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Suplemento de los Puntos más Interesantes del Póster Clínico sobre Protección de la Barrera Cutánea del Niño: Avances y Discernimientos.
Suplemento de Pediatric News.
Este suplemento ha sido subvencionado por Johnson & Johnson Consumer Products Company.
• Introducción-Proteger la Barrera Cutánea del Niño: Avances y Discernimientos
• Comparación del Desarrollo de la Piel del Niño en Nueva Jersey, Mumbai, y Pekín (Stamatas et al)
• Diferencias interculturales en el Sueño del Niño y el Niño Pequeño (Mindell et al)
• El Desarrollo de la Pigmentación Solar Secundaria a los Rayos UVB Comienza en el Primer Verano de vida (Mack et al)
• Eficacia de una Medida Online para el Sueño del Niño y el Niño Pequeño (Mindell et al)
• Función Deteriorada de la Barrera Cutánea en la Dermatitis del Pañal Leve y Moderada (Stamatas et al)
• Las Partículas Micronizadas de los Protectores Solares no Demostraron Penetrar Más Allá del Estrato Córneo ni en Adultos ni en Niños (Stamatas et al)
• Estudio de Diversidad Bacteriana en la Piel del Niño Durante el Primer Año de Vida (Capone et al)
• Avances Tecnológicos en Limpiadores para Niños: Revisión Histórica y Mirada Hacia el Futuro (Walters et al)
• Productos de Protección Solar para el Bebé: Evaluación Competitiva de la Suavidad en los Ojos, Cociente FPS-FPu, Estabilidad, y Solidez Antimicrobiana (Bonner et al)
• Un Caso de Infecciones que Comprometen la Vida por la Ausencia de Conservantes en una Crema Tópica y Revisión que Demuestra la Magnitud del Problema (Sultan et al)
• Efecto de los Regímenes Estandarizados del Cuidado de la Piel en la Función de la Barrera Cutánea del Neonato en Diferentes Zonas del Cuerpo (Bartels et al)
Profesorado/Declaraciones del Profesorado
PROFESOR MICHAEL J. CORK, Licenciado en Ciencias, Doctor en Medicina, Licenciado en Medicina y Cirugía, Miembro del Real Colegio de Médicos
Jefe de la Unidad Académica de Investigación en Dermatología
Departamento de Infección e Inflamación
Facultad de Medicina
Universidad de Sheffield, Beech Hill
Sheffield, Inglaterra
PEGGY VERNON, Enfermera Colegiada, Auxiliar de Medicina, Enfermera Pediatra Titulada en Prácticas
Enfermera Pediatra en Prácticas
Sorkin Dermatology
Greenwood Village, Colorado
El Profesor Cork trabaja como asesor para Johnson and Johnson.
La Sra. Vernon no hizo ninguna otra declaración.
Copyright © 2010 by Elsevier Inc.
Suplemento de Pediatric News.
Este suplemento ha sido subvencionado por Johnson & Johnson Consumer Products Company.
• Introducción-Proteger la Barrera Cutánea del Niño: Avances y Discernimientos
• Comparación del Desarrollo de la Piel del Niño en Nueva Jersey, Mumbai, y Pekín (Stamatas et al)
• Diferencias interculturales en el Sueño del Niño y el Niño Pequeño (Mindell et al)
• El Desarrollo de la Pigmentación Solar Secundaria a los Rayos UVB Comienza en el Primer Verano de vida (Mack et al)
• Eficacia de una Medida Online para el Sueño del Niño y el Niño Pequeño (Mindell et al)
• Función Deteriorada de la Barrera Cutánea en la Dermatitis del Pañal Leve y Moderada (Stamatas et al)
• Las Partículas Micronizadas de los Protectores Solares no Demostraron Penetrar Más Allá del Estrato Córneo ni en Adultos ni en Niños (Stamatas et al)
• Estudio de Diversidad Bacteriana en la Piel del Niño Durante el Primer Año de Vida (Capone et al)
• Avances Tecnológicos en Limpiadores para Niños: Revisión Histórica y Mirada Hacia el Futuro (Walters et al)
• Productos de Protección Solar para el Bebé: Evaluación Competitiva de la Suavidad en los Ojos, Cociente FPS-FPu, Estabilidad, y Solidez Antimicrobiana (Bonner et al)
• Un Caso de Infecciones que Comprometen la Vida por la Ausencia de Conservantes en una Crema Tópica y Revisión que Demuestra la Magnitud del Problema (Sultan et al)
• Efecto de los Regímenes Estandarizados del Cuidado de la Piel en la Función de la Barrera Cutánea del Neonato en Diferentes Zonas del Cuerpo (Bartels et al)
Profesorado/Declaraciones del Profesorado
PROFESOR MICHAEL J. CORK, Licenciado en Ciencias, Doctor en Medicina, Licenciado en Medicina y Cirugía, Miembro del Real Colegio de Médicos
Jefe de la Unidad Académica de Investigación en Dermatología
Departamento de Infección e Inflamación
Facultad de Medicina
Universidad de Sheffield, Beech Hill
Sheffield, Inglaterra
PEGGY VERNON, Enfermera Colegiada, Auxiliar de Medicina, Enfermera Pediatra Titulada en Prácticas
Enfermera Pediatra en Prácticas
Sorkin Dermatology
Greenwood Village, Colorado
El Profesor Cork trabaja como asesor para Johnson and Johnson.
La Sra. Vernon no hizo ninguna otra declaración.
Copyright © 2010 by Elsevier Inc.
Suplemento de Pediatric News.
Este suplemento ha sido subvencionado por Johnson & Johnson Consumer Products Company.
• Introducción-Proteger la Barrera Cutánea del Niño: Avances y Discernimientos
• Comparación del Desarrollo de la Piel del Niño en Nueva Jersey, Mumbai, y Pekín (Stamatas et al)
• Diferencias interculturales en el Sueño del Niño y el Niño Pequeño (Mindell et al)
• El Desarrollo de la Pigmentación Solar Secundaria a los Rayos UVB Comienza en el Primer Verano de vida (Mack et al)
• Eficacia de una Medida Online para el Sueño del Niño y el Niño Pequeño (Mindell et al)
• Función Deteriorada de la Barrera Cutánea en la Dermatitis del Pañal Leve y Moderada (Stamatas et al)
• Las Partículas Micronizadas de los Protectores Solares no Demostraron Penetrar Más Allá del Estrato Córneo ni en Adultos ni en Niños (Stamatas et al)
• Estudio de Diversidad Bacteriana en la Piel del Niño Durante el Primer Año de Vida (Capone et al)
• Avances Tecnológicos en Limpiadores para Niños: Revisión Histórica y Mirada Hacia el Futuro (Walters et al)
• Productos de Protección Solar para el Bebé: Evaluación Competitiva de la Suavidad en los Ojos, Cociente FPS-FPu, Estabilidad, y Solidez Antimicrobiana (Bonner et al)
• Un Caso de Infecciones que Comprometen la Vida por la Ausencia de Conservantes en una Crema Tópica y Revisión que Demuestra la Magnitud del Problema (Sultan et al)
• Efecto de los Regímenes Estandarizados del Cuidado de la Piel en la Función de la Barrera Cutánea del Neonato en Diferentes Zonas del Cuerpo (Bartels et al)
Profesorado/Declaraciones del Profesorado
PROFESOR MICHAEL J. CORK, Licenciado en Ciencias, Doctor en Medicina, Licenciado en Medicina y Cirugía, Miembro del Real Colegio de Médicos
Jefe de la Unidad Académica de Investigación en Dermatología
Departamento de Infección e Inflamación
Facultad de Medicina
Universidad de Sheffield, Beech Hill
Sheffield, Inglaterra
PEGGY VERNON, Enfermera Colegiada, Auxiliar de Medicina, Enfermera Pediatra Titulada en Prácticas
Enfermera Pediatra en Prácticas
Sorkin Dermatology
Greenwood Village, Colorado
El Profesor Cork trabaja como asesor para Johnson and Johnson.
La Sra. Vernon no hizo ninguna otra declaración.
Copyright © 2010 by Elsevier Inc.
Intensifying type 2 diabetes therapy: Assessing the options
An inevitable question faced by primary care physicians managing patients with type 2 diabetes mellitus is: “How should treatment be intensified when the combination of lifestyle management and metformin does not provide the desired glycemic control?” While many options are available, there is no single answer to this question. This supplement discusses the benefits and limitations of the options for lowering blood glucose, with emphasis on the glucagon-like peptide-1 receptor agonists and insulin. Designed to provide a practical discussion of individualizing treatment and promoting patient self-management, tips are included to improve physician-patient communication and case studies are presented to reinforce key concepts.
An inevitable question faced by primary care physicians managing patients with type 2 diabetes mellitus is: “How should treatment be intensified when the combination of lifestyle management and metformin does not provide the desired glycemic control?” While many options are available, there is no single answer to this question. This supplement discusses the benefits and limitations of the options for lowering blood glucose, with emphasis on the glucagon-like peptide-1 receptor agonists and insulin. Designed to provide a practical discussion of individualizing treatment and promoting patient self-management, tips are included to improve physician-patient communication and case studies are presented to reinforce key concepts.
An inevitable question faced by primary care physicians managing patients with type 2 diabetes mellitus is: “How should treatment be intensified when the combination of lifestyle management and metformin does not provide the desired glycemic control?” While many options are available, there is no single answer to this question. This supplement discusses the benefits and limitations of the options for lowering blood glucose, with emphasis on the glucagon-like peptide-1 receptor agonists and insulin. Designed to provide a practical discussion of individualizing treatment and promoting patient self-management, tips are included to improve physician-patient communication and case studies are presented to reinforce key concepts.
An Expert Update on Managing External Genital Warts
External genital warts (EGW) are caused by the human papillomavirus (HPV), a highly contagious sexually transmitted infection (STI). HPV infects the basal epithelium via microabrasions and tissue disruption of genital skin/mucosa or oral mucosa. EGW are only one manifestation of HPV infection; HPV DNA may also integrate into the host genome and may lead to malignant transformation.
External genital warts (EGW) are caused by the human papillomavirus (HPV), a highly contagious sexually transmitted infection (STI). HPV infects the basal epithelium via microabrasions and tissue disruption of genital skin/mucosa or oral mucosa. EGW are only one manifestation of HPV infection; HPV DNA may also integrate into the host genome and may lead to malignant transformation.
External genital warts (EGW) are caused by the human papillomavirus (HPV), a highly contagious sexually transmitted infection (STI). HPV infects the basal epithelium via microabrasions and tissue disruption of genital skin/mucosa or oral mucosa. EGW are only one manifestation of HPV infection; HPV DNA may also integrate into the host genome and may lead to malignant transformation.
10 (+1) practical, evidence-based recommendations for you to improve contraceptive care now
- Update on contraception
Rachel B. Rapkin, MD; Mitchell D. Creinin, MD (August 2011) - An appeal to the FDA: Remove the black-box warning for depot medroxyprogesterone acetate!
Andrew M. Kaunitz, MD; David A. Grimes, MD (August 2011) - Levonorgestrel or ulipristal: Is one a better emergency contraceptive than the other?
Robert L. Barbieri, MD (Editorial; March 2011) - IUD use in nulliparous and adolescent women
Jennefer A. Russo, MD; Mitchell D. Creinin, MD (Update on Contraception, August 2010)
EDITOR’S NOTE: Brand names are given parenthetically in some places in the text solely to provide better recognition of methods discussed.
As other articles in this issue of OBG Management attest, medical science continues to focus attention on improving methods of family planning. That emphasis has meant a regular flow of new reports, studies, and guidelines for you to absorb and translate into better practice—no easy task.
Here is help: 10 (+ 1) practical, sensible recommendations for improving contraceptive care that have emerged from recent evidence and that are reasonably easy to incorporate into the care you provide. As with previous installments of this occasional “recommendations” series, we include a brief discussion and pertinent references for each tip.
1. Pelvic exam? It isn’t mandatory.
Do not require pelvic examination before you prescribe an oral contraceptive.
Henderson JT, Sawaya GF, Blum M, Stratton L, Harper CC. Pelvic examinations and access to oral hormonal contraception. Obstet Gynecol. 2010;116(6):1257–1264.
The World Health Organization and ACOG recommend that you consider pelvic examination optional before prescribing an oral contraceptive (OC). Recent evidence indicates, however, that many health-care providers don’t follow that recommendation. Avoiding an unnecessary pelvic exam is a plus for a patient who may fear the procedure; following this guidance therefore removes a potential barrier to care and saves time in a busy practice.
2. Provide more, not less
Prescribe (when possible, dispense) 6 to 12 months of an OC at office visits.
Potter JE, McKinnon S, Hopkins K, et al. Continuation of prescribed compared with over-the-counter oral contraceptives. Obstet Gynecol. 2011;117(3):551–557.
Foster DG, Hulett D, Bradsberry M, Darney P, Policar M. Number of oral contraceptive pill packages dispensed and subsequent unintended pregnancies. Obstet Gynecol. 2011;117(3):566–572.
Studies show that 1) women who are given six or more pill packages at a clinic visit have a lower discontinuation rate than women given one to five packs and 2) prescribing a 1-year supply of OC pill packages (as opposed to one to three packs) is associated with a 30% reduction in the odds of conceiving an unplanned pregnancy and a 46% reduction in the odds of having an abortion.
3. Make the case for long-acting reversibles
Use intrauterine devices and subdermal implants as first-line contraception more often.
American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 59: Intrauterine device. Clinical management guidelines for obstetrician-gynecologists. Obstet Gynecol. 2005;105(1):223–232.
Peipert JF, Zhao Q, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol. 2011;117(5):1105–1113.
Long-acting methods such as the copper intrauterine device (IUD) (Paragard) and the levonorgestrel intrauterine system (LNG-IUS) (Mirena) are the most effective reversible contraceptives because they eliminate the difference between perfect and typical use. A woman at low risk does not need to have a negative cervical culture before having an IUD or the LNG-IUS inserted, and a woman does not need to be on her menses at the time of insertion. In addition, antibiotic prophylaxis is not recommended before or at the time of insertion.
IUDs—and this applies to the subdermal contraceptive implant (Implanon), too—also have the highest rates of satisfaction and 12-month continuation.
4. Take advantage of broader benefits
Use hormonal contraceptives for noncontraceptive indications.
American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 110: Noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010;115(6):206–218.
Jensen JT, Parke S, Mellinger U, Machlitt A, Fraser IS. Effective treatment of heavy menstrual bleeding with estradiol valerate and dienogest: a randomized controlled trial. Obstet Gynecol. 2011;117(4):777–787.
Kaunitz AM, Bissonnette F, Monteiro I, Lukkari-Lax E, Muysers C, Jensen JT. Levonorgestrel-releasing intrauterine system or medroxyprogesterone for heavy menstrual bleeding: a randomized controlled trial. Obstet Gynecol. 2010;116:625-632.
Hormonal contraceptives have long been used for such indications as cycle control and treatment of acne. The LNG-IUS and OCs are highly effective, compared with placebo, for treating heavy menstrual bleeding in the absence of organic pathology.* As a potential alternative to surgical treatment of menorrhagia, OCs offer even broader benefit for many women.
*Mirena is approved by the Food and Drug Administration for treating heavy menstrual bleeding.
5. To encourage continuation, begin now
Get a “quick start” to improve adherence to oral contraceptives.
Westhoff C, Kerns J, Morroni C, et al. Quick start: novel oral contraceptive initiation method. Contraception. 2002;66(3):141–145.
Starting OC pills immediately—instead of waiting for the Sunday after the next menses—can improve the short-term continuation rate for women patients who choose an OC.
6. Move away from every-day regimens
Consider a nondaily combined method, such as the transdermal patch or the vaginal ring, for current OC users.
Creinin MD, Meyn LA, Borgatta L, et al. Multicenter comparison of the contraceptive ring and patch: a randomized controlled trial. Obstet Gynecol. 2008;111(2 pt 1):267–277.
Many women who use an OC are satisfied with the positive effect the method has on menses and acne but find that they miss taking a pill some days; they might benefit from a method that involves nondaily administration. Studies show that switching from oral contraception to the transdermal patch (OrthoEvra) or vaginal ring (Nuvaring), for example, is acceptable to many women.
7. Preemptive prescribing
Prescribe emergency contraception before your patient needs it.
Jackson RA, Schwarz EB, Freedman L, Darney P. Advance supply of emergency contraception: effect on use and usual contraception—a randomized trial. Obstet Gynecol. 2003;102(1):8–16.
American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 112: Emergency contraception. Obstet Gynecol. 2010;115(5):1100–1109.
Consider giving every sexually active woman a prescription for emergency contraception before she leaves your office. She can fill the prescription and keep it at home in case of an emergency.
8. Get to know ella
Become familiar with ulipristal acetate (ella) for emergency contraception.
Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet. 2010;375(9714):555–562.
Barbieri RL. Levonorgestrel or ulipristal: is one a better emergency contraceptive than the other? OBG Manage. 2011;23(3):8–11.
This new FDA-approved agent for emergency contraception is effective for as long as 5 days after intercourse and results in fewer pregnancies than levonorgestrel does. It is available by prescription only, however, and is more expensive than levonorgestrel.
9. Pursue two urogenital pathogens
When you are not performing a speculum examination, screen for N. gonorrhoeae and C. trachomatis with a vaginal swab specimen or urine-based specimen.
Johnson RE, Newhall WJ, Papp JR, et al. Screening tests to detect Chlamydia trachomatis and Neisseria gonorrhoeae infections–2002. MMWR Recomm Rep. 2002;51(RR-15):1–38; quiz CE1–4.
Schachter J, Chernesky MA, Willis DE, et al. Vaginal swabs are the specimens of choice when screening for Chlamydia trachomatis and Neisseria gonorrhoeae: results from a multicenter evaluation of the APTIMA assays for both infections. Sex Transm Dis. 2005;32(12):725–728.
Under new screening guidelines for cervical cancer, Pap smears are not required for women who are younger than 21 years. Gonorrhea and chlamydial infection screening is still important in this population, however, and can be done without a speculum exam.The patient or provider collects a specimen for testing with a vaginal swab, or the patient submits a urine specimen.
10. Now not later: An IUD, post-evacuation
Consider immediate, rather than delayed, IUD insertion after uterine evacuation for spontaneous or elective abortion in women who desire this form of contraception.
Bednarek PH, Creinin MD, Reeves MF, et al. Immediate versus delayed IUD insertion after uterine aspiration. N Engl J Med. 2011;364:2208-2217.
A recent clinical trial enrolled 575 women who underwent uterine aspiration for induced or spontaneous abortion at 5 to 12 weeks’ gestation and who desired an IUD. Subjects were randomized to IUD insertion immediately after the procedure or 2 to 6 weeks later. The 6-month expulsion rate was 5.0% after immediate insertion; 2.7%, after delayed insertion (P = NS). There were no differences in the rates of other adverse events. Only 71% of patients returned for their “delayed” IUD placement; five pregnancies occurred among these women. No pregnancies occurred in the immediate-insertion group.
Offer office-based hysteroscopic sterilization.
Levie M, Weiss G, Kaiser B, Daif J, Chudnoff SG. Analysis of pain and satisfaction with office-based hysteroscopic sterilization. Fertil Steril. 2010;94(4):1189–1194.
Office hysteroscopy is well tolerated. Two hysteroscopic sterilization systems, Essure and Adiana, are available for use in the office. The systems are especially valuable in women who are poor surgical candidates or who want to avoid the inconvenience, or the risks, of a more major surgical procedure.
We want to hear from you! Tell us what you think.
- 10 practical, evidence-based recommendations for the management of severe postpartum hemorrhage
Baha M. Sibai, MD (June 2011) - 10 practical, evidence-based suggestions to improve your minimally invasive surgical skills now
Catherine A. Matthews, MD (April 2011) - 10 practical, evidence-based suggestions to improve your gyn practice now
Mark D. Walters, MD (January 2011) - 10 practical recommendations to improve maternal and perinatal outcomes in patients with eclampsia
Baha M. Sibai, MD
Colleen Krajewski, MD
Dr. Krajewski is a Fellow in Family Planning, Department of Ob/Gyn, The Johns Hopkins Bayview Medical Center, Baltimore, Md.
Mark D. Walters, MD
Dr. Walters is Professor and Vice Chair of Gynecology, Center of Urogynecology and Pelvic Floor Disorders, OBGYN & Women’s Health Institute, Cleveland Clinic, Cleveland, Ohio. He is Co-Editor-in-Chief of the on-line surgical education journal of the International Academy of Pelvic Surgery (IAPS) (www.academyofpelvicsurgery.com).
Dr. Krajewski reports no financial relationships relevant to this article. Dr. Walters is a consultant to CP Consulting.
Colleen Krajewski, MD
Dr. Krajewski is a Fellow in Family Planning, Department of Ob/Gyn, The Johns Hopkins Bayview Medical Center, Baltimore, Md.
Mark D. Walters, MD
Dr. Walters is Professor and Vice Chair of Gynecology, Center of Urogynecology and Pelvic Floor Disorders, OBGYN & Women’s Health Institute, Cleveland Clinic, Cleveland, Ohio. He is Co-Editor-in-Chief of the on-line surgical education journal of the International Academy of Pelvic Surgery (IAPS) (www.academyofpelvicsurgery.com).
Dr. Krajewski reports no financial relationships relevant to this article. Dr. Walters is a consultant to CP Consulting.
Colleen Krajewski, MD
Dr. Krajewski is a Fellow in Family Planning, Department of Ob/Gyn, The Johns Hopkins Bayview Medical Center, Baltimore, Md.
Mark D. Walters, MD
Dr. Walters is Professor and Vice Chair of Gynecology, Center of Urogynecology and Pelvic Floor Disorders, OBGYN & Women’s Health Institute, Cleveland Clinic, Cleveland, Ohio. He is Co-Editor-in-Chief of the on-line surgical education journal of the International Academy of Pelvic Surgery (IAPS) (www.academyofpelvicsurgery.com).
Dr. Krajewski reports no financial relationships relevant to this article. Dr. Walters is a consultant to CP Consulting.
- Update on contraception
Rachel B. Rapkin, MD; Mitchell D. Creinin, MD (August 2011) - An appeal to the FDA: Remove the black-box warning for depot medroxyprogesterone acetate!
Andrew M. Kaunitz, MD; David A. Grimes, MD (August 2011) - Levonorgestrel or ulipristal: Is one a better emergency contraceptive than the other?
Robert L. Barbieri, MD (Editorial; March 2011) - IUD use in nulliparous and adolescent women
Jennefer A. Russo, MD; Mitchell D. Creinin, MD (Update on Contraception, August 2010)
EDITOR’S NOTE: Brand names are given parenthetically in some places in the text solely to provide better recognition of methods discussed.
As other articles in this issue of OBG Management attest, medical science continues to focus attention on improving methods of family planning. That emphasis has meant a regular flow of new reports, studies, and guidelines for you to absorb and translate into better practice—no easy task.
Here is help: 10 (+ 1) practical, sensible recommendations for improving contraceptive care that have emerged from recent evidence and that are reasonably easy to incorporate into the care you provide. As with previous installments of this occasional “recommendations” series, we include a brief discussion and pertinent references for each tip.
1. Pelvic exam? It isn’t mandatory.
Do not require pelvic examination before you prescribe an oral contraceptive.
Henderson JT, Sawaya GF, Blum M, Stratton L, Harper CC. Pelvic examinations and access to oral hormonal contraception. Obstet Gynecol. 2010;116(6):1257–1264.
The World Health Organization and ACOG recommend that you consider pelvic examination optional before prescribing an oral contraceptive (OC). Recent evidence indicates, however, that many health-care providers don’t follow that recommendation. Avoiding an unnecessary pelvic exam is a plus for a patient who may fear the procedure; following this guidance therefore removes a potential barrier to care and saves time in a busy practice.
2. Provide more, not less
Prescribe (when possible, dispense) 6 to 12 months of an OC at office visits.
Potter JE, McKinnon S, Hopkins K, et al. Continuation of prescribed compared with over-the-counter oral contraceptives. Obstet Gynecol. 2011;117(3):551–557.
Foster DG, Hulett D, Bradsberry M, Darney P, Policar M. Number of oral contraceptive pill packages dispensed and subsequent unintended pregnancies. Obstet Gynecol. 2011;117(3):566–572.
Studies show that 1) women who are given six or more pill packages at a clinic visit have a lower discontinuation rate than women given one to five packs and 2) prescribing a 1-year supply of OC pill packages (as opposed to one to three packs) is associated with a 30% reduction in the odds of conceiving an unplanned pregnancy and a 46% reduction in the odds of having an abortion.
3. Make the case for long-acting reversibles
Use intrauterine devices and subdermal implants as first-line contraception more often.
American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 59: Intrauterine device. Clinical management guidelines for obstetrician-gynecologists. Obstet Gynecol. 2005;105(1):223–232.
Peipert JF, Zhao Q, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol. 2011;117(5):1105–1113.
Long-acting methods such as the copper intrauterine device (IUD) (Paragard) and the levonorgestrel intrauterine system (LNG-IUS) (Mirena) are the most effective reversible contraceptives because they eliminate the difference between perfect and typical use. A woman at low risk does not need to have a negative cervical culture before having an IUD or the LNG-IUS inserted, and a woman does not need to be on her menses at the time of insertion. In addition, antibiotic prophylaxis is not recommended before or at the time of insertion.
IUDs—and this applies to the subdermal contraceptive implant (Implanon), too—also have the highest rates of satisfaction and 12-month continuation.
4. Take advantage of broader benefits
Use hormonal contraceptives for noncontraceptive indications.
American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 110: Noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010;115(6):206–218.
Jensen JT, Parke S, Mellinger U, Machlitt A, Fraser IS. Effective treatment of heavy menstrual bleeding with estradiol valerate and dienogest: a randomized controlled trial. Obstet Gynecol. 2011;117(4):777–787.
Kaunitz AM, Bissonnette F, Monteiro I, Lukkari-Lax E, Muysers C, Jensen JT. Levonorgestrel-releasing intrauterine system or medroxyprogesterone for heavy menstrual bleeding: a randomized controlled trial. Obstet Gynecol. 2010;116:625-632.
Hormonal contraceptives have long been used for such indications as cycle control and treatment of acne. The LNG-IUS and OCs are highly effective, compared with placebo, for treating heavy menstrual bleeding in the absence of organic pathology.* As a potential alternative to surgical treatment of menorrhagia, OCs offer even broader benefit for many women.
*Mirena is approved by the Food and Drug Administration for treating heavy menstrual bleeding.
5. To encourage continuation, begin now
Get a “quick start” to improve adherence to oral contraceptives.
Westhoff C, Kerns J, Morroni C, et al. Quick start: novel oral contraceptive initiation method. Contraception. 2002;66(3):141–145.
Starting OC pills immediately—instead of waiting for the Sunday after the next menses—can improve the short-term continuation rate for women patients who choose an OC.
6. Move away from every-day regimens
Consider a nondaily combined method, such as the transdermal patch or the vaginal ring, for current OC users.
Creinin MD, Meyn LA, Borgatta L, et al. Multicenter comparison of the contraceptive ring and patch: a randomized controlled trial. Obstet Gynecol. 2008;111(2 pt 1):267–277.
Many women who use an OC are satisfied with the positive effect the method has on menses and acne but find that they miss taking a pill some days; they might benefit from a method that involves nondaily administration. Studies show that switching from oral contraception to the transdermal patch (OrthoEvra) or vaginal ring (Nuvaring), for example, is acceptable to many women.
7. Preemptive prescribing
Prescribe emergency contraception before your patient needs it.
Jackson RA, Schwarz EB, Freedman L, Darney P. Advance supply of emergency contraception: effect on use and usual contraception—a randomized trial. Obstet Gynecol. 2003;102(1):8–16.
American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 112: Emergency contraception. Obstet Gynecol. 2010;115(5):1100–1109.
Consider giving every sexually active woman a prescription for emergency contraception before she leaves your office. She can fill the prescription and keep it at home in case of an emergency.
8. Get to know ella
Become familiar with ulipristal acetate (ella) for emergency contraception.
Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet. 2010;375(9714):555–562.
Barbieri RL. Levonorgestrel or ulipristal: is one a better emergency contraceptive than the other? OBG Manage. 2011;23(3):8–11.
This new FDA-approved agent for emergency contraception is effective for as long as 5 days after intercourse and results in fewer pregnancies than levonorgestrel does. It is available by prescription only, however, and is more expensive than levonorgestrel.
9. Pursue two urogenital pathogens
When you are not performing a speculum examination, screen for N. gonorrhoeae and C. trachomatis with a vaginal swab specimen or urine-based specimen.
Johnson RE, Newhall WJ, Papp JR, et al. Screening tests to detect Chlamydia trachomatis and Neisseria gonorrhoeae infections–2002. MMWR Recomm Rep. 2002;51(RR-15):1–38; quiz CE1–4.
Schachter J, Chernesky MA, Willis DE, et al. Vaginal swabs are the specimens of choice when screening for Chlamydia trachomatis and Neisseria gonorrhoeae: results from a multicenter evaluation of the APTIMA assays for both infections. Sex Transm Dis. 2005;32(12):725–728.
Under new screening guidelines for cervical cancer, Pap smears are not required for women who are younger than 21 years. Gonorrhea and chlamydial infection screening is still important in this population, however, and can be done without a speculum exam.The patient or provider collects a specimen for testing with a vaginal swab, or the patient submits a urine specimen.
10. Now not later: An IUD, post-evacuation
Consider immediate, rather than delayed, IUD insertion after uterine evacuation for spontaneous or elective abortion in women who desire this form of contraception.
Bednarek PH, Creinin MD, Reeves MF, et al. Immediate versus delayed IUD insertion after uterine aspiration. N Engl J Med. 2011;364:2208-2217.
A recent clinical trial enrolled 575 women who underwent uterine aspiration for induced or spontaneous abortion at 5 to 12 weeks’ gestation and who desired an IUD. Subjects were randomized to IUD insertion immediately after the procedure or 2 to 6 weeks later. The 6-month expulsion rate was 5.0% after immediate insertion; 2.7%, after delayed insertion (P = NS). There were no differences in the rates of other adverse events. Only 71% of patients returned for their “delayed” IUD placement; five pregnancies occurred among these women. No pregnancies occurred in the immediate-insertion group.
Offer office-based hysteroscopic sterilization.
Levie M, Weiss G, Kaiser B, Daif J, Chudnoff SG. Analysis of pain and satisfaction with office-based hysteroscopic sterilization. Fertil Steril. 2010;94(4):1189–1194.
Office hysteroscopy is well tolerated. Two hysteroscopic sterilization systems, Essure and Adiana, are available for use in the office. The systems are especially valuable in women who are poor surgical candidates or who want to avoid the inconvenience, or the risks, of a more major surgical procedure.
We want to hear from you! Tell us what you think.
- 10 practical, evidence-based recommendations for the management of severe postpartum hemorrhage
Baha M. Sibai, MD (June 2011) - 10 practical, evidence-based suggestions to improve your minimally invasive surgical skills now
Catherine A. Matthews, MD (April 2011) - 10 practical, evidence-based suggestions to improve your gyn practice now
Mark D. Walters, MD (January 2011) - 10 practical recommendations to improve maternal and perinatal outcomes in patients with eclampsia
Baha M. Sibai, MD
- Update on contraception
Rachel B. Rapkin, MD; Mitchell D. Creinin, MD (August 2011) - An appeal to the FDA: Remove the black-box warning for depot medroxyprogesterone acetate!
Andrew M. Kaunitz, MD; David A. Grimes, MD (August 2011) - Levonorgestrel or ulipristal: Is one a better emergency contraceptive than the other?
Robert L. Barbieri, MD (Editorial; March 2011) - IUD use in nulliparous and adolescent women
Jennefer A. Russo, MD; Mitchell D. Creinin, MD (Update on Contraception, August 2010)
EDITOR’S NOTE: Brand names are given parenthetically in some places in the text solely to provide better recognition of methods discussed.
As other articles in this issue of OBG Management attest, medical science continues to focus attention on improving methods of family planning. That emphasis has meant a regular flow of new reports, studies, and guidelines for you to absorb and translate into better practice—no easy task.
Here is help: 10 (+ 1) practical, sensible recommendations for improving contraceptive care that have emerged from recent evidence and that are reasonably easy to incorporate into the care you provide. As with previous installments of this occasional “recommendations” series, we include a brief discussion and pertinent references for each tip.
1. Pelvic exam? It isn’t mandatory.
Do not require pelvic examination before you prescribe an oral contraceptive.
Henderson JT, Sawaya GF, Blum M, Stratton L, Harper CC. Pelvic examinations and access to oral hormonal contraception. Obstet Gynecol. 2010;116(6):1257–1264.
The World Health Organization and ACOG recommend that you consider pelvic examination optional before prescribing an oral contraceptive (OC). Recent evidence indicates, however, that many health-care providers don’t follow that recommendation. Avoiding an unnecessary pelvic exam is a plus for a patient who may fear the procedure; following this guidance therefore removes a potential barrier to care and saves time in a busy practice.
2. Provide more, not less
Prescribe (when possible, dispense) 6 to 12 months of an OC at office visits.
Potter JE, McKinnon S, Hopkins K, et al. Continuation of prescribed compared with over-the-counter oral contraceptives. Obstet Gynecol. 2011;117(3):551–557.
Foster DG, Hulett D, Bradsberry M, Darney P, Policar M. Number of oral contraceptive pill packages dispensed and subsequent unintended pregnancies. Obstet Gynecol. 2011;117(3):566–572.
Studies show that 1) women who are given six or more pill packages at a clinic visit have a lower discontinuation rate than women given one to five packs and 2) prescribing a 1-year supply of OC pill packages (as opposed to one to three packs) is associated with a 30% reduction in the odds of conceiving an unplanned pregnancy and a 46% reduction in the odds of having an abortion.
3. Make the case for long-acting reversibles
Use intrauterine devices and subdermal implants as first-line contraception more often.
American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 59: Intrauterine device. Clinical management guidelines for obstetrician-gynecologists. Obstet Gynecol. 2005;105(1):223–232.
Peipert JF, Zhao Q, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol. 2011;117(5):1105–1113.
Long-acting methods such as the copper intrauterine device (IUD) (Paragard) and the levonorgestrel intrauterine system (LNG-IUS) (Mirena) are the most effective reversible contraceptives because they eliminate the difference between perfect and typical use. A woman at low risk does not need to have a negative cervical culture before having an IUD or the LNG-IUS inserted, and a woman does not need to be on her menses at the time of insertion. In addition, antibiotic prophylaxis is not recommended before or at the time of insertion.
IUDs—and this applies to the subdermal contraceptive implant (Implanon), too—also have the highest rates of satisfaction and 12-month continuation.
4. Take advantage of broader benefits
Use hormonal contraceptives for noncontraceptive indications.
American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 110: Noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010;115(6):206–218.
Jensen JT, Parke S, Mellinger U, Machlitt A, Fraser IS. Effective treatment of heavy menstrual bleeding with estradiol valerate and dienogest: a randomized controlled trial. Obstet Gynecol. 2011;117(4):777–787.
Kaunitz AM, Bissonnette F, Monteiro I, Lukkari-Lax E, Muysers C, Jensen JT. Levonorgestrel-releasing intrauterine system or medroxyprogesterone for heavy menstrual bleeding: a randomized controlled trial. Obstet Gynecol. 2010;116:625-632.
Hormonal contraceptives have long been used for such indications as cycle control and treatment of acne. The LNG-IUS and OCs are highly effective, compared with placebo, for treating heavy menstrual bleeding in the absence of organic pathology.* As a potential alternative to surgical treatment of menorrhagia, OCs offer even broader benefit for many women.
*Mirena is approved by the Food and Drug Administration for treating heavy menstrual bleeding.
5. To encourage continuation, begin now
Get a “quick start” to improve adherence to oral contraceptives.
Westhoff C, Kerns J, Morroni C, et al. Quick start: novel oral contraceptive initiation method. Contraception. 2002;66(3):141–145.
Starting OC pills immediately—instead of waiting for the Sunday after the next menses—can improve the short-term continuation rate for women patients who choose an OC.
6. Move away from every-day regimens
Consider a nondaily combined method, such as the transdermal patch or the vaginal ring, for current OC users.
Creinin MD, Meyn LA, Borgatta L, et al. Multicenter comparison of the contraceptive ring and patch: a randomized controlled trial. Obstet Gynecol. 2008;111(2 pt 1):267–277.
Many women who use an OC are satisfied with the positive effect the method has on menses and acne but find that they miss taking a pill some days; they might benefit from a method that involves nondaily administration. Studies show that switching from oral contraception to the transdermal patch (OrthoEvra) or vaginal ring (Nuvaring), for example, is acceptable to many women.
7. Preemptive prescribing
Prescribe emergency contraception before your patient needs it.
Jackson RA, Schwarz EB, Freedman L, Darney P. Advance supply of emergency contraception: effect on use and usual contraception—a randomized trial. Obstet Gynecol. 2003;102(1):8–16.
American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 112: Emergency contraception. Obstet Gynecol. 2010;115(5):1100–1109.
Consider giving every sexually active woman a prescription for emergency contraception before she leaves your office. She can fill the prescription and keep it at home in case of an emergency.
8. Get to know ella
Become familiar with ulipristal acetate (ella) for emergency contraception.
Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet. 2010;375(9714):555–562.
Barbieri RL. Levonorgestrel or ulipristal: is one a better emergency contraceptive than the other? OBG Manage. 2011;23(3):8–11.
This new FDA-approved agent for emergency contraception is effective for as long as 5 days after intercourse and results in fewer pregnancies than levonorgestrel does. It is available by prescription only, however, and is more expensive than levonorgestrel.
9. Pursue two urogenital pathogens
When you are not performing a speculum examination, screen for N. gonorrhoeae and C. trachomatis with a vaginal swab specimen or urine-based specimen.
Johnson RE, Newhall WJ, Papp JR, et al. Screening tests to detect Chlamydia trachomatis and Neisseria gonorrhoeae infections–2002. MMWR Recomm Rep. 2002;51(RR-15):1–38; quiz CE1–4.
Schachter J, Chernesky MA, Willis DE, et al. Vaginal swabs are the specimens of choice when screening for Chlamydia trachomatis and Neisseria gonorrhoeae: results from a multicenter evaluation of the APTIMA assays for both infections. Sex Transm Dis. 2005;32(12):725–728.
Under new screening guidelines for cervical cancer, Pap smears are not required for women who are younger than 21 years. Gonorrhea and chlamydial infection screening is still important in this population, however, and can be done without a speculum exam.The patient or provider collects a specimen for testing with a vaginal swab, or the patient submits a urine specimen.
10. Now not later: An IUD, post-evacuation
Consider immediate, rather than delayed, IUD insertion after uterine evacuation for spontaneous or elective abortion in women who desire this form of contraception.
Bednarek PH, Creinin MD, Reeves MF, et al. Immediate versus delayed IUD insertion after uterine aspiration. N Engl J Med. 2011;364:2208-2217.
A recent clinical trial enrolled 575 women who underwent uterine aspiration for induced or spontaneous abortion at 5 to 12 weeks’ gestation and who desired an IUD. Subjects were randomized to IUD insertion immediately after the procedure or 2 to 6 weeks later. The 6-month expulsion rate was 5.0% after immediate insertion; 2.7%, after delayed insertion (P = NS). There were no differences in the rates of other adverse events. Only 71% of patients returned for their “delayed” IUD placement; five pregnancies occurred among these women. No pregnancies occurred in the immediate-insertion group.
Offer office-based hysteroscopic sterilization.
Levie M, Weiss G, Kaiser B, Daif J, Chudnoff SG. Analysis of pain and satisfaction with office-based hysteroscopic sterilization. Fertil Steril. 2010;94(4):1189–1194.
Office hysteroscopy is well tolerated. Two hysteroscopic sterilization systems, Essure and Adiana, are available for use in the office. The systems are especially valuable in women who are poor surgical candidates or who want to avoid the inconvenience, or the risks, of a more major surgical procedure.
We want to hear from you! Tell us what you think.
- 10 practical, evidence-based recommendations for the management of severe postpartum hemorrhage
Baha M. Sibai, MD (June 2011) - 10 practical, evidence-based suggestions to improve your minimally invasive surgical skills now
Catherine A. Matthews, MD (April 2011) - 10 practical, evidence-based suggestions to improve your gyn practice now
Mark D. Walters, MD (January 2011) - 10 practical recommendations to improve maternal and perinatal outcomes in patients with eclampsia
Baha M. Sibai, MD
Providing Pain and Palliative Care Education Internationally
Volume 9, Issue 4, July-August 2011, Pages 129-133
How we do it
Judith A. Paice PhD, RN
Available online 2 July 2011.
Article Outline
For many clinicians in oncology, educating other health-care professionals about cancer pain and palliative care is part of their professional life. The need for education exists across clinical settings around the world. Improved education is an urgent need as the prevalence of cancer is increasing. This burden is largely carried by the developing world, where resources are often limited.[1] Global educational efforts, including managing common symptoms, communication, care at the time of death, grief, and other topics, are imperative to reduce pain and suffering.[2] International training efforts require additional expertise and preparation beyond the standard teaching skills needed for all professional education.
The goal of international training efforts in pain and palliative care is to provide useful, culturally relevant programs while empowering participants to sustain these efforts in the long term. Global efforts in palliative care have demonstrated that sharing educational materials, resources, support and encouragement with our international colleagues can provide mentorship to go beyond simply attending a course to developing and expanding their own programs of palliative care in oncology.[3] and [4] To do this well, the following provides specific suggestions for before, during, and after international palliative care training experiences.
Do Your Homework
Before a course, it is essential to learn as much as possible about the region, the culture(s), and the health-care system. Several resources for this information are listed in Table 1. Additionally, speaking with colleagues who have traveled to the country or to those who have emigrated from the country can provide valuable insight. These individuals can provide a wealth of information to assist in developing an appropriate curriculum and specific presentations. As demographics vary, it is important to know the common cancers and other leading causes of death in the region. Issues that may be seen as “competing” issues HIV/AIDS, malaria, immunizations, lack of clean water, or maternal–infant mortality.[5] and [6] Literature, including fiction and nonfiction, as well as movies and other media, can enlighten the traveler regarding life in the region. Local consulates offer opportunities for learning, as do organizations such as the Council on Global Relations. There are rapid changes in global politics, health-care systems, and governments, so it is also vital to have current information.
| American Society for Clinical Oncology (ASCO) | Offers international cancer courses as well as fellowships and other awards. |
| Centers for Disease Control and Prevention (CDC), http://wwwnc.cdc.gov/travel/ | Provides information regarding common infectious illnesses, traveler's alerts. |
| Central Intelligence Agency (CIA), The World Factbook, https://www.cia.gov/library/publications/the-world-factbook/ | Excellent review of a country's political, demographic, geographic, and other attributes. |
| City of Hope Pain & Palliative Care Resource Center, http://prc.coh.org/ | Provides a clearinghouse that includes a wide array of resources and references to enhance pain and palliative care education and research. |
| End of Life Nursing Education Consortium (ELNEC), http://www.aacn.nche.edu/elnec/ | Includes relevant articles, resources, and a summary of current international ELNEC training programs. |
| International Association for Hospice and Palliative Care (IAHPC), http://www.hospicecare.com/ | Numerous global palliative care resources, including List of Essential Medicines, Global Directory of Educational Programs in Palliative Care, Global Directory of Palliative Care Providers/Services/Organizations, as well as Palliative Care in the Developing World: Principles and Practice. |
| International Association for the Study of Pain (IASP), http://www.iasp-pain.org/ | Strong emphasis on support of developing countries with research and educational grants; publishes a Guide to Pain Management in Low-Resource Settings offered without cost. |
| Open Society Institute–International Palliative Care Initiative, http://www.soros.org/initiatives/health/focus/ipci/about | Offers support for training, clinical care, and research in palliative care, alone and in collaboration with other organizations. |
| Pain & Policy Studies Group, http://www.painpolicy.wisc.edu/ | Excellent resource for information regarding opioid consumption by country as well as guidelines for policies that allow access to necessary medications. |
| U.S. Department of State, http://www.usembassy.gov/ Bureau of Consular Affairs, http://travel.state.gov/travel/travel_1744.html | Comprehensive lists of US embassies, consulates, and diplomatic missions; information to assist travelers from the United States to other countries, including visa requirements and safety alerts. |
| World Health Organization, http://www.who.int | Many useful resources, including Access to Analgesics and to other Controlled Medicines, as well as statistics regarding common illnesses by country. |
Health-Care Structure
Understand the existing health-care structure and what health care is available to all or for select populations. What is the extent of health-care services? Are there clinics for preventive care, or is most care obtained in the hospital? Is home care available with support from nurses and other professionals? Are emergency services available (eg, does the region have ambulances to transport and emergency departments to accept critically ill patients)? Where do patients obtain medications, and do they have to pay out of pocket for these? Do most people die in the hospital or at home? While websites and government sources are valuable, verify this information with clinicians since the clinical reality may be quite different.
Available Medications
To provide useful guidance in symptom management, it is necessary to have a list of available medications used to treat pain, nausea, dyspnea, constipation/diarrhea, wounds, and other symptoms commonly seen in oncology. Your presentation may need to be modified based upon these available drugs (Table 2). Where do patients obtain medications, and do they pay out of pocket for these? There are limitations on availability and access to opioids around the world.[7] Which opioids are available and actually used? What is the process for obtaining a supply of an opioid for a person with cancer? For example, in some countries, physicians can order only one week's worth of medication at a time. In other countries, patients must obtain opioids from the police station rather than a pharmacy. In several settings, only the patient, not family members, can pick up the medication from the dispensing site. And in a few countries, only parenteral opioids are available. It is also helpful to understand issues such as the prevalence of drug trafficking in the region and how this might affect local drug laws. Are traditional medicines, such as herbal therapies, or other techniques commonly used? It is helpful to be aware of these practices and incorporate them into teaching plans where appropriate.
Education of Health-Care Professionals
International education in palliative care should consider how physicians, nurses, pharmacists, and others are educated. Is the educational system very traditional and formal, with little interaction between students and teachers? Professionals trained in this manner may be less comfortable when faced with role-play, learning through discussion, or other Socratic educational methods. That does not mean that one should exclude these methods when planning the curriculum but, rather, be prepared for silence and possibly even discomfort when first introduced. Seek guidance from local educators as to what methods will be acceptable.
Who is included in the health-care team? Are psychologists available, and are chaplains considered part of health-care services? What is the relationship between physicians, nurses, and other team members? Is collegiality accepted, or is there a hierarchy that limits true teamwork? What is the status of physicians, nurses, and other professionals in the region? In some areas, physicians are highly regarded and financially compensated accordingly. In other parts of the world, physicians have very low social status, respect, and compensation. Within diverse cultures, compensation and acceptance of tips (or bribes) to see a patient or perform an intervention may be accepted practice. Attitudes toward work hours may differ from the Western perspective. In some cultures, socialization and development of personal relationships may be considered more important than other aspects of the workload.[8]
Planning in advance to know the targeted attendees is helpful. It is advisable to inquire if the hosts might consider inviting representatives from the ministry of health, the appropriate drug institutes, other key government officials, as well as medical, nursing, and pharmacy leaders who can become champions for access to pain relief and palliative care. Having multiple disciplines and leaders from health care and government at the same program can foster ongoing communication and understanding. Include chief educators as they can incorporate this content into their respective curricula.
Plan the Curriculum and the Program
The importance of cultural issues when developing content cannot be overstated.[9] Factors that might affect pain expression and language or cultural beliefs about death and dying will greatly impact content for teaching. Be aware of local religious and spiritual beliefs impacting pain and palliative care. Consider issues surrounding disclosure of diagnosis and prognosis. Autonomy may not be the prevailing perspective as seen in North America. Ensure that slides are culturally correct and that pictures and illustrations are appropriate. Having the host country leaders review the curriculum in advance is advisable. Avoid cartoons as these may not translate well. Use case examples, but ensure that they represent the types of patients and scenarios seen by the audience. It is also important to avoid being ethnocentric as Western medicine has much to learn from other approaches. It is very helpful to use case studies from the host country. In some settings, trainers will not have access to computers and projectors, limiting the role of PowerPoint slides. Paper presentations or the use of flip-charts may be more accessible.
Consider the need for translation and, if so, which type will be used. Simultaneous interpretation generally requires a sound booth and headphones for participants, and may be more expensive. Consecutive interpretation requires that the instructor present blocks of information, usually a sentence or two, followed by the interpreter providing the content in the appropriate language. This requires speakers to plan much shorter presentations with up to 50% less content being delivered. In either case, trained interpreters can benefit from seeing the slides in advance so they can prepare and clarify prior to the presentation.
When developing an agenda, inquire about the usual times for breaks and meals, as well as time for prayers or other activities. What is considered a “full day” varies around the world, as does the value of adhering rigidly to a schedule. International education generally means that the agenda is fluid; once you are actually in the country and providing the course, other needs may arise. A common mistake is trying to squeeze in too much content. Ask your host to meet prior to the program and, optimally, plan for time before the course to tour health-care facilities. Arrange for a time to meet with key medical, nursing, pharmacy, and governmental leaders who are not scheduled to attend the meeting but might somehow influence curricula and practice. In some settings, local media may be alerted to generate local interest in the topic. Communicate with your host about these opportunities so that arrangements can be made in advance.
For resource-poor countries, consider asking for donations from colleagues before leaving, including books, CDs, and medical supplies. Check local regulations first, particularly if bringing in medications or equipment. If sending books, some countries require high tariff fees to be paid by the receiver when accepting these packages, creating a financial burden for your hosts. Inquire ahead of time if they have to pay to accept these packages. Additionally, in some resource-poor countries, professionals do not have access to personal or work computers and internet café computers often do not have CD drives. Information on jump drives may be more easily accessible.
Finally, visiting educators may want to pack small gifts to give to hosts and others. These should be easily transported and may include items that represent your city or institution. We have also found bringing candy and small toys to be universally appreciated when visiting pediatric settings. A small portable color printer can be used to print photographs of pediatric patients as some of these children have never seen pictures of themselves. You can also print photographs of participants in the training courses.
Personal Considerations
Several months prior to departure, you should contact your traveler's health information resource to identify which vaccinations and what documents are needed to enter the country. To avoid lost time due to illness, ciprofloxacin and antidiarrheal medicines should be obtained before traveling. It is advisable to update your passport. Some countries require you to have sufficient blank pages in your passport to allow entry into their country. An entry fee paid in cash may be required upon arrival. Travelers should consider the political climate of the country and check the U.S. Department of State website (included in Table 1) for alerts or precautions.
Consider appropriate attire when packing. Clothing should reflect respect for the cultural and religious beliefs of the attendees.
During the Experience
It is very useful to meet with interpreters prior to the presentations to clarify any questions. Translation can be quite complicated. For example, a slide that used the term “caring” was interpreted as “romantic love,” and concepts about suffering and death can take on a cultural meaning. Check with interpreters regularly to determine if the speed of delivery is acceptable. Also, translators may have difficulty with this emotional content. In some instances, interpreters have become tearful and required debriefing after palliative care education events. Consider nonverbal communication and personal space. In some cultures, it may not be appropriate to shake hands or to use two hands. Gestures may have very different meanings in other cultures, so avoid these forms of communication. For example, the “OK” sign commonly used in North America, with the tip of the finger touching the tip of the thumb and the other three fingers extended, is considered an obscene gesture in Brazil.
When using teaching strategies other than lecture, respect that some students may not be comfortable at first with nontraditional approaches. Informal teaching strategies that are valued in North America may be viewed as of poor academic quality in other cultures. Debate and discussion, which may make it seem that the student is questioning a teacher's view, may be seen as disrespectful. At times, eliciting personal reflection and experience can engage the audience. For example, when introducing the topic of communication, health-care professionals in the audience can be asked the following questions:
- • If you had cancer, would you want to know?
• Would you want to know that you had a disease that you could die from?
Following these with “What do you tell your patients?” usually engenders excellent discussion.
We have also found that asking participants to do “homework” can be useful, particularly if the students have been quiet or reluctant to communicate during class. Suggested assignments might include listing the five top barriers to cancer pain management in your setting, describing a difficult death or a death that you made better, or related issues. Reticence to speak during class may be due to discomfort with language skills. Some students feel more comfortable sharing ideas in writing, and these assignments have yielded valuable stories that have helped us to understand their experiences and perspectives.
Since the goal of these educational efforts should be sustained, it is helpful to develop a plan for the future with students. Assist them in identifying goals, as well as action items to meet these goals. Allow time for individual meetings between faculty and students to fine-tune these efforts. This ensures that the educational experience will have a greater likelihood of translation into action. To provide practical assistance, if Internet access is available, spend time with small groups to demonstrate literature searches, useful websites, and other information that will foster continuity.
Faculty should meet after each day of training to modify the planned agenda as needed, to optimally meet the needs of the participants. This also provides needed time to debrief about the day's activities and provide support. Particularly when new to international education, the experience may be overwhelming as the status of health-care in developing countries can cause deep personal reflection.
Finally, celebrate. We have found that many students appreciate the opportunity to have some type of closing ceremony to receive certificates and pins, acknowledge their accomplishments, and encourage their future efforts.
Afterward
E-mail, voiceover Internet services, and videoconferencing software have significantly enhanced global communication. Faculty can make themselves available to the trainees after leaving the country using these technologies. Group conversations via e-mail can help solve problems, provide encouragement, and celebrate successes. Connect attendees with international professional organizations to support ongoing educational efforts. It is very useful to identify the leaders or champions and to plan ongoing support to help sustain their commitment. Many countries do not have professional organizations or support networks. These leaders can exist in isolation and suffer great personal sacrifice to lead palliative care efforts in their country.
Conclusion
When educating about pain and palliative care to a worldwide audience, never make assumptions, expect the unexpected, and be flexible. We have found many of these international teaching experiences to be some of the most exhilarating of our professional lives, providing insight to our own practices and creating lasting relationships with colleagues from around the globe. Ultimately, these efforts will improve care for people with cancer.
Acknowledgments
The authors acknowledge the American Association of Colleges of Nursing and the City of Hope for their ongoing support of the End-of-Life Nursing Education Consortium training activities, as well as the Oncology Nursing Society Foundation and the Open Society Institute for their support of international educational efforts. They also thank Marian Grant for her input.
References [Pub Med ID in Brackets]
1 A.L. Taylor, L.O. Gostin and K.A. Pagonis, Ensuring effective pain treatment: a national and global perspective, JAMA 299 (2008), pp. 89–91 [18167410].
2 K. Crane, Palliative care gains ground in developing countries, J Natl Cancer Inst 102 (21) (2010), pp. 1613–1615 [20966432].
3 J.A. Paice, B.R. Ferrell, N. Coyle, P. Coyne and M. Callaway, Global efforts to improve palliative care: the International End-of-Life Nursing Education Consortium training programme, J Adv Nurs 61 (2007), pp. 173–180 [18186909].
4 J.A. Paice, B. Ferrell, N. Coyle, P. Coyne and T. Smith, Living and dying in East Africa: implementing the End-of-Life Nursing Education Consortium curriculum in Tanzania, Clin J Oncol Nurs 14 (2010), pp. 161–166 [20350889].
5 C. Olweny, C. Sepulveda, A. Merriman, S. Fonn, M. Borok, T. Ngoma, A. Doh and J. Stjernsward, Desirable services and guidelines for the treatment and palliative care of HIV disease patients with cancer in Africa: a World Health Organization consultation, J Palliat Care 19 (2003), pp. 198–205 [14606333].
6 C. Sepulveda, V. Habiyatmbete, J. Amandua, M. Borok, E. Kikule, B. Mudanga and B. Solomon, Quality care at the end of life in Africa, BMJ 327 (2003), pp. 209–213 [12881267].
7 E.L. Krakauer, R. Wenk, R. Buitrago, P. Jenkins and W. Scholten, Opioid inaccessibility and its human consequences: reports from the field, J Pain Palliat Care Pharmacother 24 (2010), pp. 239–243 [20718644].
8 C.M. Bolin, Developing a postbasic gerontology program for international learners: considerations for the process, J Contin Educ Nurs 34 (2003), pp. 177–183 [12887229].
9 K.D. Meneses and C.H. Yarbro, Cultural perspectives of international breast health and breast cancer education, J Nurs Scholarsh 39 (2) (2007), pp. 105–112 [19058079].
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Vitae
Dr. Paice is Director of the Cancer Pain Program, Division of Hematology-Oncology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois.
Carma Erickson-Hurt is a faculty member at Grand Canyon University, Phoenix, Arizona.
Dr. Ferrell is a Professor and Research Scientist at the City of Hope National Medical Center, Duarte, California.
Nessa Coyle is on the Pain and Palliative Care Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York.
Dr. Coyne is Clinical Director of the Thomas Palliative Care Program, Virginia Commonwealth University/Massey Cancer Center, Richmond, Virginia.
Dr. Long is a geriatric nursing consultant and codirector of the Palliative Care for Advanced Dementia, Beatitudes Campus, Phoenix, Arizona.
Dr. Mazanec is a clinical nurse specialist at the University Hospitals Seidman Cancer Center, Cleveland, Ohio.
Pam Malloy is ELNEC Project Director, American Association of Colleges of Nursing, Washington, DC.
Dr. Smith is Professor of Medicine and Palliative Care Research, Virginia Commonwealth University/Massey Cancer Center, Richmond.
Volume 9, Issue 4, July-August 2011, Pages 129-133
How we do it
Judith A. Paice PhD, RN
Available online 2 July 2011.
Article Outline
For many clinicians in oncology, educating other health-care professionals about cancer pain and palliative care is part of their professional life. The need for education exists across clinical settings around the world. Improved education is an urgent need as the prevalence of cancer is increasing. This burden is largely carried by the developing world, where resources are often limited.[1] Global educational efforts, including managing common symptoms, communication, care at the time of death, grief, and other topics, are imperative to reduce pain and suffering.[2] International training efforts require additional expertise and preparation beyond the standard teaching skills needed for all professional education.
The goal of international training efforts in pain and palliative care is to provide useful, culturally relevant programs while empowering participants to sustain these efforts in the long term. Global efforts in palliative care have demonstrated that sharing educational materials, resources, support and encouragement with our international colleagues can provide mentorship to go beyond simply attending a course to developing and expanding their own programs of palliative care in oncology.[3] and [4] To do this well, the following provides specific suggestions for before, during, and after international palliative care training experiences.
Do Your Homework
Before a course, it is essential to learn as much as possible about the region, the culture(s), and the health-care system. Several resources for this information are listed in Table 1. Additionally, speaking with colleagues who have traveled to the country or to those who have emigrated from the country can provide valuable insight. These individuals can provide a wealth of information to assist in developing an appropriate curriculum and specific presentations. As demographics vary, it is important to know the common cancers and other leading causes of death in the region. Issues that may be seen as “competing” issues HIV/AIDS, malaria, immunizations, lack of clean water, or maternal–infant mortality.[5] and [6] Literature, including fiction and nonfiction, as well as movies and other media, can enlighten the traveler regarding life in the region. Local consulates offer opportunities for learning, as do organizations such as the Council on Global Relations. There are rapid changes in global politics, health-care systems, and governments, so it is also vital to have current information.
| American Society for Clinical Oncology (ASCO) | Offers international cancer courses as well as fellowships and other awards. |
| Centers for Disease Control and Prevention (CDC), http://wwwnc.cdc.gov/travel/ | Provides information regarding common infectious illnesses, traveler's alerts. |
| Central Intelligence Agency (CIA), The World Factbook, https://www.cia.gov/library/publications/the-world-factbook/ | Excellent review of a country's political, demographic, geographic, and other attributes. |
| City of Hope Pain & Palliative Care Resource Center, http://prc.coh.org/ | Provides a clearinghouse that includes a wide array of resources and references to enhance pain and palliative care education and research. |
| End of Life Nursing Education Consortium (ELNEC), http://www.aacn.nche.edu/elnec/ | Includes relevant articles, resources, and a summary of current international ELNEC training programs. |
| International Association for Hospice and Palliative Care (IAHPC), http://www.hospicecare.com/ | Numerous global palliative care resources, including List of Essential Medicines, Global Directory of Educational Programs in Palliative Care, Global Directory of Palliative Care Providers/Services/Organizations, as well as Palliative Care in the Developing World: Principles and Practice. |
| International Association for the Study of Pain (IASP), http://www.iasp-pain.org/ | Strong emphasis on support of developing countries with research and educational grants; publishes a Guide to Pain Management in Low-Resource Settings offered without cost. |
| Open Society Institute–International Palliative Care Initiative, http://www.soros.org/initiatives/health/focus/ipci/about | Offers support for training, clinical care, and research in palliative care, alone and in collaboration with other organizations. |
| Pain & Policy Studies Group, http://www.painpolicy.wisc.edu/ | Excellent resource for information regarding opioid consumption by country as well as guidelines for policies that allow access to necessary medications. |
| U.S. Department of State, http://www.usembassy.gov/ Bureau of Consular Affairs, http://travel.state.gov/travel/travel_1744.html | Comprehensive lists of US embassies, consulates, and diplomatic missions; information to assist travelers from the United States to other countries, including visa requirements and safety alerts. |
| World Health Organization, http://www.who.int | Many useful resources, including Access to Analgesics and to other Controlled Medicines, as well as statistics regarding common illnesses by country. |
Health-Care Structure
Understand the existing health-care structure and what health care is available to all or for select populations. What is the extent of health-care services? Are there clinics for preventive care, or is most care obtained in the hospital? Is home care available with support from nurses and other professionals? Are emergency services available (eg, does the region have ambulances to transport and emergency departments to accept critically ill patients)? Where do patients obtain medications, and do they have to pay out of pocket for these? Do most people die in the hospital or at home? While websites and government sources are valuable, verify this information with clinicians since the clinical reality may be quite different.
Available Medications
To provide useful guidance in symptom management, it is necessary to have a list of available medications used to treat pain, nausea, dyspnea, constipation/diarrhea, wounds, and other symptoms commonly seen in oncology. Your presentation may need to be modified based upon these available drugs (Table 2). Where do patients obtain medications, and do they pay out of pocket for these? There are limitations on availability and access to opioids around the world.[7] Which opioids are available and actually used? What is the process for obtaining a supply of an opioid for a person with cancer? For example, in some countries, physicians can order only one week's worth of medication at a time. In other countries, patients must obtain opioids from the police station rather than a pharmacy. In several settings, only the patient, not family members, can pick up the medication from the dispensing site. And in a few countries, only parenteral opioids are available. It is also helpful to understand issues such as the prevalence of drug trafficking in the region and how this might affect local drug laws. Are traditional medicines, such as herbal therapies, or other techniques commonly used? It is helpful to be aware of these practices and incorporate them into teaching plans where appropriate.
Education of Health-Care Professionals
International education in palliative care should consider how physicians, nurses, pharmacists, and others are educated. Is the educational system very traditional and formal, with little interaction between students and teachers? Professionals trained in this manner may be less comfortable when faced with role-play, learning through discussion, or other Socratic educational methods. That does not mean that one should exclude these methods when planning the curriculum but, rather, be prepared for silence and possibly even discomfort when first introduced. Seek guidance from local educators as to what methods will be acceptable.
Who is included in the health-care team? Are psychologists available, and are chaplains considered part of health-care services? What is the relationship between physicians, nurses, and other team members? Is collegiality accepted, or is there a hierarchy that limits true teamwork? What is the status of physicians, nurses, and other professionals in the region? In some areas, physicians are highly regarded and financially compensated accordingly. In other parts of the world, physicians have very low social status, respect, and compensation. Within diverse cultures, compensation and acceptance of tips (or bribes) to see a patient or perform an intervention may be accepted practice. Attitudes toward work hours may differ from the Western perspective. In some cultures, socialization and development of personal relationships may be considered more important than other aspects of the workload.[8]
Planning in advance to know the targeted attendees is helpful. It is advisable to inquire if the hosts might consider inviting representatives from the ministry of health, the appropriate drug institutes, other key government officials, as well as medical, nursing, and pharmacy leaders who can become champions for access to pain relief and palliative care. Having multiple disciplines and leaders from health care and government at the same program can foster ongoing communication and understanding. Include chief educators as they can incorporate this content into their respective curricula.
Plan the Curriculum and the Program
The importance of cultural issues when developing content cannot be overstated.[9] Factors that might affect pain expression and language or cultural beliefs about death and dying will greatly impact content for teaching. Be aware of local religious and spiritual beliefs impacting pain and palliative care. Consider issues surrounding disclosure of diagnosis and prognosis. Autonomy may not be the prevailing perspective as seen in North America. Ensure that slides are culturally correct and that pictures and illustrations are appropriate. Having the host country leaders review the curriculum in advance is advisable. Avoid cartoons as these may not translate well. Use case examples, but ensure that they represent the types of patients and scenarios seen by the audience. It is also important to avoid being ethnocentric as Western medicine has much to learn from other approaches. It is very helpful to use case studies from the host country. In some settings, trainers will not have access to computers and projectors, limiting the role of PowerPoint slides. Paper presentations or the use of flip-charts may be more accessible.
Consider the need for translation and, if so, which type will be used. Simultaneous interpretation generally requires a sound booth and headphones for participants, and may be more expensive. Consecutive interpretation requires that the instructor present blocks of information, usually a sentence or two, followed by the interpreter providing the content in the appropriate language. This requires speakers to plan much shorter presentations with up to 50% less content being delivered. In either case, trained interpreters can benefit from seeing the slides in advance so they can prepare and clarify prior to the presentation.
When developing an agenda, inquire about the usual times for breaks and meals, as well as time for prayers or other activities. What is considered a “full day” varies around the world, as does the value of adhering rigidly to a schedule. International education generally means that the agenda is fluid; once you are actually in the country and providing the course, other needs may arise. A common mistake is trying to squeeze in too much content. Ask your host to meet prior to the program and, optimally, plan for time before the course to tour health-care facilities. Arrange for a time to meet with key medical, nursing, pharmacy, and governmental leaders who are not scheduled to attend the meeting but might somehow influence curricula and practice. In some settings, local media may be alerted to generate local interest in the topic. Communicate with your host about these opportunities so that arrangements can be made in advance.
For resource-poor countries, consider asking for donations from colleagues before leaving, including books, CDs, and medical supplies. Check local regulations first, particularly if bringing in medications or equipment. If sending books, some countries require high tariff fees to be paid by the receiver when accepting these packages, creating a financial burden for your hosts. Inquire ahead of time if they have to pay to accept these packages. Additionally, in some resource-poor countries, professionals do not have access to personal or work computers and internet café computers often do not have CD drives. Information on jump drives may be more easily accessible.
Finally, visiting educators may want to pack small gifts to give to hosts and others. These should be easily transported and may include items that represent your city or institution. We have also found bringing candy and small toys to be universally appreciated when visiting pediatric settings. A small portable color printer can be used to print photographs of pediatric patients as some of these children have never seen pictures of themselves. You can also print photographs of participants in the training courses.
Personal Considerations
Several months prior to departure, you should contact your traveler's health information resource to identify which vaccinations and what documents are needed to enter the country. To avoid lost time due to illness, ciprofloxacin and antidiarrheal medicines should be obtained before traveling. It is advisable to update your passport. Some countries require you to have sufficient blank pages in your passport to allow entry into their country. An entry fee paid in cash may be required upon arrival. Travelers should consider the political climate of the country and check the U.S. Department of State website (included in Table 1) for alerts or precautions.
Consider appropriate attire when packing. Clothing should reflect respect for the cultural and religious beliefs of the attendees.
During the Experience
It is very useful to meet with interpreters prior to the presentations to clarify any questions. Translation can be quite complicated. For example, a slide that used the term “caring” was interpreted as “romantic love,” and concepts about suffering and death can take on a cultural meaning. Check with interpreters regularly to determine if the speed of delivery is acceptable. Also, translators may have difficulty with this emotional content. In some instances, interpreters have become tearful and required debriefing after palliative care education events. Consider nonverbal communication and personal space. In some cultures, it may not be appropriate to shake hands or to use two hands. Gestures may have very different meanings in other cultures, so avoid these forms of communication. For example, the “OK” sign commonly used in North America, with the tip of the finger touching the tip of the thumb and the other three fingers extended, is considered an obscene gesture in Brazil.
When using teaching strategies other than lecture, respect that some students may not be comfortable at first with nontraditional approaches. Informal teaching strategies that are valued in North America may be viewed as of poor academic quality in other cultures. Debate and discussion, which may make it seem that the student is questioning a teacher's view, may be seen as disrespectful. At times, eliciting personal reflection and experience can engage the audience. For example, when introducing the topic of communication, health-care professionals in the audience can be asked the following questions:
- • If you had cancer, would you want to know?
• Would you want to know that you had a disease that you could die from?
Following these with “What do you tell your patients?” usually engenders excellent discussion.
We have also found that asking participants to do “homework” can be useful, particularly if the students have been quiet or reluctant to communicate during class. Suggested assignments might include listing the five top barriers to cancer pain management in your setting, describing a difficult death or a death that you made better, or related issues. Reticence to speak during class may be due to discomfort with language skills. Some students feel more comfortable sharing ideas in writing, and these assignments have yielded valuable stories that have helped us to understand their experiences and perspectives.
Since the goal of these educational efforts should be sustained, it is helpful to develop a plan for the future with students. Assist them in identifying goals, as well as action items to meet these goals. Allow time for individual meetings between faculty and students to fine-tune these efforts. This ensures that the educational experience will have a greater likelihood of translation into action. To provide practical assistance, if Internet access is available, spend time with small groups to demonstrate literature searches, useful websites, and other information that will foster continuity.
Faculty should meet after each day of training to modify the planned agenda as needed, to optimally meet the needs of the participants. This also provides needed time to debrief about the day's activities and provide support. Particularly when new to international education, the experience may be overwhelming as the status of health-care in developing countries can cause deep personal reflection.
Finally, celebrate. We have found that many students appreciate the opportunity to have some type of closing ceremony to receive certificates and pins, acknowledge their accomplishments, and encourage their future efforts.
Afterward
E-mail, voiceover Internet services, and videoconferencing software have significantly enhanced global communication. Faculty can make themselves available to the trainees after leaving the country using these technologies. Group conversations via e-mail can help solve problems, provide encouragement, and celebrate successes. Connect attendees with international professional organizations to support ongoing educational efforts. It is very useful to identify the leaders or champions and to plan ongoing support to help sustain their commitment. Many countries do not have professional organizations or support networks. These leaders can exist in isolation and suffer great personal sacrifice to lead palliative care efforts in their country.
Conclusion
When educating about pain and palliative care to a worldwide audience, never make assumptions, expect the unexpected, and be flexible. We have found many of these international teaching experiences to be some of the most exhilarating of our professional lives, providing insight to our own practices and creating lasting relationships with colleagues from around the globe. Ultimately, these efforts will improve care for people with cancer.
Acknowledgments
The authors acknowledge the American Association of Colleges of Nursing and the City of Hope for their ongoing support of the End-of-Life Nursing Education Consortium training activities, as well as the Oncology Nursing Society Foundation and the Open Society Institute for their support of international educational efforts. They also thank Marian Grant for her input.
References [Pub Med ID in Brackets]
1 A.L. Taylor, L.O. Gostin and K.A. Pagonis, Ensuring effective pain treatment: a national and global perspective, JAMA 299 (2008), pp. 89–91 [18167410].
2 K. Crane, Palliative care gains ground in developing countries, J Natl Cancer Inst 102 (21) (2010), pp. 1613–1615 [20966432].
3 J.A. Paice, B.R. Ferrell, N. Coyle, P. Coyne and M. Callaway, Global efforts to improve palliative care: the International End-of-Life Nursing Education Consortium training programme, J Adv Nurs 61 (2007), pp. 173–180 [18186909].
4 J.A. Paice, B. Ferrell, N. Coyle, P. Coyne and T. Smith, Living and dying in East Africa: implementing the End-of-Life Nursing Education Consortium curriculum in Tanzania, Clin J Oncol Nurs 14 (2010), pp. 161–166 [20350889].
5 C. Olweny, C. Sepulveda, A. Merriman, S. Fonn, M. Borok, T. Ngoma, A. Doh and J. Stjernsward, Desirable services and guidelines for the treatment and palliative care of HIV disease patients with cancer in Africa: a World Health Organization consultation, J Palliat Care 19 (2003), pp. 198–205 [14606333].
6 C. Sepulveda, V. Habiyatmbete, J. Amandua, M. Borok, E. Kikule, B. Mudanga and B. Solomon, Quality care at the end of life in Africa, BMJ 327 (2003), pp. 209–213 [12881267].
7 E.L. Krakauer, R. Wenk, R. Buitrago, P. Jenkins and W. Scholten, Opioid inaccessibility and its human consequences: reports from the field, J Pain Palliat Care Pharmacother 24 (2010), pp. 239–243 [20718644].
8 C.M. Bolin, Developing a postbasic gerontology program for international learners: considerations for the process, J Contin Educ Nurs 34 (2003), pp. 177–183 [12887229].
9 K.D. Meneses and C.H. Yarbro, Cultural perspectives of international breast health and breast cancer education, J Nurs Scholarsh 39 (2) (2007), pp. 105–112 [19058079].
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Vitae
Dr. Paice is Director of the Cancer Pain Program, Division of Hematology-Oncology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois.
Carma Erickson-Hurt is a faculty member at Grand Canyon University, Phoenix, Arizona.
Dr. Ferrell is a Professor and Research Scientist at the City of Hope National Medical Center, Duarte, California.
Nessa Coyle is on the Pain and Palliative Care Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York.
Dr. Coyne is Clinical Director of the Thomas Palliative Care Program, Virginia Commonwealth University/Massey Cancer Center, Richmond, Virginia.
Dr. Long is a geriatric nursing consultant and codirector of the Palliative Care for Advanced Dementia, Beatitudes Campus, Phoenix, Arizona.
Dr. Mazanec is a clinical nurse specialist at the University Hospitals Seidman Cancer Center, Cleveland, Ohio.
Pam Malloy is ELNEC Project Director, American Association of Colleges of Nursing, Washington, DC.
Dr. Smith is Professor of Medicine and Palliative Care Research, Virginia Commonwealth University/Massey Cancer Center, Richmond.
Volume 9, Issue 4, July-August 2011, Pages 129-133
How we do it
Judith A. Paice PhD, RN
Available online 2 July 2011.
Article Outline
For many clinicians in oncology, educating other health-care professionals about cancer pain and palliative care is part of their professional life. The need for education exists across clinical settings around the world. Improved education is an urgent need as the prevalence of cancer is increasing. This burden is largely carried by the developing world, where resources are often limited.[1] Global educational efforts, including managing common symptoms, communication, care at the time of death, grief, and other topics, are imperative to reduce pain and suffering.[2] International training efforts require additional expertise and preparation beyond the standard teaching skills needed for all professional education.
The goal of international training efforts in pain and palliative care is to provide useful, culturally relevant programs while empowering participants to sustain these efforts in the long term. Global efforts in palliative care have demonstrated that sharing educational materials, resources, support and encouragement with our international colleagues can provide mentorship to go beyond simply attending a course to developing and expanding their own programs of palliative care in oncology.[3] and [4] To do this well, the following provides specific suggestions for before, during, and after international palliative care training experiences.
Do Your Homework
Before a course, it is essential to learn as much as possible about the region, the culture(s), and the health-care system. Several resources for this information are listed in Table 1. Additionally, speaking with colleagues who have traveled to the country or to those who have emigrated from the country can provide valuable insight. These individuals can provide a wealth of information to assist in developing an appropriate curriculum and specific presentations. As demographics vary, it is important to know the common cancers and other leading causes of death in the region. Issues that may be seen as “competing” issues HIV/AIDS, malaria, immunizations, lack of clean water, or maternal–infant mortality.[5] and [6] Literature, including fiction and nonfiction, as well as movies and other media, can enlighten the traveler regarding life in the region. Local consulates offer opportunities for learning, as do organizations such as the Council on Global Relations. There are rapid changes in global politics, health-care systems, and governments, so it is also vital to have current information.
| American Society for Clinical Oncology (ASCO) | Offers international cancer courses as well as fellowships and other awards. |
| Centers for Disease Control and Prevention (CDC), http://wwwnc.cdc.gov/travel/ | Provides information regarding common infectious illnesses, traveler's alerts. |
| Central Intelligence Agency (CIA), The World Factbook, https://www.cia.gov/library/publications/the-world-factbook/ | Excellent review of a country's political, demographic, geographic, and other attributes. |
| City of Hope Pain & Palliative Care Resource Center, http://prc.coh.org/ | Provides a clearinghouse that includes a wide array of resources and references to enhance pain and palliative care education and research. |
| End of Life Nursing Education Consortium (ELNEC), http://www.aacn.nche.edu/elnec/ | Includes relevant articles, resources, and a summary of current international ELNEC training programs. |
| International Association for Hospice and Palliative Care (IAHPC), http://www.hospicecare.com/ | Numerous global palliative care resources, including List of Essential Medicines, Global Directory of Educational Programs in Palliative Care, Global Directory of Palliative Care Providers/Services/Organizations, as well as Palliative Care in the Developing World: Principles and Practice. |
| International Association for the Study of Pain (IASP), http://www.iasp-pain.org/ | Strong emphasis on support of developing countries with research and educational grants; publishes a Guide to Pain Management in Low-Resource Settings offered without cost. |
| Open Society Institute–International Palliative Care Initiative, http://www.soros.org/initiatives/health/focus/ipci/about | Offers support for training, clinical care, and research in palliative care, alone and in collaboration with other organizations. |
| Pain & Policy Studies Group, http://www.painpolicy.wisc.edu/ | Excellent resource for information regarding opioid consumption by country as well as guidelines for policies that allow access to necessary medications. |
| U.S. Department of State, http://www.usembassy.gov/ Bureau of Consular Affairs, http://travel.state.gov/travel/travel_1744.html | Comprehensive lists of US embassies, consulates, and diplomatic missions; information to assist travelers from the United States to other countries, including visa requirements and safety alerts. |
| World Health Organization, http://www.who.int | Many useful resources, including Access to Analgesics and to other Controlled Medicines, as well as statistics regarding common illnesses by country. |
Health-Care Structure
Understand the existing health-care structure and what health care is available to all or for select populations. What is the extent of health-care services? Are there clinics for preventive care, or is most care obtained in the hospital? Is home care available with support from nurses and other professionals? Are emergency services available (eg, does the region have ambulances to transport and emergency departments to accept critically ill patients)? Where do patients obtain medications, and do they have to pay out of pocket for these? Do most people die in the hospital or at home? While websites and government sources are valuable, verify this information with clinicians since the clinical reality may be quite different.
Available Medications
To provide useful guidance in symptom management, it is necessary to have a list of available medications used to treat pain, nausea, dyspnea, constipation/diarrhea, wounds, and other symptoms commonly seen in oncology. Your presentation may need to be modified based upon these available drugs (Table 2). Where do patients obtain medications, and do they pay out of pocket for these? There are limitations on availability and access to opioids around the world.[7] Which opioids are available and actually used? What is the process for obtaining a supply of an opioid for a person with cancer? For example, in some countries, physicians can order only one week's worth of medication at a time. In other countries, patients must obtain opioids from the police station rather than a pharmacy. In several settings, only the patient, not family members, can pick up the medication from the dispensing site. And in a few countries, only parenteral opioids are available. It is also helpful to understand issues such as the prevalence of drug trafficking in the region and how this might affect local drug laws. Are traditional medicines, such as herbal therapies, or other techniques commonly used? It is helpful to be aware of these practices and incorporate them into teaching plans where appropriate.
Education of Health-Care Professionals
International education in palliative care should consider how physicians, nurses, pharmacists, and others are educated. Is the educational system very traditional and formal, with little interaction between students and teachers? Professionals trained in this manner may be less comfortable when faced with role-play, learning through discussion, or other Socratic educational methods. That does not mean that one should exclude these methods when planning the curriculum but, rather, be prepared for silence and possibly even discomfort when first introduced. Seek guidance from local educators as to what methods will be acceptable.
Who is included in the health-care team? Are psychologists available, and are chaplains considered part of health-care services? What is the relationship between physicians, nurses, and other team members? Is collegiality accepted, or is there a hierarchy that limits true teamwork? What is the status of physicians, nurses, and other professionals in the region? In some areas, physicians are highly regarded and financially compensated accordingly. In other parts of the world, physicians have very low social status, respect, and compensation. Within diverse cultures, compensation and acceptance of tips (or bribes) to see a patient or perform an intervention may be accepted practice. Attitudes toward work hours may differ from the Western perspective. In some cultures, socialization and development of personal relationships may be considered more important than other aspects of the workload.[8]
Planning in advance to know the targeted attendees is helpful. It is advisable to inquire if the hosts might consider inviting representatives from the ministry of health, the appropriate drug institutes, other key government officials, as well as medical, nursing, and pharmacy leaders who can become champions for access to pain relief and palliative care. Having multiple disciplines and leaders from health care and government at the same program can foster ongoing communication and understanding. Include chief educators as they can incorporate this content into their respective curricula.
Plan the Curriculum and the Program
The importance of cultural issues when developing content cannot be overstated.[9] Factors that might affect pain expression and language or cultural beliefs about death and dying will greatly impact content for teaching. Be aware of local religious and spiritual beliefs impacting pain and palliative care. Consider issues surrounding disclosure of diagnosis and prognosis. Autonomy may not be the prevailing perspective as seen in North America. Ensure that slides are culturally correct and that pictures and illustrations are appropriate. Having the host country leaders review the curriculum in advance is advisable. Avoid cartoons as these may not translate well. Use case examples, but ensure that they represent the types of patients and scenarios seen by the audience. It is also important to avoid being ethnocentric as Western medicine has much to learn from other approaches. It is very helpful to use case studies from the host country. In some settings, trainers will not have access to computers and projectors, limiting the role of PowerPoint slides. Paper presentations or the use of flip-charts may be more accessible.
Consider the need for translation and, if so, which type will be used. Simultaneous interpretation generally requires a sound booth and headphones for participants, and may be more expensive. Consecutive interpretation requires that the instructor present blocks of information, usually a sentence or two, followed by the interpreter providing the content in the appropriate language. This requires speakers to plan much shorter presentations with up to 50% less content being delivered. In either case, trained interpreters can benefit from seeing the slides in advance so they can prepare and clarify prior to the presentation.
When developing an agenda, inquire about the usual times for breaks and meals, as well as time for prayers or other activities. What is considered a “full day” varies around the world, as does the value of adhering rigidly to a schedule. International education generally means that the agenda is fluid; once you are actually in the country and providing the course, other needs may arise. A common mistake is trying to squeeze in too much content. Ask your host to meet prior to the program and, optimally, plan for time before the course to tour health-care facilities. Arrange for a time to meet with key medical, nursing, pharmacy, and governmental leaders who are not scheduled to attend the meeting but might somehow influence curricula and practice. In some settings, local media may be alerted to generate local interest in the topic. Communicate with your host about these opportunities so that arrangements can be made in advance.
For resource-poor countries, consider asking for donations from colleagues before leaving, including books, CDs, and medical supplies. Check local regulations first, particularly if bringing in medications or equipment. If sending books, some countries require high tariff fees to be paid by the receiver when accepting these packages, creating a financial burden for your hosts. Inquire ahead of time if they have to pay to accept these packages. Additionally, in some resource-poor countries, professionals do not have access to personal or work computers and internet café computers often do not have CD drives. Information on jump drives may be more easily accessible.
Finally, visiting educators may want to pack small gifts to give to hosts and others. These should be easily transported and may include items that represent your city or institution. We have also found bringing candy and small toys to be universally appreciated when visiting pediatric settings. A small portable color printer can be used to print photographs of pediatric patients as some of these children have never seen pictures of themselves. You can also print photographs of participants in the training courses.
Personal Considerations
Several months prior to departure, you should contact your traveler's health information resource to identify which vaccinations and what documents are needed to enter the country. To avoid lost time due to illness, ciprofloxacin and antidiarrheal medicines should be obtained before traveling. It is advisable to update your passport. Some countries require you to have sufficient blank pages in your passport to allow entry into their country. An entry fee paid in cash may be required upon arrival. Travelers should consider the political climate of the country and check the U.S. Department of State website (included in Table 1) for alerts or precautions.
Consider appropriate attire when packing. Clothing should reflect respect for the cultural and religious beliefs of the attendees.
During the Experience
It is very useful to meet with interpreters prior to the presentations to clarify any questions. Translation can be quite complicated. For example, a slide that used the term “caring” was interpreted as “romantic love,” and concepts about suffering and death can take on a cultural meaning. Check with interpreters regularly to determine if the speed of delivery is acceptable. Also, translators may have difficulty with this emotional content. In some instances, interpreters have become tearful and required debriefing after palliative care education events. Consider nonverbal communication and personal space. In some cultures, it may not be appropriate to shake hands or to use two hands. Gestures may have very different meanings in other cultures, so avoid these forms of communication. For example, the “OK” sign commonly used in North America, with the tip of the finger touching the tip of the thumb and the other three fingers extended, is considered an obscene gesture in Brazil.
When using teaching strategies other than lecture, respect that some students may not be comfortable at first with nontraditional approaches. Informal teaching strategies that are valued in North America may be viewed as of poor academic quality in other cultures. Debate and discussion, which may make it seem that the student is questioning a teacher's view, may be seen as disrespectful. At times, eliciting personal reflection and experience can engage the audience. For example, when introducing the topic of communication, health-care professionals in the audience can be asked the following questions:
- • If you had cancer, would you want to know?
• Would you want to know that you had a disease that you could die from?
Following these with “What do you tell your patients?” usually engenders excellent discussion.
We have also found that asking participants to do “homework” can be useful, particularly if the students have been quiet or reluctant to communicate during class. Suggested assignments might include listing the five top barriers to cancer pain management in your setting, describing a difficult death or a death that you made better, or related issues. Reticence to speak during class may be due to discomfort with language skills. Some students feel more comfortable sharing ideas in writing, and these assignments have yielded valuable stories that have helped us to understand their experiences and perspectives.
Since the goal of these educational efforts should be sustained, it is helpful to develop a plan for the future with students. Assist them in identifying goals, as well as action items to meet these goals. Allow time for individual meetings between faculty and students to fine-tune these efforts. This ensures that the educational experience will have a greater likelihood of translation into action. To provide practical assistance, if Internet access is available, spend time with small groups to demonstrate literature searches, useful websites, and other information that will foster continuity.
Faculty should meet after each day of training to modify the planned agenda as needed, to optimally meet the needs of the participants. This also provides needed time to debrief about the day's activities and provide support. Particularly when new to international education, the experience may be overwhelming as the status of health-care in developing countries can cause deep personal reflection.
Finally, celebrate. We have found that many students appreciate the opportunity to have some type of closing ceremony to receive certificates and pins, acknowledge their accomplishments, and encourage their future efforts.
Afterward
E-mail, voiceover Internet services, and videoconferencing software have significantly enhanced global communication. Faculty can make themselves available to the trainees after leaving the country using these technologies. Group conversations via e-mail can help solve problems, provide encouragement, and celebrate successes. Connect attendees with international professional organizations to support ongoing educational efforts. It is very useful to identify the leaders or champions and to plan ongoing support to help sustain their commitment. Many countries do not have professional organizations or support networks. These leaders can exist in isolation and suffer great personal sacrifice to lead palliative care efforts in their country.
Conclusion
When educating about pain and palliative care to a worldwide audience, never make assumptions, expect the unexpected, and be flexible. We have found many of these international teaching experiences to be some of the most exhilarating of our professional lives, providing insight to our own practices and creating lasting relationships with colleagues from around the globe. Ultimately, these efforts will improve care for people with cancer.
Acknowledgments
The authors acknowledge the American Association of Colleges of Nursing and the City of Hope for their ongoing support of the End-of-Life Nursing Education Consortium training activities, as well as the Oncology Nursing Society Foundation and the Open Society Institute for their support of international educational efforts. They also thank Marian Grant for her input.
References [Pub Med ID in Brackets]
1 A.L. Taylor, L.O. Gostin and K.A. Pagonis, Ensuring effective pain treatment: a national and global perspective, JAMA 299 (2008), pp. 89–91 [18167410].
2 K. Crane, Palliative care gains ground in developing countries, J Natl Cancer Inst 102 (21) (2010), pp. 1613–1615 [20966432].
3 J.A. Paice, B.R. Ferrell, N. Coyle, P. Coyne and M. Callaway, Global efforts to improve palliative care: the International End-of-Life Nursing Education Consortium training programme, J Adv Nurs 61 (2007), pp. 173–180 [18186909].
4 J.A. Paice, B. Ferrell, N. Coyle, P. Coyne and T. Smith, Living and dying in East Africa: implementing the End-of-Life Nursing Education Consortium curriculum in Tanzania, Clin J Oncol Nurs 14 (2010), pp. 161–166 [20350889].
5 C. Olweny, C. Sepulveda, A. Merriman, S. Fonn, M. Borok, T. Ngoma, A. Doh and J. Stjernsward, Desirable services and guidelines for the treatment and palliative care of HIV disease patients with cancer in Africa: a World Health Organization consultation, J Palliat Care 19 (2003), pp. 198–205 [14606333].
6 C. Sepulveda, V. Habiyatmbete, J. Amandua, M. Borok, E. Kikule, B. Mudanga and B. Solomon, Quality care at the end of life in Africa, BMJ 327 (2003), pp. 209–213 [12881267].
7 E.L. Krakauer, R. Wenk, R. Buitrago, P. Jenkins and W. Scholten, Opioid inaccessibility and its human consequences: reports from the field, J Pain Palliat Care Pharmacother 24 (2010), pp. 239–243 [20718644].
8 C.M. Bolin, Developing a postbasic gerontology program for international learners: considerations for the process, J Contin Educ Nurs 34 (2003), pp. 177–183 [12887229].
9 K.D. Meneses and C.H. Yarbro, Cultural perspectives of international breast health and breast cancer education, J Nurs Scholarsh 39 (2) (2007), pp. 105–112 [19058079].
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Vitae
Dr. Paice is Director of the Cancer Pain Program, Division of Hematology-Oncology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois.
Carma Erickson-Hurt is a faculty member at Grand Canyon University, Phoenix, Arizona.
Dr. Ferrell is a Professor and Research Scientist at the City of Hope National Medical Center, Duarte, California.
Nessa Coyle is on the Pain and Palliative Care Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York.
Dr. Coyne is Clinical Director of the Thomas Palliative Care Program, Virginia Commonwealth University/Massey Cancer Center, Richmond, Virginia.
Dr. Long is a geriatric nursing consultant and codirector of the Palliative Care for Advanced Dementia, Beatitudes Campus, Phoenix, Arizona.
Dr. Mazanec is a clinical nurse specialist at the University Hospitals Seidman Cancer Center, Cleveland, Ohio.
Pam Malloy is ELNEC Project Director, American Association of Colleges of Nursing, Washington, DC.
Dr. Smith is Professor of Medicine and Palliative Care Research, Virginia Commonwealth University/Massey Cancer Center, Richmond.
For many clinicians in oncology, educating other health-care professionals about cancer pain and palliative care is part of their professional life. The need for education exists across clinical settings around the world. Improved education is an urgent need as the prevalence of cancer is increasing.
Current Regimens and Guideline Implications for the Treatment of Actinic Keratosis: Proceedings of a Clinical Roundtable at the 2011 Winter Clinical Dermatology Conference
10 practical, evidence-based recommendations for the management of severe postpartum hemorrhage
Dr. Sibai reports no financial relationships relevant to this article.
By the time a pregnancy reaches term, approximately 500 to 800 mL of blood are circulating through the uterus and placenta every minute, thanks to the intricate network of blood vessels permeating these organs. So it is not surprising that postpartum hemorrhage complicates as many as one in every 20 deliveries, both vaginal and cesarean. Usually, hemorrhage is the result of uterine atony, but other entities may also cause or contribute to acute bleeding.
Severe postpartum hemorrhage, defined as a loss of more than 1,500 mL of blood, complicates approximately 1% of all deliveries and is a leading cause of maternal death. Severe PPH poses serious and often unpredictable challenges to obstetric providers, from the need to make an early diagnosis and establish and treat the cause to the ability to manage hemorrhagic shock.
In this article, I sort through data on the management of this potentially catastrophic event and summarize 10 evidence-based recommendations that can help reduce acute and long-term maternal complications.
1. Plan and rehearse a step-by-step approach
Wise A, Clark V. Challenges of major obstetric haemorrhage. Best Pract Res Clin Obstet Gynaecol. 2010;24(3):353–365.
It is important to anticipate and prepare for the possibility of PPH so that you can respond quickly and effectively when it occurs. Evaluation and management should be simultaneous and should not be hindered by confusion or chaos. Successful management requires early recognition; identification of the cause; the securing of help; continuous monitoring of vital signs and blood loss; prompt resuscitation with fluids, blood, and blood products; and medical or surgical treatment.
2. Know the signs and symptoms of severe hemorrhage
Moore J, Chandraharn E. Management of massive postpartum haemorrhage and coagulopathy. Obstet Gynaecol Reprod Med. 2010;20(6):174–180.
Persistent vaginal bleeding is the first sign of PPH. The bleeding may be continuous oozing or it may be profuse. In addition to bleeding, the patient will exhibit several of the signs and symptoms listed in the TABLE.
Signs and symptoms of postpartum hemorrhage
| Signs | Symptoms |
|---|---|
| Systolic pressure, ≤90 mm Hg | Anxiety |
| Restlessness | |
| Pulse, ≥110 beats per minute | Tachypnea |
| Narrow pulse pressure | Dizziness |
| Hunger for air | |
| Coldness and clamminess | Confusion |
| Pale appearance | |
| Oliguria or anuria |
3. Call for help within 10 minutes after making
the diagnosis of PPH
Driessen M, Bouvier-Colle MH, Dupont C, et al. Postpartum hemorrhage resulting from uterine atony after vaginal delivery. Factors associated with severity. Obstet Gynecol. 2011;117(1):21–31.
In the early stages of uterine atony, delaying care beyond 10 minutes increases the risk of severe PPH.
4. Identify patients at very high risk of hysterectomy
and end-organ dysfunction
O’Brien D, Babiker E, O’Sullivan O, et al. Prediction of peripartum hysterectomy and end organ dysfunction in major obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol. 2010;153(2):165–169.
Rossi AC, Lee RH, Chmait RH. Emergency postpartum hysterectomy for uncontrolled postpartum bleeding: a systematic review. Obstet Gynecol. 2010;115(3):637–644.
In a study of 117 cases of severe obstetric hemorrhage, several independent risk factors for peripartum hysterectomy and end-organ dysfunction were identified:
- number of previous cesarean deliveries (odds ratio [OR], 3.28; 95% confidence interval [CI], 1.95–5.5)
- placenta previa (OR, 13.5; 95% CI, 7.7–184)
- placenta accreta (OR, 37.7; 95% CI, 7.7–184)
- uterine rupture (OR, 7.25; 95% CI, 1.25–42)
- number of units of red blood cells (RBCs) transfused (OR, 1.31; 95% CI, 1.13–1.5).
5. Perform uterine-compression sutures within 1 hour
after delivery
Kayem G, Kurinczuik JJ, Alfirevic Z, Spark P, Brocklehurst P, Knight M; UK Obstetric Surveillance System (UKOSS). Uterine compression sutures for the management of severe postpartum hemorrhage. Obstet Gynecol. 2011;117(1):14–20.
Balloon tamponade of the uterine cavity and uterine-compression sutures are crucial in the management of PPH. In a series of 211 women who were treated with a uterine-compression suture to control PPH, the rate of hysterectomy was 16% if the procedure was performed within an hour of delivery, but it rose to 42% with a delay of 2 to 6 hours.
6. When you suspect placenta previa or placenta accreta,
plan delivery by a multidisciplinary team
Eller AG, Bennett MA, Sharshiner M, et al. Maternal morbidity in cases of placenta accreta managed by multidisciplinary care team compared with standard obstetric care. Obstet Gynecol. 2011;117(2 Pt 1):331–337.
Placenta previa and placenta accreta are frequently associated with severe intrapartum and postpartum hemorrhage. In a retrospective cohort study of 141 cases of placenta accreta that were managed by a multidisciplinary care team (n=79) or received standard obstetric care (n=62), women managed by the multidisciplinary team were less likely (43% vs 61%) to require a large volume of transfusion. They were also less likely to require reoperation within 7 days of delivery for bleeding complications (3% vs 36%) and less likely to experience composite maternal morbidity (47% vs 75%).
Sentilhes L, Ambroselli C, Kayem G, et al. Maternal outcome after conservative treatment of placenta accreta. Obstet Gynecol. 2010;115(3):526–534.
Extirpative surgery in the form of hysterectomy—with or without partial bladder resection—is usually considered the treatment of choice for these conditions. A retrospective multicenter study reported maternal outcomes after conservative treatment of 167 women who had placenta accreta or percreta (18% had percreta). Conservative management included one or more of the following:
- stepwise uterine devascularization
- pelvic vessel ligation or embolization
- uterine-compression sutures
- administration of methotrexate and antibiotics.
Conservative treatment was successful in 131 (78.5%) cases. Eighteen women underwent primary hysterectomy, and 18 women underwent delayed hysterectomy. One woman died after intraumbilical methotrexate administration, and 10 women (6%) experienced severe morbidity.
Conservative management should be offered only in centers that have adequate equipment and resources for patients who are properly counseled and who are motivated and agree to close follow-up. Planned cesarean hysterectomy remains the treatment of choice for multiparous women, as well as for women who have multiple cesarean deliveries with accreta, and those who do not accept the risks or who are not motivated to undergo close and prolonged follow-up.
8. Beware of von Willebrand disease
Pacheco LD, Costantine M, Saade GR, et al. von Willebrand disease and pregnancy: a practical approach for the diagnosis and treatment. Am J Obstet Gynecol. 2010;203(3):194–200.
This disease can cause immediate and delayed postpartum hemorrhage and has a prevalence of approximately 1% in the general population. Sixteen percent to 29% of women who have von Willebrand disease will experience PPH within 24 hours after delivery, and 20% to 29% will experience delayed postpartum bleeding.
Patients who have this disease should be managed in consultation with a hematologist and blood bank personnel. It entails use of desmopressin, plasma concentrates that contain von Willebrand factor (Humate-P), or cryoprecipitate.
9. Have fibrinogen concentrate on hand
Bell SF, Rayment R, Collins PW, Collis RE. The use of fibrinogen concentrate to correct hypofibrinogenaemia rapidly during obstetric haemorrhage. Int J Obstet Anaesth. 2010;19(2):218–223.
Rahe-Mayer N, Sørensen B. Fibrinogen concentrate for management of bleeding. J Thromb Haemost. 2011;9(1):1–5.
This product can correct hypofibrinogenemia very rapidly. In women who have severe PPH, hypofibrinogenemia may develop as a result of dilutional coagulopathy or hypofibrinogemia in conditions such as abruptio placentae with fetal demise, acute fatty liver of pregnancy, or amniotic fluid embolism. Treatment requires a high volume of fresh frozen plasma or cryoprecipitate. Fibrinogen concentrate is stored at room temperature, requires no cross-matching, and can be prepared and infused within 3 minutes.
10. Implement a protocol for massive transfusion
Sibai BM. Evaluation and management of postpartum hemorrhage. In: Management of Acute Obstetric Emergencies. New York, NY: Elsevier; 2011:41–70.
A delay in the treatment of hypovolemic shock can cause ischemic injury to the kidneys, liver, myocardium, and brain and can lead to diffuse intravascular coagulation (DIC), adult respiratory distress syndrome, and death. The objectives for having a protocol for massive transfusion include:
- administration of adequate blood and blood products
- maintenance of tissue perfusion
- ensuring adequate oxygen delivery
- correction of DIC.
These objectives are vital while the team is working to control the source of bleeding.
BY EXPERT AUTHORS
- “Postpartum hemorrhage: 11 critical questions, answered by an expert”
Q&A with Haywood L. Brown, MD(January 2011) - “What you can do to optimize blood conservation in ObGyn practice”
Eric J. Bieber, MD; Linda Scott, RN; Corinna Muller, DO; Nancy Nuss, RN; and Edie L. Derian, MD(February 2010) - “Planning reduces the risk of maternal death. This tool helps.”
Robert L. Barbieri, MD (Editorial; August 2009) - “You should add the Bakri balloon to your treatments for OB bleeds”
Robert L. Barbieri, MD (Editorial; February 2009) - “Consider retroperitoneal packing for postpartum hemorrhage”
Maj. William R. Fulton, DO (July 2008) - “Give a uterotonic routinely during the third stage of labor”
Robert L. Barbieri, MD (Editorial; May 2007)
For a related malpractice case, read Medical Verdicts.
We want to hear from you! Tell us what you think.
Dr. Sibai reports no financial relationships relevant to this article.
By the time a pregnancy reaches term, approximately 500 to 800 mL of blood are circulating through the uterus and placenta every minute, thanks to the intricate network of blood vessels permeating these organs. So it is not surprising that postpartum hemorrhage complicates as many as one in every 20 deliveries, both vaginal and cesarean. Usually, hemorrhage is the result of uterine atony, but other entities may also cause or contribute to acute bleeding.
Severe postpartum hemorrhage, defined as a loss of more than 1,500 mL of blood, complicates approximately 1% of all deliveries and is a leading cause of maternal death. Severe PPH poses serious and often unpredictable challenges to obstetric providers, from the need to make an early diagnosis and establish and treat the cause to the ability to manage hemorrhagic shock.
In this article, I sort through data on the management of this potentially catastrophic event and summarize 10 evidence-based recommendations that can help reduce acute and long-term maternal complications.
1. Plan and rehearse a step-by-step approach
Wise A, Clark V. Challenges of major obstetric haemorrhage. Best Pract Res Clin Obstet Gynaecol. 2010;24(3):353–365.
It is important to anticipate and prepare for the possibility of PPH so that you can respond quickly and effectively when it occurs. Evaluation and management should be simultaneous and should not be hindered by confusion or chaos. Successful management requires early recognition; identification of the cause; the securing of help; continuous monitoring of vital signs and blood loss; prompt resuscitation with fluids, blood, and blood products; and medical or surgical treatment.
2. Know the signs and symptoms of severe hemorrhage
Moore J, Chandraharn E. Management of massive postpartum haemorrhage and coagulopathy. Obstet Gynaecol Reprod Med. 2010;20(6):174–180.
Persistent vaginal bleeding is the first sign of PPH. The bleeding may be continuous oozing or it may be profuse. In addition to bleeding, the patient will exhibit several of the signs and symptoms listed in the TABLE.
Signs and symptoms of postpartum hemorrhage
| Signs | Symptoms |
|---|---|
| Systolic pressure, ≤90 mm Hg | Anxiety |
| Restlessness | |
| Pulse, ≥110 beats per minute | Tachypnea |
| Narrow pulse pressure | Dizziness |
| Hunger for air | |
| Coldness and clamminess | Confusion |
| Pale appearance | |
| Oliguria or anuria |
3. Call for help within 10 minutes after making
the diagnosis of PPH
Driessen M, Bouvier-Colle MH, Dupont C, et al. Postpartum hemorrhage resulting from uterine atony after vaginal delivery. Factors associated with severity. Obstet Gynecol. 2011;117(1):21–31.
In the early stages of uterine atony, delaying care beyond 10 minutes increases the risk of severe PPH.
4. Identify patients at very high risk of hysterectomy
and end-organ dysfunction
O’Brien D, Babiker E, O’Sullivan O, et al. Prediction of peripartum hysterectomy and end organ dysfunction in major obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol. 2010;153(2):165–169.
Rossi AC, Lee RH, Chmait RH. Emergency postpartum hysterectomy for uncontrolled postpartum bleeding: a systematic review. Obstet Gynecol. 2010;115(3):637–644.
In a study of 117 cases of severe obstetric hemorrhage, several independent risk factors for peripartum hysterectomy and end-organ dysfunction were identified:
- number of previous cesarean deliveries (odds ratio [OR], 3.28; 95% confidence interval [CI], 1.95–5.5)
- placenta previa (OR, 13.5; 95% CI, 7.7–184)
- placenta accreta (OR, 37.7; 95% CI, 7.7–184)
- uterine rupture (OR, 7.25; 95% CI, 1.25–42)
- number of units of red blood cells (RBCs) transfused (OR, 1.31; 95% CI, 1.13–1.5).
5. Perform uterine-compression sutures within 1 hour
after delivery
Kayem G, Kurinczuik JJ, Alfirevic Z, Spark P, Brocklehurst P, Knight M; UK Obstetric Surveillance System (UKOSS). Uterine compression sutures for the management of severe postpartum hemorrhage. Obstet Gynecol. 2011;117(1):14–20.
Balloon tamponade of the uterine cavity and uterine-compression sutures are crucial in the management of PPH. In a series of 211 women who were treated with a uterine-compression suture to control PPH, the rate of hysterectomy was 16% if the procedure was performed within an hour of delivery, but it rose to 42% with a delay of 2 to 6 hours.
6. When you suspect placenta previa or placenta accreta,
plan delivery by a multidisciplinary team
Eller AG, Bennett MA, Sharshiner M, et al. Maternal morbidity in cases of placenta accreta managed by multidisciplinary care team compared with standard obstetric care. Obstet Gynecol. 2011;117(2 Pt 1):331–337.
Placenta previa and placenta accreta are frequently associated with severe intrapartum and postpartum hemorrhage. In a retrospective cohort study of 141 cases of placenta accreta that were managed by a multidisciplinary care team (n=79) or received standard obstetric care (n=62), women managed by the multidisciplinary team were less likely (43% vs 61%) to require a large volume of transfusion. They were also less likely to require reoperation within 7 days of delivery for bleeding complications (3% vs 36%) and less likely to experience composite maternal morbidity (47% vs 75%).
Sentilhes L, Ambroselli C, Kayem G, et al. Maternal outcome after conservative treatment of placenta accreta. Obstet Gynecol. 2010;115(3):526–534.
Extirpative surgery in the form of hysterectomy—with or without partial bladder resection—is usually considered the treatment of choice for these conditions. A retrospective multicenter study reported maternal outcomes after conservative treatment of 167 women who had placenta accreta or percreta (18% had percreta). Conservative management included one or more of the following:
- stepwise uterine devascularization
- pelvic vessel ligation or embolization
- uterine-compression sutures
- administration of methotrexate and antibiotics.
Conservative treatment was successful in 131 (78.5%) cases. Eighteen women underwent primary hysterectomy, and 18 women underwent delayed hysterectomy. One woman died after intraumbilical methotrexate administration, and 10 women (6%) experienced severe morbidity.
Conservative management should be offered only in centers that have adequate equipment and resources for patients who are properly counseled and who are motivated and agree to close follow-up. Planned cesarean hysterectomy remains the treatment of choice for multiparous women, as well as for women who have multiple cesarean deliveries with accreta, and those who do not accept the risks or who are not motivated to undergo close and prolonged follow-up.
8. Beware of von Willebrand disease
Pacheco LD, Costantine M, Saade GR, et al. von Willebrand disease and pregnancy: a practical approach for the diagnosis and treatment. Am J Obstet Gynecol. 2010;203(3):194–200.
This disease can cause immediate and delayed postpartum hemorrhage and has a prevalence of approximately 1% in the general population. Sixteen percent to 29% of women who have von Willebrand disease will experience PPH within 24 hours after delivery, and 20% to 29% will experience delayed postpartum bleeding.
Patients who have this disease should be managed in consultation with a hematologist and blood bank personnel. It entails use of desmopressin, plasma concentrates that contain von Willebrand factor (Humate-P), or cryoprecipitate.
9. Have fibrinogen concentrate on hand
Bell SF, Rayment R, Collins PW, Collis RE. The use of fibrinogen concentrate to correct hypofibrinogenaemia rapidly during obstetric haemorrhage. Int J Obstet Anaesth. 2010;19(2):218–223.
Rahe-Mayer N, Sørensen B. Fibrinogen concentrate for management of bleeding. J Thromb Haemost. 2011;9(1):1–5.
This product can correct hypofibrinogenemia very rapidly. In women who have severe PPH, hypofibrinogenemia may develop as a result of dilutional coagulopathy or hypofibrinogemia in conditions such as abruptio placentae with fetal demise, acute fatty liver of pregnancy, or amniotic fluid embolism. Treatment requires a high volume of fresh frozen plasma or cryoprecipitate. Fibrinogen concentrate is stored at room temperature, requires no cross-matching, and can be prepared and infused within 3 minutes.
10. Implement a protocol for massive transfusion
Sibai BM. Evaluation and management of postpartum hemorrhage. In: Management of Acute Obstetric Emergencies. New York, NY: Elsevier; 2011:41–70.
A delay in the treatment of hypovolemic shock can cause ischemic injury to the kidneys, liver, myocardium, and brain and can lead to diffuse intravascular coagulation (DIC), adult respiratory distress syndrome, and death. The objectives for having a protocol for massive transfusion include:
- administration of adequate blood and blood products
- maintenance of tissue perfusion
- ensuring adequate oxygen delivery
- correction of DIC.
These objectives are vital while the team is working to control the source of bleeding.
BY EXPERT AUTHORS
- “Postpartum hemorrhage: 11 critical questions, answered by an expert”
Q&A with Haywood L. Brown, MD(January 2011) - “What you can do to optimize blood conservation in ObGyn practice”
Eric J. Bieber, MD; Linda Scott, RN; Corinna Muller, DO; Nancy Nuss, RN; and Edie L. Derian, MD(February 2010) - “Planning reduces the risk of maternal death. This tool helps.”
Robert L. Barbieri, MD (Editorial; August 2009) - “You should add the Bakri balloon to your treatments for OB bleeds”
Robert L. Barbieri, MD (Editorial; February 2009) - “Consider retroperitoneal packing for postpartum hemorrhage”
Maj. William R. Fulton, DO (July 2008) - “Give a uterotonic routinely during the third stage of labor”
Robert L. Barbieri, MD (Editorial; May 2007)
For a related malpractice case, read Medical Verdicts.
We want to hear from you! Tell us what you think.
Dr. Sibai reports no financial relationships relevant to this article.
By the time a pregnancy reaches term, approximately 500 to 800 mL of blood are circulating through the uterus and placenta every minute, thanks to the intricate network of blood vessels permeating these organs. So it is not surprising that postpartum hemorrhage complicates as many as one in every 20 deliveries, both vaginal and cesarean. Usually, hemorrhage is the result of uterine atony, but other entities may also cause or contribute to acute bleeding.
Severe postpartum hemorrhage, defined as a loss of more than 1,500 mL of blood, complicates approximately 1% of all deliveries and is a leading cause of maternal death. Severe PPH poses serious and often unpredictable challenges to obstetric providers, from the need to make an early diagnosis and establish and treat the cause to the ability to manage hemorrhagic shock.
In this article, I sort through data on the management of this potentially catastrophic event and summarize 10 evidence-based recommendations that can help reduce acute and long-term maternal complications.
1. Plan and rehearse a step-by-step approach
Wise A, Clark V. Challenges of major obstetric haemorrhage. Best Pract Res Clin Obstet Gynaecol. 2010;24(3):353–365.
It is important to anticipate and prepare for the possibility of PPH so that you can respond quickly and effectively when it occurs. Evaluation and management should be simultaneous and should not be hindered by confusion or chaos. Successful management requires early recognition; identification of the cause; the securing of help; continuous monitoring of vital signs and blood loss; prompt resuscitation with fluids, blood, and blood products; and medical or surgical treatment.
2. Know the signs and symptoms of severe hemorrhage
Moore J, Chandraharn E. Management of massive postpartum haemorrhage and coagulopathy. Obstet Gynaecol Reprod Med. 2010;20(6):174–180.
Persistent vaginal bleeding is the first sign of PPH. The bleeding may be continuous oozing or it may be profuse. In addition to bleeding, the patient will exhibit several of the signs and symptoms listed in the TABLE.
Signs and symptoms of postpartum hemorrhage
| Signs | Symptoms |
|---|---|
| Systolic pressure, ≤90 mm Hg | Anxiety |
| Restlessness | |
| Pulse, ≥110 beats per minute | Tachypnea |
| Narrow pulse pressure | Dizziness |
| Hunger for air | |
| Coldness and clamminess | Confusion |
| Pale appearance | |
| Oliguria or anuria |
3. Call for help within 10 minutes after making
the diagnosis of PPH
Driessen M, Bouvier-Colle MH, Dupont C, et al. Postpartum hemorrhage resulting from uterine atony after vaginal delivery. Factors associated with severity. Obstet Gynecol. 2011;117(1):21–31.
In the early stages of uterine atony, delaying care beyond 10 minutes increases the risk of severe PPH.
4. Identify patients at very high risk of hysterectomy
and end-organ dysfunction
O’Brien D, Babiker E, O’Sullivan O, et al. Prediction of peripartum hysterectomy and end organ dysfunction in major obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol. 2010;153(2):165–169.
Rossi AC, Lee RH, Chmait RH. Emergency postpartum hysterectomy for uncontrolled postpartum bleeding: a systematic review. Obstet Gynecol. 2010;115(3):637–644.
In a study of 117 cases of severe obstetric hemorrhage, several independent risk factors for peripartum hysterectomy and end-organ dysfunction were identified:
- number of previous cesarean deliveries (odds ratio [OR], 3.28; 95% confidence interval [CI], 1.95–5.5)
- placenta previa (OR, 13.5; 95% CI, 7.7–184)
- placenta accreta (OR, 37.7; 95% CI, 7.7–184)
- uterine rupture (OR, 7.25; 95% CI, 1.25–42)
- number of units of red blood cells (RBCs) transfused (OR, 1.31; 95% CI, 1.13–1.5).
5. Perform uterine-compression sutures within 1 hour
after delivery
Kayem G, Kurinczuik JJ, Alfirevic Z, Spark P, Brocklehurst P, Knight M; UK Obstetric Surveillance System (UKOSS). Uterine compression sutures for the management of severe postpartum hemorrhage. Obstet Gynecol. 2011;117(1):14–20.
Balloon tamponade of the uterine cavity and uterine-compression sutures are crucial in the management of PPH. In a series of 211 women who were treated with a uterine-compression suture to control PPH, the rate of hysterectomy was 16% if the procedure was performed within an hour of delivery, but it rose to 42% with a delay of 2 to 6 hours.
6. When you suspect placenta previa or placenta accreta,
plan delivery by a multidisciplinary team
Eller AG, Bennett MA, Sharshiner M, et al. Maternal morbidity in cases of placenta accreta managed by multidisciplinary care team compared with standard obstetric care. Obstet Gynecol. 2011;117(2 Pt 1):331–337.
Placenta previa and placenta accreta are frequently associated with severe intrapartum and postpartum hemorrhage. In a retrospective cohort study of 141 cases of placenta accreta that were managed by a multidisciplinary care team (n=79) or received standard obstetric care (n=62), women managed by the multidisciplinary team were less likely (43% vs 61%) to require a large volume of transfusion. They were also less likely to require reoperation within 7 days of delivery for bleeding complications (3% vs 36%) and less likely to experience composite maternal morbidity (47% vs 75%).
Sentilhes L, Ambroselli C, Kayem G, et al. Maternal outcome after conservative treatment of placenta accreta. Obstet Gynecol. 2010;115(3):526–534.
Extirpative surgery in the form of hysterectomy—with or without partial bladder resection—is usually considered the treatment of choice for these conditions. A retrospective multicenter study reported maternal outcomes after conservative treatment of 167 women who had placenta accreta or percreta (18% had percreta). Conservative management included one or more of the following:
- stepwise uterine devascularization
- pelvic vessel ligation or embolization
- uterine-compression sutures
- administration of methotrexate and antibiotics.
Conservative treatment was successful in 131 (78.5%) cases. Eighteen women underwent primary hysterectomy, and 18 women underwent delayed hysterectomy. One woman died after intraumbilical methotrexate administration, and 10 women (6%) experienced severe morbidity.
Conservative management should be offered only in centers that have adequate equipment and resources for patients who are properly counseled and who are motivated and agree to close follow-up. Planned cesarean hysterectomy remains the treatment of choice for multiparous women, as well as for women who have multiple cesarean deliveries with accreta, and those who do not accept the risks or who are not motivated to undergo close and prolonged follow-up.
8. Beware of von Willebrand disease
Pacheco LD, Costantine M, Saade GR, et al. von Willebrand disease and pregnancy: a practical approach for the diagnosis and treatment. Am J Obstet Gynecol. 2010;203(3):194–200.
This disease can cause immediate and delayed postpartum hemorrhage and has a prevalence of approximately 1% in the general population. Sixteen percent to 29% of women who have von Willebrand disease will experience PPH within 24 hours after delivery, and 20% to 29% will experience delayed postpartum bleeding.
Patients who have this disease should be managed in consultation with a hematologist and blood bank personnel. It entails use of desmopressin, plasma concentrates that contain von Willebrand factor (Humate-P), or cryoprecipitate.
9. Have fibrinogen concentrate on hand
Bell SF, Rayment R, Collins PW, Collis RE. The use of fibrinogen concentrate to correct hypofibrinogenaemia rapidly during obstetric haemorrhage. Int J Obstet Anaesth. 2010;19(2):218–223.
Rahe-Mayer N, Sørensen B. Fibrinogen concentrate for management of bleeding. J Thromb Haemost. 2011;9(1):1–5.
This product can correct hypofibrinogenemia very rapidly. In women who have severe PPH, hypofibrinogenemia may develop as a result of dilutional coagulopathy or hypofibrinogemia in conditions such as abruptio placentae with fetal demise, acute fatty liver of pregnancy, or amniotic fluid embolism. Treatment requires a high volume of fresh frozen plasma or cryoprecipitate. Fibrinogen concentrate is stored at room temperature, requires no cross-matching, and can be prepared and infused within 3 minutes.
10. Implement a protocol for massive transfusion
Sibai BM. Evaluation and management of postpartum hemorrhage. In: Management of Acute Obstetric Emergencies. New York, NY: Elsevier; 2011:41–70.
A delay in the treatment of hypovolemic shock can cause ischemic injury to the kidneys, liver, myocardium, and brain and can lead to diffuse intravascular coagulation (DIC), adult respiratory distress syndrome, and death. The objectives for having a protocol for massive transfusion include:
- administration of adequate blood and blood products
- maintenance of tissue perfusion
- ensuring adequate oxygen delivery
- correction of DIC.
These objectives are vital while the team is working to control the source of bleeding.
BY EXPERT AUTHORS
- “Postpartum hemorrhage: 11 critical questions, answered by an expert”
Q&A with Haywood L. Brown, MD(January 2011) - “What you can do to optimize blood conservation in ObGyn practice”
Eric J. Bieber, MD; Linda Scott, RN; Corinna Muller, DO; Nancy Nuss, RN; and Edie L. Derian, MD(February 2010) - “Planning reduces the risk of maternal death. This tool helps.”
Robert L. Barbieri, MD (Editorial; August 2009) - “You should add the Bakri balloon to your treatments for OB bleeds”
Robert L. Barbieri, MD (Editorial; February 2009) - “Consider retroperitoneal packing for postpartum hemorrhage”
Maj. William R. Fulton, DO (July 2008) - “Give a uterotonic routinely during the third stage of labor”
Robert L. Barbieri, MD (Editorial; May 2007)
For a related malpractice case, read Medical Verdicts.
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BEST PRACTICES IN: Psychosocial Impact of Rosacea
A supplement Family Practice News®. This supplement was sponsored by Galderma Laboratories, L.P.
To view the supplement, click the image above.
Topics
- NRS Digital Perception Survey
- Presentation And Diagnosis
- Treatment Strategies
Faculty/Faculty Disclosure
Debra B. Luftman, MD
Coauthor of The Beauty Prescription:
The Complete Formula for Looking and Feeling Beautiful
Calabasas, California
Dr Luftman has received funding for clinical grants from and is a consultant for Galderma Laboratories, L.P.
Copyright © 2011 Elsevier Inc.
A supplement Family Practice News®. This supplement was sponsored by Galderma Laboratories, L.P.
To view the supplement, click the image above.
Topics
- NRS Digital Perception Survey
- Presentation And Diagnosis
- Treatment Strategies
Faculty/Faculty Disclosure
Debra B. Luftman, MD
Coauthor of The Beauty Prescription:
The Complete Formula for Looking and Feeling Beautiful
Calabasas, California
Dr Luftman has received funding for clinical grants from and is a consultant for Galderma Laboratories, L.P.
Copyright © 2011 Elsevier Inc.
A supplement Family Practice News®. This supplement was sponsored by Galderma Laboratories, L.P.
To view the supplement, click the image above.
Topics
- NRS Digital Perception Survey
- Presentation And Diagnosis
- Treatment Strategies
Faculty/Faculty Disclosure
Debra B. Luftman, MD
Coauthor of The Beauty Prescription:
The Complete Formula for Looking and Feeling Beautiful
Calabasas, California
Dr Luftman has received funding for clinical grants from and is a consultant for Galderma Laboratories, L.P.
Copyright © 2011 Elsevier Inc.
