulling career.  It is available at:

https://ssl18.pair.com/aaemorg/aaemrsa/book_store/index.php

DISCLAIMER:  I get no money if you buy my book, and it is actually free if you are a student member of the AAEM Resident & Student Section (aaemrsa.org).

http://boards.medscape.com/forums?128@838.cGBwaEMdyk1@.2a025df8!comment=1

regards, taniafdi ^_^

'Superglue' for Circumcision Cost Effective and Cosmetically Appealing

http://cme.medscape.com/viewarticle/728037?src=cmemp&uac=97984HK

News Author: Karla Gale, MS
CME Author: Penny Murata, MD

CME Released: 09/03/2010; Valid for credit through 09/03/2011

September 3, 2010 — A sutureless and scalpel-free circumcision technique saves time and money, and the outcomes look good too, investigators report.

Dr. Andrew J. Kirsch and associates at Emory University School of Medicine, Atlanta, have done circumcisions using electrocautery and 2-octyl cyanoacrylate (2-OCA) instead of scalpels and sutures for the last four years.

In an August 24th online paper in the Journal of Urology, they report on 1008 boys ages 6 months to 12 years (mean 1.8 years) who had either primary circumcision or circumcision revision between 2006 and 2009.

The authors did all the procedures with electrocautery. They used 2-OCA in 493 primary procedures and 248 revisions, and 6-0 sutures in 152 primary circumcisions and 115 revisions.

The trial was not randomized, the authors note; the main reason for suture use was a resident's request for suturing experience.

The most complex condition treated was phimosis; there were no cases of chordee, penile torsion, hypospadias or phalloplasty. They did not use Gomco clamps.

After removing the foreskin, the surgeons would pinch the shaft skin at the base of the penis, push it distally toward the preputial collar, then apply a thin layer of 2-OCA dorsal and intermittently in circumferential fashion. After 30 seconds' drying time, they applied 2-OCA continuously around the apposed skin edges. They spread antibiotic ointment over the entire penis, scrotum and mons pubis (partly to keep the 2-OCA from sticking) and told parents to do the same when changing diapers or at least twice a day.

Three patients treated with 2-OCA and two treated with sutures reentered the hospital with bleeding, but none needed blood transfusion. Within a year and a half, one patient in the suture group underwent a revision because the parents didn't like the way the first procedure looked, and one patient in the 2-OCA group was treated for adhesions. There were no cases of dehiscence due to erection.

Operative times averaged 8 minutes using 2-OCA and 27 minutes using sutures (p < 0.001).

The authors note that at their institution, the anesthesia fee is about $189 per 15-minute block, and the operating room fee for circumcision is $571 for each 15 minutes. When factoring in the cost of 2-OCA and sutures, the 2-OCA technique cost $744 less than the suture technique.

"Patient satisfaction was equally high in all groups," the authors report, "but surgeon satisfaction was higher in the 2-OCA groups due to absent suture tracks and suture sinuses."

They emphasize the importance when using 2-OCA of determining how much preputial skin to excise to achieve the ideal skin fit, characterized by tension-free approximation of the shaft skin with the preputial collar even before applying 2-OCA.

In an editorial comment, Dr. Mark R. Zaontz, from Temple University School of Medicine, Philadelphia, says that his practice has also adopted the sutureless, scalpel-free technique, even though "running suture... is as rapid in my hands as applying the glue."

However, his group places holding sutures at the 6 and 12 o'clock positions to better line up wound edges. He cautions that this technique may not be as appropriate for older boys. Also, he is concerned about glue getting between the skin edges and the risk of epidermoid cyst formation.

In response, Dr. Kirsch and his group agree that this technique is probably best reserved for prepubescent boys "given the decreased vascularity and force of erection."

J Urol. 2010;184:1758-1762.

Reuters Health Information 2010. © 2010 Reuters Ltd.

regards, taniafdi ^_^

The Truth About Residency Work Hours

Joel Schofer, MD, Emergency Medicine, 01:06PM Sep 8, 2010

Recent posts about career selection and resident burnout have led to discussions about residency work hours.  On one hand, things are a lot better than they used to be.  I trained both with and without residency work hour restrictions.  I remember the days when I was on trauma surgery, my son was born, and they wouldn't let me leave to drive my wife home from the hospital.  They said I had used up all of my days off when my son was born and didn't have any left.  A few years later on trauma surgery they were practically shoving us out the door so that we wouldn't even come close to committing a work hour violation!

Medical students often assume that all residencies are compliant with the work hour restrictions.  If a residency program is not compliant, they risk losing their accreditation, so you would think there is an incentive to comply.  But all is not perfect in the world, and in a lot of residencies work hour violations are rampant.  They just don't get reported!

I'm not sure why residents don't report the work hour violations.  Reporting is anonymous, so there should be no personal consequences.  In most instances it is probably a fear that reporting a work hour violation could lead to problems with the residency program, such as a loss of accreditation or a probationary period, and no one wants to graduate from a program that is on probation or relocate because their program is no longer accredited.

So how do prospective residents find out the real deal?  How do you know if a residency program is compliant with resident work hours?

First, ask the residents during your interview/visit.  If the program is one of those places where residents just quietly accept the work hour violations, you may not get an honest answer.  If you don't ask, though, you're guaranteed to get no answer at all, so I would always ask.

Second, if you meet any rotators during your visit, such as transitional interns or off-service residents, you can always ask them about work hours.  They will have less "loyalty" to the program (since it isn't their program), and are more likely to answer your questions about work hours honestly.  And don't forget about any medical students you might meet as well.  They are even more likely to give you their opinion about the life of the residents they interact with every day.

It would be great if you could assume all residency programs are compliant with work hour limits, but they are not and you shouldn't assume compliance.  Make sure you ask the residents, off-service rotators, and medical students on the interview trail.

sumber : http://boards.medscape.com/forums?128@838.cGBwaEMdyk1@.2a029384!comment=1

regards, taniafdi ^_^

How Should I Discuss Sex With Patients ?

Sarah Averill, MD

Posted: 09/03/2010

Question:

Asking about and discussing sexual health and sexual problems with patients often isn't emphasized in medical education. How can I learn to feel comfortable with this responsibility?

Response from Sarah Averill, MD
Resident, St. Joseph's Hospital, Syracuse, New York

"So, uh... things aren't working down there," he said, looking straight at me. I was a third-year medical student on a Family Medicine rotation, suddenly taking a sexual history on a man nearly twice my age. "Wow, I can't believe he's telling me this," I thought. Then, I took a deep breath and started asking him about it: "When did this start?" It wasn't hard to ask questions that I'd asked a thousand times already.

As a premed student, I overheard an upper-class medical student talking with a group of his peers about how he wanted to be a doctor who helped his patients with all aspects of their lives, including their sexuality. I liked what he was saying, but inside I cringed and thought, "Oh God, can't I just let someone else deal with the sex stuff?" If you should happen to have the same reaction, rest assured, you are not alone. Despite years of training in dealing with complex and difficult medical conditions, many physicians still have difficulty talking to patients about their sexual health. Patients have come to expect that they won't get much help in that area from their doctors.^[1]

Yet sexual health and sexuality are areas of life that have myriad implications from reproduction to infectious disease to mental health. Sexual dysfunction can also be a clue to significant underlying medical problems, such as heart disease or hormone deficiencies.^[2] The potential implications for all areas of patient health reinforce the fact that it's worth getting comfortable taking a sexual history and addressing patients' concerns about sex and sexuality.^[1] As a medical student you may find that this is not emphasized in your training and you may need to be proactive in learning these skills.

I was fortunate as a medical student to learn to take a sexual history and the related components of the physical exam by a group of diverse volunteers, including gay and straight, young and old, and men and women of various racial backgrounds. They taught me to approach these issues in as straightforward a way as possible and offered many useful suggestions. I also learned from reading books by people with disabilities, such as Mean Little Deaf Queer and Waist-High in the World, that you can't assume anything. Nancy Mairs, author of the latter memoir, is a writer who suffers from multiple sclerosis. She writes that not one of her doctors ever asked her about her sex life, despite having a very robust one. She writes beautifully and will challenge you as she did her own physicians to consider the sex lives of patients with physical disabilities.^[3]

I don't mean to imply that asking sensitive questions is ever easy, but it does get easier with practice, like all parts of the physical exam and history-taking.

So, how do you learn how to take a sexual history as a medical student? You must practice asking questions and you must practice tolerating the discomfort you might feel about asking these questions, or listening to the answers. You may not be required to ask about sexual health as part of your social history, but it's a good idea to get in the habit of asking basic questions, such as "Are you sexually active? With men, women, or both?" The more you practice, the more comfortable you will become in the future.

According to Gloria Bachmann, MD, Chief of the OB/GYN Service at the Robert Wood Johnson Medical School, if you have only limited time, the best 2 questions to ask as part of a minimal "review of systems" are: 1) "Are you sexually active?" and 2) "Are you having any sexual difficulty such as pain or lack of sexual desire?"^[4]

As a medical student you can also try asking questions in class. I once asked if Viagra works for women. After years of spam in my email inbox, I couldn't resist the temptation of asking the physician who was teaching us about erectile dysfunction in men, including treatment options, if Viagra had a role in treating female sexual disorders. The question generated stunning silence. I wasn't the only one who wanted to hear his expert opinion that in select situations these drugs can help.

Ask the physician you are working with how she or he approached getting comfortable asking difficult questions. Ask the patients that you get to work with in medical school which qualities in a physician help them feel comfortable talking about sexual health and which ones make them uncomfortable. Medical school is a laboratory and the patients you get to work with during school are a good source of information. They will teach you more than you can imagine, but first you have to ask.

Seek out role models. If you can't find anyone at your school to work with, seek models elsewhere. Sue Johanson, a Canadian sex educator, is someone whose straight talk and nonjudgmental approach is worth emulating. The content of her website is explicit but relevant and may be helpful.^[5]

Reflect on your own biases and behaviors. Observe what makes you uncomfortable and try not to avoid that feeling. What makes you uncomfortable can be a signal to you of where you have room to grow. Approach your education as a social experiment. Remember that what in another context might be considered prurient curiosity is actually critical to your patients' health. Physicians have an obligation to be aware of what their patients may be doing in order to give thoughtful advice.

regards, taniafdi ^_^

Does Low Baseline PSA Eliminate Need for Further Screening ?

News Author: Nick Mulcahy
CME Author: Hien T. Nghiem, MD

CME Released: 09/20/2010; Valid for credit through 09/20/2011

September 20, 2010 — Men with low baseline serum prostate-specific antigen (PSA) values are not likely to benefit from further prostate cancer screening and can therefore forgo it, suggests a new European study.

This provocative observation needs to be solidified with longer follow-up, admit the study authors, led by Pim J. van Leeuwen, MD, from Erasmus Medical Center in Rotterdam, the Netherlands. They also say that their study methods might have biased their outcomes.

Dr. van Leeuwen and his coauthors were all involved in the European Randomized Study of Screening for Prostate Cancer (ERSPC), and they used data from that landmark study in their new analysis, which was published online September 13 in Cancer.

The new study, which had about 9 years of follow-up data on the men, found that the "greatest benefits of early detection programs may be" when baseline PSA values are relatively high (in the range of 4.0 to 9.9 ng/mL or 10.0 to 19.9 ng/mL).

For instance, the authors found that for men with PSA levels between 10 and 19.9 ng/mL, 133 men would need to be screened to prevent 1 death from prostate cancer.

However, for men with low PSA levels (between 0.0 and 1.9 ng/mL), the benefits of screening and treatment were much less favorable: 24,642 men would need to be screened and 724 cases of prostate cancer would need to be treated to prevent 1 disease-related death.

"Current analyses suggest that the significant reduction in disease-specific mortality with screening and early detection may be limited to men with baseline elevated PSA levels," conclude the study authors.

Furthermore, the authors say that the "benefits of continued aggressive investigation and treatment may be limited" in men with low baseline PSA levels.

However, an American prostate cancer screening expert said that this study is "not a game changer."

Andrew Wolf, MD, associate professor of medicine at the University of Virginia School of Medicine in Charlottesville, agreed with the study authors' critique of their methods and said the findings have to be taken with a "huge grain of salt."

Apples and Oranges

The study authors set out to determine whether baseline PSA values indicate just how the harms and benefits of prostate cancer screening are distributed among men who undergo the screening.

The question is crucial because it is now clear that prostate cancer screening reduces prostate-cancer-related deaths but still requires a multitude of men to be overtreated, say the study authors.

In short, it's good to know that PSA-based screening works, but it would be better to know in which men it works best, they suggest.

To address the issue, the authors turned to data from the ERSPC, which showed a 20% reduction in prostate cancer mortality among screened men, compared with unscreened control subjects.

Their "intervention" population consisted of 43,987 men 55 to 74 years of age who were enrolled between 1993 and 1999 and who were randomized to the intervention or screening group of the ERSPC.

However, the unscreened control subjects in the ERSPC study, which was conducted in the Netherlands, Sweden, and Finland, never underwent PSA testing and therefore had no baseline PSA values.

Thus, the investigators lacked a "clinical" population of men with PSA values to compare with their intervention screening population.

To remedy the situation, they turned to a database of 42,503 men in the same age range from Northern Ireland who had their PSA levels measured between 1994 and 1999. The data are from the Northern Ireland Cancer Registry, which contains the results of all PSA tests done in the country.

Herein lies a problem, suggested Dr. Wolf, who was the lead author of the American Cancer Society's recent revision of their prostate cancer screening guidelines and was asked by Medscape Medical News to comment on the study.

"They're comparing apples and oranges," he said.

The 2 populations — from the ERSPC and from Northern Ireland — had significant differences, he said. Most notably, the overall mortality was 25% in the clinical group and 14% in the screening group. "The men from Northern Ireland were clearly a sicker population," explained Dr. Wolf.

There are other differences, he continued, citing the significantly higher median baseline PSA value among the men from Northern Ireland.

The study authors adjusted their analyses of the data to account for the various differences, but Dr. Wolf thinks it was in vain.

"I don't think you can adjust enough to make them comparable populations," he said, which weakens the study conclusions.

The study authors believe that with more follow-up their study might be more valuable. Again, Dr. Wolf is doubtful. "It's hard to draw firm conclusions because of the different populations, even with more follow-up."

In the Netherlands, the ERSPC is supported by grants from the Dutch Cancer Society, the Netherlands Organization for Health Research and Development, Beckman Coulter Hybritech Inc, and Europe Against Cancer. In Sweden, the ERSPC is supported by the Swedish Cancer Society, Wallach Oy Hybritech Inc, Schering-Plough Sweden, and Abbott Pharmaceuticals Sweden. In Finland, the ERSPC is supported by the Academy of Finland, the Cancer Society of Finland, the Sigrid Juselius Foundation, the Competitive Research Funding of the Pirkanmaa Hospital District, Doctoral Programs in Public Health, the Helsingin Sanomat Centenarian Fund, Hybritech Corporation, and the Foundation for Finnish Culture.

The authors have disclosed no relevant financial relationships.

Cancer. Published online September 13, 2010.

 

sumber : http://cme.medscape.com/viewarticle/728965?src=cmemp&uac=97984HK

regards, taniafdi ^_^