Clinical Briefs

Am Fam Physician. 2003 Mar 1;67(5):1131-1135.

ACS Recommendations for Detection of Cervical Cancer

The American Cancer Society (ACS) has issued new recommendations on screening for cervical cancer. The guidelines are presented in the November/December 2002 issue of CA: A Cancer Journal for Clinicians.

The previous ACS guidelines, developed in 1987, recommended that all women 18 and older and women who are or have been sexually active have an annual Papanicolaou (Pap) test and pelvic examination. After three consecutive normal examinations, the Pap test could be performed less frequently.

The new recommendation calls for cervical cancer screening to begin three years after the onset of vaginal intercourse or by age 21. Data suggest that there is little risk of missing an important cervical lesion until three to five years after initial exposure to human papillomavirus (HPV). Screening before the three-year period may result in overdiagnosis of cervical lesions that would regress spontaneously. An upper age limit is necessary for health care professionals who do not ask patients about their sexual history and for adolescents who are unable or unwilling to disclose prior consensual or nonconsensual intercourse.

The ACS states it is critical that adolescents who may not need a cervical cytology test obtain appropriate preventive health care, including assessment of health risks, contraception, and prevention counseling, and screening and treatment of sexually transmitted diseases. The need for cervical cancer screening should not be the basis for the onset of gynecologic care.

Screening should be performed annually with conventional cervical cytology smears or every two years using liquid-based cytology. After age 30, women who have had three consecutive normal tests can be screened every two to three years unless they have a history of in utero exposure to diethylstilbestrol (DES), are infected with human immunodeficiency virus (HIV), or are immunocompromised by organ transplantation, chemotherapy, or chronic corticosteroid treatment.

Although DNA testing for HPV has not been approved by the U.S. Food and Drug Administration (FDA), the ACS found the available evidence on this technology to be promising. If the FDA approves HPV DNA testing for this purpose, it would be reasonable to consider that for women aged 30 and older, cervical screening may be performed every three years using conventional or liquid-based cytology combined with a test for DNA from high-risk HPV types.

Cervical cancer screening can be discontinued at age 70 in women with an intact cervix who have had at least three documented, consecutive, normal cervical cytology tests and no abnormal tests within the previous 10 years. Women who have a history of cervical cancer or in utero exposure to DES and women who are immunocompromised (including those infected with HIV) should continue cervical cancer screening as long as they are in good health.

Screening with vaginal cytology tests after complete hysterectomy (with removal of the cervix) for benign gynecologic disease is not recommended. Health care professionals should confirm or document via physical examination and review of the pathology report that the hysterectomy was performed for benign reasons and that the cervix was completely removed.

Buprenorphine Physician Training Sessions

The Substance Abuse and Mental Health Services Administration (SAMHSA) is conducting a series of sessions to train physicians on the proper administration of buprenorphine (Subutex) and appropriate follow-up care.

Buprenorphine and the combination buprenorphine and naloxone (Suboxone) were recently approved by the U.S. Food and Drug Administration for treatment of opioid addictions, such as prescription painkillers and heroin. Unlike other medications available to treat patients with addictions, buprenorphine can be administered by physicians in an office-based setting for the detoxification and maintenance of addiction.

To prescribe buprenorphine, physicians must obtain a waiver from provisions of the federal Controlled Substances Act and complete eight hours of training mandated by the U.S. Congress.

The eight-hour training sessions will be held in a number of cities in the spring and summer. A complete listing is available on the SAMHSA's Web site at www.buprenorphine.samhsa.gov or by calling 866-BUP-CSAT (287-2728).

CDC Guidelines for Hand Hygiene

The Centers for Disease Control and Prevention (CDC) has issued recommendations to promote improved hand hygiene and reduce transmission of pathogenic organisms to patients in health care settings. The complete report is available online at www.cdc.gov.

Recent developments in hand antisepsis have stimulated a review of the scientific data regarding hand hygiene and the development of new guidelines designed to improve hand hygiene practices in health care facilities.

The CDC recommends washing hands with soap (antimicrobial or nonantimicrobial) and water when hands are visibly soiled. An alcohol-based hand rub can be used if hands are not visibly soiled, except in the following situations, when soap and water should be used:

  • Before having direct contact with patients.

  • Before donning sterile gloves to insert a central intravascular catheter.

  • Before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure.

  • After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure).

  • After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings, if hands are not visibly soiled.

  • When moving from a contaminated-body site to a clean-body site during patient care.

  • After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

  • After removing gloves.

Hands should be washed with soap and water before eating and after using the restroom. Antimicrobial-impregnated wipes (i.e., towelettes) can be used as an alternative to washing hands with nonantimicrobial soap and water. However, they are not a substitute for using an alcohol-based hand rub or antimicrobial soap.

If a health care worker is exposed to suspected or proven Bacillus anthracis, hands should be washed with soap and water. The physical action of washing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores.

The recommended technique for using an alcohol-based hand rub is to apply the product to one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Follow the manufacturer's instructions regarding the amount of product to use.

When washing hands with soap and water, wet hands first, apply the amount of product recommended by the manufacturer, and rub hands vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands and dry them with a disposable towel. Use the towel to turn off the faucet. Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis.

Before surgical hand scrubs, all rings, watches, and bracelets should be removed. Debris from under fingernails should be removed with a nail cleaner under running water. Surgical hand antisepsis with an antimicrobial soap or an alcohol-based hand rub with persistent activity is recommended before donning sterile gloves. When using antimicrobial soap, scrub hands and forearms for the length of time recommended by the manufacturer, usually two to six minutes. Long scrub times (e.g., 10 minutes) are not necessary. When using an alcohol-based surgical hand scrub with persistent activity, follow the manufacturer's instructions. Before applying the alcohol solution, prewash hands and forearms with a nonantimicrobial soap, and dry hands and forearms completely.

Artificial fingernails or extenders are not recommended for health care workers who have direct contact with patients at high risk of infections (e.g., patients in intensive-care units or operating rooms). Natural nail tips should be kept less than 0.25 inch long. No recommendation could be made on wearing rings in health care settings.

FDA Approval

• Donna Saliva Ovulation Tester. The U.S. Food and Drug Administration (FDA) has approved the Donna Saliva Ovulation Tester for sale in the United States. The tester is a lipstick-sized, portable microscope that a woman licks to test her saliva to determine if and when she is ovulating. The salt content of the woman's saliva replicates the content of her cervical fluid as she goes through her ovulating cycle.

After the saliva dries on the microscope's lens, the woman can observe the crystallized pattern. One to three days before ovulation, short hair-like structures will appear. On the day of ovulation, a distinct fern-like pattern can be seen. Random dots will appear when the woman is not ovulating.

The tester has been manufactured in Italy since 1994. It has been shown to be 98 percent accurate, according to the manufacturer.

Intervention May Reduce Teen Driving Risk

A program that teaches parents how to limit their teenagers' driving reduces risky behavior that could lead to accidents, according to a study by the National Institute of Child Health and Human Development (NICHD). The full report was published in the September 2002 issue of Injury Prevention.

Research has shown that traffic violations are four times more likely and car crashes almost seven times more likely when parents have fewer restrictions on their teenagers' driving with friends as passengers. Other research found that many newly licensed teenagers do not report having driving restrictions, especially for high-risk driving conditions such as having other teenagers as passengers and driving at night.

The NICHD study recruited more than 450 parent-teenager pairs when the teenagers received their driving permits. Pairs in the study program, which consisted of educational materials such as a video, newsletters, and a parent-teenager driving agreement, reported stricter teenager driving limits under high-risk conditions when the teenager got his or her license. The study also found that driving restrictions imposed when teenagers were licensed was the best predictor of driving restrictions three months later.

Medication Errors in Acute Cardiac Care

A review by the American Heart Association found that medication errors are common in patients with cardiovascular disease and contribute substantially to adverse events in hospital and outpatient settings. The complete statement, “Medication Errors in Acute Cardiac Care,” appeared in the November 12, 2002, issue of Circulation.

Estimates based on death certificate data show that between 1983 and 1993, there was a 2.6-fold increase in deaths from medication errors. In addition, outpatient deaths from medication errors rose 8.5-fold during the same period.

One problem that applies primarily to patients with cardiovascular disease is drug name confusion on either handwritten or verbal orders. Prescribing and dispensing errors also are culprits. Fibrinolytic and anti-thrombotic therapy, used in the treatment of myocardial infarction and acute coronary syndromes, are targeted areas of concern because any deviation in dosage could adversely influence clinical outcome. Complex dosing and titration regimens for these drugs increase the risk of serious errors.

Key recommendations to improve patient outcome by minimizing medical errors include establishing a Center for Patient Safety, which would set national goals for patient safety; developing a nationwide mandatory reporting system to collect state-level information on adverse events that result in serious harm or death; and establishing performance standards for health care organizations that focus greater attention on patient safety. Electronic medication order-entry systems may help reduce prescribing errors.


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