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OB/GYN Chief Clinical Consultant's Corner

Volume 5, No. 5, May 2007

# Contents {#contents .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

#### Abstract of the Month page 5 {#abstract-of-the-month-page-5 .Style-Heading-4-+-Arial-14-pt-Underline}

**Social Change Might Save More Lives Than Medical Advances**

#### From your colleagues page 6 {#from-your-colleagues-page-6 .Style-Heading-4-+-Arial-14-pt-Underline}

**Scott Giberson**

-Stop The Silence

-HIV/AIDS Among American Indians and Alaska Natives: CDC Fact Sheets
available

-Opportunity to obtain technical and capacity building assistance

-Fluoroquinolones No Longer Recommended for Treatment of Gonococcal
Infections

**Amy Groom**

New HPV Brochures for Clinicians, CDC

#### Hot Topics {#hot-topics .Style-Heading-4-+-Arial-14-pt-Underline}

##### Obstetrics page 9

-More stillbirths after previous cesarean delivery

-Pregnant Moms\' Weight Affects Toddlers

-Neonatal Pneumothorax Risk Increased After Early Elective Cesarean
Delivery

-Walking is popular, practical: Predictors of physical activity during
and after pregnancy

-Preterm low birth weight and maternal periodontal status: A likely
association

and more....

**Gynecology page 12**

-Young women with CIN: Any treatment increases the risk of preterm
delivery - LEEP

-Women with C. glabrata show higher mycological cure with boric acid

-Is Pelvic Organ Prolapse Caused by Vaginal Delivery?

-Chance of woman undergoing a hysterectomy can now be accurately
predicted

-Insulin-sensitising drugs versus the combined oral contraceptive pill
for PCOS

and more....

**Child Health page 14**

-Public Opinion vs. Science Concerning Sex Education

-Young Native-American Children at Higher Risk of Fatal Accidents

-What fluoride varnish are you using? Please respond

-New Guidelines Recommend Against Drug Testing of Teens in School, Home

-Association between adolescent dieting behaviors and weight gain over
time

and more....

**Chronic Illness and Disease page 16**

-Smoking Ban Has Health Benefits for Workers

-New Guideline for Screening Mammography for Women 40 to 49 Years of Age

-MRI Detects Breast Cancer Missed by Mammography

-Low-Dose Aspirin Linked to Lower Risk for All-Cause Mortality in Women

-Intensive Smoking Cessation Intervention Reduces Mortality in High-Risk
Smokers 

and more....

#### Features page 19 {#features-page-19 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-Premature Rupture of Membranes

-Patient Testing: Ethical Issues in Selection and Counseling

##### American Family Physician

-Prevention and Management of Postpartum Hemorrhage

-ACOG Releases Guidelines on Antibiotic Prophylaxis for Gynecologic
Procedures

-Estimating 10-Year Mortality Risk

-Infertility (see also Patient Education)

-ACOG Releases Opinion on Inducing Labor for VBAC

and more....

**Agency for Healthcare Research and Quality**

-AHRQ and the Ad Council encourage patients to ask questions and get
more involved

-Primary care office / quality improvement strategies substantially
affect the cost of care

**Ask a Librarian**

Quick Check for Drugs and Lactation

**Breastfeeding**

-Breastfeeding - it's all about synergy

-Editorial comments on last month's column

-NOMOGRAM from Alcohol and Breast Feeding

**CCC Corner Digest**

-HPV Vaccine: Newest ACIP Recommendations - Comments by Amy Groom

-When Things Go Wrong: Responding to Adverse Events

-HIV Prenatal Screening Can Saves Lives-- B. Reilley / S. Giberson

-Surgery versus medical therapy for heavy menstrual bleeding

-Newborn circumcision: Improved outcomes with pediatric hospitalists

-Obesity surgeries expanding dramatically since 1998, AHRQ

-All Encouraged to Help Reduce Colorectal Cancer Deaths in Women

-Inquiring families want to know - what about breastfeeding and......

-Violence Threatens the Health of Pregnant Women and Newborns

-Guidelines for Palliative Care Services: Now Online

-Welcome to the Indian Health Methamphetamine Initiative Site

-Does misoprostol aid prior to IUD insertion?

-Testing New Drugs on the World's Poorest Patients

-The Magic of Play

-Prolonged second stage: The rest of the story

-Being Present: The spirituality of presence in midwifery care

-Oral, not Transdermal, Estrogen Increases Risk for VTE in Women 

-Prenatal screening: It is recommended for ALL ages

-Assessment of Adverse Drug Events in a Tertiary Care Medical Center

-Cesarean Delivery on Maternal Request

-Bisphosphonate Related Osteonecrosis of the Jaws

-What is the best management plan for preterm labor?

-Electronic Health Record (EHR) Implementation: Worth the effort?

-HPV Vaccine Frequently Asked Questions

-Northern Women at Most Risk: Vit. D Deficiency Widespread in Pregnancy

-Can you dispense birth control to minors without parental consent?

-How many rubella vaccines does a mother really need to get?

**Domestic Violence**

-Intimate partner abuse has no age limit

-Domestic Violence and Your Patient\'s Health: Asking the Right
Questions

**Elder Care News**

Pain reliever propoxyphene associated with hip fracture in elderly

**Family Planning**

-Oral Contraception Regimen and Breakthrough Bleeding

#### -Prescribing a one-year supply of OCs contributes to more continuous use and lower costs {#prescribing-a-one-year-supply-of-ocs-contributes-to-more-continuous-use-and-lower-costs .Style-Heading-4-+-Arial-14-pt-Underline}

-Does Oral Contraceptive Use Affect Breast Cancer Risk?

**Featured Website**

Must See Website: Indian Health Service HIV-AIDS Program

**Frequently asked questions**

What are the actual federal regulations on sterilization? Bilateral
tubal ligation, etc...

**Indian Child Health Notes**

-Infant deaths associated with Cough and Cold Medications- 2005

-Pneumococcal Conjugate Vaccine: Contrasting Alaska Natives and
Navajo/Apaches

-Meeting the needs of regional minority groups: increase the AI / AN
physician workforce.

**Information Technology**

Electronic Health Record (EHR) Implementation: Worth the effort?

International Health

-Ethics of medicine with economically vulnerable populations: Second in
the series

# -One-Visit Screening for Cervical Cancer May Be Feasible in Developing Countries

#### MCH Alert

-Issues that affect adolescent well-being

-Surgeon General Issues National Call to Action on Underage Alcohol Use

-Adolescent sexual behavior and strategies for reducing early pregnancy
and childbearing

#### MCH Headlines

-Do you walk around your vehicle before getting in it? You should

-WHO publication details evidence for the 10 Steps to Baby Friendly

#### -2nd Round Request for Oral Health Preceptorship Applications  {#nd-round-request-for-oral-health-preceptorship-applications .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Do HIV Testing Rates Improve When Written Consent Is No Longer Required? {#do-hiv-testing-rates-improve-when-written-consent-is-no-longer-required .Style-Heading-4-+-Arial-14-pt-Underline}

-You are invited to join a Meth PH Forum

and more....

#### Medical Mystery Tour

-Which Indian Health facilities lead the entire U.S. in national
obstetric benchmarks?

#### Medscape

Bone Density Evaluation in Teens Prevents Future Osteoporosis

**Menopause Management**

#### -Emergence of a range of nonhormonal treatments for vasomotor symptoms {#emergence-of-a-range-of-nonhormonal-treatments-for-vasomotor-symptoms .Style-Heading-4-+-Arial-14-pt-Underline}

-Early Estrogen Therapy May Reduce Cardiovascular Risks

**Midwives Corner**

Ultrasound affects mice brains in negative ways: First, do no harm

**Navajo News**

**XXX**

**Nurses Corner**

-Two summer programs for high school students

-Women sacrifice sleep to \"Do It All,\" survey finds

-How Should We Counsel Women About HPV Testing?

-17 Interventions That Work: Lessons Learned from PHNs in the Field

-Reducing turnover of registered nurses and certified nursing assistants

#### Office of Women's Health, CDC

Quadrivalent HPV Vaccine: Recommendations of the ACIP

**Oklahoma Perspective**

Cesarean Delivery on Maternal Request

Osteoporosis

-Calcium Supplementation May Not Benefit Healthy Children

-Osteoporosis Patients Likely to Pause Medication

-Impact of Adherence and Persistence in Management of Osteoporosis

-Role and Importance of Calcium in Preventing and Managing Osteoporosis

-Putting the Risk for Osteonecrosis of the Jaw Into Perspective

Patient Education

Infertility

Perinatology Picks

-Preconception counseling for women with diabetes and hypertension

-How should the primary care provider approach medications?

-Re-visiting the issue of \"Amnisure

-Low-dose dopamine for pre-eclampsia with oliguria should not be used
other than in trial

-Probiotics for preventing preterm labour

Primary Care Discussion Forum

Electronic Health Record (EHR) Implementation: Worth the effort?

STD Corner

-HIV/AIDS among AI/AN Fact Sheet

-Protective factors among urban American Indian youths: HIV/AIDS

-HIV-related risk behaviors, perceptions of risk, HIV testing, among
urban AI/AN

#### -Impact of HPV Immunization on Gynecologic Cancers {#impact-of-hpv-immunization-on-gynecologic-cancers .Style-Heading-4-+-Arial-14-pt-Underline}

-Increases in Gonorrhea - Eight Western States, 2000-2005

and more....

#### Barbara Stillwater, Alaska Diabetes Prevention and Control

#### -New recommendations for gestational weight gain in obesity epidemic  {#new-recommendations-for-gestational-weight-gain-in-obesity-epidemic .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Elevated Autoantibodies Linked to Preeclampsia {#elevated-autoantibodies-linked-to-preeclampsia .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Cholesterol Could be Key to Treating Fetal Alcohol Syndrome {#cholesterol-could-be-key-to-treating-fetal-alcohol-syndrome .Style-Heading-4-+-Arial-14-pt-Underline}

**Women's Health Headlines**

-Weaving it all together: 2007 Behavioral Health Conference

-CME/CEU - Quadrivalent Human Papillomavirus Vaccine

-Newly completed Pregnancy and Postpartum Quitline Toolkit

-How to Best Get the HPV Vaccine Information Sheets signed?

-Race/ethnicity, socioeconomic status, and lifetime morbidity burden in
the WHI

###### Save the Dates: Upcoming events of interest page 55

#### What's new on the ITU MCH web pages page 55

-Implementation and Use of an Electronic Health Record within the Indian
Health Service

[J Am Med Inform
Assoc.](javascript:AL_get(this, 'jour', 'J Am Med Inform Assoc.');) 2007
March-April

**Did you miss something in the last OB/GYN Chief Clinical Consultant
(CCC) Corner?**

#  {#section .Style-Heading-1-+-Underline}

# Abstract of the Month {#abstract-of-the-month .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

**Social Change Might Save More Lives Than Medical Advances**

The basic notion that more lives would be saved by eliminating
education-associated excess mortality than by medical advances is
sufficiently robust to justify a change in policy priorities. In the
past few decades, there have been heavy investments in technological
advances intended to reduce morbidity and increase life expectancy.
However, the pace of progress has been modest.

Minority groups have higher mortality rates than whites, and people of
low socioeconomic status have higher mortality rates and poorer health
status than the general population. This article explores the
possibility that addressing social determinants of health might do more
to save lives than the incremental advancements in the technology of
care that consume the bulk of societal investments in health. The
authors examined death rates among adults with inadequate education, a
group known to have excess mortality rates.

The authors examined mortality data for 1996 through 2002 reported by
the National Center for Health Statistics. They compared (1) the maximum
number of deaths averted by the downward secular trend in mortality and

\(2\) the number of deaths that would have been averted had mortality
rates among adults with less than a high-school education (LHS adults)
been the same as those among adults with some college education.

The authors found that

\* The downward secular trend in age-adjusted mortality rates in the
United States saved an average of 25,456 lives per year during 1996
through 2002.

\* Each year, an average of 195,619 deaths would have been averted if
mortality rates among LHS adults had been the same as mortality rates
among college-educated adults.

\* Disparities in education-associated excess mortality were more acute
among LHS adults than among those with a high-school education (but no
college diploma). Nonetheless, because high-school graduates outnumber
LHS adults, a majority of the lives saved by eliminating
education-associated excess mortality \-- 870,286 (63.6%) of the

1,369,335 averted deaths \-- would involve adults with a high-school
diploma.

This data suggests that correcting the conditions that cause people with
inadequate education to die in greater numbers will do far more to save
lives than making incremental improvements in the technology of medical
care.

Woolf SH, Johnson RE, Phillips, RL, et al. 2007. Giving everyone the
health of the educated: An examination of whether social change would
save more lives than medical advances. American Journal of Public
Health. [Am J Public
Health.](javascript:AL_get(this, 'jour', 'Am J Public Health.');) 2007
Apr;97(4):679-83.

[[http://www.ajph.org/cgi/content/abstract/AJPH.2005.084848v1]{.underline}](http://www.ajph.org/cgi/content/abstract/AJPH.2005.084848v1)

or

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17329654&dopt=Abstract>

#### [OB/GYN CCC Editorial comment:]{.underline}

The United States, the richest country in the world, currently ranks
27th in the health of its citizens\*. Lagging behind not only most of
the rich countries, but a few poor ones as well. Fifty years ago, the US
was among the top five. What happened in the past five decades to cause
this decline?

Stephen Bezruchka# in his lecture 'Womb to Tomb' explains that an
increasing stratification between the rich and the poor plays a major
role. Life spans and infant mortality rates depend very much on the
hierarchal structure of a society. And new research shows that half of
what influences our health as adults is largely determined before the
age of five. What can we learn from other countries whose citizens live
longer and healthier lives?

In Indian Country we should use our expertise as public health advocates
to improve the whole of Indian 'health', not just direct health care.

From Womb to Tomb, Stephen Bezruchka M.D, University of Washington

<http://www.alternativeradio.org/programs/BEZS002.shtml>

\*Life expectancy in the US has declined further since the above
lecture. It now lags behind Cuba

**Resource:**

**Deaths: Preliminary Data for 2004, National Center for Health
Statistics**

<http://www.cdc.gov/nchs/products/pubs/pubd/hestats/prelimdeaths04/preliminarydeaths04.htm>

\# Stephen Bezruchka teaches at the University of Washington and works
as an emergency room physician in Seattle. His particular areas of
research are population health and societal hierarchy and its
application to health. He is author of numerous articles and essays. His
most recent contribution is to Sickness and Wealth, a collection of
essays on the effects of global corporatization on health.

# From your colleagues {#from-your-colleagues .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

**Scott Giberson, HQE**

**Stop The Silence**

**That is the message that Indian Country will soon be seeing**

For many of us, talking about sex is an uncomfortable topic. Because of
this, we have remained silent. In turn, our children and grandchildren
have grown up not knowing how to talk about these issues. The time has
come. Our silence will not stop the devastating impact of sexually
transmitted diseases. In response, the Red Talon STD/HIV Coalition has
come together to increase community awareness about the impact that
sexually transmitted diseases can have on our native communities.

**[The Campaign]{.underline}**: To commemorate National Native HIV/AIDS
Awareness Day, celebrated on Wednesday, March 21, 2007, the Northwest
Portland Area Indian Health Board and G&G Advertising will launch its
**HIV & Sexual Health** campaign targeting the Northwest Tribes. The
campaign includes:

-   2 Teen Posters (now available in print and on the web)

-   6 Teen STD/HIV Magazines, including three versions for younger
    teens, and three versions for older teens (coming soon!)

-   2 Adult Public Service Announcements (PSAs) for placement in Tribal
    papers (now available in print, press quality available on the web
    tomorrow)

-   An Adult Tip-Sheet for talking to teens about sex and STDs (print
    quality version attached, press quality available on the web
    tomorrow)

-   2 T-Shirt designs (now available)

-   A Website - Visit
    [www.stopthesilence.org](../../../../../../../../%5C%5Cwww.stopthesilence.org)
    for more information about HIV, STDs, testing services, and ways to
    improve community awareness.

Once complete, all materials will be available for download at Project
Red Talon:
<http://www.npaihb.org/epicenter/project/prt_reports_publications_media_materials/>

**[Media Dissemination]{.underline}**: Project Red Talon will distribute
campaign products to our current Tribal Health contacts at each of the
43 NW Tribes. If you would like additional copies of any of the products
(or are not on our contact list), please contact Lisa Griggs at
lgriggs@npaihb.org or 503-228-4185 to determine product availability.

**[Some startling statistics]{.underline}**: American Indians and Alaska
Natives (AI/AN) are disproportionately impacted by high rates of
sexually transmitted diseases (STDs).

·       When compared by ethnicity, AI/AN men and women had the third
highest HIV/AIDS rate in

2004\. In 2004, the rate of HIV/AIDS diagnosis for American Indian and
Alaska Natives men

was 20.8 per 100,000, and was 7.7 per 100,000 among AI/AN women.

-   Among American Indian and Alaska Native males, the HIV/AIDS case
    rate increased 2.4% from 2001 to 2004, the most significant increase
    observed among any reported racial/ethnic group. Among American
    Indian and Alaska Native females, the HIV/AIDS case rate increased
    4.8% from 2001 to 2004, an increase that was second only behind
    Asians/Pacific Islanders (A/PIs).

-   In 2004, American Indians were nearly five times more likely than
    whites to have chlamydia, four times more likely to have gonorrhea,
    and twice as likely to have syphilis. These infections compromise
    not only individual well being, but the well being of the community
    as a whole, and direct medical costs associated with STDs can cause
    a substantial economic burden to Tribal healthcare budgets.

-   Each year, 1 in 4 sexually active teens will get an STD, and 1 in 5
    sexually active teen females will get pregnant. Two U.S. teens are
    infected with HIV every hour of every day.

STDs interacts with reproductive health on a variety of levels:

·       High rates of sexually transmitted diseases not only signify
high-risk behavior, but also indicate a vulnerability to the
transmission of HIV. People infected with an STD are 2 to 5 times more
likely to become infected with HIV.

1       Untreated STDs can cause severe health consequences for women,
including pelvic inflammatory disease (PID), ectopic pregnancy, and
infertility. Up to 40% of females with untreated chlamydia infections
develop PID, and 20% of those may become infertile.

**These are the kinds of statistics that Indian Country should not be
apart of.  We must stand up and have a voice \-- Stop the Silence!**

**HIV/AIDS Among American Indians and Alaska Natives:** **CDC Fact
Sheets available**

The CDC has updated its annual Fact Sheet on HIV/AIDS Among American
Indians and Alaska Natives. The new data was posted in March 2007 and
contains information from the most recent 2005 CDC reports.

It will be posted on the IHS HIV/AIDS website,
[www.ihs.gov/medicalprograms/hivaids/](http://www.ihs.gov/medicalprograms/hivaids/)

At CDC, the data can be found at:
<http://www.cdc.gov/hiv/resources/factsheets/aian.htm> 

**Opportunity to obtain technical and capacity building assistance**

Detailed below is an opportunity to obtain technical and capacity
building assistance (as well as training) on HIV/AIDS primary medical
care and treatment delivery. It is available to IHS sites, Urban
programs and tribally run clinics. Please read the excerpt below and the
attached brochure and review any possibilities to apply for these
resources. If you choose to apply for this, consider a brief email to
this office so we are aware of the activity, resources and outcomes.
This will continue to strengthen our networks, identify those in the
field expanding services and potentially serve as a model of care that
can be highlighted amongst our peers. Thanks to our HRSA colleagues, the
SNHC Project and Brenda Woods-Francis (HRSA / AETCs) for this
information.

Applications for technical and capacity building assistance are being
sought by the Supporting Networks of HIV Care (SNHC) by Enhancing
Primary Medical Care (EPMC) Project, a federally funded project that
seeks to develop, improve, and expand the capacity of comprehensive HIV
primary medical care and treatment service delivery in racial/ethnic
minority communities impacted by HIV/AIDS.  This national technical
assistance and capacity building project is designed to provide
technical assistance (TA), intensive capacity building, training, and
regional meetings to primary medical care organizations to improve their
ability to provide quality HIV care. Funded by the Health Resources and
Services Administration (HRSA)'s HIV/AIDS Bureau, the project is led by
the CAEAR Foundation in partnership with the Academy for Educational
Development, and the National Minority AIDS Council.  TA assistance is
available to small/moderately sized non-profit primary medical care
sites including Indian Health Service Facilities, Urban Indian Programs,
and tribal run health facilities.  Applications for the Intensive
Capacity Building services component are due April 9, 2007. Other
services have other or rolling application deadlines.  Please visit
[www.hivta.org](http://www.hivta.org/) for additional information on
eligibility, applications, and application timetables for all TA
services and training.

**Fluoroquinolones No Longer Recommended for Treatment of Gonococcal
Infections**

MMWR release April 13, 2007

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a3.htm>

or

Update to CDC\'s Sexually Transmitted Diseases Treatment Guidelines,
2006

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm>

**Amy Groom, Albuquerque**

**New HPV Brochures for Clinicians, CDC**

CDC recently updated their HPV brochure for clinicians and posted four
sets of counseling messages to assist providers in their HPV-related
discussions with patients. The counseling messages address (1)
information for parents about the HPV vaccine, (2) information for women
about the Pap and HPV tests, (3) information for women who receive a
positive HPV test result, and (4) information for patients receiving a
genital warts diagnosis.

These materials are now available online as separate PDF files at the
link below. They are also being printed as a package (brochure with
counseling insert cards) for free online ordering. We will let you know
as soon as they are available in print.

In the meantime, they hope you find these resources useful and ask that
you please share them with other providers in the field.

As always, they welcome your feedback and thank you for your continued
efforts in HPV education and the prevention of HPV-associated diseases.

[[www.cdc.gov/std/hpv/hpv-clinicians-brochure.htm]{.underline}](http://www.cdc.gov/std/hpv/hpv-clinicians-brochure.htm)

# Hot Topics {#hot-topics-1 .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

#### Obstetrics {#obstetrics .Style-Heading-4-+-Arial-14-pt-Underline}

**More stillbirths after previous cesarean delivery**

CONCLUSIONS: Pregnancies in women following a pregnancy delivered by
caesarean section are at an increased risk of stillbirth. In our study,
the risk appears to be mainly concentrated in the subgroup of explained
stillbirths. However, there are sufficient inconsistencies in the
developing literature about stillbirth risk that further research is
needed.

Gray R; Quigley MA; Hockley C; Kurinczuk JJ; Goldacre M; Brocklehurst P
Caesarean delivery and risk of stillbirth in subsequent pregnancy: a
retrospective cohort study in an English population. [BJOG.  2007;
114(3):264-70](http://www.medscape.com/medline/publicationbrowser/123?pmid=17261119) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17261119>

**Pregnant Moms\' Weight Affects Toddlers**

RESULTS: Greater weight gain was associated with higher child body mass
index z-score (0.13 units per 5 kg \[95% CI, 0.08, 0.19\]), sum of
subscapular and triceps skinfold thicknesses (0.26 mm \[95% CI, 0.02,
0.51\]), and systolic blood pressure (0.60 mm Hg \[95% CI, 0.06,
1.13\]). Compared with inadequate weight gain (0.17 units \[95% CI,
0.01, 0.33\]), women with adequate or excessive weight gain had children
with higher body mass index z-scores (0.47 \[95% CI, 0.37, 0.57\] and
0.52 \[95% CI, 0.44, 0.61\], respectively) and risk of overweight (odds
ratios, 3.77 \[95% CI: 1.38, 10.27\] and 4.35 \[95% CI: 1.69, 11.24\]).
CONCLUSION: New recommendations for gestational weight gain may be
required in this era of epidemic obesity.

[Oken
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Oken+E"%5BAuthor%5D),
et al Gestational weight gain and child adiposity at age 3 years. [Am J
Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
Apr;196(4):322.e1-8

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17403405>

**Neonatal Pneumothorax Risk Increased After Early Elective Cesarean
Delivery**

CONCLUSIONS: The timing of elective cesarean section influences the
pneumothorax risk. A reduction in neonatal iatrogenic pneumothorax would
result if elective deliveries were performed after the 39 completed
weeks of pregnancy

[Zanardo
V](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Zanardo+V"%5BAuthor%5D),
et al The influence of timing of elective cesarean section on risk of
neonatal pneumothorax. [J
Pediatr.](javascript:AL_get(this, 'jour', 'J Pediatr.');) 2007
Mar;150(3):252-5

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17307540>

**Walking is popular, practical: Predictors of physical activity during
and after pregnancy**

Declines were observed in total physical activity during pregnancy that
persisted to some degree at 6 months postpartum. Physical activity
during and following pregnancy may have beneficial effects on postpartum
weight and related health outcomes.

The authors found that

\* The mean age of women at enrollment was 32.5, 34% were overweight or
obese before pregnancy, and 24% were nonwhite. Approximately 8%-9% of
the women were depressed during either time period.

\* The percentage of women working equal to or greater than 35 hours per
week was 60% during the second trimester and 30% at 6 months postpartum.
Nearly two-thirds of the sample reported that insufficient time was a
very important barrier to physical activity at 6 months postpartum.

\* Physical activity decreased during pregnancy from 9.6 to 6.9 hours
per week and rebounded to 8.0 hours per week during the postpartum
period. This decrease was accounted for by the sustained drop in
light-to-moderate and vigorous physical activity, not including walking.

\* Prevalence of insufficiently active lifestyle increased from 12.6%
pre-pregnancy to 21.6% during pregnancy, and remained at 21.7% during
the postpartum period.

\* The odds ratio for becoming insufficiently active during pregnancy
was 1.58 in women with at least one child already in the home compared
to women with no children yet in the home.

\* Predictors of insufficient activity between pregnancy and 6 months
postpartum included postpartum weight retention, working longer hours
during pregnancy and postpartum, and reporting that child care was a
barrier to physical activity.

The authors conclude that \"walking is popular, practical \-- it can be
most easily worked into the daily routine (e.g., pushing child in
stroller) \-- and efficacious in reducing disease risks. Thus, walking
appears to be a relevant targeted activity for interventions during and
following pregnancy.\"

Pereira MA, Rifas-Shiman SL, Kleinman KP, et al. 2007. Predictors of
change in physical activity during and after pregnancy: Project Viva.

American Journal of Preventive Medicine 32(4):312-319.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17383562>

**Preterm low birth weight and maternal periodontal status: A likely
association**

RESULTS: The literature search revealed 17 articles that met the
inclusion criteria. Seven thousand one hundred fifty-one women
participated in the studies, 1056 of whom delivered a preterm and/or low
birthweight infant. The overall odds ratio was 2.83 (95% CI: 1.95-4.10,
P \< .0001). This pooled value needed to be interpreted cautiously
because there appeared to be a clear trend for the better quality
studies to be of lower association strength.

CONCLUSION: These findings indicate a likely association, but it needs
to be confirmed by large, well-designed, multicenter trials.

Vergnes JN; Sixou M Preterm low birth weight and maternal periodontal
status: a meta-analysis. [Am J Obstet Gynecol.  2007;
196(2):135.e1-7](http://www.medscape.com/medline/publicationbrowser/123?pmid=17306654) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17306654>

**High-Fat Dairy Intake Reduces Risk for Anovulatory Infertility**

CONCLUSIONS High intake of low-fat dairy foods may increase the risk of
anovulatory infertility whereas intake of high-fat dairy foods may
decrease this risk. Further, lactose (the main carbohydrate in milk and
dairy products) may not affect fertility within the usual range of
intake levels in humans.

[Chavarro
JE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Chavarro+JE"%5BAuthor%5D),
et al A prospective study of dairy foods intake and anovulatory
infertility. [Hum
Reprod.](javascript:AL_get(this, 'jour', 'Hum Reprod.');) 2007 Feb 28

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17329264>

**CDC Issues Guidelines for Preconception Care of Women **

The Centers for Disease Control and Prevention have published national
recommendations for improving preconception health and health care in
response to unfavorable aspects of the health status of women and
children in the United States. The publication explains that the
national recommendations are part of a strategic plan for improving
preconception health through the provision of clinical care as well as
the promotion of changes in individual behaviors, health policy, and
public health strategies. The concept of preconception care has been
articulated for well over a decade but has not become part of the
routine practice of family medicine. Because all women of reproductive
age presenting to the primary care setting are candidates for
preconception care, the essential and critical role of family physicians
in the provision of preconception care is apparent. As a specialty, we
are now challenged to devise ways to effectively translate the concept
of preconception care into clinical reality.

[Dunlop
AL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Dunlop+AL"%5BAuthor%5D)
et al National recommendations for preconception care: the essential
role of the family physician. [J Am Board Fam
Med.](javascript:AL_get(this, 'jour', 'J Am Board Fam Med.');) 2007
Jan-Feb;20(1):81-4

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17204739>

**Postterm delivery and short term risk for epilepsy in childhood**

We found no evidence for the association between postterm delivery and
risk for epilepsy beyond the first year of life.

CONCLUSIONS: Prolonged gestation is a risk factor for early epilepsy;
the added increase in risk for instrument-assisted and cesarean
deliveries could be attributable to factors that are related to both
birth complications and epilepsy.

Ehrenstein V et al Postterm delivery and risk for epilepsy in childhood.
[Pediatrics.  2007;
119(3):e554-61](http://www.medscape.com/medline/publicationbrowser/123?pmid=17332175) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17332175>

**Fetal movement counting for assessment of fetal wellbeing**

AUTHORS\' CONCLUSIONS: This review does not provide enough evidence to
influence practice. In particular, no trials compared fetal movement
counting with no fetal movement counting. Robust research is needed in
this area.

Mangesi L; Hofmeyr G Fetal movement counting for assessment of fetal
wellbeing. [Cochrane Database Syst Rev.  2007;
(1):CD004909](http://www.medscape.com/medline/publicationbrowser/123?pmid=17253530)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17253530>

**Management of HSV-2 during pregnancy may enhance mother-to-child HIV-1
prevention**

CONCLUSION: Herpes simplex virus type 2 is the leading cause of genital
ulcers among women in sub-Saharan Africa and was highly prevalent in
this cohort of pregnant women receiving prophylactic zidovudine. After
adjusting for plasma HIV-1 RNA levels, genital ulcers were associated
with increased risk of intrapartum HIV-1 transmission. These data
suggest that management of HSV-2 during pregnancy may enhance
mother-to-child HIV-1 prevention efforts. LEVEL OF EVIDENCE: II

Drake AL et al Herpes simplex virus type 2 and risk of intrapartum human
immunodeficiency virus transmission. [Obstet Gynecol.  2007; 109(2 Pt
1):403-9](http://www.medscape.com/medline/publicationbrowser/123?pmid=17267842) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17267842>

**Eating disorders: Higher risk of miscarriages and significantly lower
birth weight**

RESULTS: The group with bulimia nervosa had significantly higher rates
of past miscarriages (relative risk ratio 2.0, P=0.01) and the group
with anorexia nervosa delivered babies of significantly lower birth
weight than the general population (P=0.01), which was mainly explained
by lower pre-pregnancy body mass index. Preterm delivery rates were
comparable across groups

CONCLUSIONS: Women with a history of eating disorders are at higher risk
of major adverse obstetric outcomes. Antenatal services should be aware
of this higher risk.

Micali N; Simonoff E; Treasure J Risk of major adverse perinatal
outcomes in women with eating disorders. [Br J Psychiatry.  2007;
190:255-9](http://www.medscape.com/medline/publicationbrowser/123?pmid=17329747)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17329747>

**Short courses of antiretroviral drugs effective for reducing
transmission of HIV**

[Authors\' conclusions:]{.underline} Short courses of antiretroviral
drugs are effective for reducing mother-to-child transmission of HIV and
are not associated with any safety concerns in the short-term. A
combination of ZDV and 3TC given to mothers in the antenatal,
intrapartum and postpartum periods and to babies for a week after
delivery or a single dose of NVP given to mothers in labour and babies
immediately after birth may be most effective. Where HIV infected women
present late for delivery, post-exposure prophylaxis with a single dose
of NVP immediately after birth plus ZDV for the first 6 weeks of life is
beneficial. The long term implications of the emergence of resistant
mutations following the use of these regimens require further study

Volmink J et al Antiretrovirals for reducing the risk of mother-to-child
transmission of HIV infection. [Cochrane Database Syst Rev.  2007;
(1):CD003510](http://www.medscape.com/medline/publicationbrowser/123?pmid=17253490)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17253490>

**Reduction in caffeine intake in pregnancy has no effect on birth
weight or gestational age**

RESULTS: After adjustment for length of gestation, parity, prepregnancy
body mass index, and smoking at entry to the study the mean birth weight
of babies born to women in the decaffeinated group was 16 g (95%
confidence interval -40 to 73) higher than those born to women in the
caffeinated group. The adjusted difference (decaffeinated
group-caffeinated group) of length of gestation was -1.31 days (-2.87 to
0.25).

CONCLUSION: A moderate reduction in caffeine intake in the second half
of pregnancy has no effect on birth weight or length of gestation.

Bech BH; Obel C; Henriksen TB; Olsen J Effect of reducing caffeine
intake on birth weight and length of gestation: randomised controlled
trial. [BMJ.  2007;
334(7590):409](http://www.medscape.com/medline/publicationbrowser/123?pmid=17259189) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17259189>

**Immunoglobulin increased the rates of live birth in secondary
recurrent miscarriage**

CONCLUSIONS: IVIG increased the rates of live birth in secondary
recurrent miscarriage, but there was insufficient evidence for its use
in primary recurrent miscarriage.

Hutton B et al Use of intravenous immunoglobulin for treatment of
recurrent miscarriage: a systematic review. [BJOG.  2007;
114(2):134-42](http://www.medscape.com/medline/publicationbrowser/123?pmid=17166218) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17166218>

#### Gynecology {#gynecology .Style-Heading-4-+-Arial-14-pt-Underline}

**Young women with CIN: Any treatment increases the risk of preterm
delivery - LEEP**

CONCLUSION: Any treatment for CIN, including loop electrosurgical
excision procedure, increases the risk of preterm delivery. It is
important to emphasize this when treating young women with CIN. LEVEL OF
EVIDENCE: II.

Jakobsson M et al Preterm delivery after surgical treatment for cervical
intraepithelial neoplasia. [Obstet Gynecol.  2007; 109(2 Pt
1):309-13](http://www.medscape.com/medline/publicationbrowser/123?pmid=17267829) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17267829>

**Women with C. glabrata show higher mycological cure with boric acid**

RESULTS: C. glabrata was isolated in 68 (61.3%) and C. albicans in 32
(28.8%) of 111 subjects. Patients with C. glabrata vulvovaginal
candidiasis.(VVC) showed higher mycological cure with boric acid
compared with fluconazole in the ITT (21 of 33, 63.6% vs. 10 of 35,
28.6%; P = 0.01) and PP analyses (21 of 29, 72.4% vs. 10 of 30, 33.3%; P
= 0.01). The secondary efficacy outcomes were not significantly
different in the two treatment arms in the ITT and PP analyses.
CONCLUSIONS: Diabetic women with C. glabrata VVC show higher mycological
cure with boric acid vaginal suppositories given for 14 days in
comparison with single-dose oral 150-mg fluconazole.

Ray D; Goswami R; Banerjee U; Dadhwal V; Goswami D; Mandal P;
Sreenivas V; Kochupillai NPrevalence of Candida glabrata and its
response to boric acid vaginal suppositories in comparison with oral
fluconazole in patients with diabetes and vulvovaginal
candidiasis.[Diabetes Care.  2007;
30(2):312-7](http://www.medscape.com/medline/publicationbrowser/123?pmid=17259500) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17259500>

**Is Pelvic Organ Prolapse Caused by Vaginal Delivery?**

**Results:** The nulliparous women did not differ from the parous women
in any significant variable. For both groups, the mean age was 60 years
and the mean BMI was 28 kg per m2. Hysterectomy was reported in 27
percent of parous women and in 24 percent of nulliparous women. Ten of
the nulliparous women and 24 of the parous women reported previous
vaginal surgery. The average parity for the parous women was three.

There was no pelvic organ prolapse in 82.2 percent of the nulliparous
women and in 43.6 percent of the parous women. Nevertheless, a
statistically significant familial association was observed. The
concordance in prolapse stage between sisters ranged from 74.3 percent
for the anterior compartment to 91.1 percent for the apical compartment.
In the 25 pairs of sisters with discordant findings, the prolapse was
more advanced in the parous sister in all but three pairs.

Measures of pelvic support showed that at least two thirds of the sister
pairs had similar measurements (within 1 cm) except at the cervix or
vaginal cuff. In the remaining one third of pairs, the parous sister had
greater descent in 80 percent of cases. Statistical analysis showed a
twofold increase in risk of posterior wall prolapse and a threefold
increase in risk of anterior wall prolapse with each vaginal birth.
Other factors, including BMI, were not associated with risk of prolapse.

**Conclusion:** The authors conclude that familial factors are highly
significant in the development of pelvic organ prolapse. Parity appears
to confer a small additional risk of severe prolapse.

Buchsbaum GM, et al. Pelvic organ prolapse in nulliparous women and
their parous sisters. Obstet Gynecol December 2006;108:1388-93.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17138771>

**Chance of woman undergoing a hysterectomy can now be accurately
predicted**

The findings confirm a widely held, but untested, belief in gynecology
that the more symptoms of discomfort a woman has, as well as the longer
she has tried alternative therapies unsuccessfully, the more likely she
is to have a hysterectomy. CONCLUSIONS: For women with common pelvic
problems, three easily measured clinical characteristics (symptom
combination, degree of resolution, and earlier use of a
gonadotropin-releasing hormone agonist) predict the likelihood of
subsequent hysterectomy and can be used to inform counseling about the
likely success of alternative treatments.

[Learman
LA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Learman+LA"%5BAuthor%5D),
et al Predictors of hysterectomy in women with common pelvic problems: a
uterine survival analysis. [J Am Coll
Surg.](javascript:AL_get(this, 'jour', 'J Am Coll Surg.');) 2007
Apr;204(4):633-41

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17382223>

**Insulin-sensitising drugs versus the combined oral contraceptive pill
for PCOS**

CONCLUSIONS: Up to 12-months treatment with the OCP is associated with
an improvement in menstrual pattern and serum androgen levels compared
with metformin; but metformin treatment results in a reduction in
fasting insulin and lower triglyceride levels than with the OCP.
Side-effect profiles differ between the two drugs. There is either
extremely limited or no data on important clinical outcomes such as the
development of diabetes, cardiovascular disease, or endometrial cancer.
There are no data comparing ISDs other than metformin (that is
rosiglitazone, pioglitazone, and D-chiro-inositol) versus OCPs (alone or
in combination).

Costello M; Shrestha B; Eden J; Sjoblom P; Johnson N Insulin-sensitising
drugs versus the combined oral contraceptive pill for hirsutism, acne
and risk of diabetes, cardiovascular disease, and endometrial cancer in
polycystic ovary syndrome. [Cochrane Database Syst
Rev.](javascript:AL_get(this, 'jour', 'Cochrane Database Syst Rev.');)
2007 Jan 24;(1):CD005552

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17253562>

**Anal sphincter gaps on US: Common with sphincter tear and severity of
fecal incontinence**

RESULTS: Thirty-five percent of the sphincter tear group exhibited
internal sphincter gaps compared with 3% of vaginal controls (odds ratio
\[OR\] 18.4, 95% confidence interval \[CI\] 5.5-62.1) and 10% of
cesarean controls. External sphincter gaps were identified in 51% of the
tear group compared with 31% of vaginal controls (OR 2.3, 95% CI
1.3-4.0) and 28% of cesarean controls. In the tear group, fecal
incontinence severity was greater in those with internal sphincter gaps
compared with those with no internal sphincter gaps (Fecal Incontinence
Severity Index score 6.6+/-8.3 compared with 3.3+/-6.1, P=.02), as well
as in those with external sphincter gaps (6.1+/-8.4 compared with
2.7+/-5.0, P=.01), and greatest in those with both internal and external
sphincter gaps compared with at least one gap not present (7.2+/-8.1
compared with 3.4+/-6.4, P=.003). CONCLUSION: Anal sphincter gaps
detected by ultrasonography are prevalent in postpartum primiparous
women with a history of sphincter tear and are associated with fecal
incontinence severity. LEVEL OF EVIDENCE: II-2.

Richter HE et al Endoanal ultrasound findings and fecal incontinence
symptoms in women with and without recognized anal sphincter tears.
[Obstet Gynecol.  2006;
108(6):1394-401](http://www.medscape.com/medline/publicationbrowser/123?pmid=17138772) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17138772>

**Interventions to reduce haemorrhage during myomectomy for fibroids**

AUTHORS\' CONCLUSIONS: There is limited evidence from a few RCTs that
misoprostol, vasopressin, bupivacaine plus epinephrine, tourniquet and
mesna may reduce bleeding during myomectomy. There is no evidence that
oxytocin and morcellation have an effect on intraoperative blood loss.
There is need for adequately powered RCTs to shed more light on the
effectiveness, safety and costs of different interventions in reducing
blood loss during myomectomy.

Kongnyuy E; Wiysonge C Interventions to reduce haemorrhage during
myomectomy for fibroids. [Cochrane Database Syst Rev.  2007;
(1):CD005355](http://www.medscape.com/medline/publicationbrowser/123?pmid=17253552) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17253552>

**Risk of Advanced Cervical Lesions After a Diagnosis of CIN 1 or Less**

**Results:** There were 3,791 participants in the study, and the mean
follow-up period was 26.3 months. Of the women who had CIN 1 or less on
colposcopy, 1.9 percent were subsequently diagnosed with CIN 3 or
cancer. The presence of high-risk HPV on the initial examination was
more likely to be associated with subsequent CIN 3 and cancer. Women who
were 30 years or older were more likely to have subsequent CIN 3 or
cancer than younger women.

When patients were diagnosed with CIN 3 or cancer, 97.8 percent had
high-risk HPV present and 91.3 percent had abnormal cervical cytology.
Women with normal cervical cytology and high-risk HPV were significantly
less likely to be diagnosed with subsequent CIN 3 or cancer than those
with abnormal cervical cytology and high-risk HPV.

**Conclusion:** Annual cytology and HPV testing is appropriate for women
who have been diagnosed with CIN 1 or less. If high-risk HPV is present
and cervical cytology is abnormal, patients should have colposcopy. If
high-risk HPV is present and cervical cytology is normal, patients
should have colposcopy at least every two years. Women with subsequent
normal cytology and a negative high-risk HPV test for two consecutive
years can return to a routine screening schedule.

Pretorius RG, et al. Subsequent risk and presentation of cervical
intraepithelial neoplasia (CIN) 3 or cancer after a colposcopic
diagnosis of CIN 1 or less. Am J Obstet Gynecol November
2006;195:1260-5. <http://www.aafp.org/afp/20070401/tips/15.html>

#### Child Health {#child-health .Style-Heading-4-+-Arial-14-pt-Underline}

**Public Opinion vs. Science Concerning Sex Education**

**Results:** The study population included 1,096 participants with a
mean age of 46.8 years. The race/ethnicity of the respondents was
similar to other nationally representative surveys. The percentage of
individuals supporting a combined abstinence and contraception
educational program was 82 percent. Support for teaching of proper
condom use was about 68 percent. An abstinence-only program was
supported by 36 percent of the respondents and received the highest
level of opposition. Most individuals in each political ideology group
supported abstinence plus contraception programs, with the conservative
group agreeing 70.0 percent of the time, the moderate group 86.4
percent, and the liberal group 91.6 percent.

**Conclusion:** Public opinion supports the combination of abstinence
plus contraception education programs in schools. This support
demonstrates that the scientific community and the public do not support
the federal policy of abstinence-only programs.

Bleakley A, et al. Public opinion on sex education in US schools. Arch
Pediatr Adolesc Med November 2006;160:1151-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17088519>

**Young Native-American Children at Higher Risk of Fatal Accidents**

Despite years of largely successful public campaigns to reduce the
number of deadly childhood accidents, new research suggests those
efforts haven\'t had the desired effect for American Indian/Alaskan
Native children.

Statistics from 2003 show that young black children were 63 percent more
likely to die from an unintentional injury than white children, and
young American Indian and Alaskan Native children were more than two
times more likely to die.

CONCLUSIONS: These findings identify injury areas in which disparities
narrowed, improvement occurred with maintenance or widening of
disparities, and little or no progress was evident. This study further
suggests specific mechanisms whereby new strategies and approaches to
address areas that are recalcitrant to improvement in absolute rates
and/or narrowing of disparities are needed and where increased
dissemination of proven efficacious injury prevention efforts to
high-risk populations are indicated.

[Pressley
JC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Pressley+JC"%5BAuthor%5D),
et al Twenty-year trends in fatal injuries to very young children: the
persistence of racial disparities.
[Pediatrics.](javascript:AL_get(this, 'jour', 'Pediatrics.');) 2007
Apr;119(4):e875-84

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17403830>

**What fluoride varnish are you using? Please respond**

-Duraphat®:
<http://www.colgateprofessional.com/app/cop/jsp/products/productHome.jsp?prodcode=011400100>

(multi-use tube)

-Duraflor®: [http://www.medicom.com/faq.ch2]{.underline} (available in
unit-dose package)

-CavityShield®:
[http://www.omniipharma.com/cavityshield.asp]{.underline} (available in
unit-dose package)

-VarnishAmerica™:
<http://www.medicalproductslaboratories.com/products/varnishamerica/varnishamerica.html>

(available in unit-dose package)

Judith Thierry, Rockville, Maryland <Judith.Thierry@ihs.gov> Voice:
301-443-5070

**New Guidelines Recommend Against Drug Testing of Teens in School,
Home**

The American Academy of Pediatrics continues to believe that adolescents
should not be drug tested without their knowledge and consent. Recent US
Supreme Court decisions and market forces have resulted in
recommendations for drug testing of adolescents at school and products
for parents to use to test adolescents at home. The American Academy of
Pediatrics has strong reservations about testing adolescents at school
or at home and believes that more research is needed on both safety and
efficacy before school-based testing programs are implemented. The
American Academy of Pediatrics also believes that more
adolescent-specific substance abuse treatment resources are needed to
ensure that testing leads to early rehabilitation rather than to
punitive measures only.

[Committee on Substance Abuse, American Academy of
Pediatrics](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Committee+on+Substance+Abuse%2C+American+Academy+of+Pediatrics"%5BCorporate+Author%5D).
Testing for drugs of abuse in children and adolescents:
addendum\--testing in schools and at home.
[Pediatrics.](javascript:AL_get(this, 'jour', 'Pediatrics.');) 2007
Mar;119(3):627-30.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17332219&dopt=Abstract>

**Association between adolescent dieting behaviors and weight gain over
time**

This analysis provides insight into why dieting is associated with
weight gain over time.

Previous research has demonstrated a strong longitudinal association
between dieting behaviors and weight gain in adolescents. However, the
question as to how dieting leads to weight gain remains unanswered. The
article builds on previous analysis from Project EAT, a 5-year
longitudinal study of eating and weight in adolescents, and explores
possible mechanisms for the association between dieting behaviors and
weight gain over time in adolescents.

They found that

\* Among female adolescents, dieting at Time 1 strongly predicted binge
eating and breakfast skipping at Time 2.

\* Among male adolescents, dieting at Time 1 strongly predicted binge
eating and lower levels of physical activity at Time 2.

\* The behaviors most strongly associated with weight gain over time in
female adolescents (i.e., higher levels of binge eating, lower levels of
breakfast consumption, and lower levels of fruit and vegetable intake)
were, in general, the same behaviors most strongly predicted by dieting
in female adolescents.

\* The behaviors most strongly associated with weight gain over time in
male adolescents (i.e., higher levels of binge eating and decreased

MVPA) were the same behaviors most strongly predicted by dieting in male
adolescents.

\* In both female and male adolescents, the association between dieting
and BMI change was weakened, but remained statistically significant,
after the eating and activity behaviors were included in the model. This
finding suggests that there may be other factors contributing to the
association between dieting and weight gain over time.

\"Findings from our study suggest that dieting places adolescents at
risk for unhealthful eating and physical behaviors. Adolescents will
need skills and support to avoid dieting behaviors that may be
counterproductive to their aims for weight management and, instead,
adopt eating and physical activity behaviors that would be effective in
promoting health and preventing excess weight gain over time.

Neumark-Sztainer D, Wall M, Haines J, et al. 2007. Why does dieting
predict weight gain in adolescents? Findings from Project Eat-II: A
5-year longitudinal study. Journal of the American Dietetic Association
107(3):448-455.
[[http://www.adajournal.org/article/PIIS0002822306026800/abstract]{.underline}](http://www.adajournal.org/article/PIIS0002822306026800/abstract)

**Advanced Parental Age Predicts Risk for Autism Spectrum Disorder in
Children**

Advanced maternal and paternal ages are independently linked with risk
for autism spectrum disorder (ASD) in children, according to the results
of a historical birth cohort study

CONCLUSION: Advanced maternal and paternal ages are independently
associated with ASD risk. [Croen
LA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Croen+LA"%5BAuthor%5D),
et al Maternal and paternal age and risk of autism spectrum disorders.
[Arch Pediatr Adolesc
Med.](javascript:AL_get(this, 'jour', 'Arch Pediatr Adolesc Med.');)
2007 Apr;161(4):334-40

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17404129>

**Patient Education Improves Adherence to Antidepressants**

**Conclusion:** The authors conclude that, although physicians commonly
mention the medication\'s name, purpose, and adverse effects when
prescribing an antidepressant, other important information is mentioned
less often. Physicians also tend to provide more information to less
severely depressed patients. The authors conclude that adherence to
antidepressant medications might be improved by developing better
patient education strategies, especially those focusing on anticipated
duration of therapy and the need to wait several weeks before symptom
improvement will be noticeable.

Young HN, et al. Types of information physicians provide when
prescribing antidepressants. J Gen Intern Med November 2006;21:1172-7.

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17026727**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17026727) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17026727 .Style-Heading-4-+-Arial-14-pt-Underline}

**Certain types of severe abdominal injury may signal child abuse in
young children**

<http://www.ahrq.gov/research/mar07/307RA7.htm>

####  {#section-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Chronic disease and Illness {#chronic-disease-and-illness .Style-Heading-4-+-Arial-14-pt-Underline}

**Smoking Ban Has Health Benefits for Workers**

**Conclusion:** The authors conclude that, although the participants had
been bar workers for an average of nine years, health improvements were
apparent just one month after a smoking ban, as measured by objective
and subjective symptoms. The most marked improvements occurred in
participants with asthma. An accompanying editorial notes that mandating
smoke-free workplaces also results in higher rates of smoking cessation.
However, there still is a high rate of exposure to secondhand smoke,
especially among children and non-Hispanic blacks.

Menzies D, et al. Respiratory symptoms, pulmonary function, and markers
of inflammation among bar workers before and after a legislative ban on
smoking in public places. JAMA October 11, 2006;296:1742-8, and Eisner
MD. Banning smoke in public places: time to clear the air \[Editorial\].
JAMA 2006;296:1778-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17032987>

**New Guideline for Screening Mammography for Women 40 to 49 Years of
Age**

-Recommendations encourage women to become part of the decision-making
process

The American College of Physicians (ACP) released a new clinical
practice guideline for screening mammography for women 40 to 49 years of
age

Breast cancer is one of the most common causes of death for women in
their 40s in the United States. Individualized risk assessment plays an
important role when making decisions about screening mammography,
especially for women 49 years of age or younger. The purpose of this
guideline is to present the available evidence for screening mammography
in women 40 to 49 years of age and to increase clinicians\'
understanding of the benefits and risks of screening mammography.\
[Qaseem
A](http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Qaseem+A"%5BAuthor%5D)
et al Screening mammography for women 40 to 49 years of age: a clinical
practice guideline from the American College of Physicians. [Ann Intern
Med.](javascript:AL_get(this, 'jour', 'Ann Intern Med.');) 2007 Apr
3;146(7):511-5.

<http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17404353&dopt=Abstract>

**MRI Detects Breast Cancer Missed by Mammography**

RESULTS: MRI detected clinically and mammographically occult breast
cancer in the contralateral breast in 30 of 969 women who were enrolled
in the study (3.1%). The sensitivity of MRI in the contralateral breast
was 91%, and the specificity was 88%. The negative predictive value of
MRI was 99%. A biopsy was performed on the basis of a positive MRI
finding in 121 of the 969 women (12.5%), 30 of whom had specimens that
were positive for cancer (24.8%); 18 of the 30 specimens were positive
for invasive cancer. The mean diameter of the invasive tumors detected
was 10.9 mm. The additional number of cancers detected was not
influenced by breast density, menopausal status, or the histologic
features of the primary tumor. CONCLUSIONS: MRI can detect cancer in the
contralateral breast that is missed by mammography and clinical
examination at the time of the initial breast-cancer diagnosis.

[Lehman
CD](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Lehman+CD"%5BAuthor%5D),
et al MRI evaluation of the contralateral breast in women with recently
diagnosed breast cancer. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2007 Mar
29;356(13):1295-303

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17392300>

**Low-Dose Aspirin Linked to Lower Risk for All-Cause Mortality in
Women**

CONCLUSIONS: In women, low to moderate doses of aspirin are associated
with significantly lower risk of all-cause mortality, particularly in
older women and those with cardiac risk factors. A significant benefit
is evident within 5 years for cardiovascular disease, whereas a modest
benefit for cancer is not apparent until after 10 years of use

[Chan
AT](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Chan+AT"%5BAuthor%5D),
et al Long-term aspirin use and mortality in women. [Arch Intern
Med.](javascript:AL_get(this, 'jour', 'Arch Intern Med.');) 2007 Mar
26;167(6):562-72

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17389287>

**Intensive Smoking Cessation Intervention Reduces Mortality in
High-Risk Smokers **

CONCLUSION: Hospitalized smokers, especially those with cardiovascular
disease, should undergo treatment with a structured intensive cessation
intervention. The duration of the initial treatment should be 3 months.

[Mohiuddin
SM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Mohiuddin+SM"%5BAuthor%5D),
et al Intensive smoking cessation intervention reduces mortality in
high-risk smokers with cardiovascular disease.
[Chest.](javascript:AL_get(this, 'jour', 'Chest.');) 2007
Feb;131(2):446-52

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17296646>

[**Orlistat Facilitates Weight Loss After a Very Low Energy Diet in
Obese
Patients**](http://mp.medscape.com/cgi-bin1/DM/y/hBKtj0Ou5N60KNb0IHI50Eb)

Orlistat added to lifestyle intervention was linked to an additional 2.4
kg of weight loss after a very low-energy diet in obese patients, and
this loss was maintained for up to 3 years, according to the results of
a 3-year randomized, placebo-controlled study

CONCLUSIONS: The addition of orlistat to lifestyle intervention was
associated with maintenance of an extra 2.4 kg weight loss after VLED
for up to 3 years in obese subjects. The combination of orlistat and
lifestyle intervention was associated with a reduced occurrence of type
2 diabetes.

[Richelsen
B](http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Richelsen+B"%5BAuthor%5D)
et al Effect of orlistat on weight regain and cardiovascular risk
factors following a very-low-energy diet in abdominally obese patients:
a 3-year randomized, placebo-controlled study. [Diabetes
Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');) 2007
Jan;30(1):27-32.

<http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17192328&dopt=Abstract>

**AHA Publishes Guidelines on CVD Prevention in Women**

lifestyle interventions

*Cigarette Smoking.* Counseling women against smoking is recommended, as
is nicotine replacement or another indicated pharmacotherapy combined
with participation in a behavioral or formal smoking cessation program.
Women should also try to avoid secondhand smoke.

*Physical Activity.* Women at risk of CVD should aim for a minimum of 30
minutes of moderate exercise (e.g., brisk walking) on most, and
preferably all, days of the week and 60 to 90 minutes of daily moderate
exercise for those who need to lose weight or sustain weight loss.

*Weight Maintenance.* To maintain or lose weight, it is recommended that
women find an appropriate balance of physical activity and caloric
intake. Body mass index should be between 18.5 and 24.9 kg per m2, and
waist circumference should not exceed 35 inches.

*Dietary Intake.* A high intake of fruits and vegetables is recommended
for women at risk. Selecting whole-grain, high-fiber foods and consuming
oily fish at least twice a week is recommended. Dietary cholesterol
should be less than 300 mg per day, and saturated fat should make up no
more than 7 to 10 percent of the diet; women at risk of
hypercholesterolemia should have diets with less than 7 percent
saturated fat and less than 200 mg of cholesterol each day.

In conjunction with diet, omega-3 fatty acids in capsule form may be
considered for women with coronary heart disease (CHD).

*Rehabilitation.* Women who have had a recent cerebrovascular event;
acute coronary syndrome or coronary intervention; peripheral arterial
disease; new-onset or chronic angina; or symptoms of heart failure
should be offered a comprehensive risk-reduction regimen (e.g.,
physician-guided community- or home-based exercise training program,
cardiovascular or stroke rehabilitation).

*Depression.* Screening for depression in women with CHD should be
considered.

<http://www.aafp.org/afp/20070401/practice.html#p2> (Scroll down to
find)

**Intensive Smoking Cessation Intervention Reduces Mortality in
High-Risk Smokers **

CONCLUSION: Hospitalized smokers, especially those with cardiovascular
disease, should undergo treatment with a structured intensive cessation
intervention. The duration of the initial treatment should be 3 months.

[Mohiuddin
SM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Mohiuddin+SM"%5BAuthor%5D),
et al Intensive smoking cessation intervention reduces mortality in
high-risk smokers with cardiovascular disease.
[Chest.](javascript:AL_get(this, 'jour', 'Chest.');) 2007
Feb;131(2):446-52

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17296646>

**Are Opioids Effective in the Treatment of Neuropathic Pain?**

**Clinical Scenario**

A 70-year-old woman with poorly controlled type 2 diabetes presents with
burning, bilateral pain in her legs that is worsening; she requests
medication to relieve her symptoms.

**Clinical Question**

Are opioids safe and effective for the treatment of neuropathic pain?

**Evidence-Based Answer**

Eight to 60 days of opioid therapy for the treatment of neuropathic pain
effectively reduces pain scores as measured by a visual analog scale. A
lack of response to opioids in the first 24 hours should not be used to
predict whether longer-term opioid therapy might be beneficial. There
are no controlled clinical trials that include patients receiving
opioids for more than 70 days. Adverse effects (e.g., nausea, vomiting,
constipation, drowsiness, dizziness) are common. Tolerance and addiction
were not addressed in this Cochrane review.

Cochrane for Clinicians: Putting Evidence into Practice

Eisenberg E, McNicol E, Carr DB Opioids for neuropathic pain The
Cochrane Database of Systematic Reviews 2007 Issue 1

<http://www.cochrane.org/reviews/en/ab006146.html>

###### Peppermint leaf and peppermint oil: Use for digestive disorders

Peppermint leaf and peppermint oil have a long history of use for
digestive disorders. Recent evidence suggests that enteric-coated
peppermint oil may be effective in relieving some of the symptoms of
irritable bowel syndrome. A combination product including peppermint oil
and caraway oil seems to be moderately effective in the treatment of
non-ulcer dyspepsia. Topical application of peppermint oil may be
effective in the treatment of tension headache. Because of its relaxing
effects on smooth muscle, peppermint oil given via enema has been
modestly effective for relief of colonic spasm in patients undergoing
barium enemas. Peppermint oil is well tolerated at the commonly
recommended dosage, but it may cause significant adverse effects at
higher dosages. Am Fam Physician 2007;75:1027-30.

<http://www.aafp.org/afp/20070401/1027.html>

**Outpatient Management of Anticoagulation Therapy**

The Seventh American College of Chest Physicians (ACCP) Conference on
Antithrombotic and Thrombolytic Therapy provides guidelines for
outpatient management of anticoagulation therapy. The ACCP guidelines
recommend short-term warfarin therapy, with the goal of maintaining an
International Normalized Ratio (INR) of 2.5 ± 0.5, after major
orthopedic surgery. Therapy for venous thromboembolism includes an INR
of 2.5 ± 0.5, with the length of therapy determined by associated
conditions. For patients with atrial fibrillation, the INR is maintained
at 2.5 ± 0.5 indefinitely; for most patients with mechanical valves, the
recommended INR is 3.0 ± 0.5 indefinitely. Use of outpatient
low-molecular-weight heparin (LMWH) is as safe and effective as
inpatient unfractionated heparin for treatment of venous
thromboembolism. The ACCP recommends starting warfarin with
unfractionated heparin or LMWH for at least five days and continuing
until a therapeutic INR is achieved. Because patients with venous
thromboembolism and cancer who have been treated with LMWH have a
survival advantage that extends beyond their venous thromboembolism
treatment, the ACCP recommends beginning their therapy with three to six
months of LMWH. When invasive procedures require the interruption of
oral anticoagulation therapy, recommendations for bridge therapy are
determined by balancing the risk of bleeding against the risk of
thromboembolism. Patients at higher risk of thromboembolization should
stop warfarin therapy four to five days before surgery and start LMWH or
unfractionated heparin two to three days before surgery. Am Fam
Physician 2007;75:1031-42. <http://www.aafp.org/afp/20070401/1031.html>

# Features {#features .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

#### ACOG, American College of Obstetricians and Gynecologists {#acog-american-college-of-obstetricians-and-gynecologists .Style-Heading-4-+-Arial-14-pt-Underline}

**Premature Rupture of Membranes**

Practice Bulletin**,** NUMBER 80, APRIL 2007

**Summary of Recommendations and Conclusions**

The following recommendations and conclusions are based on good and
consistent scientific evidence (Level A):

-   For women with PROM at term, labor should be induced at the time of
    presentation, generally with oxytocin infusion, to reduce the risk
    chorioamni-onitis.

-   Patients with PROM before 32 weeks of gestation should be cared for
    expectantly until 33 completed weeks of gestation if no maternal or
    fetal contraindications exist.

-   A 48-hour course of intravenous ampicillin and erythromycin followed
    by 5 days of amoxicillin and erythromycin is recommended during
    expectant management of preterm PROM remote from term to prolong
    pregnancy and to reduce infectious and gestational age--dependent
    neonatal morbidity.

-   All women with PROM and a viable fetus, including those known to be
    carriers of group B streptococci and those who give birth before
    carrier status can be delineated, should receive intrapartum
    chemo-prophylaxis to prevent vertical transmission of group B
    streptococci regardless of earlier treatments.

-   A single course of antenatal corticosteroids should be administered
    to women with PROM before 32 weeks of gestation to reduce the risks
    of RDS, perinatal mortality, and other morbidities.

The following recommendations and conclusions are based on limited and
inconsistent scientific evidence (Level B):

-   Delivery is recommended when PROM occurs at or beyond 34 weeks of
    gestation.

-   With PROM at 32--33 completed weeks of gestation, labor induction
    may be considered if fetal pulmonary maturity has been documented.

-   Digital cervical examinations should be avoided in patients with
    PROM unless they are in active labor or imminent delivery is
    anticipated.

The following recommendations and conclusions are based primarily on
consensus and expert opinion (Level C):

-   A specific recommendation for or against tocolysis administration
    cannot be made.

-   The efficacy of corticosteroid use at 32--33 completed weeks is
    unclear based on available evidence, but treatment may be beneficial
    particularly if pulmonary immaturity is documented.

-   For a woman with preterm PROM and a viable fetus, the safety of
    expectant management at home has not been established.

Premature Rupture of Membranes. ACOG Practice Bulletin No. 80. American
College of Obstetricians and Gynecologists. Obstet Gynecol
2007;109:1007--19.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17400872>

**Patient Testing: Ethical Issues in Selection and Counseling**

ABSTRACT: Recommendations to patients about testing should be based on
current medical knowledge, a concern for the patient's best interests,
and mutual consultation. In addition to establishing a diagnosis,
testing provides opportunities to educate, inform, and advise. The
ethical principles of respect for autonomy (patient choice) and
beneficence (concern for the patient's best interests) should guide the
testing, counseling, and reporting process. Clear and ample
communication fosters trust, facilitates access to services, and
improves the quality of medical care.

Patient Testing: Ethical Issues in Selection and Counseling. ACOG
Committee Opinion No. 363. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2007;109:1021--3.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17400873>

## AFP, American Family Physician\*\* {#afp-american-family-physician .Style-Heading-2-+-14-pt}

Prevention and Management of Postpartum Hemorrhage

Postpartum hemorrhage, the loss of more than 500 mL of blood after
delivery, occurs in up to 18 percent of births and is the most common
maternal morbidity in developed countries. Although risk factors and
preventive strategies are clearly documented, not all cases are expected
or avoidable. Uterine atony is responsible for most cases and can be
managed with uterine massage in conjunction with oxytocin,
prostaglandins, and ergot alkaloids. Retained placenta is a less common
cause and requires examination of the placenta, exploration of the
uterine cavity, and manual removal of retained tissue. Rarely, an
invasive placenta causes postpartum hemorrhage and may require surgical
management. Traumatic causes include lacerations, uterine rupture, and
uterine inversion. Coagulopathies require clotting factor replacement
for the identified deficiency. Early recognition, systematic evaluation
and treatment, and prompt fluid resuscitation minimize the potentially
serious outcomes associated with postpartum hemorrhage. Am Fam Physician
2007;75:875-82.

[**http://www.aafp.org/afp/20070315/875.html**](http://www.aafp.org/afp/20070315/875.html)

**ACOG Releases Guidelines on Antibiotic Prophylaxis for Gynecologic
Procedures**

Although aseptic surgical techniques have dramatically reduced the
incidence of surgical site infections, these infections remain the most
common surgical complication, affecting up to 5 percent of postoperative
patients. Selective use of antibiotics is effective for infection
prophylaxis, but this benefit must be weighed against the risk for
selection of antibiotic-resistant bacteria. The American College of
Obstetricians and Gynecologists (ACOG) reviewed the evidence for
appropriate antibiotic prophylaxis in women undergoing gynecologic
procedures.

Microorganisms from the patient\'s skin or vagina are the pathogenic
source in most surgical site infections. These organisms are usually
aerobic gram-positive cocci (e.g., staphylococci) but also may include
fecal flora (e.g., anaerobic bacteria, gram-negative anaerobes) when
incisions are made near the perineum or groin. Only a narrow window of
antimicrobial effectiveness is available, requiring that antibiotics be
administered shortly before or at the time of bacterial inoculation
(i.e., when the incision is made, the vagina is entered, or the pedicles
are clamped). A delay of only three hours can result in ineffective
prophylaxis. Data indicate that for lengthy procedures, administering
additional intraoperative doses of an antibiotic can maintain adequate
levels throughout the surgery. An additional dose also may be
appropriate in patients who have lost more than 1,500 mL of blood.

Laparotomies and laparoscopies do not breach surfaces colonized with
vaginal bacteria, and infections after these procedures more often
result from contamination with skin bacteria. Hysterosalpingography,
sonohysterography, intrauterine device (IUD) insertion, endometrial
biopsy, and dilation and curettage may introduce endocervical and upper
vaginal bacteria into the endometrium and fallopian tubes. Physicians
should consider the polymicrobial nature of these infections when
choosing a treatment for endometritis or pelvic inflammatory disease.

Hysterectomy

Women undergoing abdominal or vaginal hysterectomy should receive a
single dose of antibiotics. Most studies show no particular regimen to
be superior to any other. Antibiotic prophylaxis is a reasonable option
in women undergoing laparoscopically assisted hysterectomy, although no
evidence is available to support this use. Bacterial vaginosis is a risk
factor for surgical site infection after hysterectomy. Treatment of
bacterial vaginosis with metronidazole (Flagyl) for at least four days,
beginning just before surgery, significantly reduces vaginal cuff
infection in patients with abnormal flora.

IUD Insertion and Endometrial Biopsy

Most of the risk of IUD-related infection occurs in the first few weeks
to months after insertion, which suggests that contamination of the
endometrial cavity during the procedure is the infecting mechanism.
However, four randomized clinical trials found that pelvic inflammatory
disease is uncommon after IUD insertion regardless of whether antibiotic
prophylaxis is used.

A Cochrane review found that administration of doxycycline (Vibramycin)
or azithromycin (Zithromax) before IUD insertion confers little benefit.
ACOG concludes that prophylactic antibiotic use provides no benefit in
women with negative screening results for gonorrhea and chlamydia before
IUD insertion.

No data are available on infectious complications of endometrial biopsy.
However, the incidence of such complications is thought to be
negligible, and ACOG recommends that this procedure be performed without
the use of antibiotic prophylaxis.

Laparoscopy and Laparotomy

No data are available to recommend antibiotic prophylaxis in women
undergoing abdominal surgery that does not involve vaginal or intestinal
procedures. Antibiotic prophylaxis is not indicated for diagnostic
laparoscopy.

Hysterosalpingography, Sonohysterography, and Hysteroscopy

Postoperative pelvic inflammatory disease is an uncommon but potentially
serious complication in patients undergoing hysterosalpingography.
Patients with dilated fallopian tubes at the time of the procedure are
at greater risk than women with nondilated tubes. Antibiotic prophylaxis
is not recommended for patients with no history of pelvic infection. If
the procedure demonstrates dilated fallopian tubes, 100 mg of
doxycycline may be given twice daily for five days. In women with a
history of pelvic infection, doxycycline can be administered before the
procedure and continued if dilated fallopian tubes are found.

No data are available on which to base recommendations for women
undergoing sonohysterography, but reported rates of postprocedure
infection are low. The risks of sonohysterography probably are similar
to those of hysterosalpingography, and the same considerations should be
taken into account.

Infectious complications after hysteroscopic surgery are uncommon (0.18
to 1.5 percent of patients). A prospective study evaluating the
effectiveness of amoxicillin/clavulanate (Augmentin) in preventing
bacteremia associated with the procedure found no significant difference
in postoperative infection between treated patients and the placebo
group. Therefore, ACOG does not recommend routine antibiotic prophylaxis
in women undergoing this procedure.

Surgical Abortion

A meta-analysis of 11 placebo-controlled, blinded clinical trials found
that women who were given periabortal antibiotics had a 42 percent
overall decreased risk of infection. ACOG concludes that antibiotic
prophylaxis is effective in women undergoing surgical abortion,
regardless of risk. The optimal antibiotic and dosing regimens are
unclear.

Preoperative Bowel Preparation

Appropriate prophylaxis for women undergoing surgery that may involve
the bowel includes a mechanical bowel preparation without oral
antibiotics and the use of a broad-spectrum parenteral antibiotic
administered immediately before surgery.

Antibiotic prophylaxis for gynecologic procedures. ACOG Practice
Bulletin No. 74. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2006:108:225--34.

<http://www.aafp.org/afp/20070401/practice.html#p1>

**Estimating 10-Year Mortality Risk**

**Clinical Question**

What is a patient\'s risk of dying from vascular disease, cancer,
infection, an accident, or any cause within the next 10 years?

**Evidence Summary**

Accurate estimates of patient risk or prognosis can be helpful to a
primary care physician. For example, patients may resist participation
in a screening program because they underestimate their risk. Also,
women may overestimate their risk of breast cancer1 and downplay other
important health risks. Comparing the risk of cancer or heart disease
between smokers and nonsmokers can be useful when counseling patients
about smoking cessation.

Research has shown that information about risk can be clearly
communicated to patients using absolute numbers and frequencies (e.g.,
12 in 1,000 patients), whereas percentages, probabilities, and
likelihood ratios should be avoided.2 A group of researchers has
developed a set of charts to help physicians communicate the 10-year
mortality risk from vascular disease, cancer, infection, an accident,
and any cause.3 The charts are separated based on sex and smoking
status. Mortality rates were calculated using data from the 1998
National Center for Health Statistics Multiple Cause of Death Public

**Applying the Evidence**

A 60-year-old female smoker is extremely worried about her risk of
breast cancer because two of her friends have been diagnosed with the
disease in the past 10 years. She has no risk factors for breast cancer,
but she has asked you to refer her for breast magnetic resonance imaging
(she read that this was the latest and most accurate screening test).
What is the best way to convince her that smoking cessation to prevent
lung cancer would be more beneficial to her than breast cancer
screening?

***Answer:*** You determine that her risk of dying from breast cancer in
the next 10 years is seven in 1,000. However, her risk of dying from
lung cancer in that same period is 65 in 1,000, compared with five in
1,000 if she were a never smoker. Similarly, her risk of dying from
heart disease or stroke in the next 10 years is 61 in 1,000, compared
with 18 in 1,000 if she were a never smoker. Her overall risk of dying
in the next 10 years is nearly twice as high as it would be if she were
a never smoker (199 versus 105 in 1,000). The risk for smokers who quit
is presumably somewhere between that for current and never smokers.

<http://www.aafp.org/afp/20070315/poc.html>

**Infertility (see also Patient Education)**

Infertility is defined as failure to achieve pregnancy during one year
of frequent, unprotected intercourse. Evaluation generally begins after
12 months, but it can be initiated earlier if infertility is suspected
based on history or if the female partner is older than 35 years. Major
causes of infertility include male factors, ovarian dysfunction, tubal
disease, endometriosis, and uterine or cervical factors. A careful
history and physical examination of each partner can suggest a single or
multifactorial etiology and can direct further investigation. Ovulation
can be documented with a home urinary luteinizing hormone kit.
Hysterosalpingography and pelvic ultrasonography can be used to screen
for uterine and fallopian tube disease. Hysteroscopy and/or laparoscopy
can be used if no abnormalities are found on initial screening. Women
older than 35 years also may benefit from ovarian reserve testing of
follicle-stimulating hormone and estradiol levels on day 3 of the
menstrual cycle, the clomiphene citrate challenge test, or pelvic
ultrasonography for antral follicle count to determine treatment options
and the likelihood of success. Options for the treatment of male factor
infertility include gonadotropin therapy, intrauterine insemination, or
in vitro fertilization. Infertility attributed to ovulatory dysfunction
often can be treated with oral ovulation-inducing agents in a primary
care setting. Women with poor ovarian reserve have more success with
oocyte donation. In certain cases, tubal disease may be treatable by
surgical repair or by in vitro fertilization. Infertility attributed to
endometriosis may be amenable to surgery, induction of ovulation with
intrauterine insemination, or in vitro fertilization. Unexplained
infertility may be managed with ovulation induction, intrauterine
insemination, or both. The overall likelihood of successful pregnancy
with treatment is nearly 50 percent. (Am Fam Physician 2007;75:849-56,
857-8.

<http://www.aafp.org/afp/20070315/849.html>

ACOG Releases Opinion on Inducing Labor for VBAC

There is a continued debate regarding whether the induction of labor
with or without prostaglandins increases the risk of uterine rupture
during labor. For this reason, a committee of the American College of
Obstetricians and Gynecologists (ACOG) has released an updated opinion
on inducing labor for vaginal birth after cesarean delivery (VBAC). The
statement was published in the August 2006 issue of *Obstetrics &
Gynecology*.

Several studies have shown an increased risk of uterine rupture after
induction of labor in women who have had a previous cesarean delivery.
One population-based retrospective cohort study of more than 20,000
women who had a previous cesarean delivery found that the rate of
uterine rupture was 0.16 percent in those who had another cesarean
delivery, 0.52 percent in those who had spontaneous labor, 0.77 percent
in those with induction of labor without prostaglandins, and 2.4 percent
in those with induction of labor with prostaglandins. Two larger trials
of women with previous cesarean delivery found that uterine rupture was
more likely to occur when labor was augmented or induced. Several
studies also found that the uterine rupture rate was significantly lower
in women who had successful trials of labor compared with those who had
failed trials of labor (0.01 percent and 2.0 to 2.3 percent,
respectively).

A review of these studies indicates that rates of uterine rupture are
increased when labor is induced and prostaglandins and oxytocin
(Pitocin) are used. However, the most consistently increased rates of
uterine rupture occur in failed trials of labor. Labor induction is a
reasonable option, and it may be necessary in patients with VBAC. By
choosing women who are most likely to give birth vaginally and avoiding
the repeated use of prostaglandins and oxytocin, risk of uterine rupture
can be reduced. Still, the risk of uterine rupture should be discussed
with the patient and documented in the medical record.

Induction of labor for vaginal birth after cesarean delivery. ACOG
Committee Opinion No. 342. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2006;108:465--67.

<http://www.aafp.org/afp/20070315/practice.html>

ACOG Releases Guideline for Management of Postpartum Hemorrhage

Postpartum hemorrhage is responsible for almost 140,000 deaths per year
worldwide and can cause serious morbidity. It can occur without warning;
therefore, all physicians should be prepared to manage it properly. The
American College of Obstetricians and Gynecologists (ACOG) has reviewed
the risks associated with postpartum hemorrhage and released
recommendations on its management. The full guideline was published in
the October 2006 issue of *Obstetrics & Gynecology*.

The most common cause of hemorrhage is uterine atony. If a patient has
excessive bleeding following delivery, the bladder should be emptied and
a pelvic examination performed. Massage or compression of the uterine
corpus can help slow bleeding and remove blood and clots. If the patient
continues to hemorrhage, other causes should be explored (e.g.,
lacerations, genital tract hematomas, retained placenta, coagulopathy).
Baseline studies, including complete blood count with platelets,
prothrombin time, activated partial thromboplastin time, fibrinogen, and
a type and cross order, should be ordered and repeated if clinically
necessary.

First-line treatment of postpartum hemorrhage includes the
administration of uterotonics. If these agents fail to stop contractions
and bleeding, a tamponade can be effective. If the tamponade does not
provide an adequate response, physicians should perform an exploratory
laparotomy (a midline vertical incision to the abdomen is preferred
because it provides the best possible exposure). There are several
methods for controlling continued bleeding, including uterine curettage,
uterine artery ligation, B-Lynch suture, hypogastric artery ligation,
rupture repair, and hysterectomy.

Placenta accreta is one of the most common reasons for postpartum
hysterectomy. Risk factors include placenta previa (with or without
previous uterine surgery), previous myomectomy or cesarean delivery,
Asherman\'s syndrome, submucous leiomyomata, and age older than 35
years. The presence of any of these risk factors should create a
suspicion of placenta accreta, and the physician should take the
appropriate precautionary steps, such as patient counseling, making
blood products and clotting factors available, considering the use of
cell saver technology, scheduling delivery when and where there is
access to surgical personnel and tools, and assessing preoperative
anesthesia.

Arterial embolization may be an option in patients with stable vital
signs who have persistent bleeding. It can be performed to help stop
bleeding after hysterectomy or as an alternative to a hysterectomy. If
vital signs are unstable and the blood loss is significant, transfusion
may be necessary. Surgical repair is required if a hemorrhage is caused
by a ruptured or inverted uterus; the surgical method should be adapted
to each individual patient, if possible. No matter what the cause,
replacement of red cells in patients with postpartum hemorrhage is key.

Postpartum hemorrhage. ACOG Practice Bulletin No. 76. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1039--47.

<http://www.aafp.org/afp/20070401/practice.html#p3>

**Disaster-Related Physical and Mental Health: A Role for the Primary
Care Provider**

Natural disasters, technologic disasters, and mass violence impact
millions of persons each year. The use of primary health care services
typically increases for 12 or more months following major disasters. A
conceptual framework for assisting disaster victims involves
understanding the individual and environmental risk factors that
influence post-disaster physical and mental health. Victims of disaster
will typically present to family physicians with acute physical health
problems such as gastroenteritis or viral syndromes. Chronic problems
often require medications and ongoing primary care. Some victims may be
at risk of acute or chronic mental health problems such as
post-traumatic stress disorder, depression, or alcohol abuse. Risk
factors for post-disaster mental health problems include previous mental
health problems and high levels of exposure to disaster-related stresses
(e.g., fear of death or serious injury, exposure to serious injury or
death, separation from family, prolonged displacement). An action plan
should involve adequate preparation for a disaster. Family physicians
should educate themselves about disaster-related physical and mental
health threats; cooperate with local and national organizations; and
make sure clinics and offices are adequately supplied with medications
and suture and casting material as appropriate. Physicians also should
plan for the care and safety of their own families. Am Fam Physician
2007;75:841-6.

<http://www.aafp.org/afp/20070315/841.html>

#### AHRQ, Agency for Healthcare Research and Quality  {#ahrq-agency-for-healthcare-research-and-quality .Style-Heading-4-+-Arial-14-pt-Underline}

**AHRQ and the Ad Council encourage patients to ask questions and get
more involved with their health care**

<http://www.ahrq.gov/research/mar07/307RA1.htm>

**Specific primary care office systems and quality improvement
strategies may substantially affect the cost of diabetes care**

<http://www.ahrq.gov/research/mar07/307RA15.htm>

#### Ask a Librarian Diane Cooper, M.S.L.S. / NIH {#ask-a-librarian-diane-cooper-m.s.l.s.-nih .Style-Heading-4-+-Arial-14-pt-Underline}

**Quick Check for Drugs and Lactation**

When you need to know if a drug you prescribe is safe for breastfeeding
mothers, here is a new and easy to use database to check.

LactMed is a peer-reviewed database of drugs to which breastfeeding
mothers may be exposed. LactMed is part of the National Library of
Medicine's Toxicology Data Network (TOXNET) and contains over 450 drug
records. Data include information on the levels of drugs in the breast
milk and infant blood, and possible adverse effects on the nursing
infant. There are suggested alternatives to those drugs when available.
All data are derived from the scientific literature and fully
referenced.

LactMed can be accessed using the Health Services Research Library
website at
[http://hsrl.nihlibrary.nih.gov](http://hsrl.nihlibrary.nih.gov/)

-Find PubMed in the left panel and click.

-Once you are in PubMed, click on TOXNET located on their left panel.

-Next, select LactMed from the list. In the search box, enter the drug
you are interested in.

**Sample Record for Prozac (abbreviated for space)**

DRUG LEVELS AND EFFECTS:

SUMMARY OF USE DURING LACTATION:

The average amount of drug in breastmilk is higher with fluoxetine than

with most other SSRIs and the active metabolite, norfluoxetine, is

detectable in the serum of most breastfed infants during the first 2

months postpartum and a few thereafter.......

DRUG LEVELS:

Fluoxetine is metabolized to norfluoxetine which has antidepressant

activity that is considered to be equal to fluoxetine. In a pooled
analysis of serum levels from published studies and 1unpublished case,
the authors found that 20 mothers taking an averagedaily dosage of 28 mg
(range 10 to 80 mg) had an average milk fluoxetine

level of 76 mcg/L (range 23 to 189 mcg/L)........

EFFECTS IN BREASTFED INFANTS:

Colic, decreased sleep, vomiting and watery stools occurred in a
6-day-old

breastfed infant probably caused by maternal fluoxetine.......

POSSIBLE EFFECTS ON LACTATION:

Fluoxetine has caused increased prolactin levels and galactorrhea in

nonpregnant, nonnursing patients. The clinical relevance of

these findings in nursing mothers is not known. .......

AAP CATEGORY (comment from the American Academy of Pediatrics)

Effect on nursing infant is unknown but may be of concern.

ALTERNATE DRUGS TO CONSIDER:

Nortriptyline

**REFERENCES:**

1\. Weissman AM, Levy BT, Hartz AJ et al. Pooled analysis of
antidepressant levels in lactating mothers, breast milk, and nursing
infants. Am J Psychiatry. 2004;161:1066-9.

2\. Kristensen JH, Ilett KF, Hackett LP et al. Distribution and
excretion of fluoxetine and norfluoxetine in human milk. Br J Clin
Pharmacol. 1999;48:521-7

##### 

LactMed can be accessed using the Health Services Research Library
website at
[http://hsrl.nihlibrary.nih.gov](http://hsrl.nihlibrary.nih.gov/)

#### Breastfeeding Suzan Murphy, PIMC {#breastfeeding-suzan-murphy-pimc .Style-Heading-4-+-Arial-14-pt-Underline}

**Breastfeeding - it's all about synergy**

Research has found that adults who breastfed as infants appear to have
less risk of type 2 diabetes. Now there is evidence that breastfeeding
can also reduce maternal risk. In November 2005, JAMA published,
Duration of Lactation and Incidence of Type 2 Diabetes, by Stuebe et al.
The studies described in this article associated longer duration of
breastfeeding with reduced incidence of type 2 diabetes for mothers.

Stuebe et al examined 2 Nurses's Health Studies (NHS and NHS II) to
determine the impact of feeding choice upon subsequent maternal risk of
diabetes. In 1976, NHS began by enrolling 121,700 women (30-55 years
old) from 11 states. In 1989, NHS II began with 116, 671 women (25-42
years old) from 14 states. In each group, participants completed
similar, detailed baseline questionnaires. Every 2 years, participants
completed follow-up questionnaires about medical diagnosis and related
topics like pregnancy history, breastfeeding history, diet, exercise,
medication, and smoking.

Until 1997, the standards used to confirm reported diagnosis of type 2
diabetes were the National Diabetes Data Group criteria. After 1997, the
standards were updated as the American Diabetes Association clinical
practice recommendations were implemented.

In each study, the covariates were family history of diabetes, activity
level, diet, multi-vitamin use, smoking history, and BMI at 18 years and
for each biannual reporting period.

Results:

-   In general, for each year of breastfeeding for women with births 15
    years prior, there was a decrease in risk of diabetes of 15% (NHS)
    and 14% (NHS II).

-   Both cohorts consistently indicated a reduction in the incidence of
    type 2 diabetes with each year of breastfeeding. Controlling for
    diet, exercise, smoking, and multi-vitamin use did not significantly
    change the association of breastfeeding reducing risk.

-   Maternal BMI did not appear significantly altered by lactation,
    suggesting that the reduced maternal risk for diabetes is related to
    improved maternal glucose homeostasis.

-   Exclusivity was associated with greater benefit. After controlling
    for age and parity, the NHS II cohort data showed that each year of
    lifetime exclusive breastfeeding was associated with a 37% type 2
    diabetes risk reduction compared to 24% for each year of any
    breastfeeding.

-   Longer continuous breastfeeding appeared to have greater risk
    reduction benefit than the same amount of lifetime breastfeeding
    shared by 2 or more children. To clarify, 1 year of continuous
    breastfeeding with one child was associated with greater risk
    reduction when compared to two children breastfed for 6 months each.

-   In NHS II, higher BMI at age 18 was linked with shorter
    breastfeeding duration. In both cohorts, the duration of
    breastfeeding was inversely related to family history of diabetes.
    Gestational diabetes did not appear to impact duration.

-   For women with a history of gestational diabetes (NHS II only), the
    covariates of lactation history, present activity level and diet did
    not appear to effect diabetes risk. The consistent predictors of
    diabetes risk were BMI at age 18, current BMI and family history of
    diabetes.

-   For women who did not breastfeed, the use of medication to suppress
    lactation was associated with increased risk of diabetes compared to
    those women who did not receive lactation suppression medication.

For more information, please see the article. Stuebe, et al. Duration of
Lactation and Incidence of Type 2 Diabetes. JAMA, November 2005;
294:(20):2601-10.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16304074>

**Editorial Comment: Suzan Murphy**

The questions and answers noted in my April CCC Corner Breastfeeding
column are short phone call answers to sometimes complex issues.

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0407_Feat.cfm#breast>

For more in-depth information, please consider the following:

Regarding alcohol:

-   When moms plan for a 12 oz of beer with pizza next weekend or a
    standard mixed drink or 5 oz of wine at the annual office party, the
    "2 hours for every drink" has clinical support.

-   Often moms will choose to not drink alcohol rather than worry about
    timing feedings.

-   Choosing to drink non-alcoholic beverages is the safest choice, for
    breastfeeding and driving home. Alcohol goes into the breast milk
    and until is metabolized out, safe levels have not been determined.
    Drinking extra water, more coffee, or pumping have not been shown to
    make the breast milk have less alcohol, like the rest of the body,
    the milk glands have to wait for the liver to do its job.

```{=html}
<!-- -->
```
-   Sometimes moms ask or call after drinking alcohol and need to know
    when it is safe to resume breastfeeding -- it helps to "do the math"
    with moms -- count the drinks, review portion size, multiple by 2
    hours, - also consider when the last drink was.

-   If the moms describe risky drinking patterns (defined by ACOG as
    more than 7 drinks per week or more than 3 drinks at a time) --
    consider using this opportunity to ask more questions, offer
    resources and information, and provide pathways for moms and
    families to healthier lives. ACOG link below

-   Sometimes it is hard to find behaviors to praise with those who have
    risky or serious drinking issues. For those moms who are seeking
    sobriety and choose to use formula to keep their baby safe, it can
    be a difficult and painful choice. It may help them to acknowledge
    the wisdom of their decision.

Regarding tobacco, chewed or smoked:

-   Mom/families often call about using (legal) tobacco. They ask if
    they should stop breastfeeding if they smoke or chew.

-   Exposure to the baby can be from the mom smoking or smoking/chewing
    and breastfeeding, from 2nd hand smoke, or 2nd hand to mother and
    then to the baby by way of environmental exposure or breast milk.
    The tobacco by products that appear in breast milk and infant's
    urine are cotinine and nicotine. Cotinine and nicotine are
    associated with SIDS and colic. There are no known safe levels. In
    one study, the urinary cotinine levels were higher babies breastfed
    by smoking moms than babies formula fed by smoking moms. (Becker AB
    et al1999)

-   However, study results vary. A recent study reported that babies
    breastfed by mothers who smoked had lower cotinine and nicotine
    urine levels than babies whose mothers smoked, but were formula fed.
    (Bajanowski T et al 2007)

-   Regarding nicotine patches for smoking cessation: A recent study
    found use of nicotine patches to be safer option than continued
    smoking. When mothers were smoking almost 1 ppd, the nicotine and
    cotinine levels their breast milk were similar to those mothers
    using the 21-mg/day patch. But when the patch strength was tapered
    to 14-mg and 7--mg, the nicotine and cotinine concentrations
    decreased significantly. There was also no significant influence on
    the milk supply when the patch was used. (Ilett KF et al 2003)

-   When a family does not use tobacco, it greatly reduces the risk of
    exposing new life to known problem agents. There is more to be
    learned. Currently, the American Academy of Pediatrics (AAP) states
    that the benefits of breastfeeding are greater than known risks of
    tobacco by products in breast milk.

**Follow-up from Judy Thierry on a similar topic**

I wanted to share key points from the following excerpts on a NOMOGRAM
from Alcohol and Breast Feeding: Calculation of Time to Zero Level in
Milk. Biol Neonate 2001;80:219-222

Objective: To create a nomogram that will guide lactating women who
drink socially on how to avoid neonatal exposure to ethanol through
breast milk. Design: Pharmacokinetic modeling of ethanol elimination
from milk based on reference values. Calculation of the time to zero
alcohol in breast milk for a range of doses and body weights. Results:
The elimination of alcohol and time-to-zero levels in breast milk are
described in a nomogram as a function of the amount of alcohol consumed
and the body weight of the woman. Conclusions: Careful planning of a
breast feeding schedule, by storing milk before drinking and/or waiting
for complete alcohol elimination from the breast milk, can ensure women
that their babies are not exposed to any alcohol.

Per the Nomogram:  

For a 155 pound or 70.3 Kg women: 1 drink takes 2 hr 12 min to reach
ZERO level

For a 110 pound or 49.9 Kg women: 2 drinks takes 5 hr 12 min to reach
Zero level

For a 210 pound or 95.3 Kg women: 1 drink takes 1 hr 51 min to reach
Zero level

                                                    

Several other issues are addressed in Biol Neonate 2001; 80:219-222:

-AN INFANT DETOXIFIES ALCOHOL AT ½ THE RATE OF AN ADULT

-MILK PRODUCTION VERSUS INFANT CONSUMPTION EFFECTS

-GROSS MOTOR DEVELOPMENT

-SLEEP WAKE PATTERNS

-HYPOGLYCEMIC EFFECTS OF ALCOHOL

-METHODOLOGY: ALCOHOL CONCENTRATIONS SERUM, BODY WATER

-DISTINCTION: 'MILK POLLUTION'

-ZERO ORDER KINETICS.........

[Ho
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Ho+E"%5BAuthor%5D),
et al Alcohol and Breast Feeding: Calculation of Time to Zero Level in
Milk. Biol Neonate 2001;80:219-222

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11585986>

**Resources**

**ACOG**

**Clinician Tools - Drinking and Reproductive Health**

[www.acog.org/from_home/misc/dept_pubs.cfm](http://www.acog.org/from_home/misc/dept_pubs.cfm)

Becker AB , et al, Breast-Feeding and Environmental Tobacco Smoke
Exposure, Arch Pediatr Adolesc Med, 1999 Jul;153(7):689-91

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=10401801>

Bajanowski T et al, Nicotine and cotinine in infants dying from sudden
infant death syndrome. Int J Legal Med. 2007 Feb 7

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17285322>

Ilett KF et al, Use of nicotine patches in breast-feeding mothers:
transfer of nicotine and cotinine into human milk. Clin Pharmacol Ther.
2003 Dec;74(6):516-24.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=14663454>

**American Academy of Pediatrics**

<http://www.aap.org/>

####  {#section-3 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Other {#other .Style-Heading-4-+-Arial-14-pt-Underline}

#### The WHO publication that details the evidence for the 10 Steps to Baby Friendly {#the-who-publication-that-details-the-evidence-for-the-10-steps-to-baby-friendly .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/WHO_CHD_98.9.pdf**](http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/WHO_CHD_98.9.pdf) {#httpwww.who.intchild-adolescent-healthnew_publicationsnutritionwho_chd_98.9.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-4 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CCC Corner Digest {#ccc-corner-digest .Style-Heading-4-+-Arial-14-pt-Underline}

#### Nicely laid out hard copy - A compact digest of last month's CCC Corner {#nicely-laid-out-hard-copy---a-compact-digest-of-last-months-ccc-corner .Style-Heading-4-+-Arial-14-pt-Underline}

#### Highlights include  {#highlights-include .Style-Heading-4-+-Arial-14-pt-Underline}

-HPV Vaccine: Newest ACIP Recommendations - Comments by Amy Groom

-When Things Go Wrong: Responding to Adverse Events

-HIV Prenatal Screening Can Saves Lives-- B. Reilley / S. Giberson

-Surgery versus medical therapy for heavy menstrual bleeding

-Newborn circumcision: Improved outcomes with pediatric hospitalists

-Obesity surgeries expanding dramatically since 1998, AHRQ

-All Encouraged to Help Reduce Colorectal Cancer Deaths in Women

-Inquiring families want to know - what about breastfeeding and......

-Violence Threatens the Health of Pregnant Women and Newborns

-Guidelines for Palliative Care Services: Now Online

-Welcome to the Indian Health Methamphetamine Initiative Site

-Does misoprostol aid prior to IUD insertion?

-Testing New Drugs on the World's Poorest Patients

-The Magic of Play

-Prolonged second stage: The rest of the story

-Being Present: The spirituality of presence in midwifery care

-Oral, not Transdermal, Estrogen Increases Risk for VTE in Women 

-Prenatal screening: It is recommended for ALL ages

-Assessment of Adverse Drug Events in a Tertiary Care Medical Center

-Cesarean Delivery on Maternal Request

-Bisphosphonate Related Osteonecrosis of the Jaws

-What is the best management plan for preterm labor?

-Electronic Health Record (EHR) Implementation: Worth the effort?

-HPV Vaccine Frequently Asked Questions

-Northern Women at Most Risk: Vit. D Deficiency Widespread in Pregnancy

-Can you dispense birth control to minors without parental consent?

-How many rubella vaccines does a mother really need to get?

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0407.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0407.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn0407.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-5 .Style-Heading-4-+-Arial-14-pt-Underline}

#### If you want a copy of the CCC Digest mailed to you each month, please contact [**nmurphy@scf.cc**](mailto:nmurphy@scf.cc) {#if-you-want-a-copy-of-the-ccc-digest-mailed-to-you-each-month-please-contact-nmurphyscf.cc .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-6 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Domestic Violence, Denise Grenier, Rachel Locker {#domestic-violence-denise-grenier-rachel-locker .Style-Heading-4-+-Arial-14-pt-Underline}

**Intimate partner abuse has no age limit**

<http://www.ahrq.gov/research/mar07/307RA21.htm>

**Domestic Violence and Your Patient\'s Health: Asking the Right
Questions**

<http://www.medscape.com/viewprogram/6760?sssdmh=dm1.255226&src=nlcmealert>

#### Elder Care News {#elder-care-news .Style-Heading-4-+-Arial-14-pt-Underline}

**Use of the pain reliever propoxyphene is associated with a higher risk
of hip fracture among the elderly**

<http://www.ahrq.gov/research/mar07/307RA23.htm>

#### Family Planning {#family-planning .Style-Heading-4-+-Arial-14-pt-Underline}

**Oral Contraception Regimen and Breakthrough Bleeding**

**Results:** Women who had a heavier daily flow rate during the 21/7
cycle before the extended regimen were significantly more likely to have
heavier flow and earlier breakthrough bleeding during the extended
regimen. The average daily flow rating during the extended period was
0.21 (on the 0 to 4 scale), which improved over time. Participants who
had breakthrough bleeding or spotting for seven consecutive days had a
better response to a hormone-free interval than those randomized to the
other treatment strategy.

**Conclusion:** The authors conclude that a 168-day extended oral
contraception regimen resulted in an acceptable rate of breakthrough
bleeding or spotting and had a high rate of continuation. The best
strategy for managing bleeding during the extended cycle was a three-day
hormone-free interval.

#### Sulak PJ, et al. Prospective analysis of occurrence and management of breakthrough bleeding during an extended oral contraception regimen. Am J Obstet Gynecol October 2006;195:935-41. {#sulak-pj-et-al.-prospective-analysis-of-occurrence-and-management-of-breakthrough-bleeding-during-an-extended-oral-contraception-regimen.-am-j-obstet-gynecol-october-2006195935-41. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16647684**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16647684) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids16647684 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-7 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Prescribing a one-year supply of OCs contributes to more continuous use and lower costs {#prescribing-a-one-year-supply-of-ocs-contributes-to-more-continuous-use-and-lower-costs-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Results: Women who received prescriptions for 13 cycles were significantly more likely to still be receiving OCs 15 months after the initial prescription. At the 15-month follow-up, 43 percent of women who received prescriptions for 13 cycles had obtained sufficient pills for at least one year of continuous use compared with 22 percent of women given prescriptions for three months and 20 percent of those initially prescribed one month\'s supply. The rates of pill wastage were higher in women prescribed 13 cycles than in those prescribed three cycles (6.5 percent of cycles dispensed wasted compared with 2.0 percent), but the women initially prescribed 13 cycles completed an average of 14.5 cycles during the study compared with 9.0 cycles completed by women initially prescribed three months\' supply. Despite having significantly fewer physician visits, a significantly higher percentage of women prescribed 13 cycles had Pap smears and chlamydia tests during the study. The program calculated an average saving of about \$99 per patient for women prescribed 13 cycles compared with those prescribed three cycles {#results-women-who-received-prescriptions-for-13-cycles-were-significantly-more-likely-to-still-be-receiving-ocs-15-months-after-the-initial-prescription.-at-the-15-month-follow-up-43-percent-of-women-who-received-prescriptions-for-13-cycles-had-obtained-sufficient-pills-for-at-least-one-year-of-continuous-use-compared-with-22-percent-of-women-given-prescriptions-for-three-months-and-20-percent-of-those-initially-prescribed-one-months-supply.-the-rates-of-pill-wastage-were-higher-in-women-prescribed-13-cycles-than-in-those-prescribed-three-cycles-6.5-percent-of-cycles-dispensed-wasted-compared-with-2.0-percent-but-the-women-initially-prescribed-13-cycles-completed-an-average-of-14.5-cycles-during-the-study-compared-with-9.0-cycles-completed-by-women-initially-prescribed-three-months-supply.-despite-having-significantly-fewer-physician-visits-a-significantly-higher-percentage-of-women-prescribed-13-cycles-had-pap-smears-and-chlamydia-tests-during-the-study.-the-program-calculated-an-average-saving-of-about-99-per-patient-for-women-prescribed-13-cycles-compared-with-those-prescribed-three-cycles .Style-Heading-4-+-Arial-14-pt-Underline}

#### Conclusion: The authors conclude that prescribing a one-year supply of OCs contributes to more continuous use and lower costs than limiting prescriptions to a three-month or a one-month supply. {#conclusion-the-authors-conclude-that-prescribing-a-one-year-supply-of-ocs-contributes-to-more-continuous-use-and-lower-costs-than-limiting-prescriptions-to-a-three-month-or-a-one-month-supply. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Foster DG, et al. Number of oral contraceptive pill packages dispensed, method continuation, and costs. Obstet Gynecol November 2006;108:1107-14. {#foster-dg-et-al.-number-of-oral-contraceptive-pill-packages-dispensed-method-continuation-and-costs.-obstet-gynecol-november-20061081107-14. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20070315/tips/15.html**](http://www.aafp.org/afp/20070315/tips/15.html) {#httpwww.aafp.orgafp20070315tips15.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-8 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Does Oral Contraceptive Use Affect Breast Cancer Risk? {#does-oral-contraceptive-use-affect-breast-cancer-risk .Style-Heading-4-+-Arial-14-pt-Underline}

#### Conclusion: The authors conclude that OC use is associated with an increased risk of breast cancer in premenopausal women, especially when used for prolonged periods of time before their first full-term pregnancy. This risk appears to be greatest in women who had used OCs for more than four years before their first full-term pregnancy, although the reason remains unclear. The authors express concern that the ORs may be underestimations because of the potential for survivor bias in the studies they reviewed. {#conclusion-the-authors-conclude-that-oc-use-is-associated-with-an-increased-risk-of-breast-cancer-in-premenopausal-women-especially-when-used-for-prolonged-periods-of-time-before-their-first-full-term-pregnancy.-this-risk-appears-to-be-greatest-in-women-who-had-used-ocs-for-more-than-four-years-before-their-first-full-term-pregnancy-although-the-reason-remains-unclear.-the-authors-express-concern-that-the-ors-may-be-underestimations-because-of-the-potential-for-survivor-bias-in-the-studies-they-reviewed. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Kahlenborn C, et al. Oral contraceptive use as a risk factor for premenopausal breast cancer: a meta-analysis. Mayo Clin Proc October 2006;81:1290-302. {#kahlenborn-c-et-al.-oral-contraceptive-use-as-a-risk-factor-for-premenopausal-breast-cancer-a-meta-analysis.-mayo-clin-proc-october-2006811290-302. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20070315/tips/14.html**](http://www.aafp.org/afp/20070315/tips/14.html) {#httpwww.aafp.orgafp20070315tips14.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-9 .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website David Gahn, IHS MCH Portal Web Site Content
Coordinator**

**Must See Website: Indian Health Service HIV-AIDS Program**

CDR Scott Giberson, MPH, Pharm.D, PH-C has developed a website dedicated
to the IHS HIV-AIDS Program. As most of us have seen, HIV/AIDS continues
to pose a serious risk to American Indians and Alaskan Natives (AI/AN).
This new, robust website contains a variety of useful information
including:

-   A complete description of the IHS HIV/AIDS Program

-   Useful CDC Fact Sheets

-   Details of the support IHS receives from the Minority AIDS
    Initiative

-   Current HIV/AIDS research initiatives and results involving AI/AN

-   Clinical information including HIV/AIDS CE/CME and Clinical
    Guidelines for testing and treatment (including post-exposure
    prophylaxis)

-   ARV Corner -- a description of the various antiretrovirals available
    and the clinical trials involving these drugs

-   FAQs

While the website is not yet complete, the information included is
useful and reliable. It will be a valuable resource for those of us
involved in testing for and treating HIV.

[www.ihs.gov/medicalprograms/hivaids/](http://www.ihs.gov/medicalprograms/hivaids/)

**Contact:** <Scott.Giberson@ihs.hhs.gov>

#### Frequently asked questions {#frequently-asked-questions .Style-Heading-4-+-Arial-14-pt-Underline}

**Q. What are the actual federal regulations on sterilization? Bilateral
tubal ligation, etc...**

A. Go here for several resources and the Sterilization [Electronic Code
of Federal
Regulations](http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=1d2f4bfc145e75c1372a17d62cdf447d&rgn=div6&view=text&node=42:1.0.1.4.20.2&idno=42)

<http://www.ihs.gov/MedicalPrograms/MCH/M/Bfaqs.cfm#BTL>

or

GPO Access Site: Sterilization [Electronic Code of Federal
Regulations](http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=1d2f4bfc145e75c1372a17d62cdf447d&rgn=div6&view=text&node=42:1.0.1.4.20.2&idno=42)

<http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=1d2f4bfc145e75c1372a17d62cdf447d&rgn=div6&view=text&node=42:1.0.1.4.20.2&idno=42>

**Indian Child Health Notes Steve Holve, Pediatrics Chief Clinical
Consultant**

**May 2007**

-Infant deaths associated with Cough and Cold Medications- 2005

-Prevention of Childhood Pneumococcal Invasive Disease with Pneumococcal
Conjugate Vaccine: Contrasting Experiences in Alaska Natives and
Navajo/Apaches

-Meeting the needs of regional minority groups: the University of
Washington\'s programs to increase the American Indian and Alaskan
Native physician workforce.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN507.doc>

#### Information Technology {#information-technology .Style-Heading-4-+-Arial-14-pt-Underline}

**Electronic Health Record (EHR) Implementation: Worth the effort?**

May 1, 2007

Moderator: David Johnson, MD

-Anticipated benefits of an EHR: Demonstrated through experience?

-What are the real costs: Decreased efficiency, IT support requirements,
etc...

### -Effect on the provider -- patient relationship

### How to subscribe / unsubscribe to the Primary Care Discussion Forum?

Subscribe to the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26>

Unsubscribe from the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26>

Questions on how to subscribe, contact <nmurphy@scf.cc> directly

#### International Health Update Claire Wendland, Madison, WI {#international-health-update-claire-wendland-madison-wi .Style-Heading-4-+-Arial-14-pt-Underline}

**Ethics of medicine with economically vulnerable populations: Second in
the series**

Last month I wrote about current controversies in the recruitment of
clinical trials subjects from impoverished international sites. This
month's focus is another ethical controversy in international health:
the global organ trade.

In most countries where organ transplantation is done, the list of
patients waiting for kidney transplants is far longer than the number of
donors. The shortage of organs, the desperation of those waiting for
transplants, and the money to be made in transplantation combine to
produce a situation in which ethical rules get broken, or at least bent,
frequently. At least one government times prisoner executions to
maximize organ harvest; rumors of organ stealing, though not
substantiated, course through the Third World. In fact, though selling a
kidney is almost universally illegal (it is legal in Iran, quasi-legal
in India), and is widely condemned by medical societies and professional
organizations, there is a well-documented black-market trade in kidneys
sold by poor "donors" for cash. Some ethicists, health economists, and
transplant surgeons argue that since this trade is happening anyway, it
should be legalized and regulated -- in part to protect would-be kidney
sellers from surgery done in unsafe conditions. Others believe this is
one ethical line that should not be crossed: that selling a kidney is
substantially different than selling semen or plasma, and that the
potential for exploitation of the poor by the rich is too great.

Tarif Bakdash, a Syrian bioethicist, and Nancy Scheper-Hughes, an
American anthropologist (and director of an NGO that monitors the organ
trade), debate the question of whether kidney sales should be made legal
in a thought-provoking recent article in PLoS Medicine. Bakdash believes
that poor people often sell their kidneys for altruistic reasons, as a
last-ditch effort to provide basic needs for their families (and the
social science literature backs him up on this point). It is arrogance,
even hypocrisy for the wealthy to try to "protect" the poor from selling
their organs, he argues: poor people "are always exploited from the day
they are born, and in all avenues of life. The only thing of value left
for some of them is their bodies." Scheper-Hughes believes that such
sales make human life itself the ultimate commodity, dehumanizing
everyone who comes in contact with the organ trade. She sees the
polarization of the world that allows some people to be seen as sources
of spare parts for others as "a medical, social, and moral tragedy of
immense and not yet fully recognized proportions." Readers may be left
with a disturbing conundrum: is it possible that a poor person's sale of
a kidney may be an ethical act, while a rich person buying one is
unethical?

Bakdash T, Scheper-Hughes N. Is it ethical for patients with renal
disease to purchase kidneys from the world's poor? PLoS Medicine
3(10):e349, October 2006
[www.plosmedicine.org](http://www.plosmedicine.org/)

**Other:**

# One-Visit Screening for Cervical Cancer May Be Feasible in Developing Countries

# CONCLUSION: A single-visit approach using visual inspection of the cervix with acetic acid wash and cryotherapy proved to be safe, acceptable, and feasible in an urban African setting.

[Blumenthal
PD](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Blumenthal+PD"%5BAuthor%5D),
et al Cervical cancer prevention: safety, acceptability, and feasibility
of a single-visit approach in Accra, Ghana. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
Apr;196(4):407.e1-8; discussion 407.e8-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17403438>

#### MCH Alert {#mch-alert-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Issues that affect adolescent well-being**

Child Trends recently released three new briefs in the
Research-to-Results series that offer guidance on adolescent health for
out-of-school-time policymakers and program administrators. Each brief
provides background information on selected adolescent health issues,
practical tips for recognizing signs of problems among program
participants, and outcome measures that can be used in program
evaluations. The briefs include the following:

\* Assessing the Diet, Exercise, Body Image, and Weight of Adolescents
summarizes (1) what it means to be overweight, (2) what are body image
and eating disorders, (3) what to do if you suspect that someone in your
program is suffering from an eating disorder, and (4) how to assess
weight issues among adolescents in out-of-school-time programs.

Additional resources for programs on healthy diet and eating disorders
are also provided.
[[http://www.childtrends.org/Files//Child_Trends-2007_03_14_RB_TeenDietandOST.pdf]{.underline}](http://www.childtrends.org/Files//Child_Trends-2007_03_14_RB_TeenDietandOST.pdf)

\* Assessing the Mental Health of Adolescents summarizes the signs and
symptoms of depression, suicide risk, and anxiety disorders and suggests
research questions that can help programs screen for or monitor mental
health issues. Additional program resources on these topics are also
provided.
[[http://www.childtrends.org/Files//MentalHealth.pdf]{.underline}](http://www.childtrends.org/Files//MentalHealth.pdf)

\* Assessing Substance Use and Abuse Among Adolescents discusses the
signs and symptoms of alcohol and drug use and provides recommendations
to assess substance use among adolescents in out-of-school-time
programs. Additional program resources on tobacco use, alcohol use, and
illicit drug use are also provided.
[[http://www.childtrends.org/Files//Substance%20Use.pdf]{.underline}](http://www.childtrends.org/Files//Substance Use.pdf)

**Surgeon General Issues National Call to Action on Underage Alcohol
Use**

The Surgeon General\'s Call to Action to Prevent and Reduce Underage
Drinking focuses national attention on the social costs and personal
consequences of underage alcohol use and the process of solving this
public health problem. The call to action, published by the Office of
the Surgeon General, presents research that offers new opportunities for
prevention and intervention by furthering an understanding of underage
alcohol use as a developmental phenomenon \-- a behavior directly
related to maturational processes in adolescence. Topics include the
scope of the problem, alcohol use and adolescent development, and
prevention and reduction of alcohol use and alcohol use disorders in
adolescents.

Action steps, a conclusion, and references are also presented. The
appendix contains a definition of a \"standard drink\" and diagnostic
criteria for alcohol abuse and dependence.
[[http://www.surgeongeneral.gov/topics/underagedrinking/calltoaction.pdf]{.underline}](http://www.surgeongeneral.gov/topics/underagedrinking/calltoaction.pdf)

**Adolescent sexual behavior and strategies for reducing early pregnancy
and childbearing**

With One Voice 2007: America\'s Adults and Teens Sound Off About Teen
Pregnancy assesses public opinion on adolescent pregnancy. The survey is
the fifth in a series of nationally representative surveys conducted by
the National Campaign to Prevent Teen Pregnancy that have asked
adolescents (ages 12-19) and adults (ages 20 and older) a consistent,
core set of questions about adolescent pregnancy and related issues.

Topics include parental and other adult influence; abstinence and
contraception; regret, virginity, older partners, and attitudes about
adolescent sex; gender differences; religion; social norms and beliefs;
and media. Data are presented in charts and, where available, results
from previous surveys (2001-2006) are included. A description of the
survey methodology and a summary are also provided. The survey is
intended to provide insights for policymakers, program administrators,
families, and others about adolescent pregnancy and factors that
influence adolescents\' decisions about sex.
[[http://www.teenpregnancy.org/resources/data/pdf/WOV2007_fulltext.pdf]{.underline}](http://www.teenpregnancy.org/resources/data/pdf/WOV2007_fulltext.pdf)

**MCH Headlines Judy Thierry HQE**

**Do you walk around your vehicle before getting in it? You should**

Pedestrian child fatalities kids and cars website eliminating deaths due
to backing out know your blind spots <http://www.kidsandcars.org/>

Links for child safety -- videos "Don't Back Blind"

Know your vehicles blind spots - visual aid to instruct parents

-   NBC today show -- 7 minute spot story, consumer report 'walk
    through' on REAL blind spots and what  automakers are designing as
    'parking assists' i.e. video, sonar or radar  AND making a habit of
    "WALKING AROUND THE VEHICLE".  

-   Don't Back Blind -- PSA's  

Short PSA videos compelling visual stories and informational  

-   "Driving blind" 

-   Making cars safer for children -- windows, doors, etc. 
                                                     

-   [View Point \-- The Consumers Union Perspective - \"Cars should be
    made safer for
    children.\"](http://kidsandcars.org/incidents/backover/docs/CR_Carsshouldbesafer.pdf)
    October 2003

-   'Back up systems' -- pdf at this site

> [[http://www.consumerreports.org/cro/cars/safety-recalls/mind-that-blind-spot-1005/overview/index.htm]{.underline}](http://www.consumerreports.org/cro/cars/safety-recalls/mind-that-blind-spot-1005/overview/index.htm)

![](media/image2.jpeg){width="2.8125in" height="4.59375in"}

Really! these are the distances! --  9 to 45 feet depending on vehicle
size and driver

note BEST and worst by gender (basically men are bigger than women -- so
it is the sitting height that is being represented here)

####  {#section-10 .Style-Heading-4-+-Arial-14-pt-Underline}

**The WHO publication that details the evidence for the 10 Steps to Baby
Friendly**

Thanks to Cindy Turner at Baby Friendly USA
<cturner@babyfriendlyusa.org>

#### WHO Link {#who-link .Style-Heading-4-+-Arial-14-pt-Underline}

<http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/WHO_CHD_98.9.pdf> 

####  {#section-11 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Second round request for Oral Health Preceptorship applications Announcement OHRA Preceptorship Program Phase II {#second-round-request-for-oral-health-preceptorship-applications-announcement-ohra-preceptorship-program-phase-ii .Style-Heading-4-+-Arial-14-pt-Underline}

The MCH Program on behalf of the American Academy of Pediatrics recently
sent out an announcement and have received 10 applications from ITU
sites for the first round.

Now, there is an opportunity for 3 additional AIAN sites to be funded in
this second round. 

Please take advantage of this training.

AAP Wendy Nelson  <wnelson@aap.org>

\[For those who applied in Feb/March you do not need to apply again!
 Notification soon.\]

####  {#section-12 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Do HIV Testing Rates Improve When Written Consent Is No Longer Required? {#do-hiv-testing-rates-improve-when-written-consent-is-no-longer-required-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Written informed consent is a barrier to testing and to identifying infected individuals. Secular trends in implementing routine HIV testing in healthcare settings could explain some of the testing increase seen in this study. However, the rapidity with which the testing rate increased after the policy change, and the increased number of patients identified, are impressive. This report lends further evidence that written informed consent is a barrier to testing and to identifying infected individuals. AIDS Clinical Care, Volume 4, Number 6 [http://www.medscape.com/viewarticle/554615]{.underline} {#written-informed-consent-is-a-barrier-to-testing-and-to-identifying-infected-individuals.-secular-trends-in-implementing-routine-hiv-testing-in-healthcare-settings-could-explain-some-of-the-testing-increase-seen-in-this-study.-however-the-rapidity-with-which-the-testing-rate-increased-after-the-policy-change-and-the-increased-number-of-patients-identified-are-impressive.-this-report-lends-further-evidence-that-written-informed-consent-is-a-barrier-to-testing-and-to-identifying-infected-individuals.-aids-clinical-care-volume-4-number-6-httpwww.medscape.comviewarticle554615 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Zetola NM et al. Association between rates of HIV testing and elimination of written consents in San Francisco. *JAMA* 2007 Mar 14; 297:1061-2 {#zetola-nm-et-al.-association-between-rates-of-hiv-testing-and-elimination-of-written-consents-in-san-francisco.-jama-2007-mar-14-2971061-2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [MCH Coordinator Editorial comment:]{.underline}

#### As you are aware, the IHS removed IHS Form 509 (which previously required separate and specific written informed consent for an HIV Test) in October 2006. There are ongoing and completed studies that support this type of policy action and implementation of more routinized testing -- for one example, see below. However, also as noted above, states still have jurisdiction to mandate that HIV testing be accompanied by specific written consent for an HIV test. Many states are now revisiting this issue with CDC and are continually discussing potential changes in by-laws, policies, etc. Please contact your state if you have questions and do not rely on internet/online reports of 'current' state HIV testing requirements since they have potential to be out-of-date. Also, ask your state specifically if it is possible to acquire verbal consent and document in the chart vice separate written consent. {#as-you-are-aware-the-ihs-removed-ihs-form-509-which-previously-required-separate-and-specific-written-informed-consent-for-an-hiv-test-in-october-2006.-there-are-ongoing-and-completed-studies-that-support-this-type-of-policy-action-and-implementation-of-more-routinized-testing-for-one-example-see-below.-however-also-as-noted-above-states-still-have-jurisdiction-to-mandate-that-hiv-testing-be-accompanied-by-specific-written-consent-for-an-hiv-test.-many-states-are-now-revisiting-this-issue-with-cdc-and-are-continually-discussing-potential-changes-in-by-laws-policies-etc.-please-contact-your-state-if-you-have-questions-and-do-not-rely-on-internetonline-reports-of-current-state-hiv-testing-requirements-since-they-have-potential-to-be-out-of-date.-also-ask-your-state-specifically-if-it-is-possible-to-acquire-verbal-consent-and-document-in-the-chart-vice-separate-written-consent. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-13 .Style-Heading-4-+-Arial-14-pt-Underline}

**You are invited to join a Meth PH Forum**

Interested individuals are invited to join a new Virtual Office at
[[www.HealthDisparities.net]{.underline}](../www.HealthDisparities.net)
Meth PH Forum Virtual Office (VO).

The VO includes a listserv, resources, library, calendar of shared
events, announcement capacity, working documents for review or documents
\'in-progress\' section; all of which can be used as a means for
communication. If you will be involved with this group, please join the
Meth PH Forum VO.

Membership

Membership is for a broad array of public health officials at the
municipal, state, county, Tribal and federal level. Health care
providers; child educators; academicians; child welfare workers; public
safety workers; judicial and law enforcement entities and other
stakeholders who share in the public health response to methamphetamine
should consider subscribing.

Joining the VO

If you do not already have an account at HealthDisparities.net, go to
[[http://www.healthdisparities.net]{.underline}](http://www.healthdisparities.net/)
and follow the link at the top right hand side of the page for \"new
user signup\". When you get to the section of \"New User Signup\" called
\"Group Memberships\", make sure you put a check mark next to Meth PH
Forum VO.

Group membership results in access to the VO as well as automatic
subscription to the listserv.  To opt out of the listserv or change any
of your HDC listserv subscription settings, first log-in to the site
then go to the \"Community\" menu and choose \"Listserv\".  Check or
uncheck the boxes and then click \"Save\" to alter your listserv
subscriptions.

If you already have an account at HealthDisparities.net, just log-in at
the website with user name and password and go to the \"Office\" menu,
choose \"My Account\" and click on \"Group Memberships\". Then put a
check mark next to Meth PH Forum VO under \"National Groups\" and click
\"Save Changes\".

Contact us

#### If you have any questions feel free to contact:  {#if-you-have-any-questions-feel-free-to-contact .Style-Heading-4-+-Arial-14-pt-Underline}

#### CAPT Judith Thierry, DO, MPH, Maternal and Child Health Program, Indian Health Service at judith.thierry@ihs.gov or CAPT Stephanie Bryn, HRSA, MCHB at Sbryn@hrsa.gov or the HDC Webmaster at [**webmaster@healthdisparities.net**](mailto:webmaster@healthdisparities.net) {#capt-judith-thierry-do-mph-maternal-and-child-health-program-indian-health-service-at-judith.thierryihs.gov-or-capt-stephanie-bryn-hrsa-mchb-at-sbrynhrsa.gov-or-the-hdc-webmaster-at-webmasterhealthdisparities.net .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-14 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Canada HPV vaccine rollout {#canada-hpv-vaccine-rollout .Style-Heading-4-+-Arial-14-pt-Underline}

#### The Canadian government on Monday announced that it is including about \$258 million in the 2007-2008 budget to help pay for provincial human papillomavirus vaccination programs, Toronto\'s Globe and Mail reports. Canada\'s National Advisory Committee on Immunization has recommended that girls ages nine to 13 be vaccinated against HPV, as well as older girls and women who might already be sexually active but not infected with the virus. The budget allocation, which will be distributed to provinces over the next year, \"does not imply\" that a mandatory vaccination program will be instituted in Canada, but it \"does make the possibility more likely,\" according to the Globe and Mail. The total estimated cost for provincial HPV vaccination is estimated to be more than \$860 million, according to the Department of Finance. About 400 women in Canada die from cervical cancer annually. According to the Globe and Mail, the budget allocation is being lauded by health professionals but could \"alienate some elements of the socially right-wing base\" of the ruling Conservative Party (Galloway, Globe and Mail, 3/20).  [**http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=43718**](http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=43718) {#the-canadian-government-on-monday-announced-that-it-is-including-about-258-million-in-the-2007-2008-budget-to-help-pay-for-provincial-human-papillomavirus-vaccination-programs-torontos-globe-and-mail-reports.-canadas-national-advisory-committee-on-immunization-has-recommended-that-girls-ages-nine-to-13-be-vaccinated-against-hpv-as-well-as-older-girls-and-women-who-might-already-be-sexually-active-but-not-infected-with-the-virus.-the-budget-allocation-which-will-be-distributed-to-provinces-over-the-next-year-does-not-imply-that-a-mandatory-vaccination-program-will-be-instituted-in-canada-but-it-does-make-the-possibility-more-likely-according-to-the-globe-and-mail.-the-total-estimated-cost-for-provincial-hpv-vaccination-is-estimated-to-be-more-than-860-million-according-to-the-department-of-finance.-about-400-women-in-canada-die-from-cervical-cancer-annually.-according-to-the-globe-and-mail-the-budget-allocation-is-being-lauded-by-health-professionals-but-could-alienate-some-elements-of-the-socially-right-wing-base-of-the-ruling-conservative-party-galloway-globe-and-mail-320.-httpwww.kaisernetwork.orgdaily_reportsrep_index.cfmdr_id43718 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-15 .Style-Heading-4-+-Arial-14-pt-Underline}

**Significant Association between Smoking, Mental Disorders in Pregnant
Women**\
*Alert to Healthcare Providers: Research Supports the Benefit of
Screening for Mental Disorders in Pregnant Women Unable to Quit Smoking*

New research has identified an association between mental disorders and
nicotine dependence among pregnant women in the United States, not
unlike what has been reported in the general population. The presence of
these mental disorders in nicotine addicted pregnant women may make
quitting smoking more difficult. Published in the April 2007 issue of
*Obstetrics and Gynecology*, this study was supported in part by the
National Institute on Drug Abuse (NIDA), part of the National Institutes
of Health.

The study included 1,516 pregnant women at least 18 years old who took
part in the 2001--2002 National Epidemiologic Survey of Alcohol and
Related Conditions, a nationally representative survey of more than
43,000 U.S. adults administered by the National Institute on Alcohol
Abuse and Alcoholism (NIAAA).

Researchers found that 21.7 percent of the pregnant women in the study
used cigarettes and among those women, 57.2 percent were nicotine
dependent. These results indicate that in the United States an estimated
12.4 percent of pregnant women are addicted to cigarettes. Women with
nicotine dependence were more likely to meet criteria for at least one
mental disorder compared to those that did not use cigarettes during
pregnancy. Significant associations were found for dysthymia (a chronic
depressive condition), major depressive disorder, and panic disorder.

"Understanding that these co-morbidities exist may shed light on why
some women are unable to abstain from smoking during pregnancy even
though they understand the negative health impact for them and their
unborn children," says NIDA Director Dr. Nora D. Volkow. \"There is
tremendous value in screening pregnant women who are unable to abstain
from smoking for mental disorders --- to not only identify and treat
those who have been undiagnosed but also to improve successful quit
smoking attempts."

Encouraging women to quit smoking before they become pregnant is
important to the health of the fetus, in addition to improving the
health of the mother. Pregnant women who smoke cigarettes run an
increased risk of having infants with low birth weight and their
children face an increased risk for learning and behavioral problems.

The National Institute on Drug Abuse is a component of the National
Institutes of Health, U.S. Department of Health and Human Services. NIDA
supports most of the world's research on the health aspects of drug
abuse and addiction. The Institute carries out a large variety of
programs to ensure the rapid dissemination of research information and
its implementation in policy and practice. Fact sheets on the health
effects of drugs of abuse and information on NIDA research and other
activities can be found on the NIDA home page at
[www.drugabuse.gov](http://www.drugabuse.gov/).

<http://www.nih.gov/news/pr/apr2007/nida-03.htm>

####  {#section-16 .Style-Heading-4-+-Arial-14-pt-Underline}

**Carbon Monoxide Kills Subtly, Silently**

The subtle quiet killer Carbon Monoxide \[Carbon monoxide (CO) is a
colorless, odorless gas that is produced as a result of incomplete
burning of carbon-containing fuels. Exposure to CO reduces the blood\'s
ability to carry oxygen\] a quick review below will keep you and your
community thinking of the exposures, risky heating and when to think in
your differential diagnosis that CO exposure may be a foot.  Riding in
the back of pick-up trucks, non-passenger intended spaces in vehicles is
also unwise.  Another hidden CO exposure is cigarette smoke -- first or
second hand.

Carbon monoxide (CO) from gasoline-powered generators that may be used
during winter weather-related power outages can kill in minutes.
Consumers should never use a generator, charcoal or gas grill in an
enclosed area. In addition, fuel-burning appliances can cause carbon
monoxide poisoning if they are improperly installed, poorly maintained,
have defective or blocked venting systems, or are misused.

To help prevent deaths and injuries, CPSC urges consumers to:

-   Have your heating system, water heater and any other gas, oil, or
    coal burning appliances serviced by a qualified technician every
    year.

-   Install battery-operated CO and smoke alarms in your home. Locate CO
    alarms outside the bedrooms in each separate sleeping area. Locate
    smoke alarms on each level of the house and inside every bedroom.

-   Replace smoke and CO alarm batteries in the spring and fall when you
    change the time on your clocks.

-   If an alarm sounds, leave your home immediately and call 911.

-   Seek medical attention immediately if you are feeling dizzy,
    lightheaded or nauseous. These are symptoms of CO poisoning.

additional information hazards associated with carbon monoxide and safe
use of portable generators.

<http://www.cpsc.gov/generator.html>

####  {#section-17 .Style-Heading-4-+-Arial-14-pt-Underline}

**HIV Care at a Crossroads: The Emerging Crisis in the US HIV Epidemic**

Audio Article discusses the crossroads. Narrative accompanies.  Full
article discusses increase funding 4 minute video presentation intro to
article routine opt out predicting increase numbers pressing on
treatment and care system Title III clinics now at or above capacity

Shifts in epidemiology, patient volume in flat funded programs. Dec 06
reauthorized RWCA 109-405 3.7% modest annual increase in Title III
funding of RWCA. Will it meet the needs?

<http://www.medscape.com/viewarticle/553119?src=mp>

####  {#section-18 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medical Mystery Tour {#medical-mystery-tour-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Which Indian Health facilities lead the entire U.S. in national obstetric benchmarks? {#which-indian-health-facilities-lead-the-entire-u.s.-in-national-obstetric-benchmarks .Style-Heading-4-+-Arial-14-pt-Underline}

#### And better yet, how can we translate that success to other Indian Health sites? {#and-better-yet-how-can-we-translate-that-success-to-other-indian-health-sites .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-19 .Style-Heading-4-+-Arial-14-pt-Underline}

**About Benchmarking**

Benchmarking is a method for comparing your facilities care processes to
those of the practices in the field that demonstrate the best outcomes. 
Identifying \"best practices\" through benchmarking allows all who
participate in the process to improve and adapt the care they provide in
order to obtain superior outcomes: high satisfaction, patient safety,
effectiveness and efficiency.

**One Example: ACNM**

#### The purpose of the American College of Nurse-Midwives (ACNM) Benchmarking Program is to provide a midwifery-specific mechanism to improve and maintain the superior quality of midwifery care provided to women and children by promoting member awareness of \"best practices.\"  To facilitate this, members are encouraged to participate in benchmarking their practice against other midwifery practices in the country. {#the-purpose-of-the-american-college-of-nurse-midwives-acnm-benchmarking-program-is-to-provide-a-midwifery-specific-mechanism-to-improve-and-maintain-the-superior-quality-of-midwifery-care-provided-to-women-and-children-by-promoting-member-awareness-of-best-practices.-to-facilitate-this-members-are-encouraged-to-participate-in-benchmarking-their-practice-against-other-midwifery-practices-in-the-country. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-20 .Style-Heading-4-+-Arial-14-pt-Underline}

#### In the meantime {#in-the-meantime .Style-Heading-4-+-Arial-14-pt-Underline}

#### The answers will be discussed in the next edition of the CCC Corner. In the meantime, if your facility is not one of facilities I am going to announce next month, then you should attend the 2007 National Indian Women's Health and MCH Conference. The Conference will be in Albuquerque, NM August 15- 17, 2007.  {#the-answers-will-be-discussed-in-the-next-edition-of-the-ccc-corner.-in-the-meantime-if-your-facility-is-not-one-of-facilities-i-am-going-to-announce-next-month-then-you-should-attend-the-2007-national-indian-womens-health-and-mch-conference.-the-conference-will-be-in-albuquerque-nm-august-15--17-2007. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-21 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The theme of the meeting is "Improve the System: Improve the Outcome" so it will explore how we can all work together to raise the AI/AN health status to the highest possible status.  {#the-theme-of-the-meeting-is-improve-the-system-improve-the-outcome-so-it-will-explore-how-we-can-all-work-together-to-raise-the-aian-health-status-to-the-highest-possible-status. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-22 .Style-Heading-4-+-Arial-14-pt-Underline}

#### There will be national benchmark organizations (Institute for Healthcare Improvement, American College of Nurse-Midwives, American College of Obstetricians and Gynecologists, Kaiser Family Foundation, etc...), internationally known speakers, and a rather extensive clinical Program.  {#there-will-be-national-benchmark-organizations-institute-for-healthcare-improvement-american-college-of-nurse-midwives-american-college-of-obstetricians-and-gynecologists-kaiser-family-foundation-etc-internationally-known-speakers-and-a-rather-extensive-clinical-program. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-23 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The meeting is only every 3 years, so you and a team from your facility should try your best to attend. You can either use your local facility funds, because there is a program review function, or use your CME /CEU funds. In addition, limited scholarships are available. {#the-meeting-is-only-every-3-years-so-you-and-a-team-from-your-facility-should-try-your-best-to-attend.-you-can-either-use-your-local-facility-funds-because-there-is-a-program-review-function-or-use-your-cme-ceu-funds.-in-addition-limited-scholarships-are-available. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-24 .Style-Heading-4-+-Arial-14-pt-Underline}

#### 2007 National Indian Women's Health and MCH Conference {#national-indian-womens-health-and-mch-conference .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07**](http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07) {#httpwww.ihs.govmedicalprogramsmchfcn01.cfmaug07 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-25 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Resources {#resources .Style-Heading-4-+-Arial-14-pt-Underline}

[Collins-Fulea
C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Collins-Fulea+C"%5BAuthor%5D),
et al Improving midwifery practice: the American College of
Nurse-Midwives\' benchmarking project. [J Midwifery Womens
Health.](javascript:AL_get(this, 'jour', 'J Midwifery Womens Health.');)
2005 Nov-Dec;50(6):461-71.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16260360>

#### or {#or .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://download.journals.elsevierhealth.com/pdfs/journals/1526-9523/PIIS1526952305003302.pdf**](http://download.journals.elsevierhealth.com/pdfs/journals/1526-9523/PIIS1526952305003302.pdf) {#httpdownload.journals.elsevierhealth.compdfsjournals1526-9523piis1526952305003302.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-26 .Style-Heading-4-+-Arial-14-pt-Underline}

#### ACNM Benchmarking Program {#acnm-benchmarking-program .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.acnm.org/education.cfm?id=842**](http://www.acnm.org/education.cfm?id=842) {#httpwww.acnm.orgeducation.cfmid842 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-27 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape\* {#medscape-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Bone Density Evaluation in Teens Prevents Future Osteoporosis**

<http://www.medscape.com/viewarticle/545997?src=0_nl_cme_9>

######### 

######### Ask the Experts topics in Women\'s Health and OB/GYN Index, by specialty, Medscape

######### [**http://www.medscape.com/pages/editorial/public/ate/index-womenshealth**](http://www.medscape.com/pages/editorial/public/ate/index-womenshealth)

######### 

######### OB GYN & Women\'s Health Clinical Discussion Board Index, Medscape

<http://boards.medscape.com/forums?14@@.ee6e57b>

**Clinical Discussion Board Index, Medscape**

Hundreds of ongoing clinical discussions available

<http://boards.medscape.com/forums?14@@.ee6e57b>

**Free CME: MedScape CME Index by specialty**

<http://www.medscape.com/cmecenterdirectory/Default>

\*NB: Medscape is free to all, but registration is required. It can be
accessed from anywhere with Internet access. You just need to create a
personal username and password.

**Menopause Management**

#### Emergence of a range of nonhormonal treatments for vasomotor symptoms {#emergence-of-a-range-of-nonhormonal-treatments-for-vasomotor-symptoms-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: The availability of centrally active therapies for menopausal vasomotor symptoms with risks and benefits clearly defined by results from well-designed clinical trials has the potential to allay safety concerns that are associated with the treatment of these common symptoms. {#conclusion-the-availability-of-centrally-active-therapies-for-menopausal-vasomotor-symptoms-with-risks-and-benefits-clearly-defined-by-results-from-well-designed-clinical-trials-has-the-potential-to-allay-safety-concerns-that-are-associated-with-the-treatment-of-these-common-symptoms. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Rapkin AJ Vasomotor symptoms in menopause: physiologic condition and central nervous system approaches to treatment. [Am J Obstet Gynecol.  2007; 196(2):97-106](http://www.medscape.com/medline/publicationbrowser/123?pmid=17306645)  {#rapkin-aj-vasomotor-symptoms-in-menopause-physiologic-condition-and-central-nervous-system-approaches-to-treatment.-am-j-obstet-gynecol.-2007-196297-106 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17306645**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17306645) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17306645 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-30 .Style-Heading-4-+-Arial-14-pt-Underline}

**Early Estrogen Therapy May Reduce Cardiovascular Risks**

Secondary analyses of findings from the Women's Health Initiative (WHI)
suggest that women who begin hormone therapy within 10 years of
menopause may have less risk of coronary heart disease (CHD) due to
hormone therapy than women farther from menopause.

The analysis of both estrogen and estrogen plus progestin data from the
Women\'s Health Initiative (WHI) hormone trials shows a 24 percent
reduction in risk for coronary heart disease events in women starting
hormone therapy less than 10 years after menopause The analysis also
showed a 30 percent reduction in overall deaths among women aged 50 to
59 using hormone therapy. However, the new study also found that hormone
therapy increased coronary heart disease events by 28 percent in older
women, and that deaths increased by 14 percent in women aged 70 to 79. 
There was a slightly elevated risk of stroke at all ages studied.

[Rossouw
JE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Rossouw+JE"%5BAuthor%5D),
et al Postmenopausal Hormone Therapy and Risk of Cardiovascular Disease
by Age and Years Since Menopause
[JAMA.](javascript:AL_get(this, 'jour', 'JAMA.');) 2007 Apr
4;297(13):1465-77

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17405972>

####  {#section-31 .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**, **Lisa Allee, CNM, Chinle**

**Ultrasound affects mice brains in negative ways: First, do no harm**

I was flipping through the November/December issue of Mothering magazine
and found a citation of an interesting research article on the effects
of ultrasound on mice brains. It has scary findings for an intervention
that is often considered routine and benign by providers and patients.

Eugenius, et al\*, found that when fetal mice are exposed to 30 minutes
or more of ultrasound that "a small but statistically significant number
of neurons fail to acquire their proper position and remain scattered
within inappropriate cortical layers and/or in the subjacent white
matter. The magnitude of dispersion of labeled neurons was variable but
systematically increased with duration of exposure to USW." Yikes! This
means that cells in the brain are not all in the right place. Okay,
you're saying these are mice, not humans. In their discussion the
authors discuss this---it might not apply to humans, but then again it
might in a big way:

> First it may not be applicable because "..the distance between the
> exposed cells and transducer in our experiments is shorter than in
> human. Furthermore, the duration of neuronal production and the
> migratory phase of cortical neurons in the human fetus lasts
> ![](media/image3.png){width="0.10416666666666667in"
> height="7.291666666666667e-2in"}18 times longer than in mice (between
> 6 and 24 weeks of gestation, with the peak occurring between 11 and 15
> weeks), compared with the duration of only
> ![](media/image3.png){width="0.10416666666666667in"
> height="7.291666666666667e-2in"}1 week (between E11 and E18) in the
> mouse. Thus, an exposure of 30 min represents a much smaller
> proportion of the time dedicated to development of the cerebral cortex
> in human than in mouse and, thus, could have a lesser overall effect,
> making human corticogenesis less vulnerable to USW" (ultrasound
> mwaves.)
>
> But on the other hand, "There are also some reasons to think that the
> USW may have a similar or even greater impact on neuronal migration in
> the human fetal brain. First, migrating neurons in the human forebrain
> are only slightly larger than in the mouse, and, with the acoustic
> absorption provided by the tissue stand-off pad, the amount of energy
> absorbed within a comparable small volume of tissue during the USW
> exposure was in the same general range. Second, the migratory pathway
> in the convoluted human cerebrum is curvilinear and at least an order
> of magnitude longer. Thus, the number of neurons migrating along the
> same radial glial fascicle, particularly at the later stages of
> corticoneurogenesis, is much larger and their routes are more complex,
> increasing the chance of a cell going astray from its proper migratory
> course. Third, the inside-to-outside settling pattern of isochronously
> generated neurons in primates is more precise than in rodents and
> thus, the tolerance for malpositioning may be smaller. In addition,
> different functional areas in the primate cortex are generated by
> different schedules so that exposure to USW may potentially affect
> selective cortical areas and different layers, depending on the time
> of exposure, potentially causing a variety of symptoms."

These effects of ultrasound are hard to study in humans because the
testing to find ectopic cells in the brain cannot be done in humans
according to the authors. There are some things that are known and are
concerning: "even a small number of ectopic cells might, as a result of
specific position and inappropriate connectivity, be a source of
epileptic discharge or abnormal behavior. Although we have not as yet
generated behavioral data, previous studies in rodents and primates
indicate that prenatal exposure to USW may affect higher brain function
of the offspring. Furthermore, there are numerous human neuropsychiatric
disorders that are thought to be the result of misplacement of cells as
a consequence of abnormal neuronal migration." The authors go on to say
that their research supports the recommendation by the FDA that
medically non-indicated commercial ultrasound videos should not be done.

I find this research concerning for more than just ultrasound videos
offered in malls. I wonder about repeated ultrasounds for medical
indications, dating ultrasounds during the most vulnerable periods of
cell migration in the brain, antenatal testing that has never been shown
to improve outcomes, and, the biggest of all, continuous fetal
monitoring during labor for hours on end. Remember: the ultrasound to
create pictures is pulsed---only 1/100th of the time is actual exposure
to ultrasound---whereas the fetal monitor on L & D is a continuous
deluge of ultrasound---it is not pulsed, the whole time is exposure to
ultrasound and the effects these researchers found increased with time.
Yes, most monitoring is after the time of migration of neurons cited
above, but we do know that the human brain continues to develop in a big
way for the rest of intrauterine life and a long time after, so there
may be are other effects on the brain cells. Anyone heard tell of
increased rates of autism, depression, bipolar disease, behavioral
problems, etc. in the current crop of young 'ens?? Food for thought.....

**Other Resources:**

**Physics and safety of diagnostic ultrasound in obstetrics and
gynecology, UpToDate**

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=antenatl/15779&type=A&selectedTitle=3~549>

**Indications for diagnostic obstetrical ultrasound examination,
UpToDate**

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=antenatl/7451&type=A&selectedTitle=1~549>

\*Eugenius, et al citation available from <Lisa.Allee@ihs.gov>

**Navajo News Jean Howe, Chinle**

**BTL: Nearly one half of women under 25 years old request information
on reversal**

It seems that hardly a month goes by without a woman coming in to our
clinic asking about how she can "get her tubes untied". This continues
to happen, despite the intensive counseling that we conduct prior to the
procedure. Thus I was intrigued by a recent article in the journal
Contraception, "Consent to Sterilization section of the Medicaid-Title
XIX form: is it understandable?" The authors assessed the readability
and comprehension characteristics of the current "Consent to
Sterilization" form using a tool specifically designed for informed
consent documents (Readability and Processability Form or RPF). The
current sterilization consent scored in the poor range when assessed
with this tool. A Fry reading level assessment corresponded to ninth
grade level. The authors also presented a proposal for a revised form,
which scored in the excellent range with an RPF assessment and had a Fry
reading level of sixth grade.

Of course informed consent for sterilization doesn't involve solely the
use of the federal permit. A second operative consent, specific to the
planned procedure, is also required. And true informed consent isn't
just about signing papers; it must involve a careful and thorough
discussion of the planned procedure, the alternatives, and the risk of
sterilization failure and the possibility of regret. The permanence of
the procedure is emphasized throughout this process. Yet life is
unpredictable and a woman's circumstances may change. A woman who is
completely sure that she wishes to proceed may return later, asking
about sterilization reversal and sharing a compelling story of previous
domestic violence or depression or of a new marriage.

Information about the risk of regret is available from the U.S.
Collaborative Review of Sterilization (CREST) study, which followed
11,232 women aged 18-44 who had sterilizations between 1978 and 1987 for
up to 14 years. One analysis, by Hillis, et al., clearly showed that the
risk of regret is highest in the youngest women. As part of the study,
follow-up visits were conducted over 14 years and participants were
asked at each visit "Do you still think tubal sterilization as a
permanent method of birth control was a good choice for you?" and found
that, for women under 30 at the time of sterilization, the risk of
regret was 20.3%. For women 30 or older at the time of sterilization,
the risk of regret was 5.9%. Another study of the same population
assessed the likelihood of regret by analyzing who requested information
about reversal. In this analysis, Schmidt, et al. again found the
highest risk of regret amongst the youngest women. When analyzed by age,
40.4% of women who were under 25 at the time of sterilization requested
information about reversal. This decreased with age as follows: 15.6%
for women ages 25-30, 8.2% for women ages 31-35, and 4.4% for women over
35 years old. Non-white race, \< 12 years of formal education, unmarried
status, a history of induced abortion, and postpartum sterilization,
especially after vaginal delivery, were all associated with a higher
incidence of regret, as was sterilization performed within 7 years of
the birth of the youngest child. Interestingly, the number of living
children did not correlate with the risk of regret. In some cases the
probability of regret was cumulative, for example women who were both
under 25 and unmarried at the time of sterilization had a 49% risk of
regret. Ultimately 1.1% of the study population obtained a tubal
reversal procedure; this was 8-fold more likely for women who were
sterilized at less than 30 then over 30 years of age.

One could view this information from the opposite perspective; 94% of
women over 30 and almost 80% of women under 30 did not regret their
decision to be sterilized. Even amongst the youngest age cohort, almost
60% of women under 25 did not express regret about sterilization during
up to 14 years of follow-up. Yet the fact that almost half of women
sterilized at a young age subsequently regretted the procedure is
compelling. Sterilization is one of many contraceptive options that we
can make available to our patients but it deserves a special status
because of its permanence. The same level of protection against
unplanned pregnancy can be achieved with an IUD which both avoids the
morbidity and risks of surgery and is completely reversible.

I am encouraged by Zite and her colleagues efforts in reassessing the
federal sterilization consent form. Although we are unlikely to see new
forms anytime soon, this serves as another reminder of the need to both
simultaneously respect our patients' autonomy in making contraceptive
and sterilization decisions for themselves and their families and to
equip them with proper tools to make these decisions. These tools
include both well-written and understandable consent forms and extensive
pre-procedure education that includes thorough discussions of the
alternatives to sterilization, the permanence of the procedure, and the
possibility of regret.

Zite, NB, Philipson, SJ, Wallace, LS, "Consent to Sterilization section
of the Medicaid-Title XIX form: is it understandable?", Contraception,
2007(75);256-260.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed>

Hillis, SD, et al., "Poststerilization regret: Findings from the United
States Collaborative Review of Sterilization", Obstetrics and
Gynecology, 1999(93)889-95.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=Search&DB=pubmed>

Schmidt, JE, et al., "Requesting information about and obtaining
reversal after tubal sterilization: findings from the U.S. Collaborative
Review of Sterilization", Fertility and Sterilization, 2000(74)892-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=Search&DB=pubmed>

#### [Deputy OB/GYN CCC Editorial comment:]{.underline}

**How are you going to solve your dilemma of first trimester screening
in a rural setting?**\
Last month I wrote about new recommendations from ACOG for first
trimester genetic testing and the challenges that rural facilities face
in trying to comply with these recommendations. I had hoped to follow-up
this month with some possible solutions to this dilemma but this issue
is proving to pose quite a challenge. Again, if you work at a rural
facility and have found a way to offer first trimester screening, or
combined first/second trimester screening, please share!

Also, if you have created or found a low-literacy patient education
sheet for this testing, please let me know. My e-mail address is:
<jean.howe@ihs.gov>.

####  {#section-32 .Style-Heading-4-+-Arial-14-pt-Underline}

**Nurses Corner, Sandra Haldane, HQE**

**Two summer programs for high school students**

July 21-28, 2007\-\--The Cornell Association for the Technological
Advancement of Learned Youth in Science and Technology (CATALYST)
program is a one-week summer residential program for rising high school
sophomores, juniors, and seniors from underrepresented backgrounds. 

<http://www.engineering.cornell.edu/diversity/office-diversity-programs/summer-programs/highschool-programs/catalyst/index.cfm>

July 21-28, 2007 -The CURIE Academy is a one-week residential program
for high school

girls who excel in math and science and want to learn more about careers
in engineering. 
<http://www.engineering.cornell.edu/diversity/office-diversity-programs/summer-programs/highschool-programs/curie-academy/index.cfm>

**Women sacrifice sleep to \"Do It All,\" survey finds**

#### American women are struggling to "do it all" and are sacrificing sleep to juggle their family and work responsibilities, according to a new survey led by a professor in the School of Nursing at the University of California, San Francisco. {#american-women-are-struggling-to-do-it-all-and-are-sacrificing-sleep-to-juggle-their-family-and-work-responsibilities-according-to-a-new-survey-led-by-a-professor-in-the-school-of-nursing-at-the-university-of-california-san-francisco. .Style-Heading-4-+-Arial-14-pt-Underline}

The 2007 Sleep in America Poll, sponsored by the National Sleep
Foundation, queried more than 1,000 adult women nationwide across all
ages and races. It found that 60 percent of American women get fewer
than one or two nights of good sleep each week, and 40 percent have
sleep problems every night. The result is a significant impact on their
mental and physical health, personal lives, professional work and
driving safety.

"We found that the majority of American women are continually sleep
deprived, either because of young children, biological changes like
pregnancy and menopause, stress or pets," said Kathryn Lee, PhD, a
professor in the Department of Family Health Care Nursing in the UCSF
School of Nursing, who led this year's study. "The impact on their
families, personal and professional lives, and society is enormous."

The survey results were reported at the Foundation's two-day scientific
workshop on women and sleep, held in conjunction with the Atlanta School
of Sleep Medicine. National Sleep Awareness Week, an annual health
promotion campaign sponsored by the Foundation.

Survey participants reported that the lack of sleep caused them to be
late to work, experience high stress, feel depressed or anxious, forego
exercise, be too tired for sex, drive while drowsy and have little time
for personal or family relationships.

Findings showed the primary cause of sleep deprivation was women's
efforts to fulfill their responsibilities in all aspects of their lives,
including in professional work, child care, family needs and spousal
relationships. Women's sleep is further compromised by biological
changes at various reproductive life stages, according to Lee.

The problem was most acute among working mothers, whom the study termed
the "briefcase and backpack" group. Those women's efforts to manage
full-time work schedules as well as family responsibilities left them
staying up late and continually sleep deprived, according to survey
results.

That group reported an average of only six hours in bed per night.
Nearly three-quarters of working mothers said they also suffered from
insomnia or lack of sleep.

"This is not to say that mothers should not be in the workforce," Lee
said. "In fact, they are often the most productive, organized and
efficient members of the staff. But it does point out the need for
employers and our society as a whole to support them better."

Lee said this support could include more flexible work hours, onsite
child care, shuttle services to reduce driving risks, cafeterias that
offer take-home meals for families, and opportunities for women to get
exercise during the work day. It also could include greater support from
spouses in handling home responsibilities, including preparing meals.

Other survey findings include:

• Sleep and exercise are the first things to go when women have too much
to do in a day. The last to go is work.

• Nearly half of all women say they don't get enough sleep every night.

• 30 percent of pregnant women and 42 percent of post-partum women
report rarely getting a good night's sleep, while 84 percent suffer from
insomnia a few nights per week.

• Women wake frequently during the night due to noise (39 percent),
giving care to children (20 percent) and pets (17 percent).

• 47 percent of women say they have no one to help with childcare at
night;

• 35 percent of working moms report driving while drowsy.

• 65 percent drink caffeinated beverages to cope with the lack of sleep.

Lee said these results substantiate two decades of research she has
conducted on women's sleep patterns, most of which has concentrated on
biologically-related sleep deficits throughout women's life cycle.

This is the Foundation's 10th annual survey of the American public's
sleep habits and the first to focus on women's sleep patterns at all
ages and biological states. Previous studies have focused on adults in
general; older adults; infants, toddlers and young school children; and
adolescents.

The National Sleep Foundation is an independent, nonprofit organization
dedicated to improving public health and safety by achieving greater
understanding of sleep and sleep disorders.

UCSF is a leading university that advances health worldwide by
conducting advanced biomedical research, educating graduate students in
the life sciences and health professions, and providing complex patient
care. <http://www.ucsf.edu/>

**How Should We Counsel Women About HPV Testing?**

**Question**

In our practice, we are now doing HPV screening when we do Pap smears
for women over 30 years old and for younger women if their Pap results
are equivocal. How should we adapt our patient counseling in light of
this new practice?

The National Association of Nurse Practitioners in Women\'s Health
(NPWH) recently issued guidelines for cervical cancer screening, based
on those issued by the American Society of Colposcopy and Cervical
Pathology. These new guidelines reflect evidence-based advances in our
understanding of the natural history of human papilloma virus (HPV), its
influence on the development of cervical dysplasia and cancer, and the
role of HPV DNA testing as an adjunct to Pap tests. A preview of the
guidelines is now available on the NPWH Web site.\[1\]

Your practice is currently screening according to those guidelines,
which recommend routine HPV screening, in addition to a Pap test, for
all women over 30 years of age. NPWH does not recommend routine HPV
screening for women younger than 30 unless they have an equivocal or
ASCUS (atypical squamous cells of undetermined significance) Pap result.
Younger women may be infected with HPV, but in most cases the HPV
infection clears on its own. Routine screening in the under-30
population can lead to overdiagnosis and unnecessary follow-up.
Persistent high-risk HPV is the causative factor for cervical dysplasia
and cancer.\[1\]

The NPWH guidelines also emphasize the importance of counseling for
women over the age of 30 years who are routinely tested regarding the
need for and the significance of HPV testing. Because HPV is a sexually
transmitted infection, being told that she is HPV-positive can be
alarming news to a woman who has been in a monogamous relationship for
many years when actually the positive result may indicate a persistent
infection that has never cleared. Younger women may also find the news
of a positive HPV test alarming, particularly if they are not aware that
the test might be done if their Pap result is abnormal.

Following are the points recommended by NPWH for counseling women about
HPV screening:

-   Cervical cancer is preventable and caused by high-risk types of HPV;

-   Most women will have an HPV infection at some point in their life;

-   The virus is usually cleared by an immune response;

-   Persistent HPV infection by high-risk types is the factor that
    increases the risk for cervical cancer;

-   Infection with HPV is common but cervical cancer is rare;

-   When an HPV test is positive, it does not mean that the virus is new
    or that a partner has been unfaithful; and

HPV can persist in the cells for decades so a positive test does not
necessarily indicate a new infection.

NPWH recommends covering these points at the time of testing to decrease
potential anxiety associated with a positive result.

[http://www.medscape.com/viewarticle/552678?sssdmh=dm1.255206&src=0_tp_nl_0#](http://www.medscape.com/viewarticle/552678?sssdmh=dm1.255206&src=0_tp_nl_0)

**17 Interventions That Work: Lessons Learned from PHNs in the Field**

Getting Behind the Wheel Minnesota Public Health 

<http://www.health.state.mn.us/divs/cfh/ophp/resources/phnnews/docs/0606wheelbook.pdf>

**Reducing turnover of registered nurses and certified nursing
assistants will help maintain nursing home staffing levels**

<http://www.ahrq.gov/research/mar07/307RA24.htm>

####  {#section-33 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Office of Women's Health, CDC {#office-of-womens-health-cdc-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Quadrivalent Human Papillomavirus Vaccine: Recommendations of the
Advisory Committee on Immunization Practices**

These recommendations represent the first statement by the Advisory
Committee on Immunization Practices on the use of a quadrivalent human
papillomavirus (HPV) vaccine licensed by the U.S. Food and Drug
Administration on June 8, 2006. This report summarizes the epidemiology
of HPV and associated diseases, describes the licensed HPV vaccine, and
provides recommendations for its use for vaccination among females aged
9-26 years in the United States.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr56e312a1.htm?s_cid=rr56e312a1_e>

####  {#section-34 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Oklahoma Perspective Greggory Woitte -- Hastings Indian Medical Center {#oklahoma-perspective-greggory-woitte-hastings-indian-medical-center .Style-Heading-4-+-Arial-14-pt-Underline}

**Cesarean Delivery on Maternal Request**

It was in June of last year when I last wrote about the NIH Consensus
conference on Cesarean Delivery on Maternal Request (CDMR). Over the
past year there has been several articles written on the subject. The
most recent of which is published in the New England Journal of Medicine
by Ecker and Frigoletto (excerpted below).

Here at Hasting's Indian Medical Center, we are beginning to explore
this issue through journal clubs and dialogue. We have had more patients
recently requesting Cesarean Delivery over the past year. A review of
the NIH Consensus conference points out that most of the evidence is
weak or non-existent to support planned vaginal or cesarean delivery.
Moderate quality evidence is available for only three outcome variables
(postpartum hemorrhage, maternal length of stay, and neonatal
respiratory morbidity). .

ACOG sent out a news release
[on](http://www.acog.org/from_home/publications/press_releases/nr05-09-06-1.cfm)
May 9, 2006 after the NIH consensus conference. In it they point out
that more research is needed and that CDMR is not recommended for women
planning on having several children due to the risks of placenta previa
and placenta accreta increasing with each cesarean delivery. In
addition, Dr. Zinberg, Deputy Executive Vice President of ACOG states
"ACOG continues to review all of the issues surrounding maternal-request
cesarean, but at this time our position is that cesareans should be
performed for medical reasons."

A number of the articles written have pointed out ACOG's position that a
cesarean delivery on maternal request can be ethically justified at
times. In ACOG's "Surgery and Patient Choice: The Ethics of Decision
Making," ACOG states that "In the absence of significant data on the
risks and benefits of cesarean delivery, the burden of proof should fall
on those who are advocates for a change in policy in support of elective
cesarean delivery (ie, the replacement of a natural process with a major
surgical procedure."

As many of the articles and editorials written over the past year have
pointed out, caution should be used when a patient requests a cesarean
delivery. Moving slowly in the absence of good evidence is a prudent
option. While support for a women's choice is without question of
paramount importance, performing cesarean deliveries on maternal request
may ultimately lead to a violation of the Hippocratic Oath to do no
harm.

#### [OB/GYN CCC Editorial comment:]{.underline}

**Looking for sanity in the ever increasing cesarean delivery rate**

Ecker and Frigoletto state the key question centers on both the number
needed to treat to avoid one adverse neonatal outcome and the level of
risk that is currently considered acceptable. As practicing
obstetricians, we find that the risk that women are now willing to
assume in exchange for a measure of potential benefit, especially for
the neonate, has changed: for many, the level of risk of an adverse
outcome that was tolerated in the past to avoid cesarean delivery is no
longer acceptable, and the threshold number needed to treat has thus
been reset.

In the face of the resulting continued increase in cesarean deliveries,
our obligation as providers is to educate patients about the trade-offs
entailed in choosing a particular course or intervention and to ensure
that their choices are congruent with their own philosophy, plans, and
tolerance of risk. In areas in which there is still uncertainty, we must
organize clinical trials that will produce the data we require for
counseling patients. For the moment, however, few of the relevant
factors seem likely to change, and the cesarean rate can be predicted to
continue its climb.

The March 2006 National Institutes of Health (NIH) State-of-the-Science
Conference report concluded that there was a need for research that
explicitly compared outcomes of planned cesarean delivery with outcomes
of planned vaginal delivery. Declercq et al examines 6 years of data
from a population-based linked data system to create a refined measure
identifying women with planned cesareans and planned vaginal births and
comparing maternal outcomes and costs associated with these two options.

1.) planned cesarean increases complications and re-hospitalizations and

2.) planned cesarean increases cost

Declercq et al document a small, but consistent growth in planned
primary cesareans, but higher costs, longer hospital stays, and
substantially greater risks of maternal re-hospitalization associated
with these deliveries.

The authors found that

\* The rate of re-admission to a hospital (per 1,000) within 1 month of
delivery for planned vaginal births was significantly lower than that
for planned primary cesarean births (7.5 vs. 19.2). Adjusting for age,
race or ethnicity, and parity, a woman who had a planned primary
cesarean birth was 2.3 times as likely as a woman who had a planned
vaginal birth to be re-admitted in the first month after the birth.

\* The leading reason for re-admission associated with planned primary
cesarean births in the first 30 days after birth was surgical wound
complications. Postpartum infections were a major cause of re-admission
for both groups, with the rate of re-admission for infection after
planned primary cesarean births almost twice as high as that of
infection after planned vaginal births.

\* The average initial maternal (excluding infant) hospital costs in
2003 dollars for a planned primary cesarean birth were 76% higher than
the average initial costs for a planned vaginal birth (\$4,372 vs.
\$2,487).

\* Women who had a planned primary cesarean birth averaged 4.3 days in
their initial stay and 4.4 days in cases of re-admission, compared with

2.4 and 3.9 days, respectively, for those with a planned vaginal birth.

\* Costs associated with a planned primary cesarean birth, compared with
costs associated with a planned vaginal birth, were higher for both
delivery (65%) and postpartum re-admission (11%).

# [Kennare R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Kennare+R"%5BAuthor%5D), et al just reported that after the first cesarean, the risks increase in next pregnancy. Specifically, cesarean delivery is associated with increased risks for adverse obstetric and perinatal outcomes in the subsequent birth. However, some risks may be due to confounding factors related to the indication for the first cesarean.

Dr. Woitte reminds us to do no harm. Declercq et al and [Kennare
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Kennare+R"%5BAuthor%5D),
et al findings suggest that planned primary cesareans are not without
immediate health consequences for mothers and financial implications for
society. Clinicians should be aware of the increased risk for maternal
re-hospitalization after cesarean deliveries to low-risk mothers when
counseling women about their choices.

**Reference:**

Declercq E, Barger M, Cabral HJ, et al. 2007. Maternal outcomes
associated with planned primary cesarean births compared with planned
vaginal births. Obstetrics and Gynecology 109(3):669-677.
[[http://www.greenjournal.org/cgi/content/abstract/109/3/669?etoc]{.underline}](http://www.greenjournal.org/cgi/content/abstract/109/3/669?etoc)
or

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17329519&dopt=Abstract>

[Ecker
JL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ecker+JL"%5BAuthor%5D),
[Frigoletto FD
Jr](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Frigoletto+FD+Jr"%5BAuthor%5D).
Cesarean delivery and the risk-benefit calculus. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2007 Mar
1;356(9):885-8.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17329693&dopt=Abstract>

Or <http://content.nejm.org/cgi/content/full/356/9/885>

[Kennare
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Kennare+R"%5BAuthor%5D),
et al Risks of adverse outcomes in the next birth after a first cesarean
delivery. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Feb;109(2 Pt 1):270-6

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17267823>

**NIH Consensus Conference Report**

[[http://consensus.nih.gov/2006
/2006CesareanSOS027html.htm]{.underline}](http://consensus.nih.gov/2006/2006CesareanSOS027html.htm)

**Patient-Requested Cesarean Update, ACOG Press Release**

<http://www.acog.org/from_home/publications/press_releases/nr05-09-06-1.cfm>

**Surgery and Patient Choice: The Ethics of Decision Making**

#### [**http://www.acog.org/from_home/publications/ethics/ethics021.pdf**](http://www.acog.org/from_home/publications/ethics/ethics021.pdf)  {#httpwww.acog.orgfrom_homepublicationsethicsethics021.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

#### Osteoporosis {#osteoporosis .Style-Heading-4-+-Arial-14-pt-Underline}

**Calcium Supplementation May Not Benefit Healthy Children**

Results: The meta-analysis incorporated 19 RCTs with 2,859 participants
three to 18 years of age. Calcium supplements of 300 to 1,200 mg per day
were reported. All eligible studies used tablets or pills as the source
of calcium; none used dairy foods. Studies used different body sites and
techniques to measure changes in bone mineral density. Overall, a modest
increase (1.7 percentage points) was found in the upper limb and in
total body bone mineral content, but no effect was found at the femoral
neck or lumbar spine. The effect on the upper limb persisted after
supplementation ended but was unlikely to be clinically significant.
Although girls seemed to benefit more than boys from supplementation,
the difference was not statistically significant. None of the subgroup
analyses showed any significant findings.

Conclusion: The authors conclude that calcium supplementation had little
effect on bone mineral density in healthy children and that the observed
slight increase in the upper limb should be interpreted with caution
because of design factors in the studies and meta-analysis. They suggest
more studies of supplementation with vitamin D are needed and that
measures to increase fruit and vegetable intake may be more appropriate
nutritional interventions.

Winzenberg T, et al. Effects of calcium supplementation on bone density
in healthy children: meta-analysis of randomised controlled trials. BMJ
October 14, 2006;333:775-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16980314>

**Osteoporosis Patients Likely to Pause Medication**

CONCLUSION: Extended gaps in treatment are common among users of
osteoporosis medications. Because the effectiveness of these drugs used
in an interrupted way is unknown, compliance interventions should
emphasize the need for continuous medication use. Further research is
needed to understand why patients often go for months without refilling
prescriptions and also whether similar utilization patterns exist for
other chronic medications

[Brookhart
MA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Brookhart+MA"%5BAuthor%5D),
et al Gaps in treatment among users of osteoporosis medications: the
dynamics of noncompliance. [Am J
Med.](javascript:AL_get(this, 'jour', 'Am J Med.');) 2007
Mar;120(3):251-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17349448>

**The Impact of Adherence and Persistence in the Pharmacological
Management of Osteoporosis**

<http://www.medsitecme.com/(inggvsfcvq51d0552qmdcnzl)/IDetail/Default_Campaign/Default_Program//302//sponsor.aspx>

**Role and Importance of Calcium in Preventing and Managing
Osteoporosis**

**Medscape CME**

<http://www.medscape.com/viewprogram/5237?src=0_nl_cme_9>

**Postmenopausal Osteoporosis: Putting the Risk for Osteonecrosis of the
Jaw Into Perspective**

[http://www.medscape.com/viewprogram/6720?sssdmh=dm1.255206&src=0_tp_nl_0#](http://www.medscape.com/viewprogram/6720?sssdmh=dm1.255206&src=0_tp_nl_0)

#### Patient Information {#patient-information .Style-Heading-4-+-Arial-14-pt-Underline}

#### Infertility: What You Should Know {#infertility-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20070315/857ph.html**](http://www.aafp.org/afp/20070315/857ph.html) {#httpwww.aafp.orgafp20070315857ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-35 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Perinatology Picks George Gilson, MFM, ANMC {#perinatology-picks-george-gilson-mfm-anmc .Style-Heading-4-+-Arial-14-pt-Underline}

**Preconception counseling for women with diabetes and hypertension:
What should the primary care provider do about their prescription
medications?**

Case #1

AD is a 25 y/o nullipara with newly diagnosed type 2 diabetes mellitus
and moderate essential hypertension. She also has been trying to become
pregnant. Her blood sugars have been fairly well controlled with diet
and exercise, but her blood pressure is persistently greater than
140/90. Because of her dual problem, would it be appropriate to start an
angiotensin converting enzyme (ACE) inhibitor? Could we then discontinue
it when she becomes pregnant? Or would it be safer to start another
medication that would be safer in pregnancy since she is not using any
form of contraception?

Case #2

RYC is a 34 y/o G3P3 with known type 2 diabetes mellitus. Her blood
sugars have been fairly well controlled with diet and metformin. She has
recently remarried and is trying to conceive. On her most recent
evaluation she is found to have the new onset of significant, but not
nephrotic syndrome range, proteinuria (1.5 g/24 h). Would it be wise to
start her on an ACE inhibitor, or an angiotensin receptor blocker (ARB),
at this time?

Case #3

IN is a 22 y/o nullipara who hyperlipidemia. There is a strong family
history of coronary artery disease, and her cholesterol has not been
able to be brought below 250 mg/dL despite diet and exercise. Her
triglycerides and LDL are also elevated, but her HDL is normal. Her BMI
is 34 kg/M2. She desires to become pregnant within the year and does not
wish to use any method of contraception. Would it be appropriate to
start her on an HMG-CoA reductase inhibitor (a "statin") at this time?

**Discussion**

The women in the above case vignettes are commonly encountered in
primary care practice, and present somewhat of a management dilemma.
Good guidelines for the use of common primary care therapies in women of
child-bearing age with diabetes, hypertension, and hyperlipidemia, are
not readily available. Nevertheless, such problems are being more
commonly encountered as the "obesity epidemic" progresses, especially in
our population. Is the risk of adverse cardiovascular events the same in
these young women as it is in their over 50 year old counterparts? What
is the risk of teratogenicity if they should become pregnant on the
various medicines we prescribe?

The angiotensin converting enzyme inhibitors (ACE) such as lisinopril,
enalapril, etc., are contraindicated in pregnancy. Because they relax
the glomerular afferent arteriole, they enhance glomerular blood flow
and thus reduce the incidence and severity of proteinuria and
hypertension in diabetic and hypertensive patients, a desirable effect.
However, in the fetus, they can create a situation of such persistent
glomerular high flow that destruction of the delicate fetal glomerular
capillary network may result. This can then result in fetal renal
failure and oligohydramnios. This may be seen during the latter half of
pregnancy, or in the newborn period. While this situation may be
reversible if the ACE is stopped, that cannot be assured. These same
effects have unfortunately also been described with the angiotensin
receptor blockers (ARB), such as candesartan. More recent data have now
demonstrated that ACE are also first trimester teratogens, and are
associated with congenital defects of the cardiovascular (atrial and
ventricular septal defects) and central nervous system and skeleton
(spina bifida, microcephaly, calvarial hypoplasia). Their use in the
peri-conceptional period is therefore no longer recommended. ACE also
appear in small quantities in breast milk. While I could not find any
evidence of adverse neonatal effects in breastfed infants whose mothers
were on ACE, I could likewise not find any pediatricians who were
comfortable with that situation....

REFERENCES

1.  Vijan S, et al. Screening, prevention, counseling, and treatment for
    complications of type II diabetes mellitus. J Gen Intern Med 1997;
    12:567-80.

2.  Klinke JA, Toth EL. Preconception care for women with type 1
    diabetes. Canadian Fam Physician 2003; 49:769-73.

3.  Leguizamon G, Reece A. Effect of medical therapy on progressive
    nephropathy: Influence of pregnancy, diabetes, and hypertension. J
    Mat Fet Med 2000; 9:70-8.

4.  ReproTox Data Base. Agent #: 3356, ACE Inhibitors. July 2006.

5.  Lip GYH, et al. Angiotensin-converting enzyme inhibitors in early
    pregnancy. Lancet 1997; 350:1446-7.

6.  Cooper WO, et al. Angiotensin-converting enzyme inhibitors and the
    risk of major malformations. N Eng J Med 2006; 354:2443-51.

7.  Ordovas JM, et al. Plasma lipids and cholesterol esterification rate
    during pregnancy. Obstet Gynecol 1984; 63:20-5.

8.  Dejager S, Turpin G. Hyperlipidemia in pregnancy. Press Med 1996;
    25:1839-45.

9.  ReproTox Data Base. Agent #: 4039, Atorvastatin. May 2004.

10. Hosokawa A, et al. Use of lipid-lowering agents (statins) during
    pregnancy. Canadian Fam Physician 2003; 49:774-8.

11. Edison RJ, Muenke M. Evidence for human teratogenicity of statins.
    Birth Defects Res 2003; 67:318-23.

#### [OB/GYN CCC Editorial comment:]{.underline}

**Is the glass ½ empty or ½ full?**

The fact that so many of our AI/AN patients have diabetes and/or
hypertension at younger ages is one of our greatest challenges. On the
other hand, their diabetes and hypertension are well controlled enough
that they can successfully pursue pregnancy. The above discussion is a
helpful first step. We will develop this discussion further, so keep
your eyes peeled for an upcoming Perinatology Corner module on this
topic.

In the meantime, I think you will find the link below helpful as it
combines risks and benefits beginning with rare events such as
Rhabdomyolysis, moving on to myalgia, and other systems effects and the
overall benefits to statin's use as indicated in risk reduction of CVD
which is the number one killer of AIAN women. This link from Medscape
discusses statins in a CME combined discussion
<http://www.medscape.com/viewarticle/550619>

**Other Resources**

More results from a search at the Medscape website.

<http://search.medscape.com/all-search?newSearch=1&queryText=statins>

More on ACE's

<http://search.medscape.com/all-search?newSearch=1&queryText=aces>  

ARB's angiotensin receptor blockers and their protective effects may add
to the discussion

<http://www.medscape.com/viewarticle/551042>

**Other**

**Re-visiting the issue of \"Amnisure**

CONCLUSION: Measurement of placental alpha-microglobulin-1 in
cervicovaginal secretions is superior to conventional clinical
assessment in the diagnosis of rupture of membranes. LEVEL OF EVIDENCE:
II.

[Lee
SE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Lee+SE"%5BAuthor%5D),
et al Measurement of placental alpha-microglobulin-1 in cervicovaginal
discharge to diagnose rupture of membranes. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Mar;109(3):634-40

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17329514>

#### [MFM Editorial comment:]{.underline}

Just wanted to re-visit this issue of \"Amnisure\" as a more accurate
and user-friendly method of diagnosing ruptured membranes, especially in
areas with facilities inexperienced with this problem on frequent basis,
or in doubtful cases here (not to replace the usual clinical criteria we
would continue to routinely use).

**Low-dose dopamine for pre-eclampsia with oliguria should not be used
other than in trial**

MAIN RESULTS: Only one randomised placebo controlled trial of six
hours\' duration, including 40 postpartum women, was found. This study
showed a significant increase in urinary output over six hours in women
receiving dopamine. It is unclear if this was of any benefit to the
women.

AUTHORS\' CONCLUSIONS: It is unclear whether low-dose dopamine therapy
for pre-eclamptic women with oliguria is worthwhile. It should not be
used other than in prospective trials.

Steyn D; Steyn P Low-dose dopamine for women with severe pre-eclampsia.
[Cochrane Database Syst Rev.  2007;
(1):CD003515](http://www.medscape.com/medline/publicationbrowser/123?pmid=17253491)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17253491>

**Probiotics for preventing preterm labour**

AUTHORS\' CONCLUSIONS: Although the use of probiotics appears to treat
vaginal infections in pregnancy, there are currently insufficient data
from trials to assess impact on preterm birth and its complications.

Othman M; Neilson J; Alfirevic Z Probiotics for preventing preterm
labour. [Cochrane Database Syst Rev.  2007;
(1):CD005941](http://www.medscape.com/medline/publicationbrowser/123?pmid=17253567) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17253567>

#### Primary Care Discussion Forum {#primary-care-discussion-forum .Style-Heading-4-+-Arial-14-pt-Underline}

**Electronic Health Record (EHR) Implementation: Worth the effort?**

May 1, 2007

Moderator: David Johnson, MD

-Anticipated benefits of an EHR: Demonstrated through experience?

-What are the real costs: Decreased efficiency, IT support requirements,
etc...

### -Effect on the provider -- patient relationship

### How to subscribe / unsubscribe to the Primary Care Discussion Forum?

Subscribe to the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26>

Unsubscribe from the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26>

Questions on how to subscribe, contact <nmurphy@scf.cc> directly

**STD Corner, Lori de Ravello, National IHS STD Program**

**HIV/AIDS among AI/AN Fact Sheet**

CDC Fact sheet -- updated from previous version.

Available at
[[http://www.cdc.gov/hiv/resources/factsheets/aian.htm]{.underline}](http://www.cdc.gov/hiv/resources/factsheets/aian.htm)

**HIV/AIDS protective factors among urban American Indian youths**

This research examined how family and individual factors influence 3
HIV/AIDS risk behaviors: having more than 1 sexual partner in the last 3
months, substance use at last sexual intercourse, and condom non-use at
last sexual intercourse. The sample includes 89 sexually active American
Indian adolescents living in a large Southwestern U.S. city. Logistic
regression results revealed that family communication acts as a
protective factor against HIV risk through a lower reported substance
use during last sexual intercourse, but it did not appear to affect the
number of multiple recent sex partners. Family and personal involvement
in American Indian cultural activities, both low on average in this
urban sample, had no effect on outcomes. This study advances knowledge
on sexual health risk and protective factors among American Indian
adolescents, an understudied group, and provides implications for
prevention intervention with American Indian youths and their families.
[[http://muse.jhu.edu/journals/journal_of_health_care_for_the_poor_and_underserved/]{.underline}](http://muse.jhu.edu/journals/journal_of_health_care_for_the_poor_and_underserved/)

Marsiglia FF, Nieri T, Stiffman AR HIV/AIDS protective factors among
urban American Indian youths. Journal of Health Care for the Poor &
Underserved. 17(4):745-58, 2006 Nov.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17242528>

**HIV-related risk behaviors, perceptions of risk, HIV testing, and
exposure to prevention messages and methods among urban American Indians
and Alaska Natives**

The goal of this study was to describe HIV risk behaviors, perceptions,
testing, and prevention exposure among urban American Indians and Alaska
Natives (AI/AN). Interviewers administered a questionnaire to
participants recruited through anonymous peer-referral sampling.
Chi-square tests and multiple logistic regression were used to compare
HIV testing by perception of risk and risk behavior status. Of 218
respondents with seronegative or unknown HIV status, 156 (72%, 95%
confidence interval \[CI\]: 66-78%) reported some HIV risk behavior: 57
(26%, 95% CI: 20-32%) high-risk behavior, and 99 (45%, 95% CI: 39-52%),
potentially high-risk. Among respondents reporting high-risk behavior,
44% rated themselves at no or low risk for HIV infection. Overall, 180
respondents (83%, 95% CI: 78-88%) had ever received an HIV test, 79
(36%, 95% CI: 31-57%) in the past year. HIV risk behaviors and
perception of risk were independently associated with recent HIV testing
after adjustment for gender, income, and homelessness (odds ratio \[OR\]
= 3.6; 95% CI: 1.5-9.0 for high-risk behavior vs. no reported risk
behavior, and OR: 3.2; 95% CI: 1.3-7.6, for high vs. no perceived risk).
Addressing inaccurate perception of risk may be a key to improving
uptake of HIV testing among high-risk urban AI/AN.

[[http://www.atypon-link.com/GPI/toc/aeap/18/6]{.underline}](http://www.atypon-link.com/GPI/toc/aeap/18/6)

Lapidus JA, Bertolli J, McGowan K, Sullivan P HIV-related risk
behaviors, perceptions of risk, HIV testing, and exposure to prevention
messages and methods among urban American Indians and Alaska Natives.
AIDS Education & Prevention. 18(6):546-59, 2006 Dec.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17166080>

#### Impact of HPV Immunization on Gynecologic Cancers {#impact-of-hpv-immunization-on-gynecologic-cancers-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Conclusion: In the United States, approximately 3,700 new cases of vulvar cancer are diagnosed every year, with about 800 women dying from it. The incidence is increasing, particularly in younger women with HPV infection. The authors conclude that prophylactic immunization could prevent many of these lesions and help patients avoid complex and distressing treatment, as well as death, from several genital neoplasias. {#conclusion-in-the-united-states-approximately-3700-new-cases-of-vulvar-cancer-are-diagnosed-every-year-with-about-800-women-dying-from-it.-the-incidence-is-increasing-particularly-in-younger-women-with-hpv-infection.-the-authors-conclude-that-prophylactic-immunization-could-prevent-many-of-these-lesions-and-help-patients-avoid-complex-and-distressing-treatment-as-well-as-death-from-several-genital-neoplasias. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Hampl M, et al. Effect of human papillomavirus vaccines on vulvar, vaginal, and anal intraepithelial lesions and vulvar cancer. Obstet Gynecol December 2006;108:1361-8. {#hampl-m-et-al.-effect-of-human-papillomavirus-vaccines-on-vulvar-vaginal-and-anal-intraepithelial-lesions-and-vulvar-cancer.-obstet-gynecol-december-20061081361-8. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20070315/tips/16.html**](http://www.aafp.org/afp/20070315/tips/16.html) {#httpwww.aafp.orgafp20070315tips16.html .Style-Heading-4-+-Arial-14-pt-Underline}

**Increases in Gonorrhea - Eight Western States, 2000-2005**

This report describes the epidemiology of gonorrhea in eight western
states that reported large increases in gonorrhea incidence rates from
2000 to 2005. The eight states are Alaska, California, Hawaii, Nevada,
New Mexico, Oregon, Utah and Washington. The results indicated that both
sexes and all specified age and racial/ethnic groups experienced
increases in gonorrhea rates. Causes for these increases remain unclear;
however, data suggest they likely resulted from a combination of
increases in the number of tests performed, trends in the types of test
performed, and actual increases in disease occurrence. The gonorrhea
rate among females increased 58.5%, from 52.3 per 100,000 in 2000 to
82.9 in 2005.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5610a4.htm?s_cid=mm5610a4_e>

**Sexually transmitted infections during pregnancy**

Two million of the 15 million (13.3%) new cases of sexually transmitted
infections (STIs) among persons 15 to 49 years old occur in pregnant
women. Access to care and a provider\'s ability to assess risk, screen,
and treat STIs are critical factors in preventing adverse pregnancy
outcomes. Significant variations in provider STI screening and treatment
practices exist despite recommended guidelines. This article reviews
issues related to screening and management of common STIs during
pregnancy, with emphasis on the new 2006 US Centers for Disease Control
and Prevention Sexually Transmitted Diseases Treatment Guidelines and
recently revised recommendations for HIV testing of pregnant women in
healthcare settings.

Johnson HL, Erbelding EJ, Ghanem KG. Sexually transmitted infections
during pregnancy. Curr Infect Dis Rep. 2007 Mar;9(2):125-33. 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17324350>

**Risk reduction counseling for prevention of sexually transmitted
infections: how it works and how to make it work**

Prevention research in the past decade has proved the efficacy of risk
reduction counselling in reducing the risks for sexually transmitted
infections (STIs). The question currently facing STI service providers
is therefore not so much whether counselling should be part of the
standard of STI care but rather how this intervention can be implemented
given the logistical and resource constraints of a busy practice
setting. After a brief introduction of the history and an overview of
the models for risk reduction counselling and their theoretical and
scientific underpinnings, the focus of this paper will be on the extent
to which individual prevention models have been adopted in different
clinical settings, the impediments to implementation and suggestions for
improvement.

# Risk reduction counselling for prevention of sexually transmitted infections: how it works and how to make it work C A Rietmeijer Sexually Transmitted Infections, Feb. 2007, Vol. 83 ,1, p. 2-9. 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17283359>

# 

# Racial / ethnic disparities in diagnoses of HIV/AIDS\--33 states, 2001-2005.

During 2001-2004, blacks accounted for 51% of newly diagnosed human
immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS)
infections in the United States. This report updates HIV/AIDS diagnoses
during 2001-2005 among black adults and adolescents and other
racial/ethnic populations reported to CDC through June 2006 by 33 states
that had used confidential, name-based reporting of HIV and AIDS cases
since at least 2001. Of the estimated 184,991 adult and adolescent HIV
infections diagnosed during 2001-2005, more (51%) occurred among blacks
than among all other racial/ethnic populations combined. Most (62%) new
HIV/AIDS diagnoses were among persons aged 25-44 years; in this age
group, blacks accounted for 48% of new HIV/AIDS diagnoses. New
interventions and mobilization of the broader community are needed to
reduce the disproportionate impact of HIV/AIDS on blacks in the United
States.
[[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5609a1.htm]{.underline}](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5609a1.htm)

# Racial/ethnic disparities in diagnoses of HIV/AIDS\--33 states, 2001-2005. MMWR Morb Mortal Wkly Rep. 2007 Mar 9;56(9):189-93. 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17347642>

**Burden of recurrent Chlamydia trachomatis: further uncovering the
\"hidden epidemic\"**

RESULTS: During the follow-up period of 23 318 person-months (mean, 4.7
years per person), 216 participants (52.6%) were diagnosed as having C
trachomatis infection, and 123 participants (29.9% of the total sample
and 56.9% of those with initial infections) were diagnosed as having
recurrent C trachomatis infections. Of 456 C trachomatis diagnoses made
during the study period, 241 (52.9%) were recurrent infections. The rate
of recurrent infections was 42.1 per 1000 person-months. The median time
to recurrent infection was 5.2 months. CONCLUSION: Recurrent C
trachomatis infections comprise a substantial health burden among young
women, possibly higher than previously recognized in this vulnerable
population.

Niccolai LM et al Burden of recurrent Chlamydia trachomatis infections
in young women: further uncovering the \"hidden epidemic\". Arch Pediatr
Adolesc Med. 2007 Mar;161(3):246-51.

[[http://archpedi.ama-assn.org/cgi/content/full/161/3/246]{.underline}](http://archpedi.ama-assn.org/cgi/content/full/161/3/246)

or

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17339505>

**Home screening for sexually transmitted diseases in high- risk young
women**

RESULTS: Of 197 women in the intervention group, 140 (71%) returned at
least one home test and 25 of 249 (10%) of home tests were positive.
Women who received home screening tests completed significantly more STD
tests overall (1.94 vs. 1.41 tests per woman-year, p\<0.001) and more
STD tests in the absence of symptoms (1.18 vs. 0.75 tests per
woman-year, p\<0.001). More women in the intervention group completed at
least one test when asymptomatic (162 (82.2%) vs. 117 (61.3%),
p\<0.001). The intervention was most effective among women recruited
outside of medical clinics. There was no significant difference in the
overall rate of STDs detected. CONCLUSIONS: Home screening significantly
increased the utilization of chlamydia and gonorrhea testing in this
sample of high risk young women, and thus represents a feasible strategy
to facilitate STD testing in young women.

Cook RL, et al Home screening for sexually transmitted diseases in high-
risk young women: randomized controlled trial. Sex Transm Infect. 2007
Feb 14;

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17301105>

**Pregnancy and STD Prevention Counseling: Motivational Interviewing**

RESULTS: At baseline, 59% of all participants reported a high level of
contraceptive use, 19% a low level and 22% nonuse. At two months, the
proportions of intervention and control participants who had improved
their level of use or maintained a high level (72% and 66%,
respectively) were significantly larger than the proportions who had
reported a high level of use at baseline (59% and 58%, respectively). No
significant differences were found between the groups at 12 months, or
between baseline and 12 months for either group. During the study,
10-11% of intervention and control participants became pregnant, 1-2%
received a chlamydia diagnosis and 7-9% had another STD diagnosed.
CONCLUSIONS: Repeated counseling sessions may be needed to improve
contraceptive decision-making and to reduce the risk of unintended
pregnancy and STDs. Petersen R, et al Pregnancy and STD Prevention
Counseling Using An Adaptation of Motivational Interviewing: A
Randomized Controlled Trial. Perspect Sex Reprod Health. 2007
Mar;39(1):21-8. 

[[http://www.blackwell-synergy.com/doi/pdf/10.1363/3902107]{.underline}](http://www.blackwell-synergy.com/doi/pdf/10.1363/3902107)

or

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17355378>

**Bi-Sexual Health: An Introduction and Model Practices for HIV/STI
Programming**

Sexual health issues affecting bisexuals have been largely ignored and
underrepresented in academic and professional literature. Many bisexuals
have negative experiences with health care providers, whether it is
because they are afraid to come out to their providers or because their
providers give them improper or incomplete information on HIV/STI
prevention. This report serves as an introduction to bisexuality and a
model programming guide for HIV/STI prevention.

[[http://www.thetaskforce.org/downloads/reports/reports/BisexualHealth.pdf]{.underline}](http://www.thetaskforce.org/downloads/reports/reports/BisexualHealth.pdf)

Created by the National Gay and Lesbian Task Force Policy Institute,
BiNet USA and the Fenway Institute.

####  {#section-37 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Barbara Stillwater Alaska State Diabetes Program  {#barbara-stillwater-alaska-state-diabetes-program .Style-Heading-4-+-Arial-14-pt-Underline}

**New recommendations for gestational weight gain may be required in
obesity epidemic**

As childhood obesity is increasing in prevalence and effective treatment
remains elusive, preventing childhood obesity remains critical. The
Institute of Medicine might need to re-evaluate its recommendations for
weight gain in (pregnancy), considering not only birth outcomes but also
risk of obesity for both mother and child. Pregnant women might aim for
the lower end of their recommended weight gain RESULTS: Greater weight
gain was associated with higher child body mass index z-score (0.13
units per 5 kg \[95% CI, 0.08, 0.19\]), sum of subscapular and triceps
skinfold thicknesses (0.26 mm \[95% CI, 0.02, 0.51\]), and systolic
blood pressure (0.60 mm Hg \[95% CI, 0.06, 1.13\]). Compared with
inadequate weight gain (0.17 units \[95% CI, 0.01, 0.33\]), women with
adequate or excessive weight gain had children with higher body mass
index z-scores (0.47 \[95% CI, 0.37, 0.57\] and 0.52 \[95% CI, 0.44,
0.61\], respectively) and risk of overweight (odds ratios, 3.77 \[95%
CI: 1.38, 10.27\] and 4.35 \[95% CI: 1.69, 11.24\]).

CONCLUSION: New recommendations for gestational weight gain may be
required in this era of epidemic obesity.

[Oken
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Oken+E"%5BAuthor%5D),
et al Gestational weight gain and child adiposity at age 3 years. [Am J
Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
Apr;196(4):322.e1-8

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17403405>

**Elevated Autoantibodies Linked to Preeclampsia**

Study points to potential biomarkers for risk assessment. These data
suggest that, as with sFlt-1 and insulin resistance, the AT1-AA does not
regress completely after delivery and, secondarily, that correlations
exist among these variables. The impact of AT1-AA after preeclampsia,
especially in the context of cardiovascular risk, remains to be
determined.

[Hubel
CA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Hubel+CA"%5BAuthor%5D),
et al Agonistic angiotensin II type 1 receptor autoantibodies in
postpartum women with a history of preeclampsia.
[Hypertension.](javascript:AL_get(this, 'jour', 'Hypertension.');) 2007
Mar;49(3):612-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17210828>

####  {#section-38 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Cholesterol Could be Key to Treating Fetal Alcohol Syndrome {#cholesterol-could-be-key-to-treating-fetal-alcohol-syndrome-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Small amounts of alcohol can interfere with the growth of a fetus, but
added cholesterol may help prevent a wide array of neurological and
physical defects from alcohol exposure, according to a new study in
laboratory fish. [Conclusion]{.underline}: We have shown that a simple
post-translational modification defect in a key morphogen may contribute
to an environmentally induced complex congenital syndrome. This insight
into FASD pathogenesis may suggest novel strategies for preventing these
common congenital defects.

[Li
YX](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Li+YX"%5BAuthor%5D),
et al Fetal alcohol exposure impairs hedgehog cholesterol modification
and signaling. [Lab
Invest.](javascript:AL_get(this, 'jour', 'Lab Invest.');) 2007
Mar;87(3):231-240

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17237799>

####  {#section-39 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Women's Health Headlines, Carolyn Aoyama {#womens-health-headlines-carolyn-aoyama .Style-Heading-4-+-Arial-14-pt-Underline}

**Weaving it all together: 2007 Behavioral Health Conference**

June 11-14, 2007

Albuquerque, NM

SAMHSA / IHS

Doctors, nurses, tribal leaders, behavioral health/substance abuse
program providers, psychologists, therapists, counselors, traditional
healers, health program administrators, CSAT, CSAP and CMHS tribal
grantees, youth, elders and other concerned community members are highly
encouraged to attend.

<http://www.kauffmaninc.com/2007bhconference/>

**Continuing Education - Quadrivalent Human Papillomavirus Vaccine:
Recommendations of the Advisory Committee on Immunization Practices**

This activity has been approved for 1.75 contact hours (continuing
nursing education); a maximum of 1.75 hours in category 1 credit
(continuing medical education credit for nonphysicians); a maximum of
1.75 hours in category 1 credit (continuing medical education); and 0.15
continuing education units.

<http://www2a.cdc.gov/ce/CourseDetails.asp?ActivityId=56-02&ProgramName=MMWR#Fees>

**Newly completed Pregnancy and Postpartum Quitline Toolkit**

For a one per person hard copy of the Quitline Toolkit sent to you
(include your mailing address)

Contact: Lauren DiBiase <ldibiase@schsr.unc.edu> or
<http://www.helppregnantsmokersquit.org/>

**How to Best Get the HPV Vaccine Information Sheets signed?**

Question:

Is it OK for us to send consent forms home to parents, with a letter and
Vaccine Information Sheet (VIS) sheet for Gardasil, and have them
returned to me at the school and immunize them at the school?  Or do I
need to have the parent present to sign consent for the immunization. 
Is there an IHS \"rule\"? When I ask locally all I get is opinion and
they differ.  Terry

**Answer:**

**How should we distribute Vaccine Information Sheet (VIS's) when the
parent or legal representative of a minor is not present at the time the
vaccination is given, for example during a school-based adolescent
vaccination program?**\
CDC's legal advisors have proposed two alternatives for this situation:

1.  Consent Prior to Administration of Each Dose of a Series. With this
    alternative the VIS must be mailed or sent home with the student
    around the time of administration of each dose. Only those children
    for whom a signed consent is returned may be vaccinated. The program
    must place the signed consent in the patient\'s medical record.

```{=html}
<!-- -->
```
1.  Single Signature for Series. This alternative is permissible only in
    those States where a single consent to an entire vaccination series
    is allowed under State law and in those schools where such a policy
    would be acceptable. The first dose of vaccine may be administered
    only after the parent or legal representative receives a copy of the
    VIS and signs and returns a statement that a) acknowledges receipt
    of the VIS and provides permission for their child to be vaccinated
    with the complete series of the vaccine (if possible, list the
    approximate dates of future doses); and b) acknowledges their
    acceptance of the following process regarding administration of
    additional doses:

    -   prior to administration of each dose following the initial dose,
        a copy of the VIS will be mailed to the parent (or legal
        representative) who signs the original consent at the address
        they provide on this statement, or the VIS will be sent home
        with the student; and

    -   the vaccine information statements for the additional doses will
        be accompanied by a statement notifying the parent that, based
        on their earlier permission, the next dose will be administered
        to their child (state the date), unless the parent returns a
        portion of this statement by mail to an address provided, to
        arrive prior to the intended vaccination date, in which the
        parent withdraws permission for the child to receive the
        remaining doses.

The program must maintain the original consent signature and any
additional dose veto statements in the patient\'s medical record. A
record must be kept of the dates prior to additional doses that the VIS
was mailed, or sent home with the adolescent.

<http://www.cdc.gov/nip/publications/VIS/vis-facts.htm#Anc6>

**Race/ethnicity, socioeconomic status, and lifetime morbidity burden in
the WHI**

RESULTS: Five percent of all women in the study population had high
lifetime morbidity burden. Women with high lifetime morbidity were more
likely to be AIAN or black; poor; less educated; divorced, separated, or
widowed; past or current smokers; obese; uninsured or publicly insured.
Lower SES was associated with higher morbidity among most women. The
extent to which morbidity was higher among lower SES compared to higher
SES women was about the same among Hispanic women and white women, but
was substantially greater among black and AIAN women compared with white
women. CONCLUSIONS: This study demonstrates the importance of
considering race/ethnicity and class together in relation to health
outcomes.

[Gold
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Gold+R"%5BAuthor%5D),
et al Race/ethnicity, socioeconomic status, and lifetime morbidity
burden in the women\'s health initiative: a cross-sectional analysis.
Journal of Women\'s Health. 15(10):1161-73, 2006 Dec.
[[http://www.liebertonline.com/doi/pdf/10.1089/jwh.2006.15.1161]{.underline}](http://www.liebertonline.com/doi/pdf/10.1089/jwh.2006.15.1161)

# Save the dates {#save-the-dates .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

**Training Course** **in MCH** **Epidemiology**

-   Albuquerque, New Mexico

-   June 10 - 15, 2007

-   Sponsored by HRSA / MCHB and CDC

<http://www.crpcorp.info/mchtraining2007.htm>

**Weaving it all together: 2007 Behavioral Health Conference**

-   June 11-14, 2007

-   Albuquerque, NM

-   SAMHSA / IHS

<http://www.kauffmaninc.com/2007bhconference/>

**Native Women's Health and MCH Conference**

-   August 15 -17, 2007

-   Albuquerque, NM

-   Questions? Contact <nmurphy@scf.cc>

<http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07>

**3rd Annual American Indian and Alaska Native Long Term Care
Conference**

-   September 5-6, 2007

-   Albuquerque, New Mexico

-   Visit
    [http://www.aianlongtermcare.org](http://www.aianlongtermcare.org/)

-   Contact <Bruce.Finke@ihs.gov>

**I.H.S. / A.C.O.G. Obstetric, Neonatal, and Gynecologic Care Course**

-   September 16 -- 20, 2007

-   Denver, CO

-   Contact Yvonne Malloy at 202-863-2580 or <YMalloy@acog.org>

# What's new on the ITU MCH web pages? {#whats-new-on-the-itu-mch-web-pages .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

**Electronic Health Record (EHR) Implementation: Worth the effort?**

<http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#ehr>

**Implementation and Use of an Electronic Health Record within the
Indian Health Service**

[**J Am Med Inform
Assoc.**](javascript:AL_get(this, 'jour', 'J Am Med Inform Assoc.');)
**2007 March-April**

<http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Sequist4207.doc>

There are several upcoming **Conferences**

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#top>

and **Online CME/CEU resources**, etc....

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN13.cfm>

and the latest **Perinatology Corners** (free online CME from IHS) are
at

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHpericrnr.asp>

...or just take a look at the **What's New** page

<http://www.ihs.gov/MedicalPrograms/MCH/W/WN00.asp#top>

# Did you miss something in the last OB/GYN Chief Clinical Consultant Corner? {#did-you-miss-something-in-the-last-obgyn-chief-clinical-consultant-corner .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

#### The April 2007 OB/GYN CCC Corner is available at: {#the-april-2007-obgyn-ccc-corner-is-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0407.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0407.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn0407.cfm-1 .Style-Heading-4-+-Arial-14-pt-Underline}

####  Abstract of the Month page 5 {#abstract-of-the-month-page-5-1 .Style-Heading-4-+-Arial-14-pt-Underline}

# Quadrivalent Human Papillomavirus Vaccine: Final ACIP Recommendations

Comments by Amy Groom

#### From your colleagues page 9 {#from-your-colleagues-page-9 .Style-Heading-4-+-Arial-14-pt-Underline}

Gordon Belcourt

-Project Safe Neighborhoods

-Recent changes affecting maternal mortality data

-What is known about the outcomes of school health programs?

Stephen Heath

When Things Go Wrong: Responding to Adverse Events

Scott Giberson

HHS National HIV/AIDS Mobilization Campaign

Rhonda Johnson

The Disparities Solution Center: Disparities Leadership Program

#### Hot Topics {#hot-topics-2 .Style-Heading-4-+-Arial-14-pt-Underline}

##### Obstetrics page 12

-GPRA Reporting: HIV Prenatal Screening by Brigg Reilley / Scott
Giberson

-Obstetric Causes of Cerebral Palsy Are Uncommon

-Significantly higher rehospitalization rates and costs with planned
cesareans

-Fish During Pregnancy May Boost Childrens\' IQ

-Induction after 41 completed weeks or later is associated with fewer
perinatal deaths

and more .....

**Gynecology page 17**

-Ultrasonography Detects Malignant Adnexal Masses

-High rates of complications after sling surgery suggest the need for
quality improvement

-Surgery versus medical therapy for heavy menstrual bleeding

\- Inside-out for transobturator tape placement was closer to
neurovascular structures

-Monsel\'s paste and fulguration with ball electrode appear be equally
effective

and more .....

**Child Health page 19**

-Newborn male circumcision: Improved outcomes with pediatric
hospitalists

-Eleven medications account for one-third of errors that harm
hospitalized children

-Croup: Single dose of prednisolone less effective than single dose of
dexamethasone

-Use of Child Restraints in 2006: New NHTSA Research Note

-Failure to thrive: No associations found with social class or parental
education

**Chronic Illness and Disease page 20**

# -New Findings Support Fetal Overnutrition Hypothesis

-Obesity surgeries have jumped dramatically since 1998, AHRQ

-High BP in Pregnancy Increases Risk for Future Atherosclerosis

-Switching from tamoxifen to aromatase inhibitor improves survival in
breast cancer

-Telephone Counseling Improves Smoking Cessation Rates

and more .....

#### Features page 22 {#features-page-22 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-Ob-Gyns Encouraged to Help Reduce Colorectal Cancer Deaths in Women

-Medical Futility - Committee Opinion

##### American Family Physician

-Treatment of the Common Cold

-Cough: Diagnosis and Management: Practice Guidelines

-Common Oral Lesions: Part I. Superficial Mucosal Lesions

-Common Oral Lesions: Part II. Masses and Neoplasia

-Iron Deficiency Anemia

and more .....

**Agency for Healthcare Research and Quality**

-Diagnostic errors are typically the result of multiple individual and
system breakdowns

-Some pregnant women are still prescribed medications with the potential
to harm the fetus

-Shifting from a culture of blame to a culture of safety could help
prevent medical errors

**Ask a Librarian**

### **The CDC website should be bookmarked: Pelvic Inflammatory Disease**

**Breastfeeding**

-Inquiring families want to know - what about breastfeeding and......

-Breast-Feeding Enhances Vision Development in Infants

#### -Simple antenatal preparation to improve breastfeeding practice: RCT {#simple-antenatal-preparation-to-improve-breastfeeding-practice-rct .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Longer duration of lactation associated with favorable changes in metabolic risk factors {#longer-duration-of-lactation-associated-with-favorable-changes-in-metabolic-risk-factors .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Postpartum Mastitis and Community-Acquired Methicillin-Resistant S. Aureus {#postpartum-mastitis-and-community-acquired-methicillin-resistant-s.-aureus .Style-Heading-4-+-Arial-14-pt-Underline}

**CCC Corner Digest**

-Healing words: The power of \'I\'m sorry\' in medical practice

-Ryan White HIV / AIDS Treatment Modernization Act of 2006

-GDM Guidelines: Major discrepancies to identify GDM and predict
pregnancy outcome

-Cystocoele Repair: The Mesh Controversy

-Review and Comment: Newborn record form IHS-298 and its revision

-Does Delay in Diagnosis of Breast Cancer Impact Prognosis?

-ACOG Opposes Sex Selection for Family Planning Purposes

-ACOG Calls on Employers to Support Breastfeeding

-Abstinence counseling vs family planning: Which is more effective?

-The MCH Coordinators Site has a clean new look, plus new functionality

-How many rubella vaccines does a mother really need to get?

-Sexual behavior in context: A public health perspective

-Scrub Club

-Prolonged second stage with an epidural

-Maternal positioning and pain relief: Promoting effective pushing

-Clomiphene "bests" Metformin in a NEJM study

-A \"Small Fall\" and a Trip to the Emergency Department

-Indian Health Surveillance Report---Sexually Transmitted Diseases 2004

-Ultrasound is better at finding Neural Tube Defects than AFP

-Adolescent with knee pain, Web M+M, Terry Cullen - Moderator

-A First: STD Rates Available by IHS Area

-Fertility rises as weight drops

-Women\'s Health Week will be celebrated May 13-19, 2007

-2^nd^ methamphetamine issue of the IHS Primary Care Provider online

**Domestic Violence**

-Violence Threatens the Health of Pregnant Women and Newborns

-Intimate Partner Violence in Pregnancy: Clinicians Guidelines Tutorial,
CDC

-Health Cost Higher for Survivors of Domestic Violence

**Elder Care News**

-Guidelines for Palliative Care Services in the Indian Health: Now
Online

-3rd annual American Indian and Alaska Native Long Term Care Conference

-Disability among older Americans continues significant decline

**Family Planning**

#### -Non-latex versus latex male condoms for contraception {#non-latex-versus-latex-male-condoms-for-contraception .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Population effect of increased access to emergency contraceptive pills {#population-effect-of-increased-access-to-emergency-contraceptive-pills .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

**Indian Health Service Methamphetamine Initiative Site**

**Frequently asked questions**

-Does misoprostol aid prior to IUD insertion?

-What are Pilates?

**Indian Child Health Notes**

-Iron deficiency in infancy may have permanent cognitive effects

-Same health issues facing the developing world are in force in Indian
Country

**Information Technology**

-2007 Physician Quality Reporting Initiative Webpage Is Now Available

-HIPPA mandated standard unique identifiers for health care providers:
NPPES

International Health

Testing New Drugs on the World's Poorest Patients

#### MCH Alert

How science has revolutionized the understanding of drug addiction

Disparities in Fetal and Perinatal Mortality

#### MCH Headlines

Training opportunity -- Infant mental health

The Magic of Play

Cervical Cancer in America

A MUST tool for multidisciplinary teams reviewing infant / child deaths

Remember the car seat video I sent out in the past year about being 4'9"
tall?

and more .....

#### Medical Mystery Tour

#### Prolonged second stage with an epidural {#prolonged-second-stage-with-an-epidural .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

######### -Exercise in the Age of Evidence-Based Medicine: A Clinical Update

######### -Genital Warts: Best Practices for Diagnosis and Management

######### -Routine Testing for HIV Infection: CDC Screening Recommendations 

-Preventing STD-Related Cancers: An Update on Vaccination Strategies

-How to Optimize the Management of Acid-Peptic Disorders

and more .....

**Menopause Management**

Oral, not Transdermal, Estrogen Increases Risk for VTE in Women 

#### -New low dose estradiol transdermal gel for postmenopausal symptoms {#new-low-dose-estradiol-transdermal-gel-for-postmenopausal-symptoms .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Unopposed estradiol: Anticipate uterine bleeding and endometrial biopsy {#unopposed-estradiol-anticipate-uterine-bleeding-and-endometrial-biopsy .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Nonhormonal therapies for menopausal hot flashes: systematic review  {#nonhormonal-therapies-for-menopausal-hot-flashes-systematic-review .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

-The spirituality of presence in midwifery care

-History and Evidence Base for Normal Birth

**Navajo News**

Sharing strategies to meet ACOG standards with limited resources

**Nurses Corner**

-Adverse Drug Events Among Patients in a Tertiary Care Medical Center

#### -Family Support in Patient-Centered Care: New Guidelines Issued {#family-support-in-patient-centered-care-new-guidelines-issued .Style-Heading-4-+-Arial-14-pt-Underline}

#### -A Call to Action for Caregivers and Patients: Imaging X-rays Cause Cancer {#a-call-to-action-for-caregivers-and-patients-imaging-x-rays-cause-cancer .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Role of Exercise in Treating Postpartum Depression: A Review {#role-of-exercise-in-treating-postpartum-depression-a-review .Style-Heading-4-+-Arial-14-pt-Underline}

#### Office of Women's Health, CDC

# -QuickStats: Birth Rates\* Among Females Aged 15\--19, by State

-Fetal and Perinatal Mortality, United States, 2003

**Oklahoma Perspective**

Cesarean Delivery on Maternal Request

Osteoporosis

Bisphosphonate Related Osteonecrosis of the Jaws

Patient Education

# -Anemia: When Low Iron Is the Cause

# -Iron Deficiency Anemia in Infants and Children: How to Prevent It

-Does Diabetes Run in Your Family?  

# -Canker Sores: What Are They and What Can You Do About Them?

#### -The Common Cold: What You Should Know {#the-common-cold-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

and more .....

Perinatology Picks

-What is the best management plan for the woman with suspected preterm
labor?

-Short Interval Between Pregnancy and Cervical Conization May Raise
Preterm Birth Risk

-Concern about women taking bromocriptine long term for
hyperprolactinemia?

-Results caution against a repeat dose of glucocorticoid in high-risk
pregnancies

-If normal ultrasound at 22-24 weeks the risk of developmental delay is
not increased

and more .....

Primary Care Discussion Forum

Electronic Health Record (EHR) Implementation: Worth the effort?

STD Corner

#### -HPV Vaccine FAQs {#hpv-vaccine-faqs .Style-Heading-4-+-Arial-14-pt-Underline}

-Updated CDC Guidelines for the Treatment of STDs

#### -CDC Releases Data on HIV-Related Risk Behaviors in U.S. High School Students {#cdc-releases-data-on-hiv-related-risk-behaviors-in-u.s.-high-school-students .Style-Heading-4-+-Arial-14-pt-Underline}

#### Barbara Stillwater, Alaska Diabetes Prevention and Control

Northern Women at Most Risk: Vitamin D Deficiency Widespread During
Pregnancy

**Women's Health Headlines**

-Can you dispense birth control agents to minors without parental
consent?

-Welcome to the Indian Health Service Methamphetamine Initiative Site

###### Save the Dates: Upcoming events of interest page 63

#### What's new on the ITU MCH web pages page 64

-Can one dispense birth control agents to minors without parental
consent?

-Are birthing center regulations less restrictive than hospitals?

-How many rubella vaccines does a mother really need to get?

The past CCC Corners are archived at:

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN01.cfm#top>

The CCC Corner is good way to inform ITU providers about recent updates,
while decreasing the number of e-mail messages.

Let me know if you want to add something to next month's CCC Corner at
<nmurphy@scf.cc>

or 907 729 3154 (with voicemail)

\*The opinions expressed in the OB/GYN CCC Corner are strictly those of
the authors, and not necessarily those of the Indian Health System, or
the author of this newsletter. If you have any comments, please share
them by joining the Primary Care Discussion Forum where this topic was
recently discussed. To join the Primary Care Listserv, click on
'Subscribe' here
<http://www.ihs.gov/MedicalPrograms/MCH/F/MCHdiscuss.cfm>

4/16/07njm