Group 2

Question 1

how is pre-diabetes defined

Answer 1

FPG 100-125 mg/dL

Question 2

recommended therapeutic approach for pre-diabetes

Answer 2

Diet, exercise (150 min/week), limit alcohol consumption, avoidance of tobacco, stress reduction, plus
alternative medicine support, and sufficient sleep.

Question 3

diabetes type 2 diagnostic criteria

Answer 3

• FPG concentration (after 8 or more hours of no caloric intake) of 126 mg/dL or greater or
• Plasma glucose concentration of 200 mg/dL or greater 2 hours after ingesting 75-g oral glucose
load in the morning after an overnight fast of at least 8 hours, or
• Symptoms of uncontrolled hyperglycemia (e.g., polyuria, polydipsia, polyphagia) and a random
(casual, non-fasting) plasma glucose concentration of 200 mg/dL or greater or
• A1C level of 6.5% or higher

Question 4

evaluation and managment recommendations for type 2 diabetes

Answer 4

Evaluation and Management Recommendations:
Each visit should include:
• Monofilament testing
• Blood Pressure
• Foot exam
• Peripheral blood flow
• BMI, waist circumference
Quarterly:
• A1C (if not on target)
• CMP (if not on target)
• UA (if not on target)
• Lipids (if not on target)
Semi-annually:
• A1C (if on target)
• Neurological exam (if not on target)
Annual:
• dilated eye exam (refer out)
• micro albumin
• Lipids
• CMP (if on target)

Question 5

treatment for type 2 diabetes

Answer 5

• Target Glucose Control : A1C≤ 6.5%, FPG <110 mg/dL, peak postprandial PG <140 mg/dL
Blood pressure: < 130/80mmHg,
• Lipids: LDL <100, <70 mg/dL in patients with CAD, HDL: >40 mg/dL men, >50 mg/dL women, TG:
<150 mg/dL)

Current guidelines now recommend that drug therapy be initiated in all patients as soon as the diagnosis
of diabetes is established to prevent the deterioration of glycemic control. The American Association of
Clinical Endocrinologists guidelines aim for an HbA1c ≤6.5%, and the American Diabetes
Association guidelines aim for an HbA1c ≤7.0%

Question 6

type 2 diabetes : NUNM Health Center Guidelines- to be used in conjunction with AACE guidelines below.

Answer 6

If there is a FPG of 126-139 mg/dL, without risk factors (Hypertension, Hyperlipidemia, ethnic
background, peripheral vascular disease, obesity, family history) we may treat for three months with
pre-diabetes therapeutic recommendations. The patient will have a clear understanding that if followup readings still meet diagnostic criteria for diabetes after three months, we will start metformin and/or
other DM medication.
FPG 140 mg/dL or greater &/or A1C of 6.5% or greater, initiate pharmaceutical treatment in
conjunction with natural therapies and lifestyle modification.

Question 7

American Association of Clinical Endocrinologists guidelines tyoe 2 diabetes

Answer 7

Monitor the patient and adjust the treatment regimen over a 2- to 3-month period to achieve a goal
HbA1c ≤6.5%. If the HbA1c is still >6.5% after 3 months, intensify lifestyle modifications, and adjust the
medication regimen as follows, again depending on the patient’s HbA1c:
• In patients with an HbA1c <6.5%, continue the current regimen. Monitor fasting and
postprandial glucose levels, and adjust the regimen to maximize glycemic control
• In patients with an HbA1c of 6.5% to 8.5% on monotherapy, initiate combination therapy with
oral agents or basal insulin plus an oral agent. See the complete guideline for details
• In patients with an HbA1c of 6.5% to 8.5% on combination therapy, maximize the combination
oral medication and/or insulin regimen, and address fasting or postprandial hyperglycemia with
adjustments in basal and/or prandial insulin, respectively. See the complete guideline for details
• In patients with an HbA1c >8.5%, initiate or intensify insulin therapy, using basal and prandial
insulin or premixed preparations
The recommended order of therapies is based on expert opinion of the Diabetes Mellitus Clinical
Practice Guidelines Task Force. The initial medication regimen depends on the patient’s initial HbA1c:
• In patients with an HbA1c of 6.5% to 7%, initiate treatment with metformin,
a thiazolidinedione, acarbose, or sitagliptin. Metformin is the preferred first-line agent in most
patients. Alternatives include a low-dose sulfonylurea, a meglitinide, or prandial insulin (a rapidacting insulin analog or regular insulin)
• In patients with an HbA1c of 7% to 8%, initiate treatment with a combination of two or more of
the following agents: metformin, a thiazolidinedione, acarbose, a sulfonylurea, sitagliptin, or a
meglitinide. There are many commercially available combinations of oral agents that improve
patient compliance with dosing regimens. Prandial, premixed, or basal insulin analog (insulin
glargine or insulin detemir) regimens may be considered as an alternative
A1C of greater than 8.5%- after 3 months of medication , initiate insulin therapy through referral unless
trained in insulin therapy management.
• In patients with an HbA1c of 8.5% to 9%, initiate treatment with a combination of the
aforementioned agents (with the exception of acarbose) and/or a prandial insulin, premixed
insulin, isophane (NPH) insulin, or basal insulin regimen
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• In patients with an HbA1c of 9% to 10%, initiate treatment with a combination of the
aforementioned agents (with the exception of acarbose, meglitinides, and sitagliptin) and/or a
prandial, premixed, NPH, or basal insulin regimen
• In patients with an HbA1c >10%, initiate intensive insulin therapy with either a basal insulin
analog, NPH insulin, prandial insulin, or premixed insulin preparations. Certain combinations of
oral agents may be effective in selected patients

Question 8

type 2 diabetes criteria for hospitalization

Answer 8

• When there is an in-office blood glucose level of over 400 mg/dL.
• If patient is in DKA

Question 9

immediate pharmacological intervention for type 2 diabetes

Answer 9

• In patients with triglyceride levels >1,000 mg/dL (11 mmol/L):
• Initiate therapy immediately to decrease triglyceride levels to <400 mg/dL (4.5 mmol/L) because
of the risk of pancreatitis and other manifestations of hyperchylomicronemia syndrome
• Patients with hypoglycemia who are receiving insulin or sulfonylurea therapy:
o Administer rapidly absorbed carbohydrate (e.g., glucose tablets, glucose drink, orange
juice, or cola) if the patient is alert and able to swallow without the risk of aspiration
o Administer glucagon, 1 mg subcutaneously, if the patient is obtunded or unresponsive.
This requires administration by a friend, relative, or emergency personnel. It is
important to note that glucagon will only increase blood glucose for approximately 45
minutes, so additional treatment is needed
o Consider administering 50% dextrose, 25 to 50 mL intravenously, for severe
hypoglycemia when the patient is under medical care and venous access can be
obtained
o Recognize that urgent admission to the hospital may be required

Question 10

when is the Escharotic treatment considered?

Answer 10

Level 5 treatment
• Used in cases of CIN 2, 3 with an adequate colposcopy & (=) ECC (you will get to practice this in gyn
lab and clinic with supervision) & in some cases of persistent CIN 1 (> 2 yrs)
• May cause less scarring of the cx compared with other therapies, however clinical research is
needed. Research to provide evidence regarding recurrence, issues with fertility and obstetric
complications is needed. When recommending this therapy for patients it is important to inform
them of the lack of evidence and have them sign a consent to treat just like any other minor
surgery procedure.
• Treatment is C/I in pregnancy, if pt has cervicitis or other gynecological infection treat before
beginning escharotic treatment.
• Side Effects: cramping, spotting, d/c, and pain during the procedure and afterwards

Question 11

definition of Escharotic protocol

Answer 11

Definition - agent used to destroy tissue and to cause sloughing which produces what is known as
eschar (a slough, esp. following a cauterization or burn). The agents are caustics.

Question 12

step 1 of eschorotic tx

Answer 12

Bromelain32
• Powder that is applied to the cervix, the enzyme begins to break down the cell wall.
• It is left on the cervix for 15 minutes with light source to add in increasing the temperature
to activate the enzymatic action.
• In both in vitro and in vivo studies it has been shown that it can effectively debride fullthickness burns in pig skin in less than 24 hrs due to its enzymatic digestion.32
• It also edema and has anti-tumor effects.32,79

Question 13

step 2 of escorotic tx

Answer 13

Calendula officinalis (marigold) Succus
• Remove bromelain powder using a cotton swab saturated with succus.

Question 14

step 3 of escorotic protocol

Answer 14

ZnCl – ¼ tsp/Sanguinaria – ¾ tsp mixture
• Sanguinaria candensis (bloodroot) has anti-tumor (by inducing apoptosis), antimicrobial,
antioxidant, irritant, has strong escharotic effects.82
• This preparation is the main escharotic in the treatment.
• It is applied to the cervix and left on for only 1 minute
• It is then removed with calendula succus.

Question 15

step 4 or escorotic protocol

Answer 15

Vag Pack Suppositories
Contents:
Thuja, Berberine, Echinacea, vitamin A & E, Lomatium- Antimicrobial, specifically against HPV, healing
support for the mucosal membrane
• Insert 2 suppositories at end of each treatment

Question 16

treatment schedule

Answer 16

Visits last about 30 minutes and should be done 2x/wk with at least 2 days between
treatments for a total of 10 treatments.

Question 17

Suppositories following Escharotic tx or for CIN 1 without Escharotic tx (C/I in pregnancy)

Answer 17

ories following Escharotic tx or for CIN 1 without Escharotic tx (C/I in pregnancy)
• Vitamin A - insert PV qhs x 6 nights wks 1 & 3
• Herbal (Thuja, Lomatium, Vit A) – insert PV qhs x 6 nights wks 2 & 4
• Green Tea capsules - insert PV qhs 2x/wk - wks 5-12 weeks.
• Vitamin D suppositories – 12,500 IU 3nights/week for 6 weeks – consider this for CIN 1 only
– study showed women with CIN 1 using this suppository - found good antidysplastic effects
– of the 20 follow-up pts 15 had improved pap at 2 yrs, 3 had CIN1, 1 had a CIN 2-3, and 1 had CIN 3.

Question 18

Patients Requiring Immediate Referral (to an HIV specialist):

Answer 18

Pediatric patients
• Pregnant patients
• Patients with CD4 T-cells counts <350 cells/uL
• Patients with opportunistic infections
• Patients with concomitant Hepatitis B or Hepatitis C infections
• Patients with other HIV co-morbidities, including HIV-nephropathy, cardiovascular disease,
neurological disease, etc.

Question 19

Baseline Evaluation: for HIV patients

Answer 19

Each HIV-infected patient entering care should have:
• Complete medical history, including:
o Substance abuse history
o Presence of social, psychiatric and other medical issues
o Social support
o Medical insurance status
o Exploration of factors that might inhibit proper treatment
• Physical examination
• Laboratory evaluation, including:
o HIV antibody testing (if prior documentation is not available or if HIV RNA is below the
assay’s limit of detection)
o CD4 T-cell count (with follow-up testing every 3-4 months)
o Plasma HIV RNA (viral load)
o CBC; CMP + lipids: including transaminase levels, BUN, creatinine, fasting glucose;
urinalysis
o Serology for Hepatitis A, B, C viruses
o Genotypic resistance testing at entry into care, regardless of whether ART will be
initiated immediately. For patients who have HIV RNA levels <500-1000 copies/mL,
amplification of virus for resistance testing may not always be successful.
o Testing for other STI’s if indicated by history

Question 20

therapy initiation recommendations for HIV patients

Answer 20

In January 2011, the Department of Health and Human Services (DHHS) Panel on Antiretroviral
Guidelines for Adults and Adolescents issued updated guidelines on initiation of antiretroviral therapy,
as follows:
• Antiretroviral therapy should be initiated in all patients with a history of an AIDS-defining illness
or with a CD4 count below 350 cells/µL
• Antiretroviral therapy should be initiated regardless of CD4 count in pregnant patients, patients
with HIV-associated nephropathy, and those with hepatitis B virus co-infections when treatment
of hepatitis B virus infection is indicated
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• The panel was divided on the initiation of antiretroviral therapy in patients with CD4 counts
between 350 and 500 cells/µL: 55% of panel members considered this a strong
recommendation, while 45% considered it a moderate recommendation
The panel was also divided on initiation of antiretroviral therapy in patients with CD4 counts above 500
cells/µL: half of the panel members favored initiation in this setting, while the other half considered
treatment initiation as optional
Antiretroviral therapy should be managed by an infectious disease specialist

Question 21

Guidelines for evaluation: HTN

Answer 21

Guidelines for evaluation:
• Bilateral readings - first visit
• 3 separate readings at least 1 day apart
• If first day reading is Stage 2:
o return for repeat reading within one week.

Question 22

evaluation requirements: HTN

Answer 22

CBC,
• CMP,
• Lipids – consider CRP,
• Urinalysis,
• Fundoscopic exam,
• Electrocardiogram (ECG), if stage 2

Question 23

treatment L: HTN

Answer 23

• Over 60 years of age, and no chronic kidney disease (CKD) or diabetes (DM), goal is
<150/90
• Under 60 years of age or patients with CKD or DM, goal is <140/90

Question 24

changes to JNC 8 guidelines ( HTN

Answer 24

First-line and later-line treatments should now be limited to 4 classes of medications:
thiazide-type diuretics, calcium channel blockers (CCBs), ACE inhibitors, and ARBs.
• Second- and third-line alternatives included higher doses or combinations of ACE
inhibitors, ARBs, thiazide-type diuretics, and CCBs. Several medications are now
designated as later-line alternatives, including the following: beta-blockers,
alphablockers, alpha1/beta-blockers (eg, carvedilo), vasodilating beta-blockers (eg,
nebivolol), central alpha2/-adrenergic agonists (eg, clonidine), direct vasodilators (eg,
hydralazine), loop diruretics (eg, furosemide), aldosterone antagoinsts (eg,
spironolactone), and peripherally acting adrenergic antagonists (eg, reserpine).
• When initiating therapy, patients of African descent without CKD should use CCBs and
thiazides instead of ACE inhibitors.
• Use of ACE inhibitors and ARBs is recommended in all patients with CKD regardless of
ethnic background, either as first-line therapy or in addition to first-line therapy.
• ACE inhibitors and ARBs should not be used in the same patient simultaneously.
• CCBs and thiazide-type diuretics should be used instead of ACE inhibitors and ARBs in
patients over the age of 75 years with impaired kidney function due to the risk of
hyperkalemia, increased creatinine, and further renal impairment.

Question 25

treatment fro Systolic 120-139 / diastolic 80-89

Answer 25

• Diet and exercise
• Include ND treatments
• Stress reduction

Question 26

treatment for Systolic 140-159, Diastolic 90-99 [Stage One HTN]

Answer 26

Initiate treatment
o Pharmaceutical first line agent
▪ Consider lipids, insulin resistance, inflammatory markers, and lifestyle when
making decisions about pharmaceuticals
OR
o ND treatments trials, such as rauwolfia
▪ Treat 3 months and revaluate monthly (or rewrite as Treat 1-3 months with
monthly evaluation)
• Initiate pharmaceutical management if not controlled

Question 27

Systolic >160, Diastolic >100 [Stage Two HTN] tx

Answer 27

In addition to supportive naturopathic care;
• Must initiate at least one antihypertensive pharmaceutical
o Choice based on clinical judgment,
o ACE inhibitors & Thiazide diuretics are common starting points.
• Re-evaluate 2-4 weeks and consider adding another medication, if not controlled.

Question 28

Systolic >210, Diastolic >130 HTN

Answer 28

• Refer to Emergency Department
OR
• If managing in office, must be:
o Asymptomatic
o No signs of end organ damage
o Normal fundoscopic exam,
o No hematuria
o No microalbuminuria
o Normal CBC with smear
o Normal BUN/creatinine
o Normal electrolytes
o Normal ECG

Question 29

Signs of End-Organ damage at any elevated blood pressure

Answer 29

o Refer immediately for emergency blood pressure control

Question 30

HTN: monitor at each visit

Answer 30

• Physical examination at each visit should include:
o Vital signs
o Heart exam
o Lung exam
o Peripheral vascular exam

Question 31

IUD protocol: what to have ready

Answer 31

Sterile speculum
• Clip-on speculum light
• Betadine swabs X 3
• Hurricaine spray anesthetic
• Cervical dilators
• Uterine sound
• Tenaculum
• Ring forceps
• Curved scissors
• IUD of patient’s choice
• Kidney basin
• Tubes of sterile saline
• 2 pairs of Sterile gloves
• Non-sterile gloves
• Drapes

Question 32

IUD pre-procedure

Answer 32

1. Consult with the patient about long-acting reversible contraception (LARC) options and
   preferences.
2. Determine if the patient desires anesthetic on the cervix during the procedure.
3. Recommend crampbark (viburnum opulis) or ibuprofen (400mg) to reduce discomfort
   a. Advise patient to take 30 minutes to 1 hour prior to procedure.
   b. SIG Crampbark Plus pills 3-4; or tincture, ½ ounce; 30 minutes before procedure.
4. Complete a PARQ.
5. Confirm that specific consent for the procedure has been signed.
6. Confirm that an STI screen, including wet prep, GC/CT and if patient has risk factors for
   syphilis, an RPR (or anti-Treponema Ab) has been completed and that all tests have been
   collected (and ideally are already resulted as negative or are being treated).
7. Confirm there are no contraindications to the use of LARC.*
8. Perform an hCG test and confirm it is negative.
9. Note: LARC should not be inserted during symptomatic pelvic infection. Treat prior to
   insertion. If patient is asymptomatic, testing and prophylactic antibiotic treatment should
   be provided at the time of LARC insertion.`

Question 33

IUD procedure

Answer 33

1. Ensure use of sterile techniques throughout the entire procedure.
2. Have the patient disrobe from the waist down and sit on a clean drape on the examination
   table.
3. Place the patient as comfortably as possible in lithotomy position.
4. Put on 2 pairs of gloves.
5. Standing, using a small amount of lubricant, perform a bimanual exam to determine
   location of cervix, size and position of uterus (anteverted vs. retroverted), and absence of
   masses or other contraindications to LARC use.
6. Remove and discard the outer pair of gloves.
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7. Seated, insert speculum, adjust light and visualize the cervix.
8. Swab the cervix 3 times with iodine.
9. Spray the cervix with Hurricaine for 3 seconds. Remove and discard the second pair of
   gloves.
10. Put on sterile gloves.
11. Using the tenaculum, grasp the cervix firmly but gently.
    a. Tenaculum should remain in place throughout the insertion procedure.
    b. Anterior lip is recommended for anteverted uteri; posterior lip for retroverted.
    c. Provide gentle traction to straighten the body of the uterus during the insertion
    procedure.
12. Using sterile technique, gently introduce the uterine sound through the cervical os to
    determine the depth of the uterine cavity, confirm its direction and exclude the presence of
    uterine anomalies.
    a. If cervical stenosis is encountered, use dilation, not force to overcome resistance.
    b. Uterus should sound to a depth of 6-9 cm.
    c. Clamp ring forceps at point on uterine sound where it exits the os.
    d. Remove uterine sound with clamp still attached.
    e. Measure the distance from the clamp to the end of the uterine sound to determine
    depth of uterus.
    f. Set measuring flange on IUD insertion tube to the same depth.
13. Open the IUD package.
14. Load the IUD into the insertion tube:
    a. For the Mirena, Kyleena, and Skyla, advance the slider forward with your thumb as
    far it will go.
    b. For the ParaGard, fold both of the arms of the IUD downwards into the end of the
    insertion tube until they remain there. Place the white insertion rod into the
    insertion tube, being careful not to displace the IUD from its loaded position.
15. Insert the IUD. Make sure the IUD is inserted horizontally so that it will sit in the coronal
    plane when the arms are extended. Hold the insertion tube with the IUD in the horizontal
    plane. Provide gentle traction with the tenaculum while advancing the IUD through the
    cervical os.
    a. For the Mirena, Kyleena and Skyla:
    i. STOP when the flange is 1.5 cm anterior to the os. This position allows
    sufficient space for the arms to open fully when released into the uterine
    cavity.
    ii. Roll the slider back until it aligns with the mark on the handle.
    iii. WAIT 10 seconds for the arms to regain their T shape.
    iv. Then, advance the inserter till the flange rests against the os.
    v. Roll the slider all the way down to release the IUD into the fundus.
    vi. Remove the insertion device.
    b. For ParaGard:
    i. Advance the insertion tube and IUD all the way into the uterus until the
    measuring flange rests against the cervical os and you feel uterine resistance.
    ii. Hold the white insertion rod steady with one hand while retracting the
    insertion tube with the other hand. This will release the IUD into the fundus.
    iii. Remove the insertion rod, verifying that the strings are visible coming from
    the insertion tube which is still in the cervical os.
    iv. Remove the insertion tube.
16. Remove the tenaculum.
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17. Using the ring forceps to carefully hold the strings, use sterile curved scissors to trim the
    IUD strings to 3cm from the cervical os, tucking them back into the vaginal fornix. Take care
    not to tug on the strings.
18. Record the length of the visible threads in the patient’s chart.
19. Place a patient reminder message in the patient’s chart for removal of the IUD:
    a. Mirena: 5 years
    b. Kyleena: 5 years
    c. Skyla: 3 years
    d. Paraguard: 10 years

Question 34

Lice general guidelines

Answer 34

Treatment for head lice is recommended for persons diagnosed with an active infestation. All household
members and other close contacts should be checked; those persons with evidence of an active
infestation should be treated.
• All infested persons (household members and close contacts) and their bedmates
should be treated at the same time.

Question 35

treatment for lice

Answer 35

Over-the-counter Medications: Apply lice medicine according to the instructions contained in the box or
printed on the label. If the infested person has very long hair (longer than shoulder length), it may be
necessary to use a second bottle. Pay special attention to instructions on the label or in the box
regarding how long the medication should be left on the hair and how it should be washed out.
• Pediculocides (see Note, below) available OTC:
• Pyrethrins combined with piperonyl butoxide (Brand name products: A–200, Pronto,
R&C, Rid, Triple X).
• Permethrin lotion, 1% (Brand name product: Nix). A 5% Permethrin lotion is available
by prescription but has not been shown to be more effective that the OTC version.
• Repeat application is indicated with permethrins and pyrethroids in 7-10 days

Question 36

General Medication Guidelines for lice

Answer 36

• Do not use a combination shampoo/conditioner, or conditioner before using lice medicine. Do
not re–wash the hair for 1–2 days after the lice medicine is removed.
• Have the infested person put on clean clothing after treatment.
• After each treatment, checking the hair and combing with a nit comb to remove nits and lice
every 2–3 days will decrease the chance of self–reinfestation.
• Continue to check for 2–3 weeks to be sure all lice and nits are gone. Nit removal is not needed
when treating with spinosad topical suspension.
• When to retreat:
• If a few live lice are still found 8–12 hours after treatment, but are moving more slowly
than before, do not retreat. The medicine may take longer to kill all the lice. Comb dead
and any remaining live lice out of the hair using a fine–toothed nit comb.
• If, after 8–12 hours of treatment, no dead lice are found and lice seem as active as
before, the medicine may not be working. Nit (head lice egg) combs, often found in lice
medicine packages, should be used to comb nits and lice from the hair shaft. Many flea
combs made for cats and dogs are also effective.
• Retreatment is meant to kill any surviving hatched lice before they produce new eggs.
• For some drugs, retreatment is recommended routinely about a week after the first
treatment (7–9 days, depending on the drug) and for others only if crawling lice are
seen during this period. Retreatment with lindane shampoo is not recommended.
• Avoid prolonged exposure to the pediculocide. Permethrins and pyrethrins may be neurotoxic
at very high doses.

Question 37

Supplemental Measures fro lice

Answer 37

Head lice do not survive long if they fall off a person and cannot feed. You don’t need to spend a lot of
time or money on housecleaning activities. Follow these steps to help avoid re–infestation by lice that
have recently fallen off the hair or crawled onto clothing or furniture.
1. Machine wash and dry clothing, bed linens, and other items that the infested person wore or
used during the 2 days before treatment using the hot water (130°F) laundry cycle and the high
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heat drying cycle. Clothing and items that are not washable can be dry–cleaned. If machine
washing/dry cleaning not available, keep clothing sealed in a plastic bag and stored for 2 weeks.
2. Soak combs and brushes in hot water (at least 130°F) for 5–10 minutes.
3. Vacuum the floor and furniture, particularly where the infested person sat or lay. Head lice
survive less than 1–2 days if they fall off a person and cannot feed; nits cannot hatch and usually
die within a week if they are not kept at the same temperature as that found close to the human
scalp.
4. Do not use fumigant sprays; they can be toxic if inhaled or absorbed through the skin.

Question 38

Alternative Head Lice Treatment Strategies

Answer 38

Many alternatives to OTC or prescription head lice control products have been suggested. Although
there is little scientific information to support these methods, successful treatment has been reported
using several alternative treatments. People often use alternative treatments when conventional
treatments haven’t worked, or when there is a concern about the toxicity of using head lice control
products repeatedly. The Minnesota Department of Health cannot recommend these treatments without
further evidence of their effectiveness. However, we feel it is important to mention some of the more
commonly used methods.
The alternative treatments listed below are referred to as suffocants. When applied, the treatment may
suffocate and/or create a habitat unfavorable to the head lice.
• petroleum jelly (Vaseline®)
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• mayonnaise
• oil (e.g., vegetable, olive, or mineral)

Question 39

General Instructions for Suffocant Treatment*

Answer 39

1. Apply the selected suffocant generously to the hair, making sure the hair and scalp are saturated
   (for petroleum jelly, approximately two ounces should be sufficient).
2. Cover the hair with a close-fitting shower cap. Leave the cap on for eight hours (the exact time
   needed to kill the lice is unknown. Some people have reported success with shorter times). Avoid
   treatment while the infested person sleeps, as the cap may become a suffocation hazard.
3. Remove the shower cap and wash the hair with shampoo to remove most of the suffocant
   (petroleum jelly may be hard to remove, and we are not certain of the best method to do this, but
   commonly suggested methods include rinsing with a mild degreasing soap like Dawn®, or baby oil).
4. Remove all nits and any live lice as discussed under the Nit Removal section.
5. Wash hair thoroughly with shampoo to remove the remaining suffocant.
   *Note: Specific, well-tested procedures have not been developed for these treatments. Many treatment
   variations exist.
   While the optimal time to repeat alternative treatments is unknown, treatments should be repeated 7-
   10 days later to ensure that all freshly hatched nymphs and surviving adult lice are killed. The
   advantages to alternative treatments are the low costs and the non-toxicity. Disadvantages include the
   lack of established treatment procedures and scientific evidence demonstrating effectiveness, difficulty
   of removing petroleum jelly or oils from the hair, and the amount of time necessary for the procedure.

Question 40

Nit Removal

Answer 40

Removal of viable nits after treatment is an important supplement to the use of OTC head lice control
products and suffocants. Nits do not fall off the hair after treatment, and can be difficult to remove as
they are firmly cemented onto the hair shaft. Nits found near the scalp and up to 1/4 inch up on the hair
shaft may still be viable and should be removed with a louse comb or fingernails to help end the
infestation. The majority of nits that are over 1/2 inch out on the hair shaft are already hatched or dead.
The infested person’s head should be checked regularly for two weeks following head lice control
product treatment to ensure that active lice and potentially viable nits are removed.

Question 41

General Instructions for Nit Removal

Answer 41

1. Select a comfortable area with strong overhead lighting to facilitate inspecting the hair
   for nits. A television show or videotape may help the child sit quietly while the
   inspection takes place.
2. Use a head louse removal comb (metal may be better than plastic) for nit removal.
   Finger nails may also be used to remove nits from the hair shaft.
3. Lift a one-inch wide tuft of wet hair and place the louse comb as close to the scalp as
   possible. Comb slowly away from the scalp to the end of the hair tuft. Wipe the comb
   with a tissue to remove accumulated nits.
4. Hair clips may be used to pin the back the sections of hair you have completed, and
   keep them separated from uninspected hair. Continue the systematic inspection until all
   hair has been checked (nits are especially common behind the ears and near the nape of
   the neck).

Question 42

some unresearched methods for nit removal

Answer 42

Vinegar and water (one-to-one mixture) is commonly used to help remove nits. Hair is
soaked with the mixture for 30-60 minutes (a damp towel soaked in the same mixture
may be used to contain the solution). Rinse the hair following removal of nits.
• An over-the-counter product such as Clear® may be applied at least three minutes prior
to removing nits. The product may be rinsed out after use. An OTC head lice treatment
is then recommended to kill live lice.
• Hairclear 1-2-3®, a 15-minute hair treatment available at health food stores, has been
used by people as a nit removal aid. The product may also irritate live lice to the point
where they attempt to leave the hair, thus making them easier to remove.
• Alternative treatments such as mayonnaise, oils, and petroleum jelly are usually oily
enough to make louse combing easier.

Question 43

head lice Environmental clean up

Answer 43

While the majority of head lice are transmitted directly from person to person, to control any head lice
that are temporarily surviving off of a human host, you should:
1. Wash bedding in hot water (above 130 degrees F) and dry in a hot dryer or iron with a
hot iron. Wash and dry recently worn clothing (including coats, caps and scarves) in hot
temperatures. Clothing or bedding that cannot be washed may be dry cleaned or sealed
in a plastic bag for two weeks (the plastic bags contain the lice until they are dead, and
prevent head lice from temporarily infesting these items again while the treatment
process is taking place). While people often place bagged items outside in below
freezing temperatures to kill the lice, we do not know how long it takes to freeze head
lice.
2. Clean combs, brushes and similar items by:
o soaking in the medicated shampoo for 10 minutes, or
o soaking in a 2% Lysol® solution for one hour, or
o heating in water of at least 130 degrees F for 10 minutes.
3. Clean floors, carpeting and furniture by thorough vacuuming only. The use of insecticide
spray is not recommended.
Cleaning efforts should occur on the day of the first head lice treatment, and subsequently whenever
live lice are found on the patient’s head during the daily inspections. The effort should focus on areas
frequented by the infested person.

Question 44

prevention of head lice

Answer 44

Parents should be encouraged to check their children’s heads for lice on a regular basis throughout the
year. Families should not depend on someone else to check a child’s head, as this may delay treatment.
Remember, if one person in a family, camp, daycare or school has head lice, there’s a chance others will
too. Check everyone and use the same treatment if necessary. Treating persons without lice or nits will
unnecessarily expose them to potentially harmful chemicals. Parents are encouraged to communicate
with other parents of children that may have been exposed to their child. To avoid reinfestation, speak
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with their child about reducing direct contact with other children (touching heads), and avoiding shared
objects such as brushes, combs, and clothing.
The Minnesota Department of Health makes the following recommendations to schools concerning
head lice:
• Schools districts should make their own policies on whether or not to do “head checks” at
school. Parents should not rely on school staff to check for lice but should do this at home,
whether or not the children are checked at school.
• Infested children do not need to be dismissed from school.
• When a case of head lice is found, notices should be sent home to inform parents about head
lice, outline the current problem in the school, and advise them to check for lice and nits in their
children’s hair

Question 45

Acute Mastoiditis diagnostic criteria

Answer 45

Classic features of acute mastoiditis include:
• Fever
• Otalgia, which may manifest as irritability in young children
• Postauricular tenderness
• Postauricular erythema
• Postauricular swelling (with loss of the postauricular crease), fluctuance (or draining fistula), or
mass; postauricular fluctuance or mass indicates subperiosteal abscess
• Protrusion of the auricle (usually downward and outward in children younger than two years
and upward and outward in children older than two years)
• Sagging or edema (narrowing) of the external auditory canal

Question 46

treatment for mastoiditis

Answer 46

IM or IV antibiotics & drainage – emergent referral is required to otolaryngologist