Andrea Sikon

Cervical cancer screening: Less testing, smarter testing.

In its 2009 recommendations for cervical cancer screening, the American College of Obstetricians and Gynecologists (ACOG) calls for less-frequent but smarter screening that integrates testing for human papillomavirus (HPV) infection with the Papanicolaou (Pap) test. We review the recommendations from this and other organizations and how and why they are evolving. The latest guidelines call for less frequent but smarter screening that integrates human papillomavirus testing with the Papanicolaou test.

Teaching while learning while practicing: reframing faculty development for the patient-centered medical home.

Soaring costs of health care, patients living longer with chronic illnesses, and continued attrition of interest in primary care contribute to the urgency of developing an improved model of health care delivery. Out of this need, the concept of the team-based, patient-centered medical home (PCMH) has developed. Amidst implementation in academic settings, clinical teachers face complex challenges not previously encountered: teaching while simultaneously learning about the PCMH model, redesigning clinical delivery systems while simultaneously delivering care within them, and working more closely in expanded interprofessional teams.To address these challenges, the authors reviewed three existing faculty development models and recommended four important adaptations for preparing clinical teachers for their roles as system change agents and facilitators of learning in these new settings. First, many faculty find themselves in the awkward position of teaching concepts they have yet to master themselves. Professional development programs must recognize that, at least initially, health professions learners and faculty will be learning system redesign content and skills together while practicing in the evolving workplace. Second, all care delivery team members influence learning in the workplace. Thus, the definition of faculty must expand to include nurses, pharmacists, social workers, medical assistants, patients, and others. These team members will need to accept their roles as educators. Third, learning to deliver health care in teams will require support of both interprofessional collaboration and intraprofessional identity development. Fourth, learning to manage change and uncertainty should be part of the core content of any faculty development program within the PCMH.

Cervical cancer screening: what's new and what's coming?

In their 2012 guidelines for cervical cancer screening, several organizations call for less-frequent but more-effective screening that incorporates testing for human papillomavirus (HPV). We review these recommendations and the possible future direction of screening. In their 2012 guidelines, several organizations call for less-frequent but more-effective screening that incorporates testing for human papillomavirus.

An observational study on the adherence to treatment guidelines of osteopenia.

BACKGROUND Osteopenia/low bone mineral density (BMD) can lead to osteoporosis and is far more prevalent than osteoporosis. The National Osteoporosis Foundation (NOF) has recommendations for prevention and treatment of low BMD; however, the condition remains underrecognized and undertreated. We assessed practice patterns between physician knowledge of low BMD and prescribing of additional pharmacological therapies as defined by the NOF guidelines. METHODS This is a retrospective, observational chart review of electronic medical records of 99 postmenopausal women aged > or =60 years with T-scores between -1.0 and -2.5 on baseline BMD done in 2003 at the Cleveland Clinic Womens Health Center. Counseling, advisement of weightbearing exercise, recommendation of calcium and vitamin D supplementation, and adequate pharmacological therapy in the form of bisphosphonates, hormone therapy, or selective estrogen receptor modulators (SERMs) were assessed. The management of bone specialists credentialed both by the International Society of Clinical Densitometry and the North American Menopause Society and non-bone specialists was also compared. RESULTS Bone specialists were more likely than non-bone specialists to offer counseling in the form of letters, phone encounters, and follow-up office visits and recommend weightbearing exercises. Most physicians recommended calcium and vitamin D supplementation regardless of specialty. There is no significant difference in the prescribing of pharmacological agents vs. conservative measures for osteopenic postmenopausal women by non-bone specialists vs. bone specialists as defined by the NOF guidelines, such that non-bone specialists did not treat these women any less aggressively than did bone specialists. CONCLUSIONS Osteopenia is adequately managed in our institution regardless of physician group. However, non-bone specialists should consider more direct counseling about bone health and consider advisement of weightbearing exercise.

Human papillomavirus vaccine: safe, effective, underused

Vaccination against human papillomavirus (HPV) is safe and effective. It is recommended for females age 9 to 26 and for males age 11 to 26, yet vaccination rates are low. We review the host immune response, the data behind the recommendations for HPV vaccination, and the challenges of implementing the vaccination program. Because HPV is sexually transmitted, HPV vaccination has met with public controversy. A review of the data and the challenges.

Osteoporosis for the Female Patient

As more women will suffer from an osteoporotic fracture than from myocardial infarction, strokes and cancers combined, providers must be competent with identifying and treating osteoporosis (OP). The diagnostic criteria for OP rests mostly on identification of risk factors, bone mineral density (BMD) results, and a history of fragility fracture. The clinician must differentiate therapeutic strategies for prevention and treatment of osteoporosis. Additional pharmacologic therapy is indicated in all patients with OP, diagnosed either by BMD or clinically by presence of a fragility fracture. For those with low bone density, the Fracture Risk Assessment Tool (FRAX®) is utilized to calculate absolute 10 year fracture risk. Additional pharmacologic therapy is indicated in all patients with OP, diagnosed either by BMD or clinically by presence of a fragility fracture. Fracture Risk Assessment Tool (FRAX®) can be utilized to calculate absolute 10 year fracture risk and help in therapeutic decisions.

Menopausal and bone risk assessments in postmenopausal women

The National Osteoporosis Foundation expects an increased prevalence of low bone mass and osteoporosis to 61 million cases by 2020. Nearly 50% of C aucasian postmenopausal women have osteopenia or osteoporosis, with a lifetime risk of an osteoporotic fracture of 40%. As bone loss is clinically silent until a fracture occurs, identifying risk factors and measuring bone density are currently the best available methods for determining a woman’s probability of developing osteoporosis. A careful history and physical should assess for potential secondary causes of low bone density and help to guide further evaluations and treatments. Hormonal therapy, best when initiated within the first few years of perimenopause, can decrease the risk of osteoporotic fractures by approx 50% while treating common menopausal symptoms. Recent studies questioning the risks of hormonal therapy mandate an individualized assessment of the potential risk-benefit ratio.

Clinical Update: Osteoporosis Management

The clinical update serves as a brief review of recently published, high-impact, and potentially practice changing journal articles summarized for our readers. Topics include menopause, sexual dysfunction, breast health, contraception, osteoporosis, and cardiovascular disease. In this clinical update, we selected recent publications relevant to osteoporosis management. We highlight articles on the safety of long-term use of denosumab and bisphosphonates, fracture risk after discontinuing menopausal hormone therapy, calcium intake and cardiovascular risk, as well as the value of repeat dual X-ray absorptiometry scanning to monitor those on osteoporosis treatment.