Physicians' Update

Issue 98, October 2014

(Read previous issues)

In partnership with the Academy of Medicine Ottawa

In this issue: 

News Flash:

Articles:

Sexual Health:

Tobacco:          

Alcohol:

Programs for your patients:

Upcoming professional development:

Other: 

Message from the Medical Officer of Health

Dear colleagues,

Dr. Isra Levy Medical Officer of Health

Ottawa Public Health (OPH) has recently sent electronic notifications to primary care providers on newsworthy topics, such as Ebola and fever in the returning traveller and updated requirements under the Immunization of School Pupils Act. The most up-to-date information on topics such as these is available on our website at ottawapublichealth.ca in the Resources for health professionals section.

In this issue of the Physician’s Update, we give you notice of other new resources, like a free on-line geriatric journal oriented for primary care providers, updated guidance on feeding babies and toddlers, and new information on the challenges high school-age patients in Ottawa may be facing.

Additional articles focus on emerging issues such as syphilis occurring in women in Ottawa, recommendations for early detection and screening for anal cancer, addressing the risk of failure of oral emergency contraception in women weighing 165 lbs (75 kg) and over, and promoting nicotine replacement therapy during pregnancy and breastfeeding.

As we aim to provide timely information, we also continue with core programs to use new approaches such as prenatal classes, falls prevention programming, and TB workshops for your patients and staff.

As usual, if you have outstanding questions or comments, please do not hesitate to contact me or one of the other Public Health and Preventive Medicine specialists at OPH.

Best,

Isra

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The 2014 Ontario Student Drug Use and Health Report new local data available 

The 2014 Ottawa Student Drug Use and Health Report (OSDUHS) provides valuable information about the experience of local youth to guide counseling and intervention for promoting health and development. Healthcare providers play an important role in prevention of risk behaviours in their young patients; 77% of whom visit a doctor about their physical health at least once a year. Youth are often hesitant to discuss their health and risk behaviours, so it is important to stay informed about emerging trends and be prepared to start conversations with them in a non-judgmental way.

Below is a snapshot of the health risk behaviours among grade 7 to 12 students in Ottawa from theOntario Student Drug Use and Health Survey:

The report reveals concerning and emerging public health risks in youth:

Easy access to tobacco, alcohol and drugs - often from home

  • Seven-in-ten high school students said it would beeasy to get cigarettes and eight-in-ten said it would be easy to get alcohol.
  • Six-in-ten high school students said it would be easy to get cannabis.
  • 13% of grade 7 to 12 students had used prescription opioids non-medically in the past year – and two-thirds of them got the drug from home.

A culture of binge drinking that is causing harm

  • One-in-five students reported being drunk in the past month.
  • More than 20% reported drinking 5 or more drinks on one occasion at least once in the past month.
  • About 12% of Ottawa high school students were injured or injured someone in the past year as a result of their drinking.

New trends in substance misuse 

  • Past year use of OTC cough/cold medication to get high rose from 6% in 2009 to 13% in 2013, and Ottawa use was significantly higher than in Ontario (9%).
  • Driving while high is now more common than drunk driving.
  • One-in-five high school students had used an e-cigarette at least once and thirteen percent of students had used a waterpipe or hookah at least once.

A need for mental health support, but unsure how to access it

  • Twenty-six percent of students experienced a time in the past year where they wanted to talk to someone about a mental health or emotional problem, but didn’t know where to turn for mental health advice.
  • A quarter of students were bullied at school in the past year. Girls were more likely to have been bullied.
  • One-in-four students visited a mental health professional (e.g. doctor, nurse, counselor) at least once in the past year. Compare this to three-in-four who had visited a doctor about their physical health.

More recreational screen-time than physical activity, and unhealthy eating habits

  • Six-in-ten students spend more than two hours a day in front of a screen for entertainment.
  • Only one-quarter of students achieve the recommended 60 minutes of physical activity per day.
  • Two-in-five (41%) Ottawa students had not eaten breakfast on all five of the previous school days. 

For the full 2014 OSDUHS report and infographics visit: ottawa.ca/healthreports 

Author: Jacqueline Willmore, MPH, Epidemiologist at Ottawa Public Health

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Feeding Babies: New guidelines on what parents should know

You can now promote updated guidelines for feeding older infants and young children: 6-24 months. These guidelines, developed by Health Canada, Dietitians of Canada, the Canadian Paediatric Society, and the Breastfeeding Committee of Canada, guide parents in the introduction of complementary foods that promote appropriate nutrition for their babies, along with the progression towards mature feeding skills that enhance lifelong healthy eating habits.

What’s new at 6 months?

  • Along with breast milk, the first complementary foods introduced by parents should be soft and lumpy.
  • Iron-rich foods including meat & meat alternatives and iron fortified cereals should be the first soft and lumpy foods offered. These foods can be cooked, mashed, finely minced, or scrambled, and iron fortified cereals can be mixed with breast milk or water for a softer texture.
  • Delaying lumpy textures can result in feeding difficulties with older children and even lower intakes of healthier foods like fruit and vegetables.
  • After iron-rich foods are introduced foods from all the different food groups can be introduced in any particular order except for:

It is important to introduce safe finger foods at 6 months. These foods can include: pieces of any soft-cooked vegetable or fruit, soft, ripe fruit such as banana or mango, finely minced ground or mashed cooked meat or fish, grated cheese, thin pieces of bread crust.

What’s new at 7-8 months?

  • Time for parents to add more texture into their babies’ diets, progressing to small, bite-sized family foods.
  • Start introducing small amounts of water in an open cup - not a “sippy cup” - to encourage mature drinking skills and to reach the goal of becoming bottle free by age one.

What’s new at 9-12 months?

  • Babies are ready to chew, so parents can progress to offering family foods that are grated, finely chopped, or in pieces and strips.
  • Homogenized (3.25%) cow’s milk can slowly be introduced at this time as long as a wide variety of iron-rich foods are being offered.

Healthy Tips:

  • Encourage family meals at the table without any distractions, including screens.
  • Parents decide what healthy foods to offer, when to offer meals/snacks, and where their child will eat. The child decides how much and which foods they will eat from what is offered. This allows for children to follow their hunger and satiety cues, which promotes early development of self-regulatory energy intake.
  • Sample menus and questions/answers are available as a tool to help parents

Resources for you and your patients:

Written by: Tristyn Cleveland BSc. HNU, and Ellen Lakusiak R.D. Ottawa Public Health

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New Free Online Geriatric CME Journal

The Canadian Geriatrics Society, (a society composed of specialists in Geriatric Medicine, Care of the Elderly MDs and Primary Care MDs interested in the care of seniors), has created a free, online, open access Geriatric CME Journal focused on the needs of Primary Care Practitioners caring for older patients.

Under the editorship of Dr. Frank Molnar (Division of Geriatric Medicine at The Ottawa Hospital and Medical Director of the Regional Geriatric Program of Eastern Ontario), the CME journal has and will develop short practical articles on the care of older patients that present to primary care offices with a variety of issues including dementia, behavioral and psychological symptoms of dementia, fitness-to-drive, congestive heart failure, Atrial Fibrillation, etc.

You are invited to visit this new journal as it grows to better meet your needs. Please note the learning topics are listed shaded in dark blue to the right on the following webpage: ( www.cmegeriatrics.ca  and  www.geriatricsjournal.ca   ).

Dr. Molnar and his editorial team, which include primary care physicians, also invite you to suggest future topics via the form that can be accessed on the webpage. This is your chance to contribute to this emerging practical resource.

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Anal Intraepithelial Neoplasia and Anal Cancer – Early Detection and Screening Recommendations

This article provides you with information to help foster prevention and early detection of anal cancer, which is increasing in incidence14.

Epidemiology

Anal cancer (AC) is a rare malignancy that is becoming more common around the world, accounting for about 2-4% of all cancers of the lower gastrointestinal tract.  In Canada, there were 554 new cases in 2007 (230 males, 324 females, 261 Ontarians) and 96 AC-related deaths in 2011 (31 males, 65 females).  The national age standardized annual incidence is 1.3 per 100,000 (1.2/100 000 men, 1.8/100 000 women).

Risk Factors

AC and anal dysplasia are linked with behaviours and medical conditions that facilitate Human Papillomavirus (HPV) acquisition or persistence.  HPV (especially high risk strains 16 and 18) is detected in about 90% of ACs.  HIV positive men-who-have-sex-with-men (MSM) are the highest risk group (annual incidence 131 per 100,000).  The increase in AC burden in the highly active antiretroviral therapy (HAART) era is hypothesized to result from improvements in life expectancy that allow more time for dysplasia to progress.

Risk Factors include:

  1. MSM
  2. HIV positive
  3. Genital warts, cervical dysplasia, or other HPV-related cancers
  4. Receptive anal intercourse
  5. Cigarette smoking, especially current use
  6. Organ transplantation
  7. >10 lifetime sexual partners, especially without barrier protection
  8. Known HPV positivity, particularly if high risks strains or persistent infection
  9. Advancing age
  10. History of other sexually transmitted infections
  11. Possible association with autoimmune disorders and chronic benign anal irritation

Anatomy and Classification

The anal canal extends from the distal rectum to the anal verge/opening.  AC etiology, natural history and management more closely resemble cervical than colorectal or anal margin (perianal skin) cancers.  Precursor lesions originate in the transformation zone (squamocolumnar junction) as the squamous epithelium of the anus becomes columnar mucosa of the rectum.  Most anal malignancies are squamous cell in origin (60-85%) and are associated with HPV infection.  Adenocarcinomas (5-18%) and other rare tumors including melanoma (<1%) are not associated with HPV.

Symptoms and Signs

AC and benign anal conditions (e.g. hemorrhoids, warts, skin tags, fissures) present similarly:

  1. Anorectal bleeding
  2. Lump (seen or felt) around anus
  3. Increase in size or number of hemorrhoids
  4. Constipation, urge to pass stool or sensation of anal pressure
  5. Anal discharge or mucus
  6. Anal pain, swelling, itching, burning, persistent redness or pigmentation changes
  7. Faecal incontinence
  8. Inguinal lymphadenopathy

Primary Care Physicians – What Can You Do?

  1. Administer the quadrivalent vaccine to all those eligible and at risk.  Quadrivalent vaccination (covering HPV types 6, 11, 16, and 18) is indicated for women and men aged 9 through 26 for the prevention of anal cancer and AIN (efficacy 50-75%) regardless of HPV/dysplasia history (greatest benefit in HPV-unexposed)4.   The National Advisory Committee on Immunization (NACI) also recommends the quadrivalent vaccine for all MSM aged 9 and older4.  Although the provincial program only covers it for young women, patients in all these groups need to know it is recommended to be able to benefit from the quadrivalent HPV vaccine.
  2. Canadian consensus guidelines for AC/dysplasia screening do not yet exist.
    Specialists recommend clinical evaluation as a first step, including a sexual and symptom history, genital inspection, inguinal lymph node palpation and, most importantly, a digital anal and rectal exam (DARE) including a full 360 degree “anal sweep” of the anal canal to feel for abnormalities.  The optimal frequency of re-assessment is unknown, but Ottawa expert Dr. Paul MacPherson recommends a yearly DARE for all MSM.
  3. Anal Papanicolaou (Pap) testing and follow-up with High Resolution Anoscopy (HRA) may be useful, but randomized controlled trial data are still lacking.   HRA will be available in Ottawa within the next few months and local Guidelines with respect to anal paps and HRA will be forthcoming in a future issue of the Physicians’ Update.   For now, please refer any patient with risk factors, anal symptoms and suspicious clinical exam findings to a Colorectal Surgeon. 

Key Messages related to anal cancer

  1. Offer smoking cessation counseling and support
  2. Offer the quadrivalent HPV vaccine to all eligible patients, including all MSM age 9 and older
  3. Offer a yearly DARE, including anal sweep, to all MSM
  4. Consider AC/dysplasia in patients with HPV, anal symptoms and medical or behavioural risk factors (especially HIV-positive MSM).
  5. In Ontario, if AC is suspected, refer to a Colorectal Surgeon.

References

  1. Anal Cancer Information.  Canadian Cancer Society.  Last accessed March 24, 2014.  http://www.cancer.ca/en/cancer-information/cancer-type/anal/overview/?region=on.
  2. Beating Bowel Cancer: Anal Cancer Fact Sheet.  Harlequin House, Middlexex England & Wales.  Version 4.0, published Feb 2013.  http://www.beatingbowelcancer.org/sites/default/files/images/AnalCancerFactsheetV3.0Final.pdf.
  3. Cachay ER, and Mathews WC.  Human Papillomavirus, Anal Cancer, and Screening Considerations among HIV-infected individuals.  AIDS Reviews (2013); 15: 122-133.
  4. Canada Communicable Disease Report (CCDR): Update on Human Papillomovirus (HPV) Vaccines.  Advisory Committee Statement: National Advisory Committee on Immunization (NACI).  Public Health Agency of Canada.  Volume 31, January 2012.
  5. Coutlee F, et al.  Epidemiology, natural history and risk factors for anal intraepithelial neoplasia.  Sexual Health (2012); 9: 547-555.
  6. Deaths, by cause, Chapter II: Neoplasms (C00 to D48), age group and sex, Canada.  Statistics Canada, CANSIM Table 102-0522.  Accessed March 24, 2014.  http://www5.statcan.gc.ca/cansim/a01?lang=eng.
  7. Eaman E, et al.  Does anal cancer screening reduce morbidity and mortality in men who have sex with men?  The Journal of Family Practice (2012); 61 (7): 427-428.
  8. National Cancer Institute: PDQ Anal Cancer Prevention.  Bethesda, MD: National Institutes of Health.  Site last updated Feb 21, 2014.  Last accessed March 24, 2014.  http://www.cancer.gov/cancertopics/pdq/prevention/anal/HealthProfessional/page2.
  9. New cases and age-standardized rate for ICD-O-3 primary sites of cancer (based on the July 2011 CCR tabulation file), by sex, Canada, provinces and territories.  Statistics Canada, CANSIM Table 103-0553.  Accessed March 24, 2014.  http://www5.statcan.gc.ca/cansim/a01?lang=eng.
  10. Park IU, and Palefsky JM.  Evaluation and Management of Anal Intraepithelial Neoplasia in HIV-Negative and HIV-Positive Men Who Have Sex with Men.  Current Infectious Disease Reports (2010); 12:126-133.
  11. Ryan DP, et al.  Classification and epidemiology of anal cancer.  UpToDate.  Last updated Feb 14, 2014.  Last accessed March 20, 2014.
  12. Simpson J, and Scholefield J.  Diagnosis and management of anal intraepithelial neoplasia and anal cancer.  BMJ (2011); 343: 6818-6826.
  13. Smyczek P, et al.  Anal intraepithelial neoplasia: review and recommendations for screening and management.  International Journal of STI & AIDS (2013); 24 (11): 843-851.
  14. Van der Zee RP, et al.  The increasing incidence of anal cancer: can it be explained by trends in risk groups?  The Netherlands Journal of Medicine (2013); 71 (8): 401-411.

Written by Emily Brecher, MD CCFP, PGY3 Women’s Health, University of Ottawa, Ottawa Public Health with contributions from Paul MacPherson PhD, MD, FRCPC, The Ottawa Hospital; Edited by Gila Metz, MD CCFP, Medical Director for Sexual Health, Ottawa Public Health.

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Emergency Contraception (EC): addressing risk of failure

Recently, concerns have been raised regarding the use of oral emergency contraception for certain patients.  This article outlines options and considerations to address risks.

What EC options are available in Canada?

1. Levonorgestrel (LNG) (Plan B, Next Choice, NorLevo, Option 2)

  • 1.5mg (2 tabs) orally once
  • Can be used within 5 days of unprotected vaginal intercourse (UVI), but effectiveness diminishes over time
  • Delays ovulation, but less effective once luteinizing hormone (LH) has started to rise mid-cycle
  • Highly convenient: cheap, available without a prescription, no true contraindications

2. Yuzpe (Ovral)

  • 2 tabs orally initially, then again in 12 hours (1 tab = 50ug Ethinyl Estradiol + 250ug Levonorgestrel)
  • Poorly tolerated (often requires anti-emetic for nausea), leading to poor patient adherence.
  • Considerably less effective than LNG, as per the following table:

Timing of Administration (after USC)

Proportion of Pregnancies Prevented

LNG

Yuzpe

<=24h

95%

77%

25-48h

85%

36%

49-72h

58%

31%

73-120h

<50%

<30%

  • For reasons of poor tolerability and relatively lower effectiveness than LNG, the Yuzpe method is no longer used in Canada as an oral EC.

3. Copper Intrauterine Device (Cu-IUD)

  • Inserted by health care provider within 5 days of UVI
  • Can remain in place as long-term contraception (5 years)
  • Extremely effective (estimated failure rate: 0.09%)
  • No risk of drug-drug interactions
  • Works by pre and post-fertilization mechanisms (delays ovulation and disrupts implantation)
  • Note that the Levonorgestrel Intrauterine System (L-IUS) has not been studied as an EC

Key Factors Associated with Failure of oral EC

  1. Body weight
    1. The risk of pregnancy is at least 2 to 3 times greater for obese women (Odds Ratio 2.1-4.41) and 1.5 times greater for overweight women (OR 1.53) with oral EC.
    2. Efficacy decreases with increasing body mass index (BMI) and weight; emerging studies suggest the limit of effectiveness may be as low as 70kg (BMI 26) for LNG
    3. Doubling the dose of EC for women over 70kg has been proposed, but data regarding efficacy and safety of this practice is lacking
  2. Further episodes of unprotected intercourse in the same menstrual cycle as EC use (OR 4.64)
  3. Intercourse during peak fertility period in cycle (OR is 4.42 for UVI in the 24h prior to predicted ovulation) 

Health Canada Warning

March 26, 2014:
Emergency contraceptive pills available in Canada “are less effective in women weighing 165-176 pounds (75-80kg), and are not effective in women over 176 pounds (80kg).”

Society of Obstetricians and Gynaecologists of Canada (SOGC) Response

“If a copper IUD isn’t an option, a woman who weighs over 75 kilograms should still consider taking the emergency contraceptive pill as soon as possible, because it may help reduce the risk of pregnancy.

Bottom Line

  1. LNG remains the best oral option for EC in Canada at this time and should be offered to any woman at risk of unintended pregnancy
  2. Women seeking EC should be counselled that LNG is less effective:
    1. In women >70 kg (or BMI >26)
    2. With increasing delay between UVI and EC treatment (especially > 72 hours)
    3. With additional episodes of UVI in the same cycle
    4. From several days before ovulation until the end of the cycle
  3. Cu-IUDs inserted within 5 days of UVI prevent pregnancy more effectively than all other methods of EC

References

  1. Batur, P.  Emergency contraception: Separating fact from fiction.  Cleveland Clinic Journal of Medicine (Nov 2012); 79 (11): 771-776.
  2. Burnett, M et al.  SOGC Clinical Practice Guidelines (JOGC 2012).  International Journal of Gynecology and Obstetrics (2013); 120: 102-107.
  3. Glasier, A.  Emergency contraception: clinical outcomes.  Contraception (2013); 87: 309-313.
  4. Glasier, A et al.  Can we identify women at risk of pregnancy despite using emergency contraception?  Data from randomized trials of ulipristal acetate and levonorgestrel.  Contraception (2011); 84: 363-367.
  5. Glasier, A et al.  Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis.  The Lancet (2010); 375: 555-562.
  6. Lalitkumar, PGL et al.  Emergency contraception.  Best Practice & Research in Clinical Endocrinology & Metabolism (2013); 27: 91-101.
  7. Moreau, C and Trussell, J.  Results from pooled Phase III studies of ulipristal acetate for emergency contraception.  Contraception (2012); 86 (6): 673-680.

Written by Emily Brecher, MD CCFP, PGY3 Women’s Health, University of Ottawa, Ottawa Public Health
Edited by Gila Metz, MD CCFP, Medical Director for Sexual Health, Ottawa Public Health

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Infectious syphilis in women in Ottawa

Within the last 12 months, 5 women in Ottawa have been diagnosed with infectious syphilis, compared with an average of 0 to 2 cases per year during the previous 10 years.  The 5 women were between the ages of 20-49 years with a mean age of 35. 

Overall, infectious syphilis has decreased in Ottawa from a high of 6.1 cases per 100,000 in 2009 down to 3.4 cases per 100,000 in 2013.  However, 4.8 cases per 100,000 (a total number of 19 cases) were reported during January to end-July 2014.  Syphilis is transmitted through oral, genital or anal sex without a condom.  During the past five years, 90% of cases have been among men who have sex with men (MSM). 

Cases of syphilis among women are concerning for several reasons1:

  • Infectious syphilis is a highly infectious sexually-transmitted infection with the risk of long-term sequelae if not detected and adequately treated;
  • Young women are a population generally identified as low risk for syphilis and as such may not be routinely tested;
  • Infectious syphilis among women who are of childbearing age could lead to congenital syphilis;

Ottawa Public Health (OPH) is carefully monitoring the situation, following up with contacts of reported cases, and recommending syphilis testing for all patients who meet at least one of the following criteria:

  1. Women considering pregnancy;
  2. All pregnant women in their 1st trimester;
  3. Pregnant women at ongoing risk should be re-tested in their 3rd trimester and at delivery if indicated;
  4. Sexually active MSM with multiple partners (consider testing q6-12 months);
  5. Sexual partners of syphilis cases;
  6. Sexually active individuals with multiple partners;
  7. All persons who had sexual relations with a partner who is from a region where syphilis is endemic (including sub-Saharan Africa, South and South East Asia, Latin America and the Caribbean);
  8. All persons exhibiting signs and symptoms consistent with syphilis such as chancres, diffuse rashes, normally including palms of the hands and soles of the feet or influenza‑like illnesses; and
  9. All persons requesting screening after pre-test counselling, even in the absence of a known risk factor.

Managing cases

A useful summary of Syphilis Laboratory Interpretation is available on the Toronto Public Health website:

Toronto Public Health Syphilis Lab Interpretation Guide

Benzathine penicillin G is the antibiotic of choice for treating infectious syphilis. Primary care providers may obtain it free of charge from Ottawa Public Health by calling the Ottawa Public Health Line (OPHIL) at 613-580-6744.  Alternatively, patients requiring free treatment may be referred to the Sexual Health Centre at 179 Clarence Street.

Further information on window periods, stages of infection, modes of transmission, laboratory analyses, treatment and follow‑up for syphilis are available in the Public Health Agency of Canada’s Canadian Guidelines on Sexually Transmitted Infections online at:

Public Health Agency of Canada Syphilis Chapter

Syphilis is a reportable disease

Please fax the completed OPH Infectious Disease Reporting Form to 613-580-2831.

For More information

Ottawa Public Health Information Line 613-580-6744 (TTY: 613-580-9656)

Reference: 

  1. Canadian Guidelines on Sexually-Transmitted Infections: Section 5, Management and Treatment of Specific Infections: Syphilis Infections.  Revised July, 2013.  Public Health Agency of Canada (PHAC).  Last accessed Aug 22, 2014 Public Health Agency of Canada Syphilis Chapter

Submitted by Gila Metz MD, CCFP, Medical Director for Sexual Health, Ottawa Public Health with input from Dara Spatz Friedman, Epidemiologist, Ottawa Public Health

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Nicotine replacement therapy promoted during pregnancy and lactation

Experts agree that nicotine replacement therapy (NRT), in the form of a patch, gum, or lozenge, is safer in pregnancy than smoking. Guidelines from numerous expert organizations in Canada and around the world recommend NRT for pregnant and breastfeeding smokers who have been unable to quit using behavioural interventions only.

The Canadian gold standard

The Centre for Addiction and Mental Health (CAMH), the Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment (CAN-ADAPTT), the Ontario Medical Association (OMA), and the Society of Obstetricians and Gynaecologists of Canada (SOGC) guidelines suggest that pregnant and breastfeeding women be offered NRT once behavioural interventions have failed.  CAMH recommends NRT under the following conditions:

  • They have already tried to quit but are still smoking; and/or,
  • They smoke more than 10 cigarettes per day; and/or,
  • They want to try using the patch or gum, in conjunction with behavioural interventions.

Discussing risk/benefits with your patients

The risks of smoking during pregnancy and breastfeeding are significant.  Provide this patient handout (hyperlink) to help your patient better understand the risks and benefits of NRT use during pregnancy or lactation.

Using nicotine replacement therapy when pregnant or breastfeeding

Benefits

Risks

  • Baby is not exposed to the over 4,000 chemicals found in cigarette smoke
  • Helps with cravings and withdrawal symptoms
  • Doubles chances of successfully quitting smoking
  • The patch exposes baby to lower levels of nicotine than smoking cigarettes does.
  • Nicotine might affect oxygen delivery to the baby. However, NRT exposes baby to lower levels of nicotine than smoking cigarettes does, and the nicotine is delivered more slowly. Therefore, the risk is not as great as with smoking.
  • More research will help fully establish safety.

Encourage your patients to:

  • Try to quit smoking as early as possible;
  • Use the lowest effective dose of NRT (keeping in mind that higher doses may be required in pregnancy, due to increased metabolism);
  • Use the patch for 16 hours instead of 24 hours to give the baby a brief nicotine-free period when pregnant;
  • Use NRT when breastfeeding, because minimal amounts of nicotine are found in breast milk;
  • Continue breastfeeding if they start smoking again. The benefits of breastfeeding outweigh the risks from smoking.

Written by Natalia Abraham MD, BSc, MA, MSc(c), Medical Resident (PGY-3), Public Health and Preventative Medicine, University of Ottawa, (OPH). 

References:

Helping You Quit - for Pregnant and Breastfeeding Women

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Do you ask your patients about alcohol use?

Alcohol screening and brief intervention has been found to reduce alcohol consumption in primary care populations.1,2,3 A systematic review reported that brief intervention in patients was associated with a statistically significant reduction in alcohol consumption at one year when compared with controls.4

Why start the conversation with your patients?

Alcohol misuse is a leading cause of preventable death and disability. It is estimated that direct alcohol-related health care costs alone total $3.3 billion in Canada.5 If all Canadian adults followed Canada's Low Risk Alcohol Drinking Guidelines, alcohol-related deaths would be reduced by approximately 4,600 per year.6
Ottawa residents are consuming more alcohol than is recommended (and more than the Ontario average):

  • In 2013, Ottawa Paramedics responded to more than 3,000 calls related to alcohol intoxication.7
  • Almost 30% of Ottawa adults exceed the recommended weekly limits in Canada’s Low Risk Alcohol Drinking Guidelines.8
  • Twenty-two percent of high school students reported binge drinking (drinking 5 or more standard drinks on one occasion) in the past month.9
  • In 2011, 45.0% (40.3%, 49.6%) of adults drank five or more drinks on one occasion at least once in the past year. 
  • Heavy drinking (frequent binge drinking of once or more per month,) among adults in Ottawa has increased from 15% in 2000/01 to 24% in 2011.10

Physicians are a trusted source of information. You are uniquely positioned to directly influence the health of your patients, motivating them to engage in healthier lifestyles for themselves and their families.

Tools to help you:

  1. Alcohol Screening, Brief Intervention and Referral (SBIR) 
    This three-step Clinical Guide helps you efficiently identify, assess and advise patients who drink alcohol above the recommended levels and refer them if needed. 
    The associated website is created by the College of Family Physicians of Canada in partnership with the Canadian Centre for Substance Abuse. It provides resources and tools to assist you in helping your patients better manage their alcohol consumption. For example, there are six role play videos on engaging patients in SBIR using a motivational and non judgmental approach. In addition, you can earn CME/CPD Credits through reviewing the information on this site. 
    The College of Family Physicians of Canada has established four SBIR Champion roles across Canada for qualifying members. Presenting at their local Annual Scientific Assemblies or alcohol-related conferences, Champions will help spread the word about SBIR and how it can be effectively used. If you are a family physician interested in receiving more information about the SBIR program, please visit http://www.sbir-diba.ca/ or if you want to be involved as a SBIR champion, please contact Patricia Marturano, Health Policy Coordinator at pm@cfpc.ca.
  2. Self Assessment Tool 
    Encourage your patients to check their drinking themselves! This free, anonymous on-line survey allows your patients to self assess their drinking behavior by comparing the amount of alcohol consumed against the drinking guidelines. The web-based tool provides feedback to them, such as the long term health risks associated with their level of drinking. Patients can print or email the results to you for follow up at their next appointment.

Written by Hai Rong Li R.N., B.Sc.N, Public Health Nurse, Ottawa Public Health

 References: 

  1. Moyer A, Finney JW, Swearingen CE, Vergun P. (2002). Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction 2002; 97:279-92.
  2. Ballesteros JA, Duffy JC, Querejeta I, Arino J, Gonzalez-Pinto , A.(2002). Efficacy of brief interventions for hazardous drinkers in primary care: systematic review and meta-analysis. Alcohol, Clin Exp Res 2004; 28:608-18.
  3. Bertholet N, Daeppen J-B, Wietlisbach V, Fleming M, Burnand B.(2005). Brief alcohol intervention in primary care: systematic review and meta-analysis. Arch Intern Med; 165:986-95.
  4. Kaner E, Beyer F, Dickinson H, Pienaar E, Campbell F, Schlesinger C, et al.(2007). Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev(2):CD004148.
  5. Rehm J, Baliunas D, Brochu S, Fishcer B, Gnam W, Patra J, et al. (2006) The Cost of Substance Abuse in Canada in 2002. CCSA Misuse
  6. Butt, P., Beirness, D., Glicksman, L., Paradis, C., & Stockwell, T. (2011). Alcohol and health in Canada: a summary of evidence and guidelines for low-risk drinking. Ottawa: Canadian Centre on Substance Abuse. http://www.ccsa.ca/Resource%20Library/2011-Summary-of-Evidence-and-Guide... 
  7. City of Ottawa (2014) Ottawa Paramedic Service Annual Report 2013. Available at: http://www.google.ca/url?url=http://ottwatch.ca/meetings/file/189508/Fil...
  8. Statistics Canada (2011). Canadian Community Health Survey
  9. Ottawa Public Health (2011 ) Ontario Student Drug Use and Health Survey (OSDUHS )Report at http://documents.ottawa.ca/sites/documents.ottawa.ca/files/documents/201...
  10. Ottawa Public Health.(2013)Substance Misuse in Ottawa: Technical Report. March 2013. Ottawa (ON): http://ottawa.ca/calendar/ottawa/citycouncil/obh/2013/03-18/Report%20C%2...

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Free fall prevention exercise program for adults 65+

Better Strength, Better Balance! Free fall prevention exercise program for adults 65+

Your patients can now access an innovative program to address a leading cause of hospitalizations of people over 65 in Ottawa.  Ottawa Public Health is collaborating with The City of Ottawa’s Parks, Recreation, and Cultural Services to offer an expanded evidenced-based fall prevention program through project funding from the Champlain LHIN. This initiative is part of the provincial Seniors Strategy to increase community-based falls prevention and exercise programming.

Your patients can now access an innovative program to address the leading cause of injury among older adults in Ottawa: falls. Falls cause over 7,000 ER visits, 1,700 hospitalizations and 80 deaths among Ottawa adults 65 years and older annually. 

Who:  Patients 65 and older

What:

  • Group program
  • Strength and balance exercises led by a certified fitness instructor
  • Participants learn tips on how to prevent falls with education by Ottawa Public Health
  • No cost to participate

When: Offered twice a week for 12 weeks
For locations and a detailed schedule visit the Ottawa Public Health web site. 

How:  People can be referred by you to the program, or they may self-refer, by calling Ottawa Public Health at 613-580-6744

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Ottawa Public Health’s Prenatal Education Options

Prenatal education is associated with better birth outcomes and provides expecting parents with knowledge about pregnancy and life after the birth of their baby. Ottawa Public Health (OPH) has designed their prenatal education programs based on the identified needs of clients.

For your patients’ convenience, to increase access and uptake of prenatal education, there are three options available from OPH (private prenatal classes are also available in Ottawa):

  • An online program
  • A series of three in-person classes (complements online program)
  • Pregnancy Circles (for vulnerable patients) 

The Online Program - (A New Prenatal Life) is:

  • easily accessible to patients
  • free of charge
  • available in both English and French

Provides information in a series of eight modules on:

  • having a healthy pregnancy
  • avoiding preterm labour and low birthweight
  • breastfeeding
  • preparing for parenting
  • caring for a newborn
  • infant safety

This program offers your patients the flexibility and convenience to learn at their own pace from the comfort of their own home and includes interactive diagrams, easy to read explanations and test questions. In addition, your patients have the option of being contacted by a public health nurse (PHN) after three weeks and six weeks of signing up for the online course.  The PHN will answer questions, offer support and information about community resources that could be beneficial to them and their babies. 

Online program combined with three classes

The three in-person classes entitled, “Birth Basics”, “Breastfeeding Basics”, and “Baby Basics” are designed to complement the learning in the online program. Classes are available in both English and French. They are offered free of charge at the following Ottawa Public Library branches:Barrhaven, Nepean/Centrepointe, Alta Vista, Cumberland, St-Laurent, and Hazeldean.  The classes are available from Mondays to Thursdays, and Saturday mornings, and are held once or twice a month depending on the location.  For a detailed schedule, go to the Ottawa Public Library website. 

Pregnancy Circles

  • Pregnancy Circles are a series of free in-person prenatal groups available to expectant parents who are in need of extra support. They are offered on a regular basis, occur once a week for a duration of six to eight weeks. For a list of Pregnancy Circle locations, phone numbers and for registration patients can visit www.ottawa.ca/prenatal

For more information

OPH assists patients throughout pregnancy and life with a baby. Please refer your pregnant patients to call the Ottawa Public Health Information Line at 613-580-6744 (TTY: 613-580-9656) to speak with a public health nurse. Your patients can also visit www.ottawa.ca/prenatal to access the online program, to register for the tin-person classes and for more information on other available services.

Adapted by Miriah Botsford, BScN, RN (Temp), Reproductive Health and Baby-Friendly Initiative Program, Ottawa Public Health

Original written by Courtney Anderson, BScN Student, Consolidation Student, Reproductive Health and Baby-Friendly Initiative Program, Ottawa Public Health

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Upcoming professional development:

Ottawa Public Health TB Prevention Workshop

Date: Spring 2015 (date to be determined)
Cost: $20 per person

Attend Ottawa Public Health’s TB Prevention Workshop (offered each spring and fall) to learn about:

  • The pathogenesis and transmission of TB
  • The epidemiology of TB
  • The tuberculin skin test (TST): administration, reading and interpretation
  • Management of a positive TST result and treatment of latent tuberculosis infection

For further information and/or to indicate your interest in attending, contact OPH by phone at 613-580-6744 or by e-mail at healthsante@ottawa.ca

Academy of Medicine Ottawa (AMO) 8th Annual Clinical Day

Friday, February 20, 2015
Ottawa Conference & Event Centre 200 Coventry Rd, Ottawa

The AMO Clinical Day is designed for physicians, nurses and allied health professionals, to support clinical best practice and promote health for patients. We offer the highest quality accredited continuing medical education with an interdisciplinary program, to build awareness of options, strategies and resources.

Register now and save! Early bird registration is until November 30.

For information on speakers, topics and registration: http://bit.ly/Zd5nQz

Dawna Ramsay
Executive Director
Academy of Medicine Ottawa

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Why become an AMO member?

The Academy of Medicine Ottawa (AMO) is your local medical organization. Led by a team of elected physicians from Ottawa, the AMO works hard to advocate on behalf of physicians in the Ottawa region and to serve as an excellent source of collegiality, support, and leadership. The AMO is a branch society of the Ontario Medical Association (OMA), and delegates from the Ottawa region represent your interests at the OMA.

Please see the AMO’s Report to OMA Council for highlights of our active involvement last year.

AMO fees will not increase in 2014
AMO membership provides an opportunity for interaction with colleagues and a way to stay connected with the local medical community through educational, social and representational opportunities. Membership fees support operational costs of the Academy, which permit physician volunteers to work on projects and programs that benefit local physicians and patients.

Not an AMO member? Join now!

Enjoy the current issue of DocToc, the newsletter for AMO members.

The AMO is always keen to have more physicians involved in AMO projects, so if you're interested, please let us know. For more information about the AMO, or to share your ideas, please call or send an e-mail:

Dr. Alykhan Abdulla, President
Academy of Medicine Ottawa
1867 Alta Vista Drive
Ottawa, ON  K1G 5W8
Phone: 613-733-2604
Fax : 613-733-9083 
E-mail academy.medicine@on.aibn.com

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Contact Us:

Ottawa Public Health Logo

Ottawa Public Health

Monday to Friday 8:30 am to 4:30 pm
Phone: 613-580-6744 (Please identify yourself as a physician’s office.)
TTY: 613-580-9656
Toll-free: 1-866-426-8885
E-mail: healthsante@ottawa.ca 
Ottawa Public Health website
Follow us on Twitter @ottawahealth | @ottawasante 
Follow us on Pinterest 
Like us on Facebook (French)
Check out our Blog OttawaPublicHealth.ca | SantePubliqueOttawa.ca

Medical Officer of Health: 
Dr. Isra Levy: Medical Officer of Health ext. 23681
Dr. Vera Etches: Associate Medical Officer of Health, Clinical Programs: ext. 23675
Dr. Carolyn Pim: Associate Medical Officer of Health, Community Health Protection ext. 23684
Dr. Rosamund Lewis: Associate Medical Officer of Health, Policy and Partnerships ext. 23684

Medical Officer of Health after hours:
Call 3-1-1 and ask for the Ottawa Public Health Manager on call.

Academy of Medicine Ottawa

Academy of Medicine Ottawa Logo

Academy of Medicine Ottawa
1867 Alta Vista Drive
Ottawa, ON, K1G 5W8
Tel 613-733-2604
Fax 613-733-9083 

E-mail academy.medicine@on.aibn.com
Website: academymedicineottawa.org
Facebook: facebook.com/AMOdocs
Twitter: twitter.com/AMOdocs
Linkedin: linkedin.com/groups?gid=4688462

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