Missouri Family Physician Magazine Apr-Jun 2013

MISSOURIOfficial Publication of the Missouri Academy of Family Physicians

April-June 2013Volume 32, Issue 2

Family Physician

The future of family medicine is bright

The 2013 Match pg. 10

Resident Grand Rounds Craig Luetkemeyer, MDAndrew Horine, DO pg. 12

Resident Grand Rounds Carmella Caldwell, MDpg. 14

65th Annual Scientific Assembly Schedule of Events pg. 18

Missouri Family Physician April - June 2013 3

Inside this issue16 Help Desk Answers Resident Case Studies

18 Annual Scientific Assembly Schedule of Events/Registration

Advertisements2 Cox Health4 HEALTHeCAREERS5 Physicians Professional Indemnity Association (PPIA)6 Corizon Health8 Evidence-Based Practice/FPIN9 Cox FMR Program Job Opportunity17 ProAssurance19 United Allergy Services19 National Dairy Council20 Missouri Professionals Mutual (MPM)

4 Advocating for our patients & our members Kate Lichtenberg, DO, MPH, FAAFP

5 The 2013 Match George Harris, MD, MS, FAAFP

7 Tools for ICD-10 Implementation Available From CMS AAFP News Now (3/14/03)

7 2013 MAFP Family Physician of the Year Finalists8 Help Desk Answers Resident Case Studies

10 Match Rate Increases Again in 2013 Sheri Porter, AAFP News Now (3/15/13)

11 Members in the News12 Resident Grand Rounds Craig Luetkemeyer, MD Andrew Horine, DO

14 Resident Grand Rounds Carmella Caldwell, MD

MAFPContents

Executive CommissionBoard Chair - Todd Shaffer, MD, MBA (Lee’s Summit) President - Kate Lichtenberg, DO, MPH (Kirkwood)President-elect - Bill Fish, MD (Liberty)Vice President - Daniel Purdom, MD (Independence)Secretary/Treasurer - Tracy Godfrey, MD (Joplin)

Board of DirectorsDistrict 1 Director: Dana Granberg, MD Alternate: Jennifer Moretina, MDDistrict 2 Director: Lisa Mayes, DO Alternate: VacantDistrict 3 Director: Jeff Suzewits, DO Director: F. David Schneider, MD Alternate: Caroline Rudnick, MDDistrict 4 Director: Vacant Alternate: Vacant District 5 Director: Peter Koopman, MD Director: Vacant Alternate: James Stevermer, MD, MSPHDistrict 6 Director: Jamie Ulbrich, MD Alternate: VacantDistrict 7 Director: Kathleen Eubanks-Meng, DO Director: George Harris, MD, MS Alternate: VacantDistrict 8 Director: Mark Woods, MD Director: John Paulson, DO, PhD Alternate: VacantDistrict 9 Director: Charlie Rasmussen, DO Alternate: VacantDistrict 10 Director: Mark Schabbing, MD Alternate: Steven Douglas, MD

Resident DirectorsSuzan "Annie" Lewis, DO Imani Anwisye, MD (Alternate) Student DirectorsDavid Kramer Amanda Williams (Alternate) AAFP DelegatesLarry Rues, MD Darryl Nelson, MD Bruce Preston, MD (Alternate) Keith Ratcliff, MD (Alternate)

MAFP StaffExecutive Director - Jennifer BauerEducation & Finance Director - Nancy GriffinManaging Editor/Member Services - Laurie Bernskoetter

Missouri Academy of Family Physicians 722 West High Street Jefferson City, MO 65101 p (573) 635-0830 f (573) 635-0148 www.mo-afp.org [email protected]

Mark yourCalendar

65th Annual Scientific Assembly June 7-9, 2013 The Lodge of Four Seasons, Lake Ozark, MO

AAFP Congress of Delegates September 23-25, 2013 Marriott Marquis and Marina, San Diego, CA

AAFP NCFMRS August 1-3, 2013 KC Convention Center, Kansas City, MO

21st Annual Fall Conference & SAM Working Group November 8-10, 2013 Big Cedar Lodge, Ridgedale, MO

2013 MAFP Annual Scientific Assembly Schedule of Events and Registration Information

18

The Lodge of Four Seasons Lake Ozark, Missouri

4 Missouri Family Physician April - June 2013

It has been a rough winter through mid-Missouri, but MAFP has been busy representing you. In January,

MAFP was invited to participate with the Board of Healing Arts as part of the association liaison meeting. Several topics were discussed including Maintenance of Licensure (MOL). I was able to provide details about ABFM’s Maintenance of Certification (MOC) program so that we, as family physicians, won’t have to duplicate so many requirements.

The multi-state forum was held in February in Dallas. It was a whirlwind Saturday and Sunday filled with a federal legislative update, ideas to increase membership, and discussing legislative trends among the member states. It should

come as no surprise that scope of practice issues and Medicaid expansion are the dominant topics in many states. We also had the chance to hear about best practices among the other states and are working to incorporate some of those in Missouri.

Medicaid expansion remains a contentious issue here in Missouri. MAFP is a member of the Coalition for Healthy Economic Growth along with other organizations including MSMA, the Missouri Primary Care Association, and the Missouri Association of Free Clinics. Your Board voted unanimously at the November Board meeting to support Medicaid expansion across the state and we are busy educating our legislators about the benefits of expansion for Missouri’s

citizens.Unfortunately, Mother Nature did not

cooperate with our planned Third Annual Advocacy Day on February 26. Jefferson City saw 6-9 inches of snow that day and we were forced to cancel. We still have physicians who are traveling to Jefferson City to meet with their elected officials and testifying on our behalf. If you ever have an interest, I would invite you to contact the MAFP office at (573) 635-0830 and they can help to arrange meetings with your legislators.

I hope to see many of you at our Annual Scientific Assembly at the Lake of the Ozarks to be held June 7-9

MAFP President's Perspective

Advocating for our patients & our membersKate Lichtenberg, DO, MPH, FAAFP2012-2013 MAFP President

Congratulations Missouri Academy!AAFP recently announced the 2012 Chapter

Membership Awards. Your Missouri Academy won:

1st place - Highest Percent Increase in

Student Membership for large chapters

2nd place - Highest Percent Retention of

Active Members for large chapters

Recognition for 100% Resident Membership

MAFP will be recognized during the ALF/NCSC

luncheon on Friday, April 26, 2013.www.healthecareers.com/fpjo

...Only at:

Call us at 1-888-884-8242 email: [email protected]

Over1,200 Family Medicine jobsAnd thousands of qualifiedcandidates


This year, the National Residency Match Program (NRMP) was held from March 11-15 and

was the first year of the “All-in” NRMP policy. This policy stipulated residencies who participated in the 2013 Match could not sign applicants outside of the Match as they have done in the past. This may have accounted for the majority of the increase in the number of positions available in family medicine this year. Residencies that previously may have signed agreements with eligible applicants (mainly osteopathic or international medical school graduates) probably entered all their positions in the

Match this year. This year’s “All-in” policy will affect the ability to accurately compare this year’s Match fill rate to previous years.

According to the AAFP, preliminary information from the 2013 National Resident Matching Program (NRMP) indicates that for family medicine residency programs 2,938 positions were filled out of 3,062 positions offered (96.0%). This represents an increase in the number of family medicine residency positions offered and filled through the NRMP over 2012. However, it should be noted that the numbers also include family medicine-psychiatry, family medicine-emergency

medicine, family medicine –preventive medicine, and family medicine-internal medicine programs. The number of family medicine residency positions offered in the Match increased this year by 298 and resulted in 327 more medical students being matched into family medicine.

Hopefully, as there is more emphasis in health care for family physicians as well as more recognition of their value, this trend will continue. We need to continue to push for more intensified efforts to enroll and support medical students interested in family medicine. (See page 10 for more information about the Match)

MAFPThe 2013 Match

The 2013 MatchGeorge Harris, MD, MS, FAAFP

2012-2013 MAFP Member Services Commission Co-Chair

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MAFPTools for ICD-10 Implementation from CMS

CMS recently signaled that it intends to stand firm on its Oct. 1, 2014, implementation date for the ICD-10-CM code sets for outpatient diagnosis coding. The transition from ICD-9 to ICD-10 will increase by nearly fivefold the number of diagnosis codes available to health care professionals.

To help physicians prepare for the transition, CMS also up-dated its resources for small, medium and large physician practices to include "at-a-glance" timelines, as well as comprehensive transi-tion checklists.

For example, the checklists suggest that practices of all sizes currently should be engaged in planning, communication and assessment activities, such as creating an ICD-10 project team, as well as a project plan that identifies tasks, deadlines and respon-sible parties.

In addition, all practices should be engaged in discussions right now with payers and vendors -- including claims clear-inghouses and billing services -- about their readiness to move forward with ICD-10.

CMS urges all practices to ensure ample time for staff train-ing and system testing for the transition to ICD-10. Problems detected after the 2014 full implementation could cause cash flow problems; disruption in payment would be particularly difficult for small practices because they often operate on thin margins.

Some activities on the checklist are highlighted in red. For example, in April, May and June of 2013, physicians need to begin testing within their practices by

•using ICD-10 codes for the most common diagnoses seen in the practice, and

•confirming that all data and reports generated are accurate.

By October 2013, physicians should expand ICD-10 testing to include business partners outside the practice, and that process should continue for a minimum of 10 months to ensure that all systems are in place and working properly before full implementa-tion on Oct. 1, 2014.

One final note about the compliance date: Physicians should continue to use ICD-9 codes to bill for services provided before Oct. 1, 2014, even if the billing process takes place after the transi-tion. ICD-10 codes must be used for all services provided on or after Oct. 1, 2014.

Expert help for family physicians making the transition to ICD-10 also is available from the AAFP. Article courtesy of AAFP News Now - 3/14/13

Tools for ICD-10 Implementation Available From CMS

2013 MAFP Family Physician of the Year

Finalists

R. Aron Burke, MDRock Port, Missouri

James L. Miller, DOButler, Missouri

David V. Pulliam, DOHigginsville, Missouri

Congratulations to Missouri's 2013 Family Physician of the Year Award finalists. The award winner will be selected by the MAFP Member Services Commission and honored at

the Annual Scientific Assembly in June.


About HDAs - Resident authors work directly with a physician faculty mentor as “author teams”. Residencies meet RRC requirements, and many programs have developed their

faculty into local evidence-based medicine experts!

December 2012 EBP

MAFP Help Desk Answers

A meta-analysis pooled data from 5 cohort studies and 17 case-control studies between 1966 and 2001 and examined the risk of prostate cancer in patients with vasectomies.1 In all, the studies compared 9,825 men with prostate cancer with more than 200,000 controls. In comparing the prevalence of vasectomy between the 2 groups, the analysis found an association between vasectomy and prostate cancer (RR 1.4; 95% CI, 1.2–1.6). When the data were sorted by methodological groups, the 8 hospital-based case-control studies with 3,652 prostate cancer patients compared with 11,496 controls found the strongest association (RR 1.9; 95% CI, 1.4–2.7). In contrast, the 5 cohort studies, with 702 prostate cancer patients and 206,894 controls, and the 9 population-based case-control studies, with 5,471 prostate cancer patients and 6,189 controls, showed no differences (RR 1.2; 95% CI, 0.90–1.6 and RR 1.1; 95% CI, 0.93–1.3, respectively). The authors thought the results should be interpreted with caution because of large heterogeneity in the studies and screening bias.

Since the review, 3 more studies have been published. A retrospective cohort study in the United Kingdom analyzed hospital records for 24,773 men who had vasectomies between the ages of 20 and 59 years.2 The authors collected admission data from National Health Service hospitals in the United Kingdom. They compared men who were admitted for vasectomies and those admitted for various other surgeries and were able to follow them through subsequent hospital records. When compared with age-matched controls, men who had undergone vasectomy had no overall increased risk for developing prostate cancer (RR 0.74; 95% CI, 0.45–1.1).

A population-based case-control study identified 1,001 men diagnosed with prostate cancer.3 They were compared with 942 controls obtained from census data regarding incidence of vasectomy and time since the surgery. The prevalence of prior vasectomy was no different between the cases and the controls (OR 1.0; 95% CI, 0.8–1.2).

Another population-based case-control study from New Zealand reviewed 923 new cases of prostate cancer among men

aged 40 to 74 and compared them with 1,224 controls.4 Case subjects were identified from the National Cancer Registry of New Zealand and compared with matched controls obtained from the country’s electoral records. There was no difference in the rate of prostate cancer in men who had undergone vasectomy compared with men who had not (OR 0.92; 95% CI, 0.75–1.1).

Daniel Broadbent, MDPeter Danis, MD

Mercy Family MedicineSt. Louis, MO

1. Dennis LK, et al. Prostate Cancer Prostat Dis. 2002; 5(3):193–203. [LOE 3a]

2. Goldacre MJ, et al. Fertil Steril. 2005; 84(5):1438–1443. [LOE 2b]

3. Holt SK, et al. J Urol. 2008; 180(6):2565–2568. [LOE 3b]4. Cox B, et al. JAMA. 2002; 287(23):3110–3115. [LOE 3b]

Evidence-Based AnswerCurrently, the best evidence does not support anassociation between having a vasectomy and developingprostate cancer (SOR: B, cohort and case-controlstudies).

Is there an association between vasectomy and the later risk of prostate cancer?

From the authors who bring you HelpDesk Answers comes a relevant, concise, and clinically useful journal to assist you in delivering the best care to your patients –all without the

bias of industry support.

Evidence-Based Practice is published monthly by the Family Physicians Inquiries Network.

12 issues and 48 PRA Category 1 CME CreditsTM $119 Missouri Family Physician Reader or $59 FPIN

Member

To subscribe, or view a sample issue, visit www.ebponline.net or call 573-256-2066.


- Quitline Referral Cards

- Posters

- Stop Smoking Guide

- Patient Education Materials

- Lapel Pins

- EHR Guide

- Pharmacologic Product Guide

- Online Training

- Group Visits Guide

- Coding for Payment

Many materials available in both English and Spanish!

ASK your patients if they use tobacco.ACT to help them quit.

Tobacco cessation resources available at www.askandact.org

QUIT NOWAsk us howBe tobacco-free

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U.S. Surgeon General Regina Benjamin, MD, MBA

What is the MAFP PAC? MAFP PAC is the state political action committee of the Missouri Academy of Family Physicians. MAFP PAC is a special organization set up to collect contributions from a large number of people, pool those funds and make contributions to state election campaigns.

Where does my contribution go? MAFP PAC will make direct contributions to candidates for the Missouri General Assembly (either State House of Representatives or State Senate) and statewide offices. Contribution decisions are made in a nonpartisan way based on candidates' positions, policies and voting records as they relate to family physicians and our patients. Direct contribution decisions are made by the PAC Committee.

I already pay my dues - isn't that enough? Election laws prohibit the use of membership dues for donations to political candidates. Funds to be used for donations to candidates must be raised separately from membership dues. Voluntary MAFP PAC donations are what will enhance MAFP's clout in the elections and with elected members of the Legislature.

Get Involved! Make your 2012 contribution online at www.mo-afp.org and click on the "Political Action Committee" tab.

MAFPMO PAC/Cox FMR/Ask and Act


Ignacio Becerra-Licha matched into Family Medicine at the University of California, San Francisco. His wife, Somalee Banerjee matched into Kaiser Permanente Medical Group in Oakland, California. Both are medical students at Washington University, St. Louis, Missouri.

On Match Day 2013, University of Missouri - Columbia (UMC) medical students are (left to right): Alicia Ludden, Scott Bartkoski, Andrew Valleroy, Andrew Patel, Kendal Geno and Adam Harrold.

On Match Day (left to right): Erika Ring-dahl, MD, UMC FMR Program Director, Lorie Bousquet, UMC Residency Execu-tive Staff Assistant, Ashley Granger, UMC Administrative Assistant, Stephanie Huhn, DO, Resident, and Kristen Deane, MD, UMC FMR Associate Program Director.

Neil Kalsi and Charity Kaiser of St. Louis University School of Medicine are two of the nearly 3,000 medical students who matched into family medicine residency programs on March 15. Both are headed to the Northwestern McGaw Family Medicine Residency Program in Chicago.

Results of the 2013 National Resident Matching Program (NRMP) -- commonly referred to as the Match -- are in, and for the fourth consecutive year, the number of medical students choosing family medicine increased.

Family medicine positions available in 2013 were the most offered since the 2001 Match. Add to that the fact that 1,374 U.S. seniors -- 39 more than in 2012 -- matched to family medicine, the highest number since 2002.

On the other hand, the number of

U.S. seniors has increased, so the fill rate in 2013 in family medicine was 44.9 percent, or a 3.4 percent decrease from 2012.

AAFP President Jeff Cain, M.D., of Denver, characterized the Match results as a "call to action moment" for family medicine. "The results of the 2013 Match highlight the AAFP's ongoing efforts to position family medicine as a solution to the country's health care challenges," said Cain. "Students are hearing that choosing family medicine offers them a chance to enter a rewarding career with a bright

future, and we need to continue to focus on that message and build momentum moving forward."

by Sheri PorterAAFP News Now (posted 3/15/13)

Family Medicine Match Rate Increases Slightly Again in 2013

Eight SLU medical students match to Missouri FMR

Programs

Melissa Lao Mercy FMR

Christopher Young Mercy FMR

James Kirkpatrick UMKC FMR

Christopher Wedell SLU FMR

Doyle Witt UMKC FMR

Jackson Pugh SLU FMR

Joseph Eckelkamp Mercy FMR

Andrew Bryant Mercy FMR

To read more visit www.aafp.org

MAFP The 2013 Match


Do you have what it takes to be a leader in family medicine?

The Missouri Academy of Family Physicians invites residents and students to submit their curriculum vitae as application for Alternate Resident Director and Alternate Student Director on the MAFP Board of Directors. This is a two-year commitment as you will also serve as Resident Director or Student Director in 2014-15.

Elections will be held Friday, August 2, 2013 in Kansas City during the Missouri Reception in conjunction with the National Conference of Family Medicine Residents and Students (NCFMRS). This year the reception will begin held at Midland Theatre (Lower Lobby) - 6:30 pm 1228 Main Street Kansas City, Missouri

Please visit www.mo-afp.org and click on the Students & Residents tab. Look for "Additional Resident/Student MAFP Board Information"

If you would like your name placed on the ballot for Alternate Resident Director or Alternate Student Director, please forward your CV to: [email protected] no later than July 29, 2013.

. . . more 2013 Match Day

Logan Banks, DO, Faculty at Cox Family Medicine Residency was recently awarded C-section privileges at Cox South Hospital in Springfield, MO. Cox South Hospital is a 563- bed hospital, full-service care facility located in south Springfield. Prior to the privileges being granted, Dr. Banks completed the one-year OB fellowship within the Family Medicine Residency. During the application process, Dr. Banks and his family medicine colleagues cited the policy of the Joint Commission, the American College of Obstetrics and Gynecology, as well as the American Academy of Family Physicians, that privileging be based on licensure, training, experience, and current demonstrated competence; NOT based on

specialty affiliation. Dr. Banks completed his medical education at Kirksville College of Osteopathic Medicine in 2006 and his residency education at Cox FMR in 2009.

Congratulations to Kieth Groh, MD (Columbia, Missouri), MAFP online 2013 Needs Assessment Survey Prize Winner. MAFP received a total of 122 responses from our approximately 1,900 members - a 6% response rate. Thank you to all members who participated!

The University of Missouri-Columbia School of Medicine has earned an Achievement Award from the American Academy of Family Physicians (AAFP). This award recognizes the school's efforts to foster student interest in family medicine and produce graduates who enter the specialty. The awards ceremony will be held in conjunction with the Society of Teacher's of Family Medicine meeting May 1-5, 2013 in Baltimore, Maryland. Look for the June-July Missouri Family Physician magazine for photos.

MAFPMembers in the news

Pictured left: Aaron Meyer, SLU, matched to the University of California, San Diego combined residency in family medicine and psychiatry.

Pictured left: Bethany Davis, Washington University in St. Louis, matched into the Family Medicine Residency of Fort Collins in Fort Collins, Colorado.

Do you know a medical student interested in family medicine? Talk to

them about becoming a member.Student Membership is FREE!

Visit www.aafp.org

Stay connected! Follow us on Facebook for the latest news and information on upcoming events.

CORRECTION - Nick D'Angelo, MD, was incorrectly listed in the Resident Grand Rounds article (Jan-Mar 2013 MFP magazine issue) as completing the Mercy FM Residency. His correct title is: PGY1 at Jackson Memorial Family Residency in Miami, Florida. He graduated from Saint Louis University - SOM in May 2012. The article was titled "First Reported Case of Eastern Equine Encephalitis Virus in Missouri."

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MAFP Leadership Opportunitiesfor residents and students

MAFP Resident Grand Rounds

ABSTRACT Thyrotoxic Periodic Paralysis (TPP) is a rare complication of hyperthyroidism that is seen predominantly in men of Asian descent. However, this entity is becoming increasingly recognized in Western countries and prompt recognition of this disorder is essential to proper treatment of this rare disease. Because symptoms of hyperthyroidism may be subtle and the diagnosis of TPP may be unfamiliar to many family physicians, TPP can be easily misdiagnosed as hypokalemic periodic paralysis, psychogenic paralysis, Guillain-Barre, or Myasthenia gravis all of which are more commonly seen in the United States. This could, of course, lead to untimely or improper patient management.1 The case we discuss here illustrates the benefits of maintaining a high suspicion for TPP in patients presenting with acute generalized weakness and hypokalemia.

CASE REPORT A 28 year old healthy Caucasian male presented to a University ED as a transfer from a regional hospital for evaluation of a one day history of weakness affecting the arms and legs. The patient reported that he awoke at roughly 8 am the morning of presentation. He then ate a large breakfast and upon getting up from the breakfast table felt nauseated and fell to the floor. He did not injure his head or lose consciousness. He was able to get up and tried walking to the bathroom, at which time he again fell to the floor. He was again able to get up and tried going to the bedroom, where he fell a third time. After this episode, family members took him to a nearby ED. He denied fever, headache, loss of consciousness, diarrhea,

vomiting, palpitations, dyspnea or rash. He denied convulsions, tongue-biting or urinary incontinence. He had no recent illnesses or sick contacts and denied a recent travel history or history of tick bites. He was diagnosed with ureterolithiasis 3-4 weeks earlier and was taking oxybutynin and ciprofloxacin following ureteral stent placement done one day prior to presentation. He denied smoking, alcohol or illicit drug use. There is no family history of neuromuscular disorders, but the patient did report that “thyroid problems” run in the family.

At the first ED, workup was significant for a potassium level of 1.7 mmol/L. EKG showed sinus tachycardia with a rate of 105. IV potassium replacement was initiated and the patient was transferred to our university ED. On exam, the patient was alert and in no acute distress. Vitals were significant for a temperature of 38.3 C, HR 115, RR 28 and BP of 139/64. Tachycardia was present with regular rhythm and 2+ peripheral pulses. Respirations were non-labored and lungs were clear bilaterally. Skin was moist and warm. Neurologically, the patient was diffusely weak with 4/5 strength in upper and lower extremities with normal muscle bulk and tone. Strength was also 4/5 in ocular muscles. Sensation and position sense were normal. DTRs were brisk in all major muscle groups. Cranial nerves 2-12 were intact.

Further diagnostic workup included a hematology panel, chemistry panel, urinalysis, urine drug screen, TSH and EKG. This was significant for a potassium level of 3.1 mmol/L, and a TSH of 0.005.

EKG again showed sinus tachycardia. The patient was admitted to the general floor on the neurology service with improving weakness and a presumed diagnosis of TPP. Potassium replacement was continued, and the patient was placed on telemetry. An endocrinology consult was obtained, and the patient was treated with propranolol and propylthiouracil. Thyroid stimulating immunoglobulins were within the normal range and thyroid peroxidase antibodies were elevated. The patient’s weakness and vital signs improved dramatically throughout the hospital stay. Potassium was monitored and ranged from 3.6-4.4 mmol/L during the admission. The patient was discharged home on hospital day 3 with prescriptions for propranolol and methimazole. Propylthiouracil was discontinued. At 2 month follow-up, patient reports improvement in all symptoms, although his TSH remains suppressed. He continues to take methimazole for thyroid suppression, and has recently undergone laser lithotripsy for an 8 mm right ureteral stone.

DISCUSSION Epidemiology: The incidence of TPP is highest in persons of Asian descent. Appoximately 2% of Chinese and Japanese thyrotoxic patients have TPP, compared to only 0.1-0.2% of non-asian North-americans. While thyrotoxicosis is more common in women, TPP is much more common in men with a male to female ratio of 17:1 to 70:1.2,3

Pathophysiology: Although the pathophysiology of TPP is not entirely understood, the periodic paralysis is likely the result of an intracellular shift

ThyrotoxicPeriodicParalysis (TPP)Craig Luetkemeyer, MD, ResidentAndrew Horine, DO, ResidentRichelle Koopman, MD, Associate ProfessorUniversity of Missouri - Columbia School of Medicine, Family and Community Medicine

C. Luetkemeyer, MD A. Horine, DO R. Koopman, MD


of potassium ions. As potassium shifts intracellularly, this produces a serum hypokalemia. In turn, skeletal muscles become hyperpolarized which leads to the periodic paralysis associated with the disease. The uncertainty associated with the pathophysiology of PTT stems from an unclear understanding of how thyrotoxicosis causes this intracellular shift of potassium. It is believed the mechanism is related to the Na/K/ATPase pump located in skeletal muscle membranes. Thyroid hormones have been shown to directly activate these pumps by binding thyroid-hormone responsive elements on Na/K/ATPase subunits.2 In addition, catecholamines have been shown to activate Na/K/ATPase pumps, a finding that may partially explain the effectiveness of non-selective B-blockers in treating and preventing attacks of paralysis.2 Furthermore, studies have shown that patients with TPP often have exaggerated insulin response to oral glucose loads. This is pathophysiologic as insulin also activates Na/K/ATPase pumps. Regardless of how these pumps are activated, the resulting cascade is the same: an intracellular potassium shift leads to hypokalemia, hyperpolarization and eventual paralysis. Genetic mutations in certain HLA subtypes play a role in Na/K/ATPase activity, which may help explain racial/ethnic differences in prevalence of this disease.3

Clinical Manifestations: The most common patients are 20-40 year old males of Asian descent. The flaccid paralysis is usually symmetrical and mainly affects the extremities. The weakness is most pronounced in the legs and in proximal muscles. Although patients can present with paralysis that resembles Guillain-Barre Syndrome, bulbar and respiratory muscles are usually unaffected. Bowel and bladder function are never affected.2 Sensation and mentation are spared as well. A family history of hyperthyroidism is commonly present.2 Typical symptoms of hyperthyroidism such as weight loss, heat intolerance, palpitations, and diaphoresis are often subtle. In fact, nearly half of patients with TPP have no obvious symptoms of hyperthyroidism at all.3 In a study of 19 patients hospitalized with TPP, the number of patients with weight loss,

palpitations, and heat intolerance were 7,3, and 2 respectively. This study also showed that 84% of patients presented between 1 and 6 am after being unable to move their extremities on awakening. Many patients presented the morning after eating large carbohydrate meals or engaging in strenuous physical activity.2,5

Laboratory Manifestations: In a study of 24 episodes of TPP, all patients were found to be hypokalemic , and profound hypokalemia was common (range = 1.1-3.4 with a mean of 1.9 +/- 0.5 mmol/L). Hypophosphatemia was present in 12 of 15 episodes (range = 0.36-0.77mmol/L). During 18 paralytic episodes, low or low normal magnesium levels were identified in all episodes (range 0.6-0.8mmol/L). Approximately two thirds of patients had elevations in creatine phosphokinase or alkaline phosphatase.2,5 All patients with TPP are hyperthyroid, and about three fourths of patients have TSH levels of 0.08 microIu/L or less.2,5 Thyroid hormone directly stimulates bone cells causing accelerated bone turnover, and as such patients with TPP are commonly hypercalciuric.3 EKGs were analyzed in 17 episodes, and the following findings were common: sinus tachycardia, flattened T waves, prolonged QT intervals and U waves. A study has compared the EKG findings in 54 patients with hypokalemic paralysis (31 with TPP and 23 with non-TPP) and has found that HR, PR interval and QRS voltage were significantly higher in the TPP group.4

Management: Emergent management of paralytic episodes includes potassium replacement and use of nonselective beta blockers. Although IV potassium chloride is commonly used, there is a risk of rebound hyperkalemia when paralysis corrects and potassium leaves the intracellular compartment. Lin et al performed a case-controlled to study to examine recovery time in patients who received IV KCl at 10 mEq/hr vs patients who received no potassium replacement. Recovery time was lessened by 2 hours in the treated group, however rebound hyperkalemia occurred in 70% of patients receiving IV KCl (3). In studies examining

the effectiveness of IV vs. oral non-selective beta blockers, IV propranolol was associated with elimination of paralytic symptoms, but caused rebound hyperkalemia and cardiac arrhythmias; oral propranolol at 3-4 mg/kg has been associated with reversal of TPP symptoms without causing rebound hyperkalemia.3 The definitive treatment for TPP is correction of hyperthyroidism and producing a euthyroid state. This may be accomplished by radioactive ablation, surgery, or medication with methimazole or propylthiouracil.3

CONCLUSION TPP is an uncommon cause of acute weakness in the United States. Symptoms of overt hyperthyroidism are often subtle or absent, making diagnosis challenging. In fact, a study of 19 patients with TPP showed that only 1 of those patients was diagnosed correctly on admission. Misdiagnoses included familial or sporadic hypokalemic periodic paralysis, Guillian-Barre Syndrome, muscle weakness, polymotor neuropathy, muscle strain, and alcoholism.5 Failure to recognize TPP may lead to rebound hyperkalemia, cardiac arrhythmias and absence or delay of appropriate antithyroid treatment. Therefore, family physicians must maintain a high level of suspicion of TPP in the acutely weak, hypokalemic patient to avoid these potentially adverse outcomes and ensure appropriate management.

References:1. Lin SH et al. Diagnosing thyrotoxic

periodic paralysis in the ED. Am J Emerg Med. 2003;21:339-342.

2. Kung, A. Thyrotoxic Periodic Paralysis: A Diagnostic Challenge. J Clin Endocrinol Metab. 2006 91:2490-2495

3. Lin, SH. Thyrotoxic Periodic Paralysis. Mayo Clin Proc. 2005;80(1):99-105

4. Boccalandro C, Lopez L, Boccalandro F, Lavis V. Electrocardiographic changes in thyrotoxic periodic paralysis. Am J Cardiol. 2003;91:775-777

5. Manoukian MA, Foote JA, Crapo LM. Clinical and metabolic features of thyrotoxic periodic paralysis in 24 episodes. Arch Intern Med. 1999;159:601-606

mafpResident Grand Rounds


MAFP Resident Grand Rounds

Introduction Monochorionic Monoamniotic (MoMo) twin pregnancy is a rare event that occurs when there is development of two fetuses within one placenta and one amniotic sac during gestation.1 It is believed that this type of pregnancy occurs secondary to late cleavage of the inner cell mass between the 7th and 13th day after fertilization, when the amnion has already initiated formation.1

There are many complications associated with MoMo twin pregnancies including, but not limited to, the following: increased perinatal mortality rate, cord entanglement, true knots, oligohydramnios, growth restriction, premature delivery, discordant fetal abnormalities and inter-twin transfusion syndromes.1-5 Early diagnosis of MoMo twin gestation in the first trimester is optimal so that proper management can be provided to decrease such complications. Upon evaluation by ultrasound, the presence of a single amniotic cavity and the lack of an inter-twin septum are essential.1,6,7

The goals of this article are to 1) present a case report of a MoMo twin pregnancy with complication of cord entanglement and 2) to discuss available early surveillance techniques and studied interventions to decrease the perinatal mortality rate during MoMo twin pregnancy.

Case Report A 22 year old Caucasian female, G1P0 at 33 weeks gestational age, presented to labor and delivery triage for her bi-weekly Non-stress test (NST) evaluation for twin gestation. Upon examination, her vital signs were stable and she appeared to be in optimal health. She denied any PMH and was taking prenatal vitamins, calcium supplements and Procardia 30 mg po BID for previous preterm contractions at 31.1

weeks gestational age. Complications with her pregnancy included IUGR and possible monochorionic monoamniotic gestational sac.

Upon evaluation of the patient’s NST, baby A had fetal heart tones at 140 with moderate variability, positive accelerations and no decelerations. Baby B had fetal heart tones at 150 with moderate variability, marked accelerations into the 200’s with no decelerations. As time progressed, baby B became tachycardic with a baseline fetal heart rate into the 180’s with moderate variability and marked accelerations into the mid 200’s with no decelerations. At that time, the patient was taken to the operating room for emergent c-section for non-reassuring fetal heart tones, IUGR and possible monochorionic monoamniotic gestational sac. The operation was uneventful and monochorionic monoamniotic gestational sac with an entangled cord was confirmed. Currently, both twins are reported to be in good health.

Detection MoMo twin pregnancy is extremely rare, occurring in only 1% of monozygotic twin pregnancies, and carries an increased risk of perinatal mortality.3,6 Increased mortality is thought to be caused by cord accidents leading to occlusion and asphyxiation.3,6 Previously, it was suggested that the perinatal mortality rate was within the range of 30-70%, however, since there has been an increase in prenatal surveillance and antenatal management for MoMo twins, the perinatal mortality rate has decreased to 10-20% .3,4,6 Over the past decade, there have been advances in medicine that have assisted in the improvement of diagnoses, prenatal surveillance and management of MoMo twin pregnancies.

Upon initial evaluation of twin pregnancies, it has been recommended that scans should be highly considered between the 11th-14th week of gestation when the lambda sign is absent on ultrasound.7,8 (The lambda sign, also called the “twin peak sign”, appears on ultrasound when the chorion makes a wedge shaped protrusion into the intertwin space and is diagnostic of dichorionicity).7,8 When the lambda sign is absent, further investigation to find the intertwin membrane should be conducted for diagnosis of MoMo twin pregnancy.7,8

Surveillance and Management After diagnoses, prenatal surveillance and management can include Doppler ultrasounds of the umbilical cord, hospitalization with intensive observation beginning at 25 weeks, elective cesarean delivery, administration of NSAIDS to decrease amniotic fluid volume during the second trimester as well as frequent NST evaluations, frequent biophysical profiles, and administration of corticosteroids between 25 and 32 weeks gestation.5,9

• Doppler One early surveillance technique supported the use of pulsed wave Doppler for confirmation of monoamnionicity and cord entanglement in the first trimester of pregnancy.5,6,10 In one study, two patients with twin pregnancies were examined by this method. If two distinct arterial waveform patterns with different heart rates and within the same pulsed wave sampling gate were seen, monoamnionicity was highly suggested.6 Also, compression of the umbilical vein is identified by high blood velocity in the distal portion of the cord.11,12

In a case report, a 29 year old primagravida received a 2D ultrasound which was highly suggestive of cord

Cord Entanglement during Monochorionic Monoamniotic Twin Pregnancy

J. Frost, MDC. Caldwell, MD

Carmella Caldwell, MD, PGY-2Jennifer Frost, MD, FacultyResearch Family Medicine Residency Program - Kansas City

>>14 Missouri Family Physician April - June 2013

mafpResident Grand Rounds

entanglement that prompted further surveillance by 3D

color Doppler at 30 weeks gestation.12 At that time, there was confirmation of cord entanglement at multiple points on the umbilical cord which resulted in more intense observation of FHR .12 Seven days later, the fetal heart tracing was non-reassuring and cesarean section was performed.12 These studies portray the importance of using Doppler ultrasound early in MoMo twin pregnancy management.

•Intense Observation A study consisting of thirteen monoamniotic pregnancies, showed a decrease in perinatal mortality rate through intense observation of non-stress tests and/or biophysical profiles beginning at 24 to 26 weeks of gestation.8 Antenatal fetal surveillance varied from monitoring fetal heart rate daily, versus 2-3 times a week, versus less than twice weekly.8 The common indication for cesarean section delivery was non-reassuring fetal heart rate testing.8 Patterns ranged from persistent variable decelerations, unresponsive fetal bradycardia, fetal tachycardia with absent variability and persistent non-reassuring fetal heart rate with non-reassuring fetal biophysical assessment.8

•NSAID to Decrease Amniotic Fluid Volume Sulindac therapy has also been suggested as an optional intervention in the management of MoMo twin pregnancies.13 Sulindac is an NSAID that serves to decrease fetal urine output resulting in decreased amniotic fluid volume.13 The mechanism of action is similar to indomethacin but does not cause ductal constriction, allowing it to be used on a long term basis.13 In one study, mother’s of three sets of MoMo twins were given sulindac 200 mg po daily, initiated between 24 and 29 weeks.13 The goal of this study was to decrease the amniotic fluid volume to decrease excessive fetal movement that could potentially result in severe cord entanglement.13 Dosages were titrated to maintain an amniotic index between 5 and 8.13 The results in two of the cases were dose related amniotic fluid index reductions as well as decrease in fetal urine production with sulindac therapy. After use of sulindac there were no changes in fetal lie during evaluation, insinuating a decrease in chances of further cord entanglement as pregnancy continued.

Conclusion Overall, there have been tremendous advances in the diagnoses, evaluation and management of MoMo twin pregnancies. The use of Doppler ultrasound during the first trimester provides solid establishment of cord entanglement. Early detection allows patient management (e.g. increased observation during pregnancy through non-stress tests, biophysical profiles, hospitalizations, sulindac) which ultimately may decrease the perinatal mortality rate of MoMo twin pregnancy due to cord entanglement.

References1. Lewi L. Cord entanglement in

monoamniotic twins: does it really matter? Ultrasound Obstet Gynecol, 2010; 35(2):139-41.

2. Dias T,Mahsud-Dorman S, Bhide A, et al. Cord entanglement and perinatal outcome in monoamniotic twin pregnancies. Ultrasound Obstet Gynecol, 2010; 35(2): 201-4.

3. Hack KE, Derks JB, Schaap AH, et al. Perinatal outcome of monoamniotic twin pregnancies. Obstet Gynecol,

2009; 113(2 Pt 1): 353-60.4. Allen VM, Windrim R, Barrett J, et

al. Management of monoamniotic twin pregnancies: a case series and systematic review of the literature. BJOG, 2001; 108(9): 931-6.

5. Ezra Y, Shveiky D, Ophir E, et al. Intensive management and early delivery reduce antenatal mortality in monoamniotic twin pregnancies. Acta Obstet Gynecol Scand, 2005; 84(5):432-5.

6. Overton TG, Denbow ML, Duncan KR, et al. First-trimester cord entanglement in monoamniotic twins. Ultrasound Obstet Gynecol, 1999; 13(2):140-2.

7. Sebire NJ, Souka A, Skentou H, et al. First trimester diagnosis of monoamniotic twin pregnancies. Ultrasound Obstet Gynecol, 2000; 16(3):223-5.

8. W. Sepulveda, N. J. Sebire, K. Hughes, et al. The lambda sign at 10-14 weeks of gestation as a predictor of chorionicity in twin pregnancies. Ultrasound Obstet Gynecol, 1996; 7(6):421-3.

9. Rodis JF, McIlveen PF, Egan JF, et al. Monoamniotic twins: improved perinatal survival with accurate prenatal diagnosis and antenatal fetal surveillance. Am J Obstet Gynecol, 1997; 177(5):1046-9.

10. Arabin B, Laurini RN, van Eyck J. Early prenatal diagnosis of cord entanglement in monoamniotic multiple pregnancies. Ultrasound Obstet Gynecol, 1999; 13(3): 181-6.

11. Shahabi S, Donner C, Wallond J, et al. Monoamniotic twin cord entanglement. A case report with color flow Doppler Ultrasonography for antenatal diagnosis. J Reprod Med, 1997; 42(11):740-2.

12. Kuwata T, Matsubara S, Suzuki M. 3D color Doppler of monoamniotic twin cord entanglement. Arch Gynecol Obstet, 2010; 281(5):973-4.

13. Peek MJ, McCarthy A, Kyle P, et al. Medical amnioreduction with sulindac to reduce cord complications in monoamniotic twins. Am J Obstet Gynecol, 1997; 176(2): 334-6.

>>



Intermenstrual bleeding is defined as bleeding between periods and is common in the first 3 to 4 cycles of COC use. A narrative review recommends that other causes of bleeding should be considered before changing the COC (TABLE 1).1

A 2011 Cochrane review analyzed 21 RCTs (with about 10,000women)comparingCOCscontaining≤20mcgethinylestradiol (EE) with those with >20 mcg EE.2COCscontaining≤20mcg EE had higher rates of irregular bleeding (one trial; N=778; OR 1.6; 95% CI, 1.1–2.2) and discontinuation due to abnormal bleeding (one trial; N=1,000; OR 2.6; 95% CI, 1.5–5.0). This review involved multiple progestin types and the data did not allow statistical comparison among them.

Another 2011 Cochrane review evaluated 30 RCTs including nearly 14,000 women using a COC with 30 mcg EE to compare different generations of progestin (TABLE 2) and intermenstrual bleeding.3 Women using a second-generation monophasic progestin were less likely to stop their COC due to cycle disturbances compared with a monophasic first-generation progestin (one trial; N=875; RR 0.69; 95% CI, 0.52–0.91) or a triphasic first-generation preparation (3 trials; N=581; RR 0.61; 95% CI, 0.43–0.85). Based on one double-blind RCT with unclear randomization of 456 women receiving a monophasic preparation

over 6 cycles, women using gestodene (third generation) reported less bleeding than those using levonorgestrel (second generation) (RR 0.71; 95% CI, 0.55–0.91; NNT=8).

A 2006 Cochrane review evaluated the effect of phasic formulation of progestin on intermenstrual bleeding.4 Only one trial of limited quality compared a biphasic and monophasic progestin preparation. The study examined 533 user cycles of a biphasic pill (500 mcg norethindrone plus 35 mcg EE for 10 days, followed by 1,000 mcg norethindrone plus 35 mcg EE for 11 days) and 481 user cycles of a monophasic contraceptive pill (1,500 mcg norethindrone acetate plus 30 mcg EE daily). The study found no significant differences in intermenstrual bleeding between the monophasic and biphasic progestin formulations.

A 2011 Cochrane review compared continuous (>28-day use) with cyclic formulations of a COC, including 5 RCTs with a total of 765 women on continuous COCs and 416 on cyclic COCs.5 COCs given continuously had equivalent bleeding patterns compared with traditional cyclic dosing, although there was a slight improvement (not statistically significant) with continuous administration.

Carin E. Reust, MDSonia Acevedo Espinoza, MD

Jacqueline Ruplinger, MDSarah Swofford, MD

University of Missouri-Columbia

1. Schrager S. Am Fam Physician. 2002; 65(10):2073–2081. [LOE 5]

2. Gallo MF, et al. Cochrane Database Sys Rev. 2011; (1):CD003989. [LOE 1a-]

3. Lawrie TA, et al. Cochrane Database Sys Rev. 2011; (5):CD004861. [LOE 1a]

4. Van Vliet HA, et al. Cochrane Database Sys Rev. 2006; (3):CD003283. [LOE 1a]

5. Edelman A, et al. Cochrane Database Sys Rev. 2005; (3):CD004695. [LOE 1a]

Evidence-Based Practice / Vol. 15, No. 12 29

Causes of intermenstrual bleeding in a woman on oral contraceptives

not related to pill type1

Missed pill

Tobacco use

Pregnancy-related issues, including ectopic pregnancy

Infection – cervicitis, endometritis, and specifically chlamydia, gonorrhea, trichomonas

Cervical abnormalities – polyp, dysplasia, carcinoma

Endometrial abnormalities – polyp, hyperplasia, carcinoma; leiomyomas

Metabolic abnormalities – thyroid, prolactin, liver or renal failure, coagulation defects

TABLE 1

Classification of progestins used in combined oral contraceptive pills3

First generation

• Norethindrone acetate

• Ethynodiol diacetate

• Lynestrenol

• Norethynodrel

Second generation

• dl-Norgestrel

• Levonorgestrel

TABLE 2

Third generation

• Desogestrel

• Gestodene

• Norgestimate

Unclassified

• Drospirenone

• Cyproterone acetate

2.5; 95% CI, 1.4–4.4). Women who chose UAE had shorter procedures than either hysterectomy (one trial; N=156; mean difference [MD] –16 minutes; 95% CI, –26 to –6.8) or myomectomy (one trial; N=121; MD –50 minutes; 95% CI, –59 to –41), and resumed normal activities earlier (one trial; N=96; MD –26 days; 95% CI, –32 to –20). UAE was associated with shorter hospitalizations when compared with hysterectomy by 2.2 days (one trial; N=57; 95% CI, 1.6–2.8) to 4.1 days (one trial; N=57; 95% CI, 2.9–5.4). There was no statistical difference between surgery and UAE as far as ovarian failure (2 trials; N=297; OR 1.0; 95% CI, 0.53–1.9) or recurrence of fibroids (one trial; N=120; OR 1.3; 95% CI, 0.38–4.6).1

Laura Davis, BSBridgette Provost, BA, MPH

José E. Rodríguez, MDFSU College of Medicine

Tallahassee, FL

1. Gupta JK, et al. Cochrane Database Syst Rev. 2012; (5):CD005073. [LOE 1a]

What is the approach to intermenstrual bleeding in a woman taking a combined oral contraceptive?

Evidence-Based AnswerCauses of bleeding not related to combined oral contraceptive (COC) pill use should be considered first (SOR: C, expert opinion). If the bleeding is directly related to the COC, changing to a COC that contains >20 mcg ethinyl estradiol (EE) or a newer generation progestin may cause less intermenstrual bleeding. Altering the phasic formulation of progestin or changing between continuous and cyclic COC does not improve intermenstrual bleeding (SOR: B, systematic review with heterogeneous RCTs).


A 2011 Cochrane review analyzed 21 RCTs (with about 10,000 women) comparing COCs containing ≤20 mcg ethinyl estradiol (EE) with those with >20 mcg EE.2 COCs containing ≤20 mcg EE had higher rates of irregular bleeding (one trial; N=778; OR 1.6; 95% CI,

1.1–2.2) and discontinuation due to abnormal bleeding (one trial; N=1,000; OR 2.6; 95% CI, 1.5–5.0). This review involved multiple progestin types and the data did not allow statistical comparison among them. Another 2011 Cochrane review evaluated 30 RCTs including nearly 14,000 women using a COC with 30 mcg EE to compare different generations of progestin (TABLE 2) and intermenstrual bleeding.3 Women using a second-generation monophasic progestin were less likely to stop their COC due to cycle disturbances compared with a monophasic first-generation progestin (one trial; N=875; RR 0.69; 95% CI, 0.52–0.91) or a triphasic first-generation preparation (3 trials; N=581; RR 0.61; 95% CI, 0.43–0.85). Based on one double-blind RCT with unclear randomization of 456 women receiving a monophasic preparation over 6 cycles, women using gestodene (third generation) reported less bleeding than those using levonorgestrel (second generation) (RR 0.71; 95% CI, 0.55–0.91; NNT=8). A 2006 Cochrane review evaluated the effect of phasic formulation of progestin on intermenstrual bleeding.4 Only one trial of limited quality compared

Evidence-Based Practice / Vol. 15, No. 12 29

Causes of intermenstrual bleeding in a woman on oral contraceptives

not related to pill type1

Missed pill

Tobacco use

Pregnancy-related issues, including ectopic pregnancy

Infection – cervicitis, endometritis, and specifically chlamydia, gonorrhea, trichomonas

Cervical abnormalities – polyp, dysplasia, carcinoma

Endometrial abnormalities – polyp, hyperplasia, carcinoma; leiomyomas

Metabolic abnormalities – thyroid, prolactin, liver or renal failure, coagulation defects

TABLE 1

Classification of progestins used in combined oral contraceptive pills3

First generation

• Norethindrone acetate

• Ethynodiol diacetate

• Lynestrenol

• Norethynodrel

Second generation

• dl-Norgestrel

• Levonorgestrel

TABLE 2

Third generation

• Desogestrel

• Gestodene

• Norgestimate

Unclassified

• Drospirenone

• Cyproterone acetate

2.5; 95% CI, 1.4–4.4). Women who chose UAE had shorter procedures than either hysterectomy (one trial; N=156; mean difference [MD] –16 minutes; 95% CI, –26 to –6.8) or myomectomy (one trial; N=121; MD –50 minutes; 95% CI, –59 to –41), and resumed normal activities earlier (one trial; N=96; MD –26 days; 95% CI, –32 to –20). UAE was associated with shorter hospitalizations when compared with hysterectomy by 2.2 days (one trial; N=57; 95% CI, 1.6–2.8) to 4.1 days (one trial; N=57; 95% CI, 2.9–5.4). There was no statistical difference between surgery and UAE as far as ovarian failure (2 trials; N=297; OR 1.0; 95% CI, 0.53–1.9) or recurrence of fibroids (one trial; N=120; OR 1.3; 95% CI, 0.38–4.6).1

Laura Davis, BSBridgette Provost, BA, MPH

José E. Rodríguez, MDFSU College of Medicine

Tallahassee, FL

1. Gupta JK, et al. Cochrane Database Syst Rev. 2012; (5):CD005073. [LOE 1a]

What is the approach to intermenstrual bleeding in a woman taking a combined oral contraceptive?



A 2011 Cochrane review analyzed 21 RCTs (with about 10,000 women) comparing COCs containing ≤20 mcg ethinyl estradiol (EE) with those with >20 mcg EE.2 COCs containing ≤20 mcg EE had higher rates of irregular bleeding (one trial; N=778; OR 1.6; 95% CI,

1.1–2.2) and discontinuation due to abnormal bleeding (one trial; N=1,000; OR 2.6; 95% CI, 1.5–5.0). This review involved multiple progestin types and the data did not allow statistical comparison among them. Another 2011 Cochrane review evaluated 30 RCTs including nearly 14,000 women using a COC with 30 mcg EE to compare different generations of progestin (TABLE 2) and intermenstrual bleeding.3 Women using a second-generation monophasic progestin were less likely to stop their COC due to cycle disturbances compared with a monophasic first-generation progestin (one trial; N=875; RR 0.69; 95% CI, 0.52–0.91) or a triphasic first-generation preparation (3 trials; N=581; RR 0.61; 95% CI, 0.43–0.85). Based on one double-blind RCT with unclear randomization of 456 women receiving a monophasic preparation over 6 cycles, women using gestodene (third generation) reported less bleeding than those using levonorgestrel (second generation) (RR 0.71; 95% CI, 0.55–0.91; NNT=8). A 2006 Cochrane review evaluated the effect of phasic formulation of progestin on intermenstrual bleeding.4 Only one trial of limited quality compared

What is the approach to intermenstrual bleeding in a woman taking a combinedoral contraceptive?


MAFP Help Desk Answers

December 2012 EBP


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Attention Residents & Students

• Complimentary conference registration• Poster contest and presentation• Prize money for top three poster winners• Network with family medicine colleagues

Schedule of Events/Speakers

65th Annual Scientific AssemblyJune 7-9, 2013

The Lodge of Four Seasons, Lake Ozark, MOwww.4seasonsresort.com . 1-888-265-5500

Friday, June 77 - 8am Registration & Breakfast Buffet with Exhibitors7 - 11am Exhibit Hall Open (Granada A & B Rooms)8 - 9am Improving the Identification and Management of Osteoporosis: A

Curriculum for the Primary Care Physician - Kathryn M. Diemer, MD9 - 10:00am Travel Medicine Tips - Kate Lichtenberg, DO, MPH10 - 10:45am Refreshment Break with Exhibitors10:45 - 11:45am

An Approach to Bipolar Disease in Primary Care - An Algorithm - Peter Koopman, MD

11:45am - 1pm Considerations for the Management of Patients with Allergic Rhinitis: Controlling the Burden of Disease (with lunch) - Gary N. Gross, MD

1 - 2pm What's New in Pediatric ADHD? - Suzanne Hestwood, MD2 - 3pm Cervical Cancer Screening Update - Jennifer Frost, MD3 - 4:15pm Practice Changing Updates from the Literature (Break available in

back of room) - James Stevermer, MD, MSPH5:30 - 7pm Family Fun Picnic (Valencia Room)

Saturday, June 8 7 - 8am Registration & Breakfast Buffet with Exhibitors7 - 11am Exhibit Hall Open (Granada A & B Rooms)8 - 9am AGS Updated 2012 Beers Criteria for Potentially Inappropriate

Medication Use in Older Adults - Jon Dedon, MD

Saturday, June 8 (continued)9 - 10am Increasing Skin Cancer Screening to Reduce Skin Cancer Mortality:

A Cooperative Effort Between Dermatologists and Primary Care Providers - Jeffrey North, MD

10 - 10:45am Refreshment Break with Exhibitors10:45 - 11:45am Identifying, Diagnosing, and Managing Patients with Chronic

Migraine in Primary Care - Roger Cady, MD11:45 am - 1:15pm

Annual Business Meeting & Legislative Luncheon (Marbella Room)

1:15 - 2pm Update on STI Screening and Treatment - Kate Lichtenberg, DO, MPH2 - 3:30pm Raising Your Gout IQ (Break available in back of room) -

Paul P. Doghramji, MD3:30 - 4:30pm Otitis Media - 2013 Practice Guidelines & Fever without Source in

Young Children - Suzanne Hestwood, MD5:15 - 6:15pm Social Mixer - Meet and Greet the Future of Family Medicine

(Marbella Foyer)• Resident & Student Poster Awards . Hors d'oeuvres Reception

6:15 - 8pm Awards & Installation Dinner (Marbella Room)

Sunday, June 99:15 - 10:45am Commission Meetings with continental breakfast10:45 am - 1:15 pm Board Meeting with working lunch


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