Thursday, September 23, 2010

Sources of fiber in your diet: case

This one comes up so often there is no particular case I can describe.

Here are the resources I recommend to patients at the clinic:

Family Doctor: Fiber: How to increase the amount in your diet
Family Doctor: Irritable Bowel Syndrome: Tips on controlling your symptoms
Mayo Clinic: Dietary fiber: Essential for a healthy diet
WebMD Fibor-o-meter
HealthLink BC: Fibre and your health
BC cancer Agency: Dietary fibre content of common foods

Clinical queries, various

Lately the Clinical Medical Librarianship (CML) component of the service has been giving me a lot of interesting opportunities to support practice at the clinic. Often clinicians are faced with conflicting evidence, or their patients read something in the news and they need to be able to respond (Check out What Your Patient Reads, developed by the University of Manitoba Health Sciences Libraries).

I thought I would share a few of the topics I've worked on recently that go beyond the usual 5 min clinical question:
  1. Evidence for and against PSA screening for prostate cancer. I put together a fairly extensive annotated bibliography which I would be happy to share with anyone who contacts me. Included in the bibliography:

    • Incidence/mortality statistics for Canada & US
    • Most recent studies & guidelines 2006-2010 (International)
    • Decision aids and evidence to support their use

  2. Evidence to support, or dispute, what has been in the news lately re: calcium supplements and heart disease:

  3. Association between accutane & ulcerative colitis?

Thursday, April 22, 2010

Drugs & Herbs while breastfeeding: case

Has it really been 4 months since my last post?! I've been busy training my new assistant who will be handling the suddenly large volume of pamphlet orders and working with me to develop a new and improved classification system so that pamphlets are easier to find. Referrals have been steadily coming in and I am busy fielding requests in the teaching rooms. Our next challenge is to see how I can support the patient education needs of the walk-in centre or Clinique réseau intégré universitaire...


A question I got recently was from a woman in her thirties who wanted to be able to find out which medications are safe to take while breastfeeding. Her question was specifically about non-prescription medications, for example those she might take for allergies, colds or stomach upset. She also wanted to know whether certain herbal supplements are safe while breastfeeding.



There are a few places I told here she could look that have reliable and freely accessible information about the effect of medications on breast milk NB these resources are American. Use the generic drug name as brand names can be different in Canada and the US:

Lactmed (from the National Library of Medicine- NLM)
A peer-reviewed and fully referenced database of drugs to which breastfeeding mothers may be exposed. Among the data included are maternal and infant levels of drugs, possible effects on breastfed infants and on lactation, and alternate drugs to consider.
The MedlinePlus Drugs, Supplements, and Herbal Information
is available from the American Society of Health-System Pharmacists (ASHP) via AHFS® Consumer Medication Information , and Natural Standard.
  • AHFS® Consumer Medication Information provides extensive information about more than 1,000 brand name and generic prescription and over-the-counter drugs, including side effects, precautions and storage for each drug.
  • Natural Standard is an evidence-based, peer-reviewed collection of information on alternative treatments. MedlinePlus has over 80 monographs on herbs and supplements.
Search this database by drug. At the bottom of each description you will find a link to pregnancy and breastfeeding warnings. This is also a good place to search for interactions between drugs, and for detailed information about side effects.

Herbs & supplements

To find information about the safety of herbal supplements while breastfeeding I again recommended the MedlinePlus Drugs, Supplements, and Herbal Information. I also suggested that she speak to her physician, nurse and/or pharmacist before taking anything.

Thursday, December 17, 2009

Patient journals/diaries/calendars: case(s)

I've just realized I haven't posted since October! I guess there has been a lot going on and not much time to write about it. Mostly I have been busy in the teaching rooms which continues to be productive and fascinating. The rest of the time is increasingly taken up with ordering pamphlets and tracking pamphlet orders. For some reason more and more of them are being requested by various nurses and doctors, even though fewer of them are available for order in print format as information goes digital. Finding a balance between print and e-resources is proving to be a challenge which is a topic for another day.

Keeping track

What I' m going to post today is a list of journals/diaries/calendars that can be given to patients and families when they are asked to keep track of behaviours, symptoms and/or side effects of medications. Doing so can help in the diagnostic and treatment process. Because it is often hard remember how often you can't sleep or feel anxious for example, keeping track while it happens helps the doctor/nurse get a better sense of what's really going on. There are a variety of instances in which such a thing can be useful.

Here are some of the most commonly requested:


Health Link BC: Sleep diary

Keeping track of symptoms:

Depression and Bipolar Support Alliance: Mood and anxiety calendar
Mood Disorders Association of Ontario: Mood diary (pdf)
International Foundation for Functional Gastrointestinal Disorders: Bowel disorder symptom diary (pdf)
Ovarian Cancer Action: Ovarian cancer symptom diary Daily symptom diary for kids Tracking fibromyalgia or chronic fatigue syndrome symptoms
The Lung Association: Asthma diary card (scroll down)
American Urogynecologic Society Foundation: Bladder diary
National Headache Foundation: Headache diary
World Headache Alliance: Headache diary

Medication side effects and pain:

American Cancer Society: Track cancer side effects and pain


WebMD: Food diary and food allergy triggers
American Cancer Society's Great American health challenge: Food diary
US Gov. Weight-Control Information Network: Sample food diary (scroll down)

Thursday, October 8, 2009

Unreliable-reliable information: case

The other day I was in the teaching room and I was putting out some of the new brochures I ordered on the topic of contraception. We have a little display in there so the residents can grab something quickly when I'm not at the clinic.

Information about choosing a contraceptive method is one of the most commonly requested handouts and we keep running out. I found what I thought was a really good one produced by the Society of Obstetricians and Gynecologists of Canada (SOGC). You can't get more reliable and authoritative than that, I figured. I still think that... but....

One of the supervisors opened one up- they look like little brochures but actually they are little posters folded up nicely. When you unfold them you get a comparison chart at the top that shows the number of unintended pregnancies for all the different methods, from Intrauterine system (IUS), through Oral contraception, Condoms, Diaphragm etc., all the way to No contraception (no surprise, pretty high failure rate here: 850 out of 1000, or 85%).

It struck the doctor as odd that Intrauterine device (IUD) had such a high failure rate compared to the others (9 out of 1000 with perfect use vs 3 out of 1000 for the pill for example). It did seem a bit odd. Also for typical use there was a little "-" instead of a number, implying what I'm not sure. No data? Zero failure rate? An asterisk next to the 9 brings you to a little footnote: "This perfect use failure rate corresponds to the Nova-T 200. The typical use failure rate for the Nova-T 200 is likely slightly superior." So then shouldn't there be a number there instead of "-", maybe a higher number than 9?

I decided to check out the references listed right below the chart: Trussell 2007, Trussell 2004, Black 2004* and Andersson 1994.

The paper that seems to have provided the data for the chart is Trussell 2007, or complete reference:

Reducing unintended pregnancy in the United States
Contraception, Volume 77, Issue 1, Page 1
J. Trussell, L. Wynn doi:10.1016/j.contraception.2007.09.001

I am still a bit confused. The paper has a table that shows numbers that correspond exactly to all the other data in the chart except for under IUD we have:

Contraceptive method Typical use Perfect use
ParaGard (copper T) 0.8 0.6
Mirena (LNG-IUS) 0.2 0.2

So where is the Nova-T 200? And how come the above numbers aren't used? I did not find Nova-T 200 data in the other papers either. Provided I found the right ones.**

I still think the handout is great. It provides much more than just data. Aside from the chart there is information about all the contraceptive methods, what they are, how they work, advantages, disadvantages, stuff that will certainly help people make informed choices. And if they have any questions they can discuss with their GP.

However it is interesting to see that even information provided by the most authoritative sources can be flawed. Considering all the shocking debacles we have seen recently, Elsevier's fake journals, authors ghostwriting for pharmas, this is just one more reason to start assessing the contents of individual resources, and not rely so much on authorship.

* These are the Canadian contraception guidelines:

** Once again, is it too much to ask that people provide the full reference?
Some authors are prolific. It took me a while to figure out which Trussell 2007, and which Trussell 2004 etc. Still not sure about all of them. It shouldn't be so hard.