Editorials

The ALSO Article Series

See article on page 1707.

MARK DEUTCHMAN, M.D.
University of Colorado Health Sciences Center
Denver, Colorado

CHARLES J. CARTER, M.D.
Atlanta Medical Center Family Medicine Residency
Morrow, Georgia

BARBARA APGAR, M.D., M.S.
University of Michigan Medical Center
Ann Arbor, Michigan

In this issue of American Family Physician, we begin an article series based on the Advanced Life Support in Obstetrics (ALSO®) course with an article on shoulder dystocia by Baxley and Gobbo.1 The ALSO program was developed initially at the University of Wisconsin by two family physicians, James R. Damos, M.D., who originated the concept, and John W. Beasley, M.D.2 They thought that clinicians providing maternity care could enhance their confidence and competence by preparing for the urgent problems that can arise during prenatal care and delivery.

A group of family physicians, obstetricians, and nurses wrote the original ALSO materials in 1991. The demand for the course was so great that it required a national organizational structure, and the American Academy of Family Physicians acquired the program in 1993. Over the years, the ALSO concept evolved into an evidence-based approach to obstetric emergency management. This evolution is realized in the current fourth edition, which is noteworthy for its evidence-based structure and documentation.2

The wide appeal of the ALSO program stems from its ability to fine-tune skills that clinicians do not want to have to think about during an emergency. As with the advanced cardiac life support protocols, the steps of obstetric emergency management should be so routine that a physician can move automatically into them. The course is a compact review of the knowledge and skills necessary to cope with situations such as preeclampsia, preterm labor, assisted vaginal delivery, and shoulder dystocia (see accompanying table on page 1610).2 Because an emergency is no time to attempt the unfamiliar, the course allows clinicians to practice without the stress of a real emergency. A unique aspect is the inclusion of several mnemonics that help students perform technical procedures and interpret electronic fetal monitors. For those who deliver without immediate surgical back-up, ALSO training assists in building management strategies to use until back-up arrives or the patient can be transported to another facility.

ALSO Chapters Chapter topic Lecture or workshop Required or optional First-trimester complications Lecture Required Medical complications of pregnancy Lecture Required Vaginal bleeding in late pregnancy Lecture Required Preterm labor and premature rupture of membranes Lecture Required Intrapartum fetal surveillance Workshop Required Labor dystocia Lecture Required Malpresentations, malpositions, and multiple gestation Workshop Required Assisted vaginal delivery Workshop Required Shoulder dystocia Workshop Required Postpartum hemorrhage Lecture Required Maternal resuscitation and trauma Lecture Required Safety in maternity care Lecture Required Obstetric cases Workshop Required Third- and fourth-degree perineal lacerations Workshop Optional Diagnostic ultrasonography in labor and delivery Workshop Otional Neonatal resuscitation Workshop Optional Cesarean delivery Workshop Optional Birth crisis Workshop Optional NOTE: Information about the ALSO program and a listing of available courses are provided at: http://www.aafp.org/also. Information from ALSO: Advanced Life Support in Obstetrics provider course syllabus. 4th ed. Leawood, Kan.: American Academy of Family Physicians, 2000.

More than 30,000 physicians have taken the ALSO course since its inception. Most attendees have been family physicians in the United States and Canada, but increasing numbers of nurses, midwives, and obstetricians are taking the course as well. The majority of courses are conducted within family medicine residency settings, and many courses include community physicians, who serve as role models for providing maternity care. When nurses attend the course, the team approach to labor and delivery management can be modeled.

ALSO has undergone significant international expansion in the past several years, with licensed affiliates in Canada, the United Kingdom, Brazil, Haiti, Australia, New Zealand and the Pacific Islands, Scandinavia, Hong Kong, Greece, United Arab Emirates, Pakistan, Kenya, Qatar, Sudan, Gaza/West Bank, and the People's Republic of China. Courses also have been held in Uzbekistan, Ecuador, Nepal, Kyrgyzstan, Iraq, Bangladesh, and Zambia. ALSO has been adopted widely in the United Kingdom by the obstetrics and midwifery communities for use with their trainees and active practitioners.

The results of studies show that ALSO training increases short- and long-term confidence in handling obstetric emergencies.3-5 Other benefits are anecdotal but common. For example, residents appreciate having evidence-based information assembled in an organized fashion. Practicing physicians appreciate the review of factual information and the chance to rehearse manual skills they may not have had the chance to employ since residency. Furthermore, the program is cited commonly as being a catalyst for positive changes in hospital policy and procedure; some hospitals and insurers recommend or require the course.

This article series allows AFP to present useful articles about obstetric emergencies; in addition, it allows the ALSO course to take its proper place in the medical literature. Although more than 30,000 practitioners have taken the course, there are few references to it in print. Granted, the article series will not (and should not) take the place of participation in an ALSO course. However, it can serve as a readily available reference for health care professionals who want to keep current about problems that may arise during delivery.

When clinicians, residents, and students search for a review on shoulder dystocia or a similar topic, we hope these articles will be regarded as an authoritative and reliable resource. ALSO can empower trainees with the knowledge, skill, and confidence to provide maternity care and can encourage existing practitioners to continue providing maternity care. For our specialty, these goals are more important than ever. Harry A. Taylor, M.D., of Middletown, R.I., is the ALSO managing editor who will be overseeing the article series.

ALSO is a registered trademark of the American Academy of Family Physicians.

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Mark Deutchman, M.D., is professor in the Department of Family Medicine and director of the Family Medicine Perinatal Service and Advanced Training Track, University of Colorado Health Sciences Center, Denver.

Charles J. Carter, M.D., is a faculty member at Atlanta Medical Center Family Medicine Residency, Morrow, Ga. He is also a contributing editor with AFP.

Barbara Apgar, M.D., M.S., is clinical professor of Family Medicine, University of Michigan Medical Center, Ann Arbor. She is also an associate editor with AFP.

Address correspondence to Charles J. Carter, M.D., Atlanta Medical Center Family Medicine Residency Program, 1000 Corporate Center Dr., Suite 200, Morrow, GA 30260. Reprints are not available from the authors.

REFERENCES

1. Baxley EG, Gobbo RW. Shoulder dystocia. Am Fam Physician 2004;69:1707-14.

2. ALSO: Advanced Life Support in Obstetrics provider course syllabus. 4th ed. Leawood, Kan.: American Academy of Family Physicians, 2000.

3. Beasley JW, Damos JR, Roberts RG, Nesbitt TS. The advanced life support in obstetrics course. A national program to enhance obstetric emergency skills and to support maternity care practice [published correction in Arch Fam Med 1995;4:206]. Arch Fam Med 1994;3:1037-41.

4. Bower DJ, Wolkomir MS, Schubot DB. The effects of the ALSO course as an educational intervention for residents. Advanced Life Support in Obstetrics. Fam Med 1997;29:187-93.

5. Taylor HA, Kiser WR. Reported comfort with obstetrical emergencies before and after participation in the advanced life support in obstetrics course. Fam Med Feb 1998;30:103-7.

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Health Effects from Pesticide Exposure

GEOFFREY M. CALVERT, M.D., M.P.H.
Centers for Disease Control and Prevention
Cincinnati, Ohio

All Americans are exposed to pesticides. Among approximately 1,900 subjects selected in 1999 and 2000 from the National Health and Nutrition Examination Survey (NHANES) to represent the United States population six to 59 years of age, at least 90 percent of these persons had detectable serum levels of dichlorodiphenyltrichloroethane (DDT) metabolites.1 In addition, detectable levels of five of the six measured urinary organophosphate insecticide metabolites were found in at least 50 percent of the subjects, with those six to 11 years of age having the highest metabolite concentrations.1

The sources of these pesticide exposures include diet,2 indoor pesticide exposures (indoor pesticide applications to control pests3 and tracking-in of pesticides used outdoors),4 other environmental exposures (drift of pesticides from their intended target),5 and occupational exposures (exposures on farms and in pest-control occupations).6

There are approximately 16,000 different pesticide products currently used in the United States, and each of them contains one or more of approximately 600 approved pesticide active ingredients. According to the U.S. Environmental Protection Agency, 1.23 billion lb of conventional pesticides (excluding disinfectants and wood preservatives) are used annually in this country, a figure that accounts for more than one fifth of global pesticide use.7

Despite the pervasiveness of pesticides, relatively few acute poisonings are identified annually. The Toxic Exposure Surveillance System (TESS), which collects poisoning reports submitted by poison control centers in the United States, identified 20,110 acute pesticide poisoning cases in 2001.8 However, this number should be considered a minimal estimate of the true magnitude of the problem because reporting to poison control centers is voluntary, and poison control centers appear to capture only a minority of acute pesticide poisoning cases.9 Unfortunately, no better national estimate of acute pesticide poisoning exists.

Another reason for the low detection of acute pesticide poisonings is that physicians may fail to make the correct diagnosis. This failure may result because the clinical findings of pesticide poisoning are rarely pathognomonic but instead can resemble an acute upper respiratory illness, acute conjunctivitis, or acute gastrointestinal illness, among other conditions.

Making the correct diagnosis requires the physician to obtain an occupational and environmental history that solicits information on pesticide exposures. Physicians whose patients reside or work in agricultural areas, or are employed in the pest-control industry should be particularly vigilant about the role that pesticides may play in a patient's illness. Advice on acute pesticide poisoning management is available from published sources,10 and from poison control centers (the local poison control center can be contacted by dialing 1-800-222-1222). The accompanying table on page 1616 lists additional pesticide information resources.

TABLE Resources for Clinicians Managing Pesticide-Related Illnesses Resource Conact information Local poison control center Telephone: 1-800-222-1222 U.S. Environmental Protection Agency     Pesticide Poisoning Handbook. Provides advice on recognizing and managing pesticide poisoning. Web site: http://www.epa.gov/ oppfead1/safety/healthcare/ handbook/handbook.htm.   To find a copy of a pesticide product's label Web site: http://www.epa.gov/ pesticides/pestlabels   Compendium of electronic pesticide resources, including information on alternative pest-control measures Web site: http://www.epa.gov/ oppfead1/pmreg Pesticide Action Network Database. Provides current toxicity information on pesticides. Web site: http://www.pesticideinfo.org/ index.html NIOSH/CDC. Provides links to state-based programs that track acute pesticide poisoning. Telephone: 1-800-356-4674 Web site: http://www.cdc.gov/niosh/ topics/pesticides Information on integrating information data on pesticide-related health conditions into health care professional educational and practice settings Web site: http://www.neetf.org/ Health/providers/index.shtm NIOSH/CDC = National Institute for Occupational Safety and Health/Centers for Disease Control and Prevention.

Little is known about the health effects associated with chronic, low-level pesticide exposure. Although studies have identified associations between low-level pesticide exposures and chronic illness, for almost none of these associations has a causal link been established.11 Studying the human health effects associated with chronic, low-level pesticide exposure is fraught with difficulty, often because accurate data are not available on relevant pesticide exposures or on nonpesticide exposures that may confound or modify the effects of pesticide exposure. In addition, there may be a genetic component to a pesticide-related chronic illness, but associating pesticide exposure with such an illness is troublesome in the absence of biologic markers to identify genetically susceptible patients.

Apart from better recognition of acute pesticide poisoning, what measures can physicians take to reduce acute and chronic pesticide-related illnesses? First, physicians can encourage patients to minimize pesticide exposures. Patients can be reminded about exposure sources and be advised about ways to reduce those exposures. Patients who use pesticides should be counseled to comply with all pesticide label instructions and to take measures to prevent tracking pesticides into unintended locations (such as homes or cars).

Second, recognizing that most diseases are multifactorial and that pesticides or other chemicals may contribute to the etiology of some diseases (e.g., arsenic exposure is associated with lung cancer),11 the physician should consider whether chemical exposures may be playing a role in a patient's illness. When a physician suspects that chemicals are responsible for an illness, referral to an occupational and environmental health specialist may be prudent.

Fortunately, efforts are under way to assist physicians in the recognition and prevention of occupational and environmental illnesses. For example, the National Environmental Education & Training Foundation, in collaboration with several federal government agency and academic partners, is identifying effective approaches that clinicians can adopt in practice settings that will lead to improved recognition, management, and prevention of pesticide-related illnesses.12

Finally, by reporting pesticide-related illnesses to a poison control center or state department of health, physicians can help prevent and improve our understanding of pesticide toxicity. These reports are useful for identifying the most problematic pesticides and can draw attention to gaps in epidemiologic and toxicologic data. Ultimately, these reports can aid in the adoption of healthier pest-control approaches.

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Geoffrey M. Calvert, M.D., M.P.H., is a senior medical officer at the Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Cincinnati, Ohio.

Address correspondence to Geoffrey Calvert, M.D., M.P.H., National Institute for Occupational Safety and Health, 4676 Columbia Pkwy., R-17, Cincinnati, OH 45226. Reprints are not available from the author.

REFERENCES

1. NCEH. Second national report on human exposure to environmental chemicals. Atlanta, Ga.: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Environmental Health. 2003. DHHS (NCEH) publication no. 02-0716. 2003. Accessed online March 5, 2004, at: http://www.cdc.gov/exposurereport.

2. Groth E III, Benbrook CM, Lutz K. Update: pesticides in children's foods. New York: Consumers Union, 2000. Accessed online March 15, 2004, at: http://www.ecologic-ipm.com/PDP/Update_Childrens_Foods.pdf.

3. Gurunathan S, Robson M, Freeman N, Buckley B, Roy A, Meyer R, et al. Accumulation of chlorpyrifos on residential surfaces and toys accessible to children. Environ Health Perspect 1998;106:9-16.

4. Nishioka MG, Lewis RG, Brinkman MC, Burkholder HM, Hines CE, Menkedick JR. Distribution of 2,4-D in air and in surfaces inside residences after lawn applications: comparing exposure estimates from various media for young children. Environ Health Perspect 2001;109:1185-91.

5. Ames RG. Pesticide impacts on communities and schools. Int J Toxicol 2002;21:397-402.

6. Calvert GM, Sanderson WT, Barnett M, et al. Surveillance of pesticide-related illness and injury in humans. In: Krieger RI, ed. Handbook of pesticide toxicology. 2d ed. San Diego: Academic Press, 2001:603-41.

7. Donaldson D, Kiely T, Grube AH. Pesticides industry sales and usage. 1998 and 1999 market estimates. Washington, D.C.: U.S. Environmental Protection Agency, 2002.

8. Litovitz TL, Klein-Schwartz W, Rodgers GC Jr, Cobaugh DJ, Youniss J, Omslaer JC, et al. Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2002;20:391-452.

9. Calvert GM, Mehler LN, Rosales R, Baum L, Thomsen C, Male D, et al. Acute pesticide-related illnesses among working youths, 1988-1999. Am J Public Health 2003;93:605-10.

10. Reigart JR, Roberts JR, Morgan DP. Recognition and management of pesticide poisonings. 5th ed. Washington, D.C.: U.S. Environmental Protection Agency. Publication no. 735-R-98-003. 1999.

11. Dich J, Zahm SH, Hanberg A, Adami HO. Pesticides and cancer. Cancer Causes Control 1997;8:420-43.

12. NEETF. National strategies for health care providers: pesticides initiative. Implementation Plan. Washington, D.C.: National Environmental Education & Training Foundation, 2002. Accessed online March 15, 2004, at: http://www.neetf.org/health/providers/index.shtm.

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