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...

Scenario

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.

Resolution

Medications

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.

Drugs.com

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.

IBS: Challenge

I get a lot of questions about irritable bowel syndrome (IBS), so I thought I would feature it today. It is another one of those conditions that gets you a list of questionable sites intermixed with authoritative ones.

As usual it is not always easy to tell one from the other, and some of the less trustworthy ones are often the most tempting because they make promises and sometimes seem to have more detailed information.

Trustworthy sites rarely, if ever, make promises, and can be very general which may be discouraging. But promises and information that are not evidence-based are unfortunately not worth much. Evidence Based Medicine provides a very good and easy to understand explanation of, you guessed it, evidence-based medicine and why it's so important.

Of course sometimes the reason there is no evidence is that the research hasn't been done, which can also be frustrating.

Another thing to keep in mind is that even trustworthy sites recommend treatments that haven't yet been approved by, say, Health Canada, but have by the FDA, the European Medicines Agency (EMEA), or whatever your country's equivalent of these bodies is (or vice versa), so it's important to be aware of what country the information is coming from.

If you are ever unsure whether you can trust a source of information, ask your health care provider, local librarian, or ask me and I'll be happy to help. The Oakland Public Library gives some good suggestions for how to judge online health information, and Behind the Medical Headlines provides expert commentary on what you're hearing about in the news.

Behind the Medical Headlines aims to provide the public and health professionals with authoritative and independent commentaries from leading medical experts on articles or news items which appear in our daily media (nationally and internationally) in an attempt to reduce the confusion which can often arise from conflicting, incomplete or misleading media reports of medical areas.

And don't forget to check for the HonCode symbol .


Finally, here are some of the evidence-based consumer resources I recommend for IBS:

Irritable bowel syndrome: tips on controlling your symptoms (American Academy of Family Physicians)
Irritable bowel syndrome (National Library of Medicine)
IBS diet: can yogurt ease symptoms? (Mayo Clinic)
Symptoms of IBS (International Foundation for Functional Gastrointestinal Disorders)
Irritable bowel syndrome (IBS) Health Center (WebMD)
Should I have tests for irritable bowel syndrome? (WebMD)
Irritable bowel syndrome: Controlling symptoms with diet (WebMD)

Converting blood glucose measurements US > CA: case

Scenario

A young man tells me he would like to be able to convert US blood glucose levels (milligrams per deciliter: mg/DL) to Canadian (millimoles per liter: mmol/L).

Resolution

After much searching in various resources, and finally Google, I am able to find an online converter from Lifescan Inc., the people who make the OneTouch® System for monitoring blood glucose levels.

I would like to make it clear that I am in no way endorsing their products (I am not qualified to make any judgement about them), and usually I prefer to avoid information offered by such companies as it is likely biased, but in this case I decide to make an exception. The tool they provide is freely accessible and actually quite handy.

I would suggest that if you are looking for reliable information about diabetes there are other better resources. To list just a few:

Canadian Diabetes Association
recipes
Diabetes Quebec
Public Health Agency of Canada
Neuro-Patient Resource Centre
MedlinePlus - diabetes
UpToDate - diabetes

And now, without further ado, here is the link to the converter:

Blood glucose monitoring: converting measurements

Like other online converters, you can plug in the number you have and you will be given the number you want.

You can also use it to convert plasma results to whole blood results.

Tetanus vaccine: case

I haven't posted a case in while so I thought I would put my discussion of shared-decision-making and decision aids on hold, and spend the next couple of posts writing up cases instead.

Scenario

A man sends me an email. He would like some information about tetanus shots. He is scheduled for one the following week and would like to know what to expect in terms of normal reactions because a friend of his told him her arm swelled up a week after getting her shot.

Resolution

Judging from the man's email he has relatively high literacy and so I an able to give him information at a fairly complex level.

MedlinePlus - Medical encyclopedia entry on tetanus vaccines.

Immunization Action Coalition - vaccine information for the public and health professionals: Questions & answers about the tetanus vaccine.

The Immunization Action Coalition works to increase immunization rates and prevent disease by creating and distributing educational materials for health professionals and the public that enhance the delivery of safe and effective immunization services. The Coalition also facilitates communication about the safety, efficacy, and use of vaccines within the broad immunization community of patients, parents, health care organizations, and government health agencies.

UpToDate - Adult immunization (there is a nice section that covers possible side-effects from mild to severe, and a brief description of tetanus the disease).

Discussion

Immunization is THE top subject of interest to patients at the Herzl. Aside from a few questions I've received on the topic, my website statistics show that so far 832 people have visited the Vaccinations page 501 times since April (when the page was created). In second place is the page providing links to online Resources in French with 627 visits by 224 people (since January); and Heart disease and stroke in third place with 402 visits by 202 people (since March).

Ureteral cancer: case

Scenario

One of the GPs asks me for patient level information on the topic of ureteral cancer. One of his patients has been recently diagnosed and would like to have some information about it. Also he would like his patient to have some information about treatment options.

Resolution

There is a lot of information on urethral cancer but not a lot on ureteral cancer,* so I try a few places before finding a good overview on the BC Cancer Agency website.

BC Cancer agency > Patient/public info> Types of cancer > ureteral.

MedlinePlus has an entry in the encyclopedia: Cancer - renal pelvis or ureter.

Neither one goes into whole lot of detail about treatment options.

For that I find the National Cancer Institute's (NCI) PDQ®** on the subject through Onkolink. This can also be found on the NCI website of course, but Onkolink presents the information from the PDQ® in a way that is easier to navigate and read.

To get to the PDQ® though Oncolink: Oncolink > Types of Cancer > Urinary Tract Cancers > Urethral Cancer > NCI Resources.***

To get to it on NCI's website: NCI > A-Z list of cancers > S-Z > Ureter and Renal Pelvis, Transitional Cell Cancer

Last but certainly not least I Google ureteral cancer treatment options and find a great overview of ureteral cancer on the Fox Chase Cancer Center website which also discusses treatments at the various stages of the disease and the information is based on the NCI PDQ® as well.



* Click here for a definition of the two terms.

** What is PDQ®?

*** To be perfectly honest this is the path as it appears on the Onkolink website. If you try to follow it it doesn't work. Urinary tract cancers does not appear on the list of cancers! But if you do a site search for ureter it will be the first hit on the list.

Parkinson's info English and Italian: case

It's been a while since I posted a case. Here's one I like.

Scenario

A young man is referred to me by his GP. His father has been diagnosed with Parkinson's and he would like some information on the disease.

Resolution

As usual my first stop is MedlinePlus. I type in Parkinson's and in addition to the disease overview, find an interactive tutorial that might be helpful, as well as being directed to family doctor's page on the topic. I also recommend Mayo Clinic's section on the topic.

I can see that the man wants as much information as possible, as this is a new diagnosis and he is the primary caregiver. So, I add eMedicine's section on Parkinson's to my recommendations. I also don't want to get lazy and just recommend the same ones over and over out of habit, while overlooking other excellent ones.

A couple of other useful resources I recommend for someone wanting as much information as possible:

• CMA.ca provides Canadian drug information (the drugs Canadian doctors prescribe are often not listed in American resources by the same name) .

• Lab tests online, which provides information on whatever tests might be ordered in relation to a specific condition. In this case, Parkinson's is not listed as one of the conditions, however I explain that he can look up each test separately as well.

While we are talking he wonders whether it might be possible to find some information for his father in Italian. Luckily I speak Italian which will make the search easier, however I have already discovered that there is a dearth of reliable resources in Italian.

The first thing I do is take a look at Medline's new multiple language resource to see if anything is there. Unfortunately there is not. I was very excited when the resource was launched a few weeks ago, as I'm sure many people were. Since then the initial excitement has worn off. There is great potential, but not much on offer just yet. I will keep checking as new topics are entered.

The first thing I do is look up the exact term in Italian. I go the the HONselect tool that allows you to look up MeSH headings in different languages. I type in parkinson's, select Parkinson disease, click on Italian and am told that the correct term is Malattia di parkinson. So far so good. I then go to the one Italian HONcode resource I have been able to find: Paginemediche.it*. I type in the term and get a list of clustered results. Under malattie e condizioni (diseases and conditions) I see 9 hits. Unfortunately none of these hits is directly relevant. I click on one to see how it relates to Parkinson's and discover that in this resource it is listed as Morbo di Parkinson. So now I do a search for that, only to discover that, while listed in the glossary and referred to in relation to malnutrition, incontinence, Huntington's etc., there is no page on that topic. So I have reached a dead end.

I do a Google search which I am unable to recall at the time of writing, and am able to find a multiple language resource that is new to me, NSW Multicultural Health Communication Service, and this one has a long list of topics in Italian, including the one I'm looking for. I am not surprised to find that NSW is Australian, as the country always has excellent health resources in multiple languages. Along with the one on Parkinson's I print the full list of topics for the man in case any other questions come up., and I add the resource to MyHq.


*This resource is only useful if you speak Italian, as there is no English version.

Depression: case

Scenario

A young man visits me at the clinic. He believes he is suffering from depression and would like to have some information on the topic, as well as about various medications, and alternative therapies. He admits that he is hesitant to go on medication, but also realizes that this may be his best option. He would like to be better informed before discussing his situation with his doctor. He has already looked online, but admits that most of what he's read is not particularly trustworthy and would like some advice on better resources.

Resolution

The first thing I do is show him MedlinePlus. I run a sample search and show him how he can also search the encyclopedia, and the drugs and supplements. It occurs to me that a decision aid might be useful to him, since he is in the process of trying to make a decision. I search the Ottawa health research Institute A-Z Inventory of Patient decision aids and find the Mayo Clinic's Depression guide which includes information on antidepressant meds, complementary and alternative therapies, personal stories and things to consider.

While we are talking it becomes apparent that he is a voracious reader, and quite prepared to actively participate in managing his own health, so I decide to also recommend a couple of books that he might find useful:

The Noonday demon: An atlas of depression, by Andrew Solomon, provides an astute and in depth look at depression through the ages and the controversy. The book is an engrossing read, is well researched, and provides a balanced look at the pros and cons of medication as treatment.

Full catastrophy living: Using the wisdom of your body and mind to face stress, pain and illness, by Jon Kabat-Zin. This book is a companion to the Stress Reduction Clinic at the University of Massachusetts Medical Centre, founded by the author. Yoga and mindfulness meditation are taken out of the realm of spirituality and religion, and used as practical and effective stress, pain and illness management tools. The program can be followed independently using guided yoga and medication tapes.

Discussion

It feels good to recommend books as well as online resources for a change. I don't often get the chance to do so since most of the questions I get are better answered in a relatively quick and dirty way. Usually people who come to me are looking for immediate and timely answers: information about clinical trials, medications, back exercises, dietary recommendations related to various conditions etc.

Total time: 1 hr

Low back pain week: 2 cases

I am glad to report that this week I was presented with not one, but two cases, both having to do with low back pain.

Case #1

Scenario

A French-speaking middle-aged man has been referred to me by his physician at the clinic. He suffers from chronic low back pain and would like to know which exercises might help.

Resolution

First I go to Passeportsanté, hoping to find something in French similar to the MedlinePlus interactive tutorials, or at least with illustrated exercises.

Passportsanté > A-Z > D > Dos (mal de). This takes you to the same page as Douleurs lombaires.

Unfortunately there are no illustrations and certainly nothing interactive. I print it out anyway and then try CiSMeF (sites médicaux francophones à destination des patients et de leurs familles) to see what they have there.

CiSMeF > keywords: "exercises dos." I get two results, neither of which include illustrations, or even examples of exercises. Somewhat interesting though, so I print them out too.

Mal de dos: guide pratique
Mal de dos: pour faire le point

At this point I decide it's time to go to MedlinePlus. Since the information is illustrated, and the patient does speak some English, he will still be able to benefit from it.

MedlinePlus > keywords: "back exercises." I print out the list of results so he can access it again at home, and also print out the text summary of the interactive tutorial (which includes illustrations), and the second hit on the list which is a Low back pain exercise guide from the American Academy of Orthopaedic Surgeons.


Case #2

Scenario

One of the health professionals (HP) at the clinic comes into my room and asks if there is a pamphlet on back exercises. I know which one he is thinking of but we have run out.

Resolution

Since the patient speaks English and I have already fielded a similar question earlier in the week, I go directly to MyHq where I have bookmarked some useful links under the Pain management section.

I show the HP the aforementioned MedlinePlus interactive tutorial which he thinks is great (it really is), and Low back pain exercise guide from the American Academy of orthopaedic Surgeons, and this time I also include Low back pain: tips on pain relief and prevention from familydoctor.org.

I ask the HP to fill out an Rx so I can document the consultation and he is happy to do so even though it means returning to the exam room to get the patient's information (name, chart no.). I run into him later in the hall and he tells me he was impressed by how quickly I was able to find the information and that he is going to go back and explore MedlinePlus for himself.

Discussion

I often find that the French language information I am able to find is rich in theory and somewhat lacking in terms of image/illustration and maintaining an appropriate reading level. Fortunately most of the patients I see at the clinic are able to read enough English to still benefit from those resources. It is interesting to note that CiSMeF links directly from each topic to the corresponding section in MedlinePlus. All roads lead...

It is also interesting to note that this resource that we (librarians/information professionals) take for granted, is still not well known to all health professionals. I think this is true of many of the resources we use on a regular basis. I have noticed that health professionals at the clinic often request information in pamphlet form, even though they are all too aware that their patients are going online for information. The clinic used to have a "pamphlet room" and a pamphlet database, so I suspect that this is partly due to habit rather than ignorance.

What not to feed gout & whose pager is it anyway?: case

Case/challenge

Scenario

I am at the library helping to conduct a workshop for a small group of residents. They are reviewing how to use selected EBM resources to answer clinical questions and a couple of the cases at the end of the session are specifically related to providing health information to patients and families. This is why I have agreed to assist during a time when I would normally be on site and available to patients. It is also an opportunity to promote the service to residents, who have so far been extremely enthusiastic about using the service. A short way into the workshop a beeper goes off. After a moment's pause I realize it's mine. I excuse myself to call in and am told that a patient is waiting for me at the clinic which is in an entirely separate building. I run over to the clinic and arrive slightly out of breath to find a young woman waiting for me. Her father's physician would like him to have some information about which foods to avoid when suffering from Gout.

Resolution

I do a quick search on MedlinePlus and find a link to the Arthritis Foundation that answers the question (literally since it is a Q&A from the Arthritis Foundation's consumer health magazine Arthritis Today, in the On call section). I ask if she thinks her father would like more information and shen answers that for now she thinks it will be enough and will contact me if she or her father have more questions. I run back to the library in time to cover the 2 cases that deal with the information needs of patients and families.

Discussion

In this case what is interesting is not so much the information need or how it was met, but rather the challenge that was presented by the fact that I was engaged in other aspects of my position which required that I be off-site during a time when I would normally be available to patients. In the end my having a pager helped to resolve the issue to everyone's satisfaction and the timing worked out just right. Had the person been unable or unwilling to wait the ten minutes it took for me to arrive on site, an opportunity to provide the service would have been lost. This has already happened once so far. The fact that a librarian was paged in a room full of physicians was an added bonus! I could not have found a better way to promote the service than that.

CAM for HCV: case

Case

Scenario

One of the health professionals (HP) at Herzl comes to me asking that I meet with one of her patients (a young man) who has Hepatitis C and is resisting interferon. The HP tells me her patient is interested in complementary and alternative therapies (CAM). Although she would prefer that he accept the recommended treatment she is open to discussing alternatives with him. She hopes the young man's specialist will be open to exploring CAM treatments.

Resolution

When the young man meets with me I mention to him that since he is not sure about interferon a decision aide might help him decide. He hesitates but is amenable once I explain that the aid will not force him to decide one way or another but will rather give him a structure for clearing his thoughts. While we talk he shows me a link to a resource he has already accessed on the subject. It turns out to be a good resource, www.hepatitis-central.com, that has HONcode accreditation which is at present undergoing annual review.

I give the patient some information I had prepared ahead of time: information about HCV and CAM on the Public Health Agency of Canada website and about interferon from MedlinePlus, a decision aid from the Ottawa Health Research Institute, and a research report from the National Centre for Complementary and Alternative Medicine, as well as some fact sheets from the HCV Advocate website.

The patient is very happy with what I have printed for him. In addition he would like to find some information about the use of vitamine C as a therapy, having heard that it can cure HCV completely. We look together and find a few references to vitamin C and HCV but I am not able to find anything definitive or evidence-based, although something is mentioned on Hepatitis Central that might be worth showing to his specialist. We discuss some criteria to use in order to judge whether a website can be trusted including: who maintains the site? who wrote the article? when was it updated? is the information cited?

Discussion

It remains to be seen whether the patient will decide to accept the interferon treatment or whether his specialist will be amenable to exploring CAM therapies.