New contributors to Indian Child Health Notes

Doug Esposito, Fort Defiance Reviews of the recent AI/AN children
literature

David Gahn Featured Website(s)

Roslayn Singleton, Alaska CDC Updates on infectious diseases and
immunizations

![](media/image1.png){width="6.375in" height="1.0520833333333333in"}

OB/GYN Chief Clinical Consultant's Corner

Volume 3, No. 9, September, 2005

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

#### Abstract(s) of the Month: page 4 {#abstracts-of-the-month-page-4 .Style-Heading-4-+-Arial-14-pt-Underline}

**Cesarean delivery in Native American women: are low rates explained by
practices common to the Indian health service?**

#### From your colleagues: page 5 {#from-your-colleagues-page-5 .Style-Heading-4-+-Arial-14-pt-Underline}

Terry Cullen

-UpToDate available even while you are deployed

-The Commonwealth Fund/Harvard Fellowship in Minority Health Policy

Chuck North

-Summary: Appropriate use of narcotics for chronic non-malignant pain

**Meera Ramesh**

**-**Diabetes prevention and control - Prenatal program

Judy Thierry

-Maternal Morbidity in AI/AN Women, 2002-2004

-Methamphetamine in Indian Country: Good Resources

-FDA Director of the Office of Women\'s Health resigns

-Women\'s Health USA 2005 is online

-Healthy People 2010 midcourse review seeks your comments

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

##### Obstetrics: page 8

-Meperidine for Dystocia During First Stage of Labor: Limit Use

-Progesterone therapy ameliorates other risk factors in previous preterm
delivery

-Misoprostol: Effective and safe treatment option in term premature
rupture of membranes

-Risk of stillbirth is substantially elevated among very and extremely
high parity gravidas

-The 4P\'s Plus screen for substance use in pregnancy: clinical
application and outcomes

and more....

**Gynecology: page 10**

-PID: Outpatient treatment was as effective in preventing reproductive

-Every woman matters study: Improving female health care through
practice change

-Metformin for Anovulation in Normoandrogenic Women

-Virtually all women with prolapse can be treated and their symptoms
alleviated

-Colposcopy: An Evidence-Based Update

and more.....

**Child Health: page 11**

-Adolescents Prefer Honesty and Patient-Centered Care

-Parent Intervention in Risky Adolescent Behaviors Can Help

-Clustering of fast food restaurants around schools

-AMA releases findings on sources of alcohol for adolescents

-School-based dental sealant program manual now available online

and more....

**Chronic Illness and Disease: page 12**

-One Third of Deaths From GI Bleeding Due to NSAIDs

-Withdrawing Aspirin May Significantly Increase Stroke Risk 

-Dietary Calcium Intake and Obesity

-Intertrigo and Common Secondary Skin Infections

-Screening for HCV Infection: Understanding the USPSTF Recommendation

and more....

**Features:** **page 13**

##### American Family Physician -- Cochrane for Clinicians

-Room Air vs. Oxygen for Resuscitating Infants at Birth

-Short-Acting Insulin Analogues vs. Human Insulin for Diabetes

American College of Obstetricians and Gynecologists

-Elaine Locke: Key Contributor to Improve AI/ AN Women's Health for 35
years

-Management of abnormal cervical cytology and histology, ACOG Practice
Bulletin No. 66

-Obesity in Pregnancy

-The Importance of Preconception Care in the Continuum of Women's Health
Care

-Meningococcal Vaccination for Adolescents

**Agency for Healthcare Research and Quality**

-AHRQ Research Activities Relevant to the American Indian and Alaska
Native Community

### -Omega-3 Fatty Acids, Effects on Child and Maternal Health

-Prenatal screening and Tx needed to identify pregnant women with Asx
chlamydia infection

-Screening asymptomatic, low-risk pregnant women for hepatitis C virus
is not cost effective

-AHRQ-Supported Study Finds Medical Disparities Narrowing

**Ask a Librarian**

-The Known and the Unknown - Clinical Evidence Summarized

**Breastfeeding**

-Glyburide nor glipizide compatible with breast-feeding

**Case Managers Corner**

#### -Wouldn't it be nice if there was more distance education available to nurses? {#wouldnt-it-be-nice-if-there-was-more-distance-education-available-to-nurses .Style-Heading-4-+-Arial-14-pt-Underline}

-What are some resources for nurse staffing ratios in L/D and
postpartum**?**

**CCC Corner Digest**

**-**Open access can work for any type of practice. It is the wave of
the future

-New IHS Women's Health Consultant / Advanced Practice Nurse Consultant

-Relative value of physical exam of the breast as a screening tool

-Trial of Labor After Cesarean: Evidence based guidelines

-Ovarian conservation benefits survival in women undergoing hysterectomy

-AAP Releases Report on Excessive Sleepiness in Adolescents

-Existing heart disease is undiagnosed in 1/2 of women with first heart
attack

-Management of Endometrial Cancer ACOG Practice Bulletin NUMBER 65

-The Known and the Unknown - Clinical Evidence Summarized

-Stress and verbal abuse in nursing

-Toward optimal screening strategies for older women: Should cost matter
the most?

-Over-The-Counter Sales of Emergency Contraception Do Not Increase
Unsafe Sex

-Magical Mystery Tour: The Answer: 2 positive blood cultures in a
postpartum patient with fever

-Please help us build the Midwives Indian Health Patient Education
Resources page

-Is the patch more dangerous than the pill?

-Glyburide, Glargine, and Effects of Obesity

-Condom effectiveness for prevention of *Chlamydia trachomatis*
infection

-Women the stronger gender? Men more carbohydrate intolerant / less
physical endurance

**Domestic Violence**

-Patients May Prefer That Physicians Ask About Family Conflict

-Guides to Investigating Child Abuse

**Elder Care News**

-Cancer screening in elderly patients: a framework for individualized
decision making

**Family Planning**

-EC in adolescents: No compromise of family planning or increased sexual
behavior

#### -Contraception, the 'Patch', and reports of adverse events including death {#contraception-the-patch-and-reports-of-adverse-events-including-death .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

-CDC "Key Facts about Flu Vaccine"

**Frequently asked questions**

-Should a urine test be performed on every pregnant patient each
prenatal visit?

-Should we be performing some type of long term follow-up on our GDM
patients?

-Should we do a test of cure for Chlamydia in pregnancy? If so, when?

-What is the safest, most effective approach to prodromal labor?

-Should we use glargine use in pregnancy?

and more.....

**Indian Child Health Notes**

-Early Childhood Longitudinal Study provides a wealth of background
information

-Roslayn Singleton, ANMC: Information on the new adolescent pertussis
booster vaccination

-Doug Esposito of Fort Defiance, AZ: Effort to reduce suicide in AI/AN
communities

**Information Technology**

-Physicians\' Use of Electronic Medical Records

-NCHS Statistics on the Use of Electronic Medical Records

-ISAC Request for Issues/Recommendations

International Health

-Indigenous peoples\' health\--why are they behind everyone, everywhere?

-Volunteer Opportunities - Hurricane Katrina

#### MCH Alert

-Adolescent pregnancy prevention

-Cost effectiveness of interventions for major depression in low income
minority women

#### Medical Mystery Tour

-Overbooked clinic and next patient with chronic pelvic pain

#### Medscape

**Menopause Management**

-AHRQ Releases Evidence Report on Managing Menopause-Related Symptoms

-Tibolone and Low-Dose Hormone Therapy Seen as Postmenopausal

#### -Natural History of Menopause Symptoms in Primary Care Patients {#natural-history-of-menopause-symptoms-in-primary-care-patients .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

#### -Centering Pregnancy -- Group Prenatal Care, Amy Doughty, Zuni {#centering-pregnancy-group-prenatal-care-amy-doughty-zuni .Style-Heading-4-+-Arial-14-pt-Underline}

-Public health approach to suicide prevention in an AI/AN, Marsha
Tahquechi, GIMC

**Navajo News**

-Annual Navajo Area Women's Health Provider Meeting, September 23^rd^ in
Chinle

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

-Breast and Cervical Cancer Program Highlights

**Oklahoma Perspective**

-Electronic Health Record for care of women and children

Osteoporosis

#### -Osteoporosis Prevention in Postmenopausal Women {#osteoporosis-prevention-in-postmenopausal-women .Style-Heading-4-+-Arial-14-pt-Underline}

#### -New Report on Soy Finds Limited Evidence for Health Outcomes {#new-report-on-soy-finds-limited-evidence-for-health-outcomes .Style-Heading-4-+-Arial-14-pt-Underline}

Patient Education

-The "talk-sing test" -- If patient can sing, then the pace can be
increased

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

Perinatology Picks

First trimester prenatal genetic screening: Is it ready for 'Prime Time'
at your facility?

Primary Care Discussion Forum

Rectal bleeding: Is it hemorrhoids? November 1, 2005\
Morbidity and Mortality Rounds - Web Based - Moderator: Terry Cullen

STD Corner

-Evaluating a teen STD prevention Web site

-Screening for sexually transmitted diseases in non-traditional
settings: a personal view

-Should we do a test of cure for Chlamydia in pregnancy? If so, when?

#### Barbara Stillwater Alaska Diabetes Prevention and Control

-Reduce insulin resistance during pregnancy

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

**What's new on the ITU MCH web pages** **page 38**

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

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

**Cesarean delivery in Native American women: Are low rates explained by
practices common to the Indian health service?**

**Background:** Studying populations with low cesarean delivery rates
can identify strategies for reducing unnecessary cesareans in other
patient populations. Native American women have among the lowest
cesarean delivery rates of all United States populations, yet few
studies have focused on Native Americans. The study purpose was to
determine the rate and risk factors for cesarean delivery in a Native
American population.

**Methods:** We used a case-control design nested within a cohort of
Native American live births, \>/= 35 weeks of gestation (n = 789),
occurring at an Indian Health Service hospital during 1996-1999. Data
were abstracted from the labor and delivery logbook, the hospital\'s
primary source of birth certificate data. Univariate and multivariate
analyses examined demographic, prenatal, obstetric, intrapartum, and
fetal factors associated with cesarean versus vaginal delivery.

**Results:** The total cesarean rate was 9.6 percent (95% CI 7.2-12.0).
Nulliparity, a medical diagnosis, malpresentation, induction, labor
length \> 12.1 hours, arrested labor, fetal distress, meconium, and
gestations \< 37 weeks were each significantly associated with cesarean
delivery in unadjusted analyses. The final multivariate model included a
significant interaction between induction and arrested labor (p \<
0.001); the effect of arrested labor was far greater among induced (OR
161.9) than noninduced (OR 6.0) labors. Other factors significantly
associated with cesarean delivery in the final logistic model were an
obstetrician labor attendant (OR 2.4; p = 0.02) and presence of meconium
(OR 2.3; p = 0.03).

**Conclusions**: Despite a higher prevalence of medical risk factors for
cesarean delivery, the rate at this hospital was well below New Mexico
(16.4%, all races) and national (21.2%, all races) cesarean rates for
1998. Medical and practice-related factors were the only observed
independent correlates of cesarean delivery. Implementation of
institutional and practitioner policies common to the Indian Health
Service may reduce cesarean deliveries in other populations.

[Mahoney
SF](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Mahoney+SF"%5BAuthor%5D),
[Malcoe
LH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Malcoe+LH"%5BAuthor%5D).
Cesarean delivery in Native American women: are low rates explained by
practices common to the Indian health service? Birth. 2005
Sep;32(3):170-8.

<http://www.ihs.gov/MedicalPrograms/MCH/M/Pr01.cfm#AlaskaNative>

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

I have always marveled at what great patients AI/AN women are to
practice medicine with. I assumed our patient's many favorable obstetric
traits were in part genetic and part cultural, plus a degree of genetic
homogeneity.

Sheila Mahoney and her colleagues became aware of the low cesarean
delivery rates in the IHS and she felt that it would be good to look at
possible reasons in a systematic way. This article joins the growing
body of literature that raises issues about the ability of AI/AN women
to maintain both low rates of cesarean delivery and stable perinatal
morbidity / mortality. This trend continues while the US all races
cesarean delivery rate has significantly increased with no corresponding
improvement in perinatal morbidity / mortality.

References on related topics include:

-Do all hospitals need cesarean delivery capability?

[Leeman(s): Outcome based study: Zuni, New
Mexico](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=11978210&dopt=Abstract)

-Native American Community with a 7% Cesarean Delivery Rate

[Leeman(s):](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=11978210&dopt=Abstract)
[What explains the low rate in
Zuni?](http://lyris.aafp.org/t/15218/6112154/159/0/)

<http://www.ihs.gov/MedicalPrograms/MCH/M/Pr01.cfm#Accesstocare>

**Here is some background on the lead author**

Sheila Mahoney is a commissioned officer in the USPHS. Sheila joined the
PHS directly from nurse-midwifery school in 1990 and went to Gallup,
where she worked for 4 years as a nurse- midwife. She transferred to
Santa Fe in 1994 and was there until 2003. The work was completed as
part of her MPH thesis which she obtained at the University of New
Mexico in 2002. Sheila transferred to the NIH in 2003 to become more
involved in health research. Sheila works on the Gynecology Consult
Service for the NIH and is involved in the fibroid and endometriosis
trials. Unfortunately there is no obstetrics which she sorely feels the
lack of. <mahoneys@mail.nih.gov>

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

#### Terry Cullen, Tucson {#terry-cullen-tucson .Style-Heading-4-+-Arial-14-pt-Underline}

**UpToDate available even while you are deployed**

Up To Date is graciously offering access to help those MD's who are
giving care to people that have been affected by Hurricane Katrina.

Please contact me if you know of any IHS providers that need this
access, and I will forward the user name and password to them. This will
enable them to access this information from the Internet without being
on the IHS WAN or VPN. <Theresa.Cullen@IHS.GOV>

The Commonwealth Fund/Harvard Fellowship in Minority Health Policy
(CFHUF)

Supported by The Commonwealth Fund, administered by the Minority Faculty
Development Program at Harvard Medical School, this innovative
fellowship is designed to prepare physicians, particularly minority
physicians, for leadership roles in formulating and implementing public
health policy and practice on a national, state, or community level.
 Five one-year, degree-granting fellowships will be awarded per year.
 Fellows will complete academic work leading to a Master of Public
Health (MPH) degree at the Harvard School of Public Health, and, through
additional program activities, gain experience in and understanding of
major health issues facing minority, disadvantaged, and underserved
populations. CFHUF also offers a Master of Public Administration (MPA)
degree at John F. Kennedy School of Government to physicians possessing
an MPH. It is expected that CFHUF will support the development of a
cadre of leaders in minority health, well-trained academically and
professionally in public health, health policy, health management, and
clinical medicine, as well as actively committed to careers in public
service.

As Director of CFHUF, I seek your assistance in informing potential
candidates of this opportunity to gain exposure to and understanding of
major health issues facing minority and disadvantaged populations.  For
application materials, information, and other training opportunities,
please contact the CFHUF Program Coordinator by telephone at (617)
432-2922; by fax at 617-432-3834; or by e-mail at
<mfdp_cfhuf@hms.harvard.edu>

Sincerely,

Joan Y. Reede, M.D., M.P.H., M.S. Dean, Office for Diversity and
Community Partnership

#### Chuck North, Albuquerque {#chuck-north-albuquerque .Style-Heading-4-+-Arial-14-pt-Underline}

**Summary: Appropriate use of narcotics for chronic non-malignant pain**

I would like to personally thank all of the participants in the online
discussion. Sharing your feelings, thoughts and experiences has
benefited many others and will have an impact by improving patient care
and community health. It has become clear that many clinicians struggle
with the appropriate use of opioids in chronic non-malignant pain.

There appears to be a demand for more educational opportunities to learn
better therapy for chronic pain. There has also been an expressed need
for training in substance abuse treatment, specifically for
buprenorphine and Suboxone outpatient therapy. An organized approach is
needed by our pharmacies to prevent prescription drug abuse by
communicating with each other across I/T/U lines of authority. Most of
the respondents would like to have more therapeutic modalities available
on site to manage chronic pain patients starting with behavioral health
services up to multidisciplinary integrated pain management teams.

Referral out of I/T/U sites to consulting pain clinics was not an option
for many but not successful for many others. We need to address adverse
childhood experiences and substance abuse at the community level in
order to improve the lives of our patients. Perhaps with earlier
intervention we will find greater success in evaluating and treating
chronic non-malignant pain conditions in the future. We look forward to
better guidance from research and clinical practice guideline
development.

Here is a link to entire captured Forum discussion

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Opioid83005.doc>

Here is a link to some of the many resources we have gathered through
this discussion

<http://www.ihs.gov/MedicalPrograms/MCH/M/PCdiscForumMod.asp#narcNonCanc>

**Meera Ramesh, Bethel, Alaska**

**Diabetes prevention and control - Prenatal program**

The Bethel Diabetes prevention and control program has four\
clinical diabetes educators in a four tiered rural health care delivery\
system. Diabetes educators collaborate with the hospital OB and
prenatal\
departments, the village clinic CHA/P\'s and the Alaska Native Medical\
Center.  Educators provide the initial education and follow-up on a
weekly\
basis, and through out the pregnancy to maintain a consistent\
relationship. Weekly glucose reports are collected via all
communication\
means, from patients with class A1, and  A2 prenatal diabetes. Reports
are\
reviewed with the prenatal case manager and at the high risk OB
committee.\
The committee addresses all issues such as hypertension, pre-eclampsia,\
glucose control, tobacco cessation and other maternal morbidities. All\
prenatal patients are required to enter the Bethel pre-maternal home at
36\
weeks gestation. The diabetes registry tracks all prenatal diabetes\
patients.  Data is entered into the RPMS system, and reports can be\
retrieved through Q-Man and other report generating systems. Random
chart\
audits track key outcomes such as high birth weight, delivery problems
and\
other prenatal difficulties.  Tracking of long-term infant and maternal\
outcomes is being planned. Past audits have proven good outcomes for
those\
patients followed by the diabetes program. All CHA/P\'s have access to
the\
Advanced Diabetes Training classes so that they may be a resource to
their\
villages. Meera Ramesh, MS, RD, LD, CDE, Director, Community Health and
Wellness\
Yukon-Kuskokwim Health Corporation. Questions? <Judith.Thierry@ihs.gov>

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

#### Judy Thierry, HQE {#judy-thierry-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**Maternal Morbidity in AI/AN Women, 2002-2004**

**Purpose:** Maternal morbidity, defined as a condition that results
from or is aggravated by pregnancy, is a significant economic and public
health burden in the United States. The most common morbidities reported
in recent studies include preterm labor, genitourinary complications,
hemorrhage, and hypertensive disorders. However, few studies have
reported data specific for American Indian and Alaska Native (AI/AN)
women. The purpose of our analysis was to examine maternal morbidity in
AI/AN women present at delivery hospitalizations using a
population-based design.

**Methods:** Using the Indian Health Service (IHS) National Patient
Information Reporting System, we analyzed aggregated data from five IHS
medical centers from July 2002 through June 2004. Delivery
hospitalizations were identified by the ICD-9 code V27 listed in any of
the 15 diagnosis fields. Maternal morbidity was identified by ICD-9
codes 640-677 listed in any diagnosis fields. All analyses were
performed using SPSS version 12.0.

**Results:** Overall, 6,761 deliveries were performed at the IHS medical
centers during our study period. The average age of AI/AN women who
delivered was 25.5 years, with the youngest being 13 years and the
oldest being 47 years. The most common complication was gestational
diabetes occurring in 7.4% of women. Pregnancy-related hypertension was
reported in 5.3% of women and 2.3% of women experienced genitourinary
infections.

**Conclusions:** AI/AN women who delivered at these five medical centers
had higher rates of some maternal morbidity compared to women in the
general population. Our findings stress the need for continual
surveillance and etiologic research to understand the elevated health
risk among these women.

<http://www.ihs.gov/MedicalPrograms/MCH/M/Pr01.cfm#AlaskaNative>

From Stephen J. Bacak, Judy Thierry, Myra Tucker, Edna Paisano

17^th^ Annual Research Conference, Indian Health Service

For further information: Stephen J. Bacak, MPH <sb897694@ohio.edu>

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

This is a major step forward to help the Indian Health system better
plan clinical programs and resource allocation. Clearly, there is
significant work to be done to improve the health care status of AI/AN
pregnant woman. This data should be a lightening rod for us to improve
our perinatal care for AI/AN women.

The process of analyzing this data set is open to each of the Indian
Health system Areas. One would simply need to contact Judy Thierry\* to
participate in analyzing the data from your area. The possibilities are
quite open ended.

Here a just few comments from Chris Carey M.D. Chairman of the ACOG
Committee on American Indian Affairs "...What about mentioning preterm
labor/preterm birth or hemorrhage in the AN/AI population?  You list
them as most common in the general population.  Were their rates lower? 
As you know, some reports show lower rates of preterm birth in AI/AN
populations and lower infant mortality, but that may be due to
mis-classification as Caucasian race.  What about stillbirths and
neonatal deaths?\..."

**Resource:**

**Indian Health Maternal Mortality data available in a Powerpoint
format**

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/MatMort81805.ppt>

\*Please contact Judy Thierry to analyze similar data in your Area,
<Judith.Thierry@ihs.gov>

**Methamphetamine in Indian Country: Good Resources**

In follow-up to the recent Primary Care Discussion Forum the
methamphetamine ppt presentations at the site below should be reviewed,
even if you do not deal with patients using meth, or think you are not
seeing them. 

The demographics for those entering into treatment should be reviewed to
give a clear picture of the multifactor demographic, exposure history
including abuse, sexual abuse, other drugs,. And while the age of
treatment is in the 30\'s for both men and women the lifetime history is
telling. Billings is one of the treatment centers so does contribute to
the AI/AN demographics though all of the sites have enrolled AI/AN
clients.    

<http://www.methamphetamine.org/presentations.htm>

and

[www.methamphetamine.org](http://www.methamphetamine.org/) 

The whole Indian Health Primary Care Discussion Forum on Methamphetamine
in Indian Country is available here with many other resources

<http://www.ihs.gov/MedicalPrograms/MCH/M/PCdiscForumMod.asp#MethUse>

**FDA Director of the Office of Women\'s Health resigns**

By the way, IHS National Supply and Support Center purchases all methods
of FDA approved contraception, including emergency contraception. An
article will be forthcoming in the IHS Primary Care Provider.
<http://www.chron.com/cs/CDA/ssistory.mpl/editorial/3339516>

From Guttmacher -- on Plan B or Emergency contraception

<http://www.guttmacher.org/media/supp/ec121702.html>

**Please see Family Planning below (in Features section)**

**EC in adolescents: No compromise of family planning or increased
sexual behavior**

**Women\'s Health USA 2005 is online**

HRSA's Office of Women's Health is pleased to present *Women's Health
USA 2005,* the fourth edition of the data book. To reflect the ever
changing, increasingly diverse population and its characteristics,
*Women's Health USA 2005* will selectively include emerging issues and
trends in women's health. Information and data on household composition,
maternity leave, contraception, and adolescent pregnancy are a few of
the new topics included in this edition. Where possible, every effort
has been made to highlight racial and ethnic disparities as well as
sex/gender differences. <http://mchb.hrsa.gov/whusa_05/index.htm>

**Healthy People 2010** **midcourse review seeks your comments**

On behalf of the US Department of Health and Human Services (HHS), the
Office of Disease Prevention and Health Promotion (ODPHP) is soliciting
the submission of electronic comments for consideration on changes and
revisions proposed to the Healthy People 2010 objectives as a result of
the Midcourse Review process. I have the MCH specific portion, but there
are many revisions, developmental additions and changes in the other
sub-objectives that you should review and comment
<Judith.Thierry@ihs.gov>
<http://www.healthypeople.gov/data/midcourse/comments/facontents.asp?id=16>

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

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

**Meperidine for Dystocia During First Stage of Labor: Limit Use**

CONCLUSION: Because of the absence of any benefits in patients with
dystocia in labor and the presence of harmful effects on neonatal
outcomes, meperidine should not be used during labor for this specific
indication.

Sosa CG, et al. Meperidine for dystocia during the first stage of labor:
a randomized controlled trail. Am J Obstet Gynecol October
2004;191:1212-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15507943&query_hl=23>

**Progesterone therapy ameliorates other risk factors in previous
preterm delivery**

Conclusion: The use of 17alpha-hydroxyprogesterone caproate in women
with a previous preterm delivery reduces the overall risk of preterm
delivery and changes the epidemiology of risk factors for recurrent
preterm delivery. In particular, these data suggest that
17alpha-hydroxyprogesterone caproate reduces the risk of a history of
more than 1 preterm delivery. Level of Evidence:

[Meis
PJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Meis+PJ"%5BAuthor%5D),
et al Does Progesterone Treatment Influence Risk Factors for Recurrent
Preterm Delivery? Obstet Gynecol. 2005 Sep;106(3):557-561\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16135587&dopt=Abstract>

**Misoprostol: Effective and safe treatment option in term premature
rupture of membranes**

Conclusion: Misoprostol is an effective and safe agent for induction of
labor in women with term premature rupture of membranes. When compared
with oxytocin, the risk of contraction abnormalities and the rate of
maternal and neonatal complications were similar among the 2 groups

[Lin
MG](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Lin+MG"%5BAuthor%5D)
et al Misoprostol for Labor Induction in Women With Term Premature
Rupture of Membranes: A Meta-Analysis.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16135593&dopt=Abstract>

**Risk of stillbirth is substantially elevated among very and extremely
high parity gravidas**

Conclusions: The risk for stillbirth is substantially elevated among
very high and extremely high parity women, and care providers may
consider these groups for targeted periconceptional counseling. Level of
Evidence: II-2.

[Aliyu
MH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Aliyu+MH"%5BAuthor%5D)
et al Extreme parity and the risk of stillbirth. Obstet Gynecol. 2005
Sep;106(3):446-53.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16135572&dopt=Abstract>

**Editorial**

**How Much Does Parity Matter?**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16135571&dopt=Abstract>

**The 4P\'s Plus screen for substance use in pregnancy: clinical
application and outcomes**

CONCLUSION: The 4P\'s Plus identifies not only those pregnant women
whose drinking or drug use is at a high enough level to impair daily
functioning, but provides an opportunity for early intervention for the
much larger group of women whose pregnancies are at risk from relatively
small amounts of substance use.

[Chasnoff
IJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Chasnoff+IJ"%5BAuthor%5D),
et al The 4P\'s Plus screen for substance use in pregnancy: clinical
application and outcomes. J Perinatol. 2005 Jun;25(6):368-74.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15703775&query_hl=1>

Editorial

[Jones
HE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Jones+HE"%5BAuthor%5D)
The challenges of screening for substance use in pregnant women:
commentary on the 4P\'S Plus tool. J Perinatol. 2005 Jun;25(6):365-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15915163&query_hl=1>

**Injuries to the Brachial Plexus: Mechanisms of Injury and
Identification of Risk Factors**

Upper-arm weakness (paresis) or paralysis indicates peripheral-nerve
damage to the brachial plexus, a network of lower cervical and upper
thoracic spinal nerves supplying the arm, forearm, and hand. Physical
findings reflect muscle paralysis from spinal nerve roots. The mechanism
of injury includes maternal, obstetric, and infant factors that apply
traction on or compression to the anatomically vulnerable brachial
plexus. Nerve regeneration can occur if nerve tissue components are
preserved. Recovery is affected by multiple factors, including the type
and site of injury, intervention timing, and developmental factors. The
majority of injuries recover in days or months; however, residual
deficits can persist. Part 1 of 2 of this article provides an overview
of the neurophysiology of peripheral-nerve damage and nerve
regeneration. Photographs and on-line video clips will enhance the
description of the brachial plexus injury classifications and illustrate
mechanisms of shoulder dystocia and obstetric relief maneuvers. A
systematic approach to the physical examination will be explored in Part
2.

[Benjamin
K](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Benjamin+K"%5BAuthor%5D).
Part 1. Injuries to the brachial plexus: mechanisms of injury and
identification of risk factors. Adv Neonatal Care. 2005 Aug;5(4):181-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16084476&query_hl=18>

**Compressive sutures of the uterus are effective in postpartum
bleeding: Case Series**

Objective: To demonstrate the usefulness of a new method of applying
compressive sutures to treat postpartum bleeding secondary to uterine
atony. Methods: Multiple sutures were applied longitudinally and
transversally around the uterus of 7 women with postpartum uterine atony
and postpartum bleeding. Results: The procedure was successful in all
cases. Conclusion: Compressive sutures of the uterus were effective in
treating uterine atony with postpartum bleeding. Level of Evidence: III.

[Pereira
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Pereira+A"%5BAuthor%5D),
et al Compressive uterine sutures to treat postpartum bleeding secondary
to uterine atony. Obstet Gynecol. 2005 Sep;106(3):569-72.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16135589&dopt=Abstract>

**Postpartum urinary retention is short-lived and can be managed with
careful bladder care**

Attention to bladder care during labor and vigilant postpartum early
detection of urinary retention are the 2 most important preventive
measures. In women unable to void within 6 hours of delivery, ultrasound
evaluation of bladder volume or straight catheterization can identify
women who need close surveillance. (In the Trenches feature)

[Yip
SK](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Yip+SK"%5BAuthor%5D)
et al Postpartum urinary retention. Obstet Gynecol. 2005
Sep;106(3):602-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16135594&dopt=Abstract>

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

**PID: Outpatient treatment was as effective in preventing reproductive
morbidity**

Conclusion: Among all women and subgroups of women with mild-to-moderate
PID, there were no differences in reproductive outcomes after
randomization to inpatient or outpatient treatment. Level of Evidence:
I.

[Ness
RB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Ness+RB"%5BAuthor%5D),
et al Effectiveness of Treatment Strategies of Some Women With Pelvic
Inflammatory Disease: A Randomized Trial. Obstet Gynecol. 2005
Sep;106(3):573-580.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16135590&dopt=Abstract>

**Every woman matters study: Improving female health care through
practice change**

CONCLUSION: The complexity of practice context and its effect on change
cannot be underestimated. Individual practice providers and staff are
often unaware of the potential challenges, and unable/unwilling to
overcome them

[Backer
EL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Backer+EL"%5BAuthor%5D),
et al Improving female preventive health care delivery through practice
change: an every woman matters study. Am Board Fam Pract. 2005
Sep-Oct;18(5):401-8.

**Metformin for Anovulation in Normoandrogenic Women**

CONCLUSION: Metformin may be useful for inducing ovulation in
anovulatory women who do not have hyperandrogenism. This effect may be
independent of a lowering of androgen or insulin levels Carmina E, Lobo
RA. Does metformin induce ovulation in normoandrogenic anovulatory
women? Am J Obstet Gynecol November 2004;191:1580-4.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15547527&query_hl=20>

**Virtually all women with prolapse can be treated and their symptoms
alleviated**

Pelvic organ prolapse, including anterior and posterior vaginal
prolapse, uterine prolapse, and enterocele, is a common group of
clinical conditions affecting millions of American women. Prolapse
encompasses a range of disorders, from asymptomatic altered vaginal
anatomy to complete vaginal eversion associated with severe urinary,
defecatory, and sexual dysfunction. Although prolapse is associated with
many symptoms, few are specific for prolapse; it is often challenging
for the clinician to determine which symptoms are attributable to the
prolapse itself and will therefore improve or resolve once the prolapse
is treated. When treatment is warranted based on specific symptoms,
prolapse management choices fall into 2 broad categories: nonsurgical,
which includes pelvic floor muscle training and pessary use; and
surgical, which can be reconstructive (eg, sacral colpopexy) or
obliterative (eg, colpocleisis). Concomitant symptoms require additional
management. Virtually all women with prolapse can be treated and their
symptoms improved, even if not completely resolved

[Weber
AM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Weber+AM"%5BAuthor%5D),
[Richter
HE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Richter+HE"%5BAuthor%5D).
Pelvic Organ Prolapse. Obstet Gynecol. 2005 Sep;106(3):615-634.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16135597&dopt=Abstract>

**Colposcopy: An Evidence-Based Update**

Colposcopy is a diagnostic procedure, most commonly used in the
diagnosis of cervical intraepithelial neoplasia and lower genital tract
carcinoma. In this article, evidence-based management strategies are
updated with discussion of the 2001 American Society for Colposcopy and
Cervical Pathology Consensus Guidelines. Practice management issues
include methods to improve cervical cancer screening rates, coding and
billing, and telemedicine. Textbooks, CD-ROMs, and courses are listed
for new learners and experienced providers who want to update and
sharpen their skills

[Dresang
LT](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Dresang+LT"%5BAuthor%5D).
Colposcopy: An Evidence-Based Update. J Am Board Fam Pract. 2005
September-October;18(5):383-392.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16148248&query_hl=6>

**Could a Vaccine Prevent Cervical Cancer?**

INTERPRETATION: The bivalent HPV vaccine was efficacious in prevention
of incident and persistent cervical infections with HPV-16 and HPV-18,
and associated cytological abnormalities and lesions. Vaccination
against such infections could substantially reduce incidence of cervical
cancer Harper DM, et al. Efficacy of a bivalent L1 virus-like particle
vaccine in prevention of infection with human papillomavirus types 16
and 18 in young women: a randomised controlled trial. Lancet November
13, 2004;364:1757-65

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15541448&query_hl=18>

**Chasteberry: Multiple GYN applications**

For centuries, chasteberry has been used to treat many hormone-related
gynecologic conditions. The current literature supports the use of
chasteberry for cyclical breast discomfort and premenstrual syndrome;
data on its use for menstrual irregularities and fertility disorders are
weak. Its traditional use as a galactagogue (i.e., a substance that
enhances breast milk production) is not well supported in the literature
and should be discouraged. There are no clinical data to support the use
of chasteberry for reducing sexual desire, which has been a traditional
application. Chasteberry is well tolerated; reported adverse effects are
minor and may include gastrointestinal complaints, dizziness, and dry
mouth. No herb-drug interactions have been reported, but caution is
advised for its concomitant use with dopamine agonists or antagonists.
Optimal standardization and dosing recommendations await clarification
in clinical studies. Am Fam Physician 2005;72:821-4.
<http://www.aafp.org/afp/20050901/821.html>

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

**Adolescents Prefer Honesty and Patient-Centered Care**

CONCLUSIONS: Participants rated aspects of interpersonal care
(especially honesty, attention to pain, and items related to respect) as
most important in their judgments of quality. As in most previous
studies of adults, technical aspects of care were also rated highly,
suggesting that adolescents understand and value both scientific and
interpersonal aspects of

Britto MT, et al. Health care preferences and priorities of adolescents
with chronic illnesses. Pediatrics November 2004;114:1272-80.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15520107&query_hl=25>

**Parent Intervention in Risky Adolescent Behaviors Can Help**

CONCLUSION: A parent monitoring intervention can significantly broaden
and sustain protection beyond that conferred through an adolescent
risk-reduction intervention

Stanton B, et al. Randomized trial of a parent intervention: parents can
make a difference in long-term adolescent risk behaviors, perceptions,
and knowledge. Arch Pediatr Adolesc Med October 2004;158:947-55.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15466681&query_hl=27>

**Clustering of fast food restaurants around schools**

Although fast-food restaurants are located throughout the city, they are
clustered in areas within a short walking distance from schools.
Fast-food consumption has increased dramatically over the past several
decades and may be an important contributor to the rise in the
prevalence of obesity in children and adolescents. The neighborhood food
environment is a relatively new concept in public health research, and
methods for defining, characterizing, and quantifying the food
environment are still under development.

\* The median distance from any school to the nearest fast-food
restaurant was 0.5 km, indicating that students in half the city\'s
schools need to walk little more than 5 minutes to reach a fast-food
restaurant.

\* Nearly 80% of schools had at least one fast-food restaurant within
800 m (approximately a 10-minute walk).

\* There was statistically significant clustering of fast-food
restaurants within 1.5 km of schools located within areas of the city
outside downtown.

Austin SB, Melly SJ, Sanchez BN, et al. 2005. Clustering of fast-food
restaurants around schools: A novel application of spatial statistics to
the study of food environments. American Journal of Public Health
95(9):1575-1581.
[[http://www.ajph.org/cgi/content/abstract/95/9/1575]{.underline}](http://www.ajph.org/cgi/content/abstract/95/9/1575)

**AMA releases findings on sources of alcohol for adolescents**

Teenage Drinking Key Findings presents data from two national surveys on
how adolescents obtain alcohol. Both surveys were conducted in spring
2005 and were funded as part of the American Medical Association\'s
(AMA\'s) partnership with the Robert Wood Johnson Foundation. The
document is intended for use by physicians in counseling parents on the
health risks of alcohol use and in advocating for policies to restrict
adolescents\' access to alcohol.

The document is available at
[[http://www.alcoholpolicymd.com/pdf/poll_080805.pdf]{.underline}](http://www.alcoholpolicymd.com/pdf/poll_080805.pdf)

Informational poster:
[[http://www.alcoholpolicymd.com/pdf/Ad080805.pdf]{.underline}](http://www.alcoholpolicymd.com/pdf/Ad080805.pdf)

**School-based dental sealant program manual now available online**

Seal America: The Prevention Invention, a how-to manual for establishing
a school-based dental sealant program, is now available online. The
manual was first developed in 1995 by the American Association of
Community Dental Programs in cooperation with the Association of State
and Territorial Dental Directors, the Health Resources and Services
Administration\'s Maternal and Child Health Bureau, and the Centers for
Disease Control and Prevention\'s Division of Oral Health.
[[http://www.mchoralhealth.org/Seal]{.underline}](http://www.mchoralhealth.org/Seal)

**Rural, Remote and Wilderness Medicine Conference**

October 20-22, 2005 San Francisco

University of California, Davis Health System

Increasingly, media is focusing on rural medicine as a \"specialty\".
Yet rural healthcare continues to suffer from physician shortage, and
rural doctors often feel themselves to be on the periphery of academic
medicine. The purpose of this conference is two-fold. First, to bring
together rural physicians in an academic forum. Second, to familiarize
all physicians with medical conditions and healthcare issues common, yet
unique, to rural and remote environments.

Up to 15.5 hours CME category 1 credit
[[www.ucdmc.ucdavis.edu/cme]{.underline}](../www.ucdmc.ucdavis.edu/cme)

[[http://www.ucdmc.ucdavis.edu/cme/Confrnce/\_05_RUMEDO6_10-20-05_web.pdf]{.underline}](http://www.ucdmc.ucdavis.edu/cme/Confrnce/_05_RUMEDO6_10-20-05_web.pdf)

**Arizona Guidelines for Identifying Substance Exposed Newborns, 2005**

<http://www.governor.state.az.us/cps/documents/SenGuidelines.pdf>

**Prevention of Perinatal Group B Streptococcal Disease: Alaska State**

<http://www.ihs.gov/generalweb/webapps/sitelink/site.asp?link=http://www.epi.hss.state.ak.us/bulletins/bltnidx.jsp>

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

**One Third of Deaths From GI Bleeding Due to NSAIDs**

CONCLUSION: Mortality rates associated with either major upper or lower
GI events are similar but upper GI events were more frequent. Deaths
attributed to NSAID/ASA use were high but previous reports may have
provided an overestimate and one-third of them can be due to low-dose
aspirin use.

[Lanas
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Lanas+A"%5BAuthor%5D),
et al A nationwide study of mortality associated with hospital admission
due to severe gastrointestinal events and those associated with
nonsteroidal antiinflammatory drug use. Am J Gastroenterol. 2005
Aug;100(8):1685-93.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16086703&query_hl=14>

**Withdrawing Aspirin May Significantly Increase Stroke Risk **

CONCLUSIONS: These results highlight the importance of aspirin therapy
compliance and give an estimate of the risk associated with the
discontinuation of aspirin therapy in patients at risk for IS,
particularly those with coronary heart disease.

[Maulaz
AB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Maulaz+AB"%5BAuthor%5D)
et al Effect of discontinuing aspirin therapy on the risk of brain
ischemic stroke. Arch Neurol. 2005 Aug;62(8):1217-20.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16087761&query_hl=24>

**Dietary Calcium Intake and Obesity**

Obesity is increasing in the United States in epidemic proportions.
Epidemiologic data suggest that people with high calcium intake have a
lower prevalence of overweight, obesity, and insulin resistance
syndrome. Studies in transgenic mice have demonstrated that calcium
influences adipocyte metabolism. High calcium intake depresses levels of
parathyroid hormone and 1,25-hydroxy vitamin D. These decreased hormone
levels cause decreases in intracellular calcium, thereby inhibiting
lipogenesis and stimulating lipolysis. High dietary calcium intakes also
increases excretion of fecal fat and may increase core body temperature.
Calcium from dairy products seems to have more of an impact than calcium
from dietary supplements. Primary care providers should include
recommendations about adequate calcium intake in standard dietary
counseling about weight management.\
[Schrager
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Schrager+S"%5BAuthor%5D).
Dietary calcium intake and obesity. J Am Board Fam Pract. 2005
May-Jun;18(3):205-10.<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15879568&query_hl=12>

**Intertrigo and Common Secondary Skin Infections**

Intertrigo is inflammation of skinfolds caused by skin-on-skin friction.
It is a common skin condition affecting opposing cutaneous or
mucocutaneous surfaces. Intertrigo may present as diaper rash in
children. The condition appears in natural and obesity-created body
folds. The friction in these folds can lead to a variety of
complications such as secondary bacterial or fungal infections. The
usual approach to managing intertrigo is to minimize moisture and
friction with absorptive powders such as cornstarch or with barrier
creams. Patients should wear light, nonconstricting, and absorbent
clothing and avoid wool and synthetic fibers. Physicians should educate
patients about precautions with regard to heat, humidity, and outside
activities. Physical exercise usually is desirable, but patients should
shower afterward and dry intertriginous areas thoroughly. Wearing
open-toed shoes can be beneficial for toe web intertrigo. Secondary
bacterial and fungal infections should be treated with antiseptics,
antibiotics, or antifungals, depending on the pathogens. Am Fam
Physician 2005;72:833-8, 840.

<http://www.aafp.org/afp/20050901/833.html>

**Screening for HCV Infection: Understanding the USPSTF Recommendation**

<http://www.aafp.org/afp/20050815/editorials.html> (scroll down page to
find)

**Integrating Risk History Screening and HCV Testing into Clinical and
Public Health**

<http://www.aafp.org/afp/20050815/editorials.html>

**Using Pegylated Interferon and Ribavirin to Treat Patients with
Chronic Hepatitis C**

<http://www.aafp.org/afp/20050815/655.html>

**Hyperthyroidism: Diagnosis and Treatment**

<http://www.aafp.org/afp/20050815/623.html>

**Management of Gallstones**

<http://www.aafp.org/afp/20050815/637.html>

**Cutaneous Warts: An Evidence-Based Approach to Therapy**

<http://www.aafp.org/afp/20050815/647.html>

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

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

Cochrane for Clinicians - Putting Evidence into Practice

Room Air vs. Oxygen for Resuscitating Infants at Birth

Clinical Question

Does using 100 percent oxygen for neonatal resuscitation increase
morbidity and mortality?

Evidence-Based Answer

Based on limited evidence, it appears that mortality is lower in infants
resuscitated with room air than in those given 100 percent oxygen.
However, these results should be treated with caution because one fourth
of studies used back-up supplementary oxygen.

Practice Pointers

Because excessive oxygen can increase free radical levels and decrease
cerebral blood flow, it is thought that it may increase ischemic injury.
Many deliveries occur outside of hospitals, where access to oxygen
supplementation is limited. In hospital deliveries, early cord clamping
often is performed to bring the newborn closer to an oxygen source for
resuscitation. Delayed cord clamping has been shown to be beneficial in
preterm infants to allow perfusion after delivery.^1^

Tan and colleagues reviewed the literature to determine whether neonatal
resuscitation with room air improves outcomes compared with 100 percent
oxygen. They found five randomized and quasirandomized studies including
1,302 infants in total. A reduction in death rate was evident for
infants resuscitated with room air (number needed to treat = 20). One
study found that infants given room air had better five-minute Apgar
scores; however, the difference was small and there were no significant
differences in 10-minute Apgar scores or rates of grade 2 or 3 hypoxic
ischemic encephalopathy. Another meta-analysis^2^ came to similar
conclusions.

Based on current evidence, 100 percent oxygen should be used with
caution during neonatal resuscitation. Routine use of oxygen should not
supersede interventions with known benefit such as delayed cord
clamping. Evidence supports the routine use of room air.

Tan A, et al. Air versus oxygen for resuscitation of infants at birth.
Cochrane Database Syst Rev 2005;(2):CD002273.
<http://www.update-software.com/cochrane/abstract.htm>

<http://www.aafp.org/afp/20050901/cochrane.html#c1> (scroll down to)

Short-Acting Insulin Analogues vs. Human Insulin for Diabetes

Clinical Scenario

A 63-year-old woman has poor control of her type 2 diabetes with oral
medications alone. You decide to discuss insulin therapy with her.

Clinical Question

Are short-acting insulin analogues (lispro, aspart) better than regular
insulin for controlling blood sugar levels, reducing A1C levels, and
preventing long-term complications of diabetes?

Evidence-Based Answer

###### For patients with type 2 diabetes, regular insulin and short-acting insulin analogues are equally effective in the treatment of diabetes and in lowering A1C levels. For patients with type 1 diabetes, short-acting analogues produce a slightly greater reduction of A1C levels than regular insulin. Regular insulin and short-acting insulin cause hypoglycemia at similar rates. No studies have compared the effects of regular insulin and insulin analogues on the long-term complications of diabetes [**http://www.cochrane.org/cochrane/revabstr/AB003287.htm**](http://www.cochrane.org/cochrane/revabstr/AB003287.htm)

<http://www.aafp.org/afp/20050901/cochrane.html#c1>

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

**Elaine Locke: Key Contributor to Improve AI/ AN Women's Health for 35
years**

On April 1, 2005 Ms. Elaine Locke celebrated her 35th anniversary with
the American College of Obstetricians & Gynecologists. Elaine began her
tenure with the College in the Government Relations department. Ms.
Locke having grown up in the Bemidji area of MN always had an interest
in American Indian issues. Ms. Locke maintained that interest in her
early years at the College and turned that interest into a more active
role in 1980 when she began to be the full time staff person for the
ACOG Indian projects.\*

The College recognized Ms. Locke\'s dedication to ACOG and to the
improvement of AI / AN women\'s health with a celebration at the ACOG
offices in Washington, DC. Ms. Locke was presented with a certificate of
appreciation and a substantial gift. The American Indian Affairs
Committee also celebrated Ms. Locke\'s long tenure and dedication at the
Indian breakfast at this year\'s ACM in San Francisco. The committee
presented Ms. Locke with a lovely vase and the committee vice chair
presented her with a Navajo purse that her parents had bought on their
honeymoon. The celebration continued in Denver at the ACOG/IHS
postgraduate course where the faculty presented Ms. Locke with a
beautiful Navajo rug as well as shared pictures of Ms. Locke on various
site visits and at different ACOG/IHS Denver courses. 35 years of
service is certainly noteworthy and we look forward to sharing many more
with Ms. Locke.

\* A few of those projects include:

ACOG /IHS Postgraduate Course on Obstetric, Neonatal, and Gynecologic
Care

<http://www.ihs.gov/MedicalPrograms/MCH/M/ACOG01.cfm>

ACOG Fellows in Service Program

<http://www.ihs.gov/MedicalPrograms/MCH/M/ACOGFellows.cfm>

ACOG Committee on American Indian Affairs --see for many activities

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHacogAIA.asp#AIAtop>

Annual IHS Area Site Visits

<http://www.ihs.gov/MedicalPrograms/MCH/M/ACOG01_nAlaska.cfm#northToAk>

Liaison Relationship -- AAP, Committee on Native American Child Health
(CONACH)

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

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

I took the ACOG / IHS Postgraduate Course in Denver in 1985 as a Family
Physician when I started working in Indian Health in Bethel, Alaska, so
I have only benefited from Elaine's hard work for a mere 20 years. Given
my short tenure of a mere 20 years, I thought I would see if there might
be a slightly longer term perspective or two on Elaine's
contributions....

**From William H.J. Haffner, M.D., OB/GYN Senior Clinician, IHS, 1981-
1994**

"Thirty-five years devoted to making a difference in health for all
women and twenty-five of these years specifically devoted to Indian
women\'s health! Elaine, in ways seen and most often unseen, has had an
impact at ACOG and in the IHS on the lives of countless women through
her tireless commitment, constant networking, and very thoughtful
personal persuasion!

Thank you, Elaine "

Captain, USPHS (Retired)

Professor of Obstetrics and Gynecology

Former Chair of the OB/GYN Department, F. Edward Hebert School of
Medicine

Uniformed Services University in Bethesda, MD

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/HaffnerACOGHonor81202.doc>

**From Alan Waxman, M.D. OB/GYN Chief Clinical Consultant, IHS, 1994 -
2000**

"Elaine has one of the most organized minds of anyone I\'ve ever worked
with. She is able to juggle numerous projects, anticipate future
deadlines, and find key players no matter where they might be. I\'ve
often gotten messages from Elaine while working at remote clinics barely
on the map. Her meticulous attention to detail has kept her very complex
projects for ACOG and IHS running seamlessly. "

Associate Professor, University of New Mexico

IHS Breast and Cervical Cancer Control Program Consultant

IHS 1976-200 primarily at Gallup Indian Medical Center

<http://www.ihs.gov/MedicalPrograms/MCH/M/mchdownloads/HaffnerWaxman101501.doc>

**Management of abnormal cervical cytology and histology**

**ACOG Practice Bulletin No. 66**

**Summary of Recommendations**

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

-   Women with ASC cytology results may undergo immediate colposcopy,
    triage to colposcopy by high-risk HPV DNA testing, or repeat
    cytology screening at 6 and 12 months. Triage to colposcopy should
    occur after positive HPV test results or ASC or higher-grade
    diagnosis. Women with ASC who test negative for HPV or whose HPV
    status is unknown and test negative for abnormalities using
    colposcopy should have a repeat cytology test in 1 year.

-   Most women with ASC who are HPV positive or women with ASC-H, LSIL,
    or HSIL test results should undergo colposcopy.

-   For women with an ASC HPV-positive test result or ASC-H or LSIL
    cytology result and a negative initial colposcopy or a histologic
    result of CIN 1, optimal follow-up is repeat cervical cytology tests
    (not screening) at 6 and 12 months or an HPV test at 12 months; a
    repeat colposcopy is indicated for a cytology result of ASC or
    higher-grade abnormality or a positive high-risk HPV test.

-   The recommendation for follow-up of untreated CIN 1 includes
    cytology tests at 6 and 12 months with colposcopy for an ASC or
    higher-grade result, or a single HPV test at 12 months, with
    colposcopy if the test result is positive.

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

-   Endocervical sampling using a brush or curette may be undertaken as
    part of the evaluation of ASC and LSIL cytology results and should
    be considered as part of the evaluation of AGC, AIS, and HSIL
    cytology results.

    -   Endocervical sampling is recommended at the time of an
        unsatisfactory colposcopy or if ablative treatment is
        contemplated.

    -   Endocervical sampling is not indicated in pregnancy.

-   Endometrial sampling is indicated in women with atypical endometrial
    cells and in all women aged 35 years or older who have AGC cytology
    results, as well as in women younger than 35 years with abnormal
    bleeding, morbid obesity, oligomenorrhea, or clinical results
    suggesting endometrial cancer.

-   Women with HSIL cytology results and negative or unsatisfactory
    colposcopy results should undergo excision unless they are pregnant
    or adolescent.

-   Women with AGC favor neoplasia or AIS cytology results and negative
    or unsatisfactory colposcopy results should undergo excision unless
    they are pregnant. A colposcopic examination negative for
    abnormalities after two AGC-NOS cytology results is also an
    indication for excision in the absence of pregnancy.

-   Pregnant women with CIN 2 or CIN 3 may undergo follow-up with
    colposcopy during each trimester and should be reevaluated with
    cytology and colposcopy examinations at 6--12 weeks postpartum or
    thereafter. Treatment of CIN 2 and CIN 3 in pregnancy is not
    indicated.

-   Women with CIN 2 or CIN 3 should be treated (in the absence of
    pregnancy) with excision or ablation. Management of CIN 2 in
    adolescents may be individualized.

-   Women treated for CIN 2 or CIN 3 with a positive margin on excision
    may be followed by repeat cytology testing, including endocervical
    sampling every 6 months for 2 years or HPV DNA testing at 6 months;
    if these test results are negative, annual screening may be
    reestablished.

-   Women with a cervical biopsy diagnosis of AIS should undergo
    excision to exclude invasive cancer. Cold-knife conization is
    recommended to preserve specimen orientation and permit optimal
    interpretation of histology and margin status.

-   After treatment of CIN 2 or CIN 3, women may be monitored with
    cytology screening three to four times at 6-month intervals or
    undergo a single HPV test at 6 months before returning to annual
    follow-up.

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

-   Colposcopic examination during pregnancy should have as its primary
    goal the exclusion of invasive cancer. Excisions in pregnant women
    should be considered only if a lesion detected at colposcopy is
    suggestive of invasive cancer.

-   Cervical cytology screening lacking endocervical cells may be
    repeated in 1 year when testing was performed for routine screening.
    Cytology screening performed for a specific indication (ie, AGC
    follow-up or posttreatment follow-up after LEEP with a positive
    margin) may need to be repeated.

-   Adolescents with ASC who are HPV positive or with LSIL results may
    be monitored with repeat cytology tests at 6 and 12 months or a
    single HPV test at 12 months, with colposcopy for a cytology result
    of ASC or higher-grade abnormality or a positive HPV test result.

-   After treatment of AIS, when future fertility is desired and
    cervical conization margins are clear, conservative follow-up may be
    undertaken with cytology and endocervical sampling every 6 months.

-   Women should not be treated with ablative therapy unless
    endocervical sampling test results are negative for abnormalities
    and the lesion seen and histologically evaluated explains the
    cytologic finding.

-   In the absence of other indications for hysterectomy, excisional or
    ablative therapy for CIN 2 or CIN 3 is preferred.

Management of abnormal cervical cytology and histology. ACOG Practice
Bulletin No. 66. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2005;106:645--64.

**Non-ACOG members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16135610&query_hl=5>

**ACOG Members**

<http://www.acog.org/publications/educational_bulletins/pb066.cfm>

**Obesity in Pregnancy**

ABSTRACT: One third of adult women in the United States are obese.
During pregnancy, obese women are at increased risk for several adverse
perinatal outcomes, including anesthetic, perioperative, and other
maternal and fetal complications. Obstetricians should provide
preconception counseling and education about the possible complications
and should encourage obese patients to undertake a weight reduction
program before attempting pregnancy. Obstetricians also should address
prenatal and peripartum care considerations that may be especially
relevant for obese patients, including those who have undergone
bariatric surgery.

Obesity in pregnancy. ACOG Committee Opinion No. 315. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2005;106:671--5

**Non-ACOG members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16135613&dopt=Abstract>

**ACOG Members**

<http://www.acog.org/publications/committee_opinions/co315.cfm>

**The Importance of Preconception Care in the Continuum of Women's
Health Care**

ABSTRACT: The goal of preconception care is to reduce the risk of
adverse health effects for the woman, fetus, or neonate by optimizing
the woman's health and knowledge before planning and conceiving a
pregnancy. Because reproductive capacity spans almost four decades for
most women, optimizing women's health before and between pregnancies is
an ongoing process that requires access to and the full participation of
all segments of the health care system.

The importance of preconception care in the continuum of women's health
care. ACOG Committee Opinion No. 313. American College of Obstetricians
and Gynecologists. Obstet Gynecol 2005;106:665--6

**Non-ACOG members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16135611&dopt=Abstract>

**ACOG Members**

<http://www.acog.org/publications/committee_opinions/co313.cfm>

**Meningococcal Vaccination for Adolescents**

ABSTRACT: Every year in the United States, approximately 1,400--2,800
individuals are infected with meningococcal disease. The Advisory
Committee on Immunization Practices (ACIP) to the Centers for Disease
Control and Prevention (CDC) released recommendations in early 2005 to
reduce the incidence of meningococcal disease during adolescence and
young adulthood. To achieve this goal, routine vaccination of
preadolescents with meningococcal conjugate vaccine (MCV4) is now
recommended. For adolescents who have not received MCV4, the CDC now
recommends vaccination before entry into high school, at approximately
15 years of age. The American College of Obstetricians and Gynecologists
supports these recommendations and encourages all health care providers
caring for adolescent and young adult patients to provide meningococcal
vaccination with MCV4 when appropriate. This includes vaccination of
college freshmen who live in dormitories. Pregnant women may be
vaccinated with meningococcal polysaccharide vaccine (MPSV4) as
indicated. Health care providers also are encouraged to discuss
meningococcal vaccination with patients whose children have reached
preadolescence, adolescence, or young adulthood and to increase
awareness of the signs and symptoms of meningococcal disease.

Meningococcal vaccination for adolescents. ACOG Committee Opinion No.
314. American College of Obstetricians and Gynecologists. Obstet Gynecol
2005;106:667--9

**Non-ACOG members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16135612&dopt=Abstract>

**ACOG Members**

<http://www.acog.org/publications/committee_opinions/co314.cfm>

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

**AHRQ Research Activities Relevant to the American Indian and Alaska
Native Community**

AHRQ released a new program brief titled *AHRQ Research and Other
Activities Relevant to American Indians and Alaska Natives*. AHRQ
research topics include examining organizational factors influencing
rural health care providers, reducing disparities in the American
Indian/Alaska Native population, developing electronic data systems for
Primary Care Practice-based Research Networks (PBRNs), and implementing
AHRQ\'s Put Prevention Into Practice program. AHRQ funds research that
enhances the health services research infrastructure and knowledge base,
while building relationships with other Federal agencies. Select to read
the program brief\*. A print copy is available by sending an e-mail to
<ahrqpubs@ahrq.gov>

\* <http://www.ahrq.gov/research/amindbrf.htm>

### **Omega-3 Fatty Acids, Effects on Child and Maternal Health**

*Effects of Omega-3 Fatty Acids on Child and Maternal Health*, noted the
absence of a safety profile (i.e., moderate-to-severe adverse events).
Pregnancy outcomes were either unaffected by omega-3 fatty acid
supplementation, or the results were inconclusive. Results concerning
the impact of the intake of omega-3 fatty acids on the development of
infants are primarily, although not uniformly, inconclusive
<http://www.ahrq.gov/clinic/tp/o3mchtp.htm>

**Prenatal screening and treatment are needed to identify pregnant women
with asymptomatic chlamydial infections**
<http://www.ahrq.gov/research/jul05/0705RA15.htm>

**(see also FAQ below on this topic)**

**Study finds that screening asymptomatic, low-risk pregnant women for
hepatitis C virus is not cost effective**
<http://www.ahrq.gov/research/jul05/0705RA16.htm>

**AHRQ-Supported Study Finds Medical Disparities Narrowing**

<http://www.ahrq.gov/news/press/pr2005/dispnarpr.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}

**The Known and the Unknown - Clinical Evidence Summarized**

A new resource offering the best available evidence on the effects of
common clinical interventions is now available online. **Clinical
Evidence** summarizes what is known -- and not known -- on over 200
medical conditions and over 2,000 treatments seen in primary and
hospital care. **Clinical Evidence** is based on thorough searches and
appraisal of the literature. It is neither a textbook of medicine nor a
set of guidelines. Instead it describes the best available evidence from
systematic reviews, randomized control trials, and observational
studies. Here are some reasons **Clinical Evidence** may be useful to
you:

-   You start with a question -- **Clinical Evidence** does too

-   Evidence is presented in clear and easy-to-read summaries

-   New and updated topics are added monthly

-   Includes information on benefits, harms and outcomes which will help
    you with you treatment decisions

-   Saves you time and effort

    To access **Clinical Evidence** go to:
    [http://hsrl.nihlibrary.nih.gov](http://hsrl.nihlibrary.nih.gov/)

    Click on **Research Tools** \> **Databases** \> **Clinical
    Evidence**

##### 

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

**Glyburide nor glipizide compatible with breast-feeding**

CONCLUSIONS: Neither glyburide nor glipizide were detected in breast
milk, and hypoglycemia was not observed in the three nursing infants.
Both agents, at the doses tested, appear to be compatible with
breast-feeding. [Feig
DS](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Feig+DS"%5BAuthor%5D),
et al Transfer of glyburide and glipizide into breast milk. Diabetes
Care. 2005 Aug;28(8):1851-5.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16043722&dopt=Abstract>

**Case Managers Corner**

#### Wouldn't it be nice if there was more distance education available to nurses? {#wouldnt-it-be-nice-if-there-was-more-distance-education-available-to-nurses-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Here is just two possibilities.....can you think of others? \* {#here-is-just-two-possibilities..can-you-think-of-others .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### For separate reasons, schools of nursing and public television stations are finding it a matter of mutual interest to work together in the production of distance education content for college nursing students in their communities. The advent of digital television (DTV) broadcasting has given these distance education partnerships new capabilities for reaching more potential students. In this article, I review one innovative collaboration between several nursing education programs and a public broadcasting service member station in South Texas. In this pilot project, nursing faculty were trained in television production techniques and became producers of DTV instructional video material. This case study demonstrates a number of ways in which nursing distance education programs can benefit by designing and delivering course material via digital broadcasting. It also highlights several difficulties that should be considered by distance educators prior to embarking on DTV curriculum development projects. {#for-separate-reasons-schools-of-nursing-and-public-television-stations-are-finding-it-a-matter-of-mutual-interest-to-work-together-in-the-production-of-distance-education-content-for-college-nursing-students-in-their-communities.-the-advent-of-digital-television-dtv-broadcasting-has-given-these-distance-education-partnerships-new-capabilities-for-reaching-more-potential-students.-in-this-article-i-review-one-innovative-collaboration-between-several-nursing-education-programs-and-a-public-broadcasting-service-member-station-in-south-texas.-in-this-pilot-project-nursing-faculty-were-trained-in-television-production-techniques-and-became-producers-of-dtv-instructional-video-material.-this-case-study-demonstrates-a-number-of-ways-in-which-nursing-distance-education-programs-can-benefit-by-designing-and-delivering-course-material-via-digital-broadcasting.-it-also-highlights-several-difficulties-that-should-be-considered-by-distance-educators-prior-to-embarking-on-dtv-curriculum-development-projects. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [**Whitmore BA**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Whitmore+BA"%5BAuthor%5D). Nursing distance education at the dawn of digital broadcasting: a case study in collaboration. J Nurs Educ. 2005 Aug;44(8):351-6. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16130341&query_hl=21**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16130341&query_hl=21) {#whitmore-ba.-nursing-distance-education-at-the-dawn-of-digital-broadcasting-a-case-study-in-collaboration.-j-nurs-educ.-2005-aug448351-6.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16130341query_hl21 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### You can obtain free online CEUs on obstetric topics from the Indian Health system. Just go to the Perinatology Corner and pick from any, or all, of the modules. This can be completed from home, or at work. Uncomfortable with the online format? You can print them out and send it, too. {#you-can-obtain-free-online-ceus-on-obstetric-topics-from-the-indian-health-system.-just-go-to-the-perinatology-corner-and-pick-from-any-or-all-of-the-modules.-this-can-be-completed-from-home-or-at-work.-uncomfortable-with-the-online-format-you-can-print-them-out-and-send-it-too. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Perinatology Corner {#perinatology-corner .Style-Heading-4-+-Arial-14-pt-Underline}

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

\*In lieu of a Case Manager submission, Reynaldo Espera, from ANMC Labor
and Delivery submitted the above, <respera@anmc.org>

C.

Here is an issue that comes up a lot, so I pulled together some
resources njm

**Q. What are some resources for nurse staffing ratios in L/D and
postpartum?**

A. That issue is moving topic. It depends on the actual acuity the
patient presents. See details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/NursStaff9405.doc>

#### 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}

**-**Open access can work for any type of practice. It is the wave of
the future

-New IHS Women's Health Consultant / Advanced Practice Nurse Consultant

-Relative value of physical exam of the breast as a screening tool

-Trial of Labor After Cesarean: Evidence based guidelines

-Ovarian conservation benefits survival in women undergoing hysterectomy

-AAP Releases Report on Excessive Sleepiness in Adolescents

-Existing heart disease is undiagnosed in 1/2 of women with first heart
attack

-Management of Endometrial Cancer ACOG Practice Bulletin NUMBER 65

-The Known and the Unknown - Clinical Evidence Summarized

-Stress and verbal abuse in nursing

-Toward optimal screening strategies for older women: Should cost matter
the most?

-Over-The-Counter Sales of Emergency Contraception Do Not Increase
Unsafe Sex

-Magical Mystery Tour: The Answer: 2 positive blood cultures in a
postpartum patient with fever

-Please help us build the Midwives Indian Health Patient Education
Resources page

-Is the patch more dangerous than the pill?

-Glyburide, Glargine, and Effects of Obesity

-Condom effectiveness for prevention of *Chlamydia trachomatis*
infection

-Women the stronger gender? Men more carbohydrate intolerant / less
physical endurance

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05AugOL.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05AugOL.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocuments05augol.pdf .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 {#domestic-violence .Style-Heading-4-+-Arial-14-pt-Underline}

**Patients May Prefer That Physicians Ask About Family Conflict**

CONCLUSION: Most patients are open to discussions about family conflict
with their physicians. The skills they recommend to physicians are well
within the domain of family medicine training.

[Burge
SK](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Burge+SK"%5BAuthor%5D),
et al Patients\' advice to physicians about intervening in family
conflict. Ann Fam Med. 2005 May-Jun;3(3):248-54.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15928229&query_hl=1>

**Guides to Investigating Child Abuse**

Provides concise, practical information to assist law enforcement
officers in investigating child fatalities in which investigators
believe abuse or neglect caused or contributed to the fatal injury. How
child fatalities differ from other types of homicide cases and offers
specific guidelines for conducting the investigation, documenting the
case, interrogating suspects, and testifying in court. The guide also
includes checklists of potential witnesses and information sources, a
"tips and reminders" page, and resource information. 'Portable Guide'
Walsh, B, OJJDP

<http://ojjdp.ncjrs.org/publications/PubAbstract.asp?pubi=209764>

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

**Cancer screening in elderly patients: a framework for individualized
decision making**

Considerable uncertainty exists about the use of cancer screening tests
in older people, as illustrated by the different age cutoffs recommended
by various guideline panels. We suggest that a framework to guide
individualized cancer screening decisions in older patients may be more
useful to the practicing clinician than age guidelines. Like many
medical decisions, cancer screening decisions require weighing
quantitative information, such as risk of cancer death and likelihood of
beneficial and adverse screening outcomes, as well as qualitative
factors, such as individual patients\' values and preferences.

Our framework first anchors decisions through quantitative estimates of
life expectancy, risk of cancer death, and screening outcomes based on
published data. Potential benefits of screening are presented as the
number needed to screen to prevent 1 cancer-specific death, based on the
estimated life expectancy during which a patient will be screened.
Estimates reveal substantial variability in the likelihood of benefit
for patients of similar ages with varying life expectancies. In fact,
patients with life expectancies of less than 5 years are unlikely to
derive any survival benefit from cancer screening.

We also consider the likelihood of potential harm from screening
according to patient factors and test characteristics. Some of the
greatest harms of screening occur by detecting cancers that would never
have become clinically significant. This becomes more likely as life
expectancy decreases. Finally, since many cancer screening decisions in
older adults cannot be answered solely by quantitative estimates of
benefits and harms, considering the estimated outcomes according to the
patient\'s own values and preferences is the final step for making
informed screening decisions.

[Walter
LC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Walter+LC"%5BAuthor%5D),
[Covinsky
KE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Covinsky+KE"%5BAuthor%5D).
Cancer screening in elderly patients: a framework for individualized
decision making. JAMA. 2001 Jun 6;285(21):2750-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11386931&query_hl=4>

**Comment: Bruce Finke, Elder Care Director, IHS**

The following are paraphrased thoughts in response to the [Mandelblatt
JS](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Mandelblatt+JS"%5BAuthor%5D),
et al article, 'Toward optimal screening strategies for older women:
Should cost matter the most?' and the subsequent comments in the August
CCC Corner\*

My read of this piece is that life expectancy remains the dominant
consideration in whether or not to recommend mammography for elderly
women. I very much like the approach of Walter and Covinsky (attached)
which this article references. It gives a way of thinking (and talking
with patients) about the competing mortality and the potential benefit
of screening.

For example, a very healthy 80 year old (in the highest quartile of life
expectancy - 13 years) has a risk of dying of breast cancer that is
higher than a very unhealthy 50 year old (in the lowest quartile of life
expectancy - 24.5 years). Since I would generally recommend a mammogram
to 50 year olds unless they are actively dying, I would also recommend
it to the active, vigorous 80 year old. We still have to assess the
patient, think about co-morbid conditions and assess relative life
expectancy, but it gives us data about the likelihood that screening
will benefit the patient.

I\'m not sure that the cost projections in this article are all that
useful. For one thing, I really have no way of assessing their accuracy.
There are an awful lot of assumptions in play. And of course they don\'t
help us to work with individuals.

I am not philosophically opposed to using cost as a factor in
understanding the value of a screening test or of screening a particular
population - I think we have the obligation to identify ways to use the
limited resources we have available in our health system to greatest
benefit for the largest number of people. But we have not, generally,
applied these kinds of calculations to population-specific decisions
about screening in the Indian health system. Breast cancer screening in
the Southwest is a good example. Because the incidence of breast cancer
in this population is substantially lower than that of the US All Races,
it\'s likely that that cost / benefit ratio is somewhat different that
that used to decide that screening on a population-wide basis makes
sense.

But we don\'t have the data or the research capacity to develop those
kinds of analyses and I think that it is just fine to go with nationally
derived recommendations.

[Bottom line:]{.underline} The [Mandelblatt
JS](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Mandelblatt+JS"%5BAuthor%5D),
et al article may not be relevant. Please take a good look at the Walter
and Covinsky article (above) and see if that doesn\'t seem useful to
your patients and your practice.

\***Toward optimal screening strategies for older women: Should cost
matter the most? August CCC Corner**
<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0805_Feat.cfm#elder>

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

**EC in adolescents: No compromise of family planning or increased
sexual behavior**

Conclusion: Young adolescents with improved access to EC used the method
more frequently when needed, but did not compromise their use of routine
contraception nor increase their sexual risk behavior. Level of
Evidence: I.

[Harper
CC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Harper+CC"%5BAuthor%5D)
et a; The effect of increased access to emergency contraception among
young adolescents. Obstet Gynecol. 2005 Sep;106(3):483-91.\
\
**[OB/GYN CCC Editorial comment:]{.underline}**

These Level I data confirm other studies that the use of EC in
adolescents is not associated with a compromise in the use of routine
contraception, nor an increase their sexual risk behavior. Our federal
regulatory agencies should rely on scientific data solely to make
decisions on medication availability.

**Emergency Contraception for adolescents, American Academy of
Pediatrics**

"....Although adolescent birth rates have declined in the past 10 years,
unintended teen pregnancy and the associated negative consequences of
adolescent pregnancy remain important public health concerns. Adolescent
birth rates in the United States are much higher than rates in other
developed countries. Emergency contraception has the potential to
significantly reduce teen pregnancy rates and this will similarly reduce
the abortion rate."
<http://www.aap.org/advocacy/releases/sept05contraception.htm>

A fact sheet is available for parents and adolescents
<http://www.aap.org/family/ecparentpage.pdf>

**From Dr. Jean Howe, Chinle - Navajo News**

#### The following is additional information from Dr. Howe and the Association for Reproductive Health Professionals, and assistance from others\*, in regard to last month's CCC Corner Ortho Evra discussion {#the-following-is-additional-information-from-dr.-howe-and-the-association-for-reproductive-health-professionals-and-assistance-from-others-in-regard-to-last-months-ccc-corner-ortho-evra-discussion .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0805_Feat.cfm#navajo**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0805_Feat.cfm#navajo) {#httpwww.ihs.govmedicalprogramsmchmobgyn0805_feat.cfmnavajo .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Contraception, the 'Patch', and reports of adverse events including death {#contraception-the-patch-and-reports-of-adverse-events-including-death-1 .Style-Heading-4-+-Arial-14-pt-Underline}

** **A number of articles have appeared in various news media over the
past year reporting deaths associated with use of the contraceptive
patch. The Association of Reproductive Health Professionals (ARHP)
concludes that the articles that have been reviewed are biased and
unfortunate, misrepresenting the available data and presenting a skewed
picture of adverse events attributable to the contraceptive patch in
particular, and medications in general. To assist ARHP member clinicians
who may face questions from their clients about the patch---and
contraception---as a result of these news reports, the organization has
prepared some evidence-based talking points on this subject.

**ARHP Talking Points**

 

-   The patch has been used by approximately five million women in the
    United States since it became available in 2002.

 

-   Deaths among young women because of medical problems such as blood
    clots and heart attacks are very rare, and they are also very rare
    among young women using contraceptive hormones.

 

-   Taking oral contraceptives or using hormonal contraceptive patches
    slightly increases the risk of cardiovascular problems---especially
    for women over 35 who smoke.

 

-   The rate for cardiovascular problems estimated for women using the
    patch is in the range that has been reported for other hormonal
    contraceptives such as oral contraceptives \[see *Contraceptive
    Technology Table 9-4, p. 230*\].

 

-   Health risks for patch users are essentially the same as risks for
    women using other hormonal contraceptives.

 

-   In context, risks for death associated with other common activities
    such as driving an automobile (1 in 5,900) or continuing a pregnancy
    to term (1 in 10,000) are significantly higher than risks associated
    with use of hormonal contraceptives.

 

-   The risk of death associated with pregnancy---a common outcome among
    women who don't use contraception---is far higher than the risk of
    death associated with using contraceptive pills or the patch.
    Pregnancy-related deaths, including those at delivery, stillbirth,
    and ectopic pregnancy, claim the lives of two to three U.S. women
    every day---with 13 deaths reported for every 100,000 live births in
    1999.

 

-   Possible adverse drug reports are submitted voluntarily to FDA by
    clinicians in the U.S. and are intended to provide a means to
    identify rare medical problems that had not been anticipated in the
    clinical studies undertaken for FDA drug approval. Serious medical
    events are reported whether or not there is a clear \"cause and
    effect\" connection to the drug. For any medication that is widely
    used, therefore, at least some deaths are bound to occur and be
    reported.

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

#### [Background]{.underline} {#background .Style-Heading-4-+-Arial-14-pt-Underline}

As of May, 2005, Ortho Evra has been safely used by more than five
million women worldwide since introduction in 2002. While adverse events
and patient concerns should be taken seriously, there is no reason for
alarm at this time. Evra is as safe as oral contraceptives and NuvaRing
for healthy reproductive age women with no contraindications to combined
hormonal contraception. As you are aware, each Evra patch delivers a
daily dose of 150 mcg of norelgestromin (the active metabolite of
norgestimate) and 20 mcg of ethinyl estradiol (per 24 hours). This dose
is considered equivalent to a 35 mcg oral contraceptive, although
comparing oral delivery and transdermal delivery is difficult.

If one only looks at fatal pulmonary embolus, and if the 16 deaths
mentioned above are directly attributable to Evra, which they aren't,
this number of deaths, though unfortunate, is less than the number of
expected deaths from pulmonary embolism among users of combined hormonal
oral contraceptives (from which we would extrapolate expected number of
deaths from Evra). Total woman-years of exposure to Ortho Evra are 4.1
million woman years. The absolute risk of death from pulmonary embolism
in current oral contraceptive users is estimated at 1 per 100,000 woman
years[^1]. This would translate into 41 expected deaths from pulmonary
embolism, not 16.

To further place this into context, 16 deaths during 4.1 million woman
years of use translates into a rate of 0.39 per 100,000 woman years. The
expected death rate from Viagara is 6 per 100,000 prescriptions. The
risk of dying from continuing a pregnancy beyond 20 weeks is 10.7 per
100,000 live births[^2].

In addition, among women who do not use OCs, do not smoke nor have any
other cardiovascular risk factors, total incidence of stroke and acute
myocardial infarction is estimated at 1 to 2 events per 100,000 woman
years in those ages 20-24 years[^3]. Much of this incidence among
non-smokers, not using oral contraceptives is attributable to ischemic
and hemorrhagic stroke which are expected at a rate of 1.9 per 100,000
woman years for ages 20 to 24; 3.4 per 100,000 woman years for ages 30
to 34; and 6.2 per 100,000 woman years for ages 40 to 44[^4].
Corresponding expected ischemic and hemorrhagic stroke per 100,000 woman
years among non-smoking oral contraceptive users are 2.2 for ages 20 to
24; 3.9 for ages 30-34; and 11.7 for ages 40-44^4^.

Extrapolating from this data, the expected [number]{.underline} of
ischemic and hemorrhagic strokes during 4.1 million years of Evra use is
90, if [all]{.underline} users were non-smokers [and]{.underline} in age
group 20-24; 160 if [all]{.underline} users were non-smokers
[and]{.underline} in age group 30-34; and 480, if [all]{.underline}
users were non--smokers [and]{.underline} in the age group 40 to 44.
Without a breakdown of age, one only can say that the expected number of
strokes is between 90 and 160 for women ages 20 to 34 using Evra, if all
Evra users were non-smokers. As expected ischemic and hemorrhagic stroke
incidence is higher among older oral contraceptive users who smoke.
Incidence rates for ischemic and hemorrhagic stroke range from 5.6 per
100,000 woman years for smokers ages 20-24 to 102 per 100,000 woman
years for women ages 30 to 34^4^.

No medication is without risk. No medical procedure is without risk. No
pregnancy is without risk. As with any health care decision, a balancing
of individual risks and benefits is required. Healthy reproductive age
women with no contraindications to combined hormonal contraception who
want Ortho Evra should be encouraged to try this method, and if already
using this method, women should not be discouraged from using it.

Goldhaber SZ. Pulmonary embolism. Lancet 2004;363:1295-1305.

^2^ Chang J, Elam-Evans LK, Berg CJ, Herndon J, Flowers L, Seed KA, et
al. Pregnancy-Related Mortality Surveillance - United States, 1991-1999.
Surveillance Summaries, February 21, 2003. MMWR 2003;52(No SS-2):1-8.

^3^ Farley TMM, Meirik O, Chang CL, Poulter NR. Combined oral
contraceptives, smoking, and cardiovascular risk. J Epidemiol Community
Health 1998;52:775-785.

^4^ World Health Organization. Cardiovascular Disease and Steroid
Hormone Contraception. Report of a WHO Scientific Group. Geneva 1998;
WHO Technical Report Series 877.

**\***<http://www.plannedparenthood.org/pp2/portal/>

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

#### Based upon the information available now it is reasonable to say that re: CV problems nothing unexpected is occurring. The number of serious adverse events reported for Evra is within the range of what is expected for oral contraceptives. The rates for Evra are not lower\-\--they should be comparable and based upon the information we have, that appears to be the case. {#based-upon-the-information-available-now-it-is-reasonable-to-say-that-re-cv-problems-nothing-unexpected-is-occurring.-the-number-of-serious-adverse-events-reported-for-evra-is-within-the-range-of-what-is-expected-for-oral-contraceptives.-the-rates-for-evra-are-not-lower---they-should-be-comparable-and-based-upon-the-information-we-have-that-appears-to-be-the-case. .Style-Heading-4-+-Arial-14-pt-Underline}

**FDA -- Home page**

<http://www.fda.gov/default.htm>

**Questions you may get from your patients about Ortho Evra** (from
Ortho-McNeil)

[www.orthoevra.com](http://www.orthoevra.com/)

**Featured Website David Gahn, IHS Women's Health Web Site Content
Coordinator**

**CDC "Key Facts about Flu Vaccine"**

As flu season quickly approaches, many of your patients will have
questions and concerns about the flu vaccine. This CDC site discusses
the two types of vaccine, when to get vaccinated, who should get
vaccinated, who should not get vaccinated, vaccine effectiveness, and
vaccine side effects. <http://www.cdc.gov/flu/protect/keyfacts.htm>
<http://www.cdc.gov/flu/protect/pdf/vaccinekeyfacts.pdf>

**Don't forget to visit IHS Women's Health Web Site regularly for new
information at**

**What's New page (all new entries to the site in chronological order)**

<http://www.ihs.gov/MedicalPrograms/MCH/W/WN00.asp#top>

Or

**IHS Women's Health Web Site**

<http://www.ihs.gov/MedicalPrograms/MCH/Wh.asp>

**Upcoming Health Observances**

-Domestic Violence Awareness Month -- October

-National Breast Cancer Awareness Month -- October

-Children's Health Month -- October

-National Depression Screening Day -- October 6th

-National Bone and Joint Disorders Awareness Week -- October 12-20

-World Osteoporosis Day -- October 20th

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

**Q. Should a urine test be performed on every pregnant patient each
prenatal visit?**

A. No, routine urine testing in pregnancy is very insensitive and
non-specific. See details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/UrinPrenat9405.doc>

**Q. Should we be performing some type of long term follow-up on our GDM
patients?**

A. Yes, perform a 75 gm OGTT initially at 6 wks pp, and a FPG or OGTT q
3 yrs. See details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/GDMfu9405.doc>

**Q. Should we do a test of cure for Chlamydia in pregnancy? If so,
when?**

A. Yes, you should do a test of cure in pregnancy. See the details below

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ChlamyTOC9205.doc>

**Q. What is the safest, most effective approach to prodromal labor?**

A. First, be sure of the diagnosis, and then there are a variety of
appropriate options.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/prodrom9405.doc>

Q. Should we use glargine use in pregnancy?

A. Short and intermediate acting insulin(s) are recommended at this
time. See details below

<http://www.ihs.gov/MedicalPrograms/MCH/m/documents/Glargine81405b.doc>

**Q. Is there an association between thyroid auto-antibodies and fetal
Down's Syndrome?**

A. Upon review no association was found. We have better methods now,
e.g., quad, NT, etc

<http://www.ihs.gov/MedicalPrograms/MCH/m/documents/DownsThyr81505.doc>\

**Q. Is repetitive intrathecal anesthesia a good alternative to epidural
anesthesia in labor?**

A. Continuous epidural anesthesia is often the more satisfactory
approach. See details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Itrathec9405.doc>

**Indian Child Health Notes**

**September 2005 -- Doug Esposito, Steve Holve, Roslayn Singleton**

Highlights for September 2005

\- Information on the Early Childhood Longitudinal Study provides a
wealth of background information about early childhood development
across the nation and in AI/AN communities

\- A new feature: A monthly update on infectious diseases and
immunizations from Roslayn Singleton, MD of Anchorage. This month will
feature information on the new adolescent pertussis booster vaccination

\- A Bonus second new feature: Review of the recent published literature
and how it applies to AI/AN children by Doug Esposito of Fort Defiance,
AZ. This month will feature an effort to reduce suicide in AI/AN
communities

<http://www.ihs.gov/MedicalPrograms/MCH/C/documents/ICHN905.doc>

**2005 Native American Child Health Advocacy Award is Dr Lori**
**Byron**

From Sunnah Kim, AAP 

I\'m pleased to announce that the recipient of the 2005 Native American
Child Health Advocacy Award is Dr Lori Byron. This award will be
presented on Sunday, October 9 at the National Conference and Exhibition
in Washington DC. Below is information about the award presentation.

-Please note that there are a limited number of seats to this function,
and there is no charge to attend. Please see the RSVP instructions
below. If you plan to be at the NCE, we hope that you will be able to
join us! 

-As a side note, this year\'s Job Lewis Smith Award will be presented to
Dr Tom Tonniges. I know that many of you know him as well.
<SKim@AAP.ORG>

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

**Physicians\' Use of Electronic Medical Records**

![](media/image2.png){width="2.8645833333333335in"
height="2.573611111111111in"}

**Figure.** Percentage of U.S. health care professionals using
electronic medical records from 2001 to 2003.

*Adapted from Burt CW, Hing E. Use of computerized clinical support
systems in medical settings: United States, 2001-03. Adv Data
2005;(353):1-8.*

NCHS Statistics on the Use of Electronic Medical Records

Data from the National Center for Health Statistics (NCHS) on the use of
electronic medical records in health care were published in the May 13,
2005, issue of *Morbidity and Mortality Weekly Report.*
<http://www.cdc.gov/nchs/data/ad/ad353.pdf>

According to the NCHS, electronic medical records were used most
frequently in the emergency department, followed closely by outpatient
departments. Electronic medical records were used less frequently in
physician offices. About 73 percent of physicians used the technology
for billing patients, 17 percent for maintaining medical records, and 8
percent for ordering prescriptions. The technology was used for
automated drug dispensing systems in 40 percent of emergency departments
but only in 18 percent of outpatient departments. See *the accompanying
figure* for results by setting.
<http://www.aafp.org/afp/20050901/practice.html#p5>

**ISAC Request for Issues/Recommendations**

The Indian Health Service (IHS) established the Information Systems
Advisory Committee (ISAC) in the late 1990s to guide the development of
a co-owned and co-managed Indian health information infrastructure and
information systems.  The goal of the ISAC is to ensure the creation of
flexible and dynamic information systems that assist in the management
and delivery of health care and contribute to the elevation of the
health status of Indian people. 

The ISAC is soliciting input from all Indian Health Service (IHS),
Tribal, and Urban health constituents on national Indian health
information technology (IT) and information resource management
issues/initiatives. Mike Danielson, Billings Area IHS,
<mike.danielson@ihs.gov>  or Reece Sherrill, Choctaw Nation Health
Services Authority, <rwsherrill@choctawnationhealth.com>

#### International Health Update {#international-health-update .Style-Heading-4-+-Arial-14-pt-Underline}

**Indigenous peoples\' health\--why are they behind everyone,
everywhere?**

Many indigenous people are unrecognized, uncounted, and systematically
marginalized. What data do exist show that indigenous people have worse
health and social indicators than others in the same society? With that
in mind, The Lancet invites submissions of original research articles
into the health of indigenous people around the world, to be published
along with a series and personal accounts on the topic.

[Stephens
C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Stephens+C"%5BAuthor%5D)
et al Indigenous peoples\' health\--why are they behind everyone,
everywhere? Lancet. 2005 Jul 2;366(9479):10-3.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15993213&query_hl=30>

**Volunteer Opportunities - Hurricane Katrina**\
The Federal Government has contracted with JCNationwide to provide
immediate medical assistance to victims of Hurricane Katrina. Physicians
can volunteer at [www.jcnationwide.com](http://www.jcnationwide.com/)
and click on the \"Apply Here\" button. You may also call (800) 272-2707
if you can be of assistance.

The Louisiana Office of Public Health has listed numbers that physicians
can call if they would like to offer assistance. Please keep in mind
that some hotlines will be overloaded.

-   Carl Maddox Field House 225.219.0821

-   Pete Maravich Assembly Center 225.578.0377

-   OLOL Medical Staff Office 225.765.8871

Emergency room doctors are needed for the Temporary Medical Operations
Staging Areas set up in Baton Rouge at the LSU Pete Maravich Assembly
Center and at Nichols State University in Thibodaux. Physicians are also
needed for triage and medical care services at special needs shelters in
Alexandria, Lake Charles, Lafayette, and Thibodaux to care for patients
who do not require acute hospital care but who require oxygen treatment,
tube feeding, or mental health care. Contact Dr. Jean Takenaka, Office
of Public Health, Emergency Operations Center, at 225.763.5751 or
<jtakenak@dhh.la.gov>

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

**Adolescent pregnancy prevention**

The supplement to the September 2005 issue of the Journal of Adolescent
Health identifies and highlights some of the lessons learned from eight
years of investment in the Community Coalition Partnership Program, a
13-community demonstration program aimed at preventing adolescent
pregnancy that was funded by the Centers for Disease Control and
Prevention (CDC) from 1995 through 2003.

[[http://www.sciencedirect.com/science?\_ob=IssueURL&\_tockey=%23TOC%235072%232005%23999629996.8998%23604617%23FLA%23&\_auth=y&view=c&\_acct=C000035538&\_version=1&\_urlVersion=0&\_userid=655954&md5=338488a44e072320e96797c2130f94f1]{.underline}](http://www.sciencedirect.com/science?_ob=IssueURL&_tockey=%23TOC%235072%232005%23999629996.8998%23604617%23FLA%23&_auth=y&view=c&_acct=C000035538&_version=1&_urlVersion=0&_userid=655954&md5=338488a44e072320e96797c2130f94f1)

**Cost effectiveness of interventions for major depression in low income
minority women**

Providing pharmacotherapy or CBT \[cognitive behavior therapy\] to
low-income minority women is cost-effective for the public health care
system. For programs funded by state and federal public health agencies
to provide coverage for effective depression treatment programs,
tailored interventions must demonstrate that they reach and are
beneficial to potential participants, in terms of depression and health
status outcomes, and they must demonstrate cost-effectiveness.

-Expenditures for improved interventions for depression in low-income
minority women represent a good investment compared with a range of
other generally acceptable medical treatments.

Revicki DA, Siddique J, Frank L, et al. 2005. Cost-effectiveness of
evidence-based pharmacotherapy or cognitive behavior therapy compared
with community referral for major depression in predominantly low-income
minority women. Archives of General Psychiatry 62(8):868-875.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16061764&dopt=Abstract>

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

**Overbooked clinic and next patient with chronic pelvic pain**

J. D. is 25 year old gravida 4, para 1, 0,2,1 who presents to the
outpatient clinic for follow-up of pelvic pain and vaginal bleeding and
is scheduled to receive methotrexate. The patient initially presented to
the emergency department (ED) 6 days ago and had followed up there again
last Friday night. The patient had been told to follow-up in outpatient
clinic on Monday.

The patient had had some vaginal spotting 5-6 weeks prior, but it was
not like her normal menses. Prior to that time the patient had a history
of irregular menstrual cycles, so she was not sure of her exact previous
cycles.

The patient's obstetric history is significant for one term vaginal
delivery of a 3,565 gram male, one ectopic pregnancy treated with
laparoscopic salpingectomy, and one ectopic pregnancy treated
successfully with single dose methotrexate. Those events occurred at
another Service Unit and the records are felt to be in transit, as the
patient had signed a release of information when her pregnancy test
first became positive 2 weeks ago.

Other history included:

-a case of cervical chlymadia trachomatis at 18 years of age treated
with azithromycin

-one case of presumed pelvic inflammatory disease treated as an
outpatient with

Ceftriaxone 250 mg IM in a single dose, Doxycycline 100 mg orally twice
a day for 14 days and*\
*Metronidazole 500 mg orally twice a day for 14 days.

-new relationship with a partner who is interested in having a large
family

Physical exam

BP 126/76, P 88, RR 16, Weight 147 lbs., Height 66 inches, Body Surface
Area 1.76 m^2^

Exam confirmed mild pelvic discomfort, right side greater than left;
small amount of recent vaginal bleeding from a closed and long cervix;
otherwise unremarkable

Laboratory evaluation:

Blood type B positive, hemoglobin 11.2, urinalysis negative

Quantitative HCG

[Value]{.underline} [Percent increase]{.underline}

6 days prior 850 -

4 days prior 1400 54% increase

2 day prior 2142 53% increase

Imaging studies:

Pelvic ultrasound performed 2 days prior revealed a 3 cm right adnexal
structure thought to be a possible an ovarian cystic structure with
complex elements or a curved hydrosalpinx. The structure had the
appearance of a donut. The radiologist's dictation stated that the study
was consistent with a hydrosalpinx or corpus luteum cyst, but that
ectopic pregnancy needed to be considered clinically. There was also
indistinct intrauterine contents not unlike a gestational sac, but no
distinct fetal pole or yolk sac. The radiologist could not rule out a
pseudosac. The radiologist's DRAFT report suggested appropriate medical
/ surgical intervention depending the patient's condition.

The patient's chart was not found due to her recent visits to the ED,
hence the ED clinical notes were not available. The lab values had been
pulled up on the RPMS system. The patient said the ED physician told her
that her HCG levels were not increasing appropriately for a normal
pregnancy.

The patient needed to get back to work to her new job at a large
box-like retail outlet nearby as soon as possible. She said as this was
another ectopic pregnancy, that she would prefer repeating a course of
single dose methotrexate, just like last time. This patient was the
first of two overbooked patients at 1:00 PM as the clinic was trying to
maintain its 3^rd^ next available statistics for improved patient
access. Both overbooked patients were in rooms and the 1:15 PM was being
checked for an evaluation of chronic pelvic pain and need for a narcotic
refill.

The patient said that ED provider told her that you would know what dose
of methotrexate to prescribe in this particular situation. She said she
heard the ED physician was concerned that her HCG had not increased by
66% during the previous serial 2 day intervals. She said the ED
physician said that you might want to call a specialist to find out,
because this was her third ectopic pregnancy.

**What dose of methotrexate would you prescribe to this patient?**

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

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

######### 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**

AHRQ Releases Evidence Report on Managing Menopause-Related Symptoms

The Agency for Healthcare Research and Quality (AHRQ) has released the
results of a systematic review on managing menopause-related symptoms.

By definition, menopause is the permanent cessation of menses caused by
reduced ovarian hormone secretion. Menopause usually occurs in women 40
to 58 years of age, and it may take several years to fully transition
from onset to completion. During this time, many women experience
symptoms that can cause reduced quality of life. Common
menopause-related symptoms include:

• Hot flashes

• Vaginal dryness

• Sleep disturbance

• Mood symptoms

• Cognitive disturbances

• Somatic complaints

• Urinary complaints

• Uterine bleeding

Many therapies exist to manage these symptoms, including hormone
therapy, antidepressants and other drugs, behavioral interventions, and
complementary and alternative medicine.

The AHRQ evidence report evaluates the benefits and harms of common
interventions to relieve menopause-related symptoms. The review included
American women who were going through menopause and who presented with
at least one of the above symptoms. A technical expert panel, which was
made up of experts and clinicians in the field, and expert reviewers
provided input for this review.

Managing Menopausal Symptoms

estrogen

Estrogen was the most consistently effective intervention for vasomotor
symptoms. The therapy also helped manage urogenital symptoms, along with
sleep, mood, sexual, and quality-of-life outcomes compared with placebo.
The most common adverse effects of estrogen therapy were breast
tenderness and uterine bleeding.

testosterone and estrogen

The reviewers found few trials evaluating testosterone therapy. However,
one trial showed no difference between combination testosterone and
estrogen therapy and estrogen therapy alone for hot flashes, vaginal
dryness, or sleep problems. The results of two trials showed that
testosterone and estrogen therapy improved sexual symptoms better than
estrogen alone or placebo. However, women receiving combination therapy
had significantly more incidences of acne and hirsutism compared with
those in the estrogen-only group.

progestin

Trials showed varying results regarding progestin in the management of
vasomotor symptoms.

tibolone

A few trials of fair to good quality showed that tibolone (Livial)
helped manage vasomotor symptoms, sleep, and somatic complaints compared
with placebo. Tibolone was similar to estrogen in the management of some
symptoms. Patients treated with tibolone experienced more uterine
bleeding, body pain, weight gain, and headaches compared with patients
who were treated with placebo.

soy isoflavones and other alternative therapies

Although results varied and more research is needed, alternative
therapies were beneficial in managing some nonvasomotor symptoms.

Conclusion

Trials evaluating therapies for the management of menopause-related
symptoms were conclusive only for estrogen in the management of
vasomotor and urogenital symptoms. After further research, other
therapies may demonstrate beneficial results.

limitations

The trials included in this evidence review had the following
limitations:

• Highly selected, small sample groups

• Short duration

• Inadequate reporting of loss to follow-up, maintenance of comparable
groups, contamination, methods of analysis, and adverse events

• Some nonstandardized and nonvalidated measures and outcomes

• Unclear inclusion and exclusion criteria

• Industry sponsorship

#### Evidence Report/Technology Assessment No. 120, \"Management of Menopause-Related Symptoms,\" [**http://www.ahrq.gov/clinic/epcsums/menosum.htm**](http://www.ahrq.gov/clinic/epcsums/menosum.htm) {#evidence-reporttechnology-assessment-no.-120-management-of-menopause-related-symptoms-httpwww.ahrq.govclinicepcsumsmenosum.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Tibolone and Low-Dose Hormone Therapy Seen as Postmenopausal Options {#tibolone-and-low-dose-hormone-therapy-seen-as-postmenopausal-options .Style-Heading-4-+-Arial-14-pt-Underline}

For postmenopausal women, both low-dose hormone therapy and tibolone, a
synthetic steroid with estrogenic, androgenic, and progestogenic
properties, \"may be considered\" as alternatives to conventional doses
of hormone therapy.CONCLUSION: Both tibolone and L-HT improved
flow-mediated response by a similar magnitude and did not significantly
increase high-sensitivity C-reactive protein. However, tibolone
significantly reduced PAI-1, but increased F1+2 more than L-HT. [Koh
KK](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Koh+KK"%5BAuthor%5D)
et al Significant differential effects of lower doses of hormone therapy
or tibolone on markers of cardiovascular disease in post-menopausal
women: a randomized, double-blind, crossover study. Eur Heart J. 2005
Jul;26(14):1362-8.**\
**<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15872028&dopt=Abstract>

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

#### Natural History of Menopause Symptoms in Primary Care Patients {#natural-history-of-menopause-symptoms-in-primary-care-patients-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Symptoms are not uncommon among premenopausal women and become more prevalent as the transition through menopause occurs. The prevalence of vasomotor symptoms in premenopausal women may be an under-recognized aspect of the natural history of the menopause transition. African American and white women may present different symptoms through menopause transition. [**Xu J**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Xu+J"%5BAuthor%5D) et al Natural History of Menopause Symptoms in Primary Care Patients: A MetroNet Study. J Am Board Fam Pract. 2005 Sep-Oct;18(5):374-82 [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16148247&query_hl=4**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16148247&query_hl=4) {#conclusions-symptoms-are-not-uncommon-among-premenopausal-women-and-become-more-prevalent-as-the-transition-through-menopause-occurs.-the-prevalence-of-vasomotor-symptoms-in-premenopausal-women-may-be-an-under-recognized-aspect-of-the-natural-history-of-the-menopause-transition.-african-american-and-white-women-may-present-different-symptoms-through-menopause-transition.-xu-j-et-al-natural-history-of-menopause-symptoms-in-primary-care-patients-a-metronet-study.-j-am-board-fam-pract.-2005-sep-oct185374-82-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16148247query_hl4 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Midwives Corner:  {#midwives-corner .Style-Heading-4-+-Arial-14-pt-Underline}

#### Amy Doughty, Zuni {#amy-doughty-zuni .Style-Heading-4-+-Arial-14-pt-Underline}

**Centering Pregnancy -- Group Prenatal Care**

Centering Pregnancy -- Group Prenatal Care

October 21& 22, 2005

Zuni, New Mexico

Registration
<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ZuniCentdirect.pdf>

Zuni PHS Hospital Directions

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ZuniCentdirect.pdf>

We are excited to offer this exciting training in Zuni. Contact
<Amy.Doughty@ihs.gov>

**Marsha Tahquechi, GIMC**

**Public health approach to suicide prevention in an American Indian
Tribal Nation**

CONCLUSIONS: Data from this community-based approach document a
remarkable downward trend-measured by both magnitude and temporal trends
in the specifically targeted age cohorts-in suicidal acts. The
sequential decrease in age-specific rates of suicide attempts and
gestures is indicative of the program\'s success.

[May
PA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="May+PA"%5BAuthor%5D)
et al Outcome evaluation of a public health approach to suicide
prevention in an American Indian Tribal Nation. Am J Public Health. 2005
Jul;95(7):1238-44.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15933239&dopt=Abstract]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15933239&dopt=Abstract)

**Navajo News Jean Howe, Chinle**

**Annual Navajo Area Women's Health Provider Meeting, September 23^rd^
in Chinle**

The upcoming Annual Navajo Area Women's Health Provider Meeting will be
held Friday, September 23^rd^, in Chinle.

The meeting will be from 11am until approximately 3pm and will be held
in the Chinle Hospital Large Conference Room.

It will be preceded by a meeting of the Four Corners Chapter of
Certified Nurse Midwives.

Lunch will be provided (we'll be "passing the hat" to help defray
expenses).

 

The agenda so far includes the following:

-An update from the Johns Hopkins study teams working in Navajo Area

-The status of VBAC in 2005

-The recent Crownpoint study of Active Management of the Third Stage of
Labor

-This year's GPRA numbers

-The ongoing Meth crisis

-Economic issues affecting the New Mexico service units

-A report from Afghanistan by Rosemary Bolza

and several other topics as well.

 

We'll also have a lunchtime CME presented by Cathleen Harris, MD, MPH of
Phoenix Perinatal Associates.

The topic will be "an obstetric update with emphasis on oral meds for
diabetes in pregnancy and first trimester genetic screening".

Please let me know of any other specific issues that you'd like to
discuss. <Jean.Howe@ihs.gov>

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

#### Also please see Dr. Howe's follow-up of the Ortho Evra issue from her column last month. (Family Planning above) {#also-please-see-dr.-howes-follow-up-of-the-ortho-evra-issue-from-her-column-last-month.-family-planning-above .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-15 .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}

**Breast and Cervical Cancer Program Highlights**

Learn how 12 CDC programs in nine states (Alabama, California, Kansas,
Maine, Maryland, Michigan, Missouri, New Mexico and Virginia) are taking
action against cancer.

#### [**http://apps.nccd.cdc.gov/cancercontacts/nbccedp/pia/index.asp**](http://apps.nccd.cdc.gov/cancercontacts/nbccedp/pia/index.asp) {#httpapps.nccd.cdc.govcancercontactsnbccedppiaindex.asp .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-16 .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}

**Electronic Health Record for care of women and children**

As many of you are aware, technology is becoming very pervasive in our
lives. Cell phones, pagers, PDAs, laptops are all part of our daily
existence. I can remember what it was like without these advances but
can't imagine going back. Electronic health records (EHR) is one of
those technologies. Here at Hastings Indian Medical Center, we began to
implement a change from written documentation to EHR over a year ago. At
that time, three physicians were chosen to begin training and
utilization of the new system. I was the OB/GYN that was to begin using
the system. Initially, I quickly discovered as did my pediatric
counterpart that this system was not designed for the OB or pediatric
population. In fact, EHR is an older version of a system used in the VA
hospitals (not many pediatric or OB patients there). So we had to adapt.
I created various templates, that we use for our daily visits but we
still had to continue to use the OB flow sheet to maintain continuity in
the system. I understand that one of the future updates will include a
flow sheet, but that it is a ways away.

Despite the pitfalls in the system and setbacks that we have had in the
year, I have a difficult time reverting to the old pen and paper system.
I find that the computer reminds me to ask things from my patients that
I might have forgotten to ask in the 15 minute appointment. I am told
that the documentation has improved drastically, not to mention the
legibility. EHR is not a panacea, and it had a rough start but, it has a
lot of potential to become one of those technologies.

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

The Office of information Technology is working to develop standardized
national pediatric and OB templates that will be available for use with
the EHR as well as PCC+, hopefully by the end of 2005. Contact
<Theresa.Cullen@ihs.gov> for questions.

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

#### Osteoporosis Prevention in Postmenopausal Women {#osteoporosis-prevention-in-postmenopausal-women-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: We observed significant reductions in the incidence of vertebral fractures with hormone replacement therapy, etidronate, and calcitonin, and significant improvements in bone mineral density with hormone replacement therapy and calcitonin. {#conclusion-we-observed-significant-reductions-in-the-incidence-of-vertebral-fractures-with-hormone-replacement-therapy-etidronate-and-calcitonin-and-significant-improvements-in-bone-mineral-density-with-hormone-replacement-therapy-and-calcitonin. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**Ishida Y**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Ishida+Y"%5BAuthor%5D), [**Kawai S**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Kawai+S"%5BAuthor%5D). Comparative efficacy of hormone replacement therapy, etidronate, calcitonin, alfacalcidol, and vitamin K in postmenopausal women with osteoporosis: The Yamaguchi Osteoporosis Prevention Study. Am J Med. 2004 Oct 15;117(8):549-55. {#ishida-y-kawai-s.-comparative-efficacy-of-hormone-replacement-therapy-etidronate-calcitonin-alfacalcidol-and-vitamin-k-in-postmenopausal-women-with-osteoporosis-the-yamaguchi-osteoporosis-prevention-study.-am-j-med.-2004-oct-151178549-55. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15465502&query_hl=16**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15465502&query_hl=16) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15465502query_hl16 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### New Report on Soy Finds Limited Evidence for Health Outcomes {#new-report-on-soy-finds-limited-evidence-for-health-outcomes-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ahrq.gov/news/press/pr2005/soypr.htm**](http://www.ahrq.gov/news/press/pr2005/soypr.htm) {#httpwww.ahrq.govnewspresspr2005soypr.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

**The "talk-sing test" -- If patient can sing, then the pace can be
increased**

# Exercise guidelines to improve glucose control

Type of activities:

Aerobic activities such as walking, stationary cycling, or swimming

Frequency:

At least 3 days per week

Duration:

20-45 minutes per session

Intensity:

Moderate. The "talk-sing test" may be used -- the patient should be able
to talk while

exercising; if she can sing, the pace can be increased. If using rating
of perceived

exertion level should feel "fairly light" to "somewhat hard".

Patient should warm-up before and cool down after exercise, drink plenty
of water, and

have snacks nearby if needed.

Initial exercise consult:

> Assessment of current physical activities and level of readiness for
> exercise
>
> Education/Information on exercise and GDM
>
> Individualized exercise plan

Supervised exercise:

> Measure blood glucose pre and post exercise
>
> Exercise on treadmill and/or recumbent cycle
>
> Monitor perceived exertion
>
> Monitor blood pressure and/or heart rate as needed

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

#### Intertrigo: What You Should Know {#intertrigo-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20050901/840ph.html**](http://www.aafp.org/afp/20050901/840ph.html) {#httpwww.aafp.orgafp20050901840ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Perinatology Picks George Gilson, MFM {#perinatology-picks-george-gilson-mfm .Style-Heading-4-+-Arial-14-pt-Underline}

**First trimester prenatal genetic screening: Is it ready for 'Prime
Time' at your facility?**

**A provider writes....**

"I have been reading a lot recently about first trimester nuchal
translucency (NT) measurement as a screening tool for fetal Down
syndrome. I already do all our OB ultrasounds and have been doing US for
over 7 years. I am excited to try NT. My question is this: If I do this
screening on women I am dating anyways, should I be offering this
screening to all our patients? How about just the high-risk women? Do
you have to do the biochemical screen as well?"

**Reply:**

First trimester screening for fetal aneuploidy by means of measurement
of the nuchal translucency (NT) combined with biochemical testing
(PAPP-A and free beta HCG) is being requested more and more by our
patients. There is a narrow window when this testing may be done (11
weeks 0 days to 13 weeks 6 days), so accurate dating is critical. The
advantages of first trimester screening are an earlier and more accurate
answer for our patients who are concerned about this issue. The
detection rate (sensitivity) of the combined NT + PAPP-A (pregnancy
associated plasma protein A) and "free beta" (not our usual bHCG
pregnancy test) approaches 90%, with a low false positive rate (FPR) of
about 3%, in the best studies.

"In the best studies" is a key phrase here. NT measurement is not an
easy skill that can be casually acquired by any sonographer. The median
normal value of the NT is just under 1 mm, so it must be obtained in a
very defined and strict fashion. A certification process, and an ongoing
quality assurance program, are necessary to assure that we have the
skills on which our clients can rely in order to make major decisions
about their pregnancy. In order to become certified you must first take
a one-day didactic course and pass a written exam (not too hard). You
must then acquire a set of your own images which must be sent to the
certifying body, followed by a video documenting how you obtained the
images. This process may take up to a year. More images must then be
submitted annually for quality assurance and renewal of certification.
The images are judged strictly and it requires quite a while for most
applicants to accumulate a certifiable number of images. Most of our
facilities will probably require referral to a quality center for this
exam at this time.

The NT measurement alone only has a sensitivity of about 75%, with a FPR
that approaches 20%, so it *must* be combined with the biochemical
panel. Medicaid and most insurance pay for these tests, but our patients
without a payment source must pay out of pocket, about \$95. It is
nevertheless probably the most cost-effective test, because the low rate
of false positives allows us to avoid a lot of unnecessary referrals,
invasive procedures, and parental anxiety.

Another issue is whether you are able to readily provide referral for
chorionic villus sampling (CVS) if the screening results are positive.
Are you able to counsel the parents appropriately about the details and
the risks of this costly invasive procedure? Or does the patient want to
wait until 15 weeks and have amniocentesis? Since less than half of
board-certified maternal-fetal medicine (MFM) specialists include CVS in
their practice, do you have a qualified specialist in your area to whom
you can refer? The ability to provide adequate counseling, referral, and
follow up is critical before your practice embarks on this screening
scheme. (See the attached abstract detailing some of the ethical issues
involved in referring or not referring.)

Patients who have had first trimester screening probably should *not* go
on to have second trimester screening (triple or quad screening) because
it will result in many more false positives (the majority of the cases
will already have been detected in the first trimester). There is a
testing scheme called "integrated screening" which "integrates" the
results of both the first and second trimester screening to give a final
answer. This actually has the best detection and the lowest false
positive rate, BUT, the lab must correct the patient's second trimester
risk with her new first trimester risk in order to give an accurate
answer and avoid a high FPR. Unlike in the U.K., where this strategy has
been extensively studied and developed, most labs in the U.S. are not
set up to "integrate" results in this fashion at the present time.

That brings up the issue of second trimester testing for fetal open
neural tube defects (ONTD). First trimester testing does not address
that issue. While the maternal serum alpha fetoprotein (AFP), collected
between 15 and 20 weeks, can detect 65% of fetal ONTD and abdominal wall
defects, it is currently available only in a "package" as the "triple
screen" or the "quad screen" where it is able to generate a software
program-derived risk assessment. It is not available as a single test
for ONTD, and, "you don't want to know" the other values that may now
give you a high false positive rate for Down syndrome! You can get
around this problem by omitting second trimester serum screening and
doing a second trimester anatomic scan (over 90% sensitivity for ONTD),
but, for most of us, this may require another costly referral.

As you can see, "the in's and out's" of implementing first trimester
screening at the present time are formidable. The laboratory logistics
have not quite caught up with the studies, or the patient demand. While
first trimester screening is preferred by clients, and eventually will
probably become the test of choice for women who present early enough,
it currently entails multiple barriers for most of us, and is not yet
"ready for prime-time". Unlike "Nike", you can't "just do it"! This
situation will certainly be evolving over time. ACOG originally called
first trimester screening "investigational", but has now stated that it
is "an option" if the following criteria can be met:

1.  Appropriate ultrasound training and ongoing quality monitoring
    programs are in place.

2.  Sufficient information and resources are available to provide
    comprehensive counseling to women regarding the different screening
    options and limitations of these tests.

3.  Access to an appropriate diagnostic test is available when screening
    test results are positive.

Our goal now should be to try to meet those standards in our practice
settings. Yes, we've implemented this option in Anchorage, but it has
been "a process". I hope that answers the questions you've raised and
will help you make the best decision for your service unit. Please read
the accompanying abstracts to further your understanding of some of
these issues. Stay tuned for further developments!

**Prospective first-trimester screening for trisomy 21 in 30,564
pregnancies**

CONCLUSION: The most effective method of screening for chromosomal
defects is by first-trimester fetal NT and maternal serum biochemistry.

[Avgidou
K](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Avgidou+K"%5BAuthor%5D),
et al Prospective first-trimester screening for trisomy 21 in 30,564
pregnancies. Am J Obstet Gynecol. 2005 Jun;192(6):1761-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15970804&query_hl=3>

**Implementation of first-trimester risk assessment for trisomy 21:
ethical considerations.**

The performance and evaluation of first-trimester risk assessment should
meet standards of scientific and ethical excellence. Scientific
standards are well understood. Ethical standards are less well
understood. On the basis of the ethical concept of the physician as
fiduciary, and the ethical principles of respect for autonomy,
beneficence, and justice, we show that the obstetrician has an ethical
obligation to routinely offer pregnant women first-trimester risk
assessment in high quality centers. On the basis of the professional
virtues of integrity and self-sacrifice, we then show that both
obstetricians and specialists in risk assessment have a strict ethical
obligation to identify, responsibly manage, and disclose both economic
and noneconomic conflicts of interests, especially when they are hidden.
We conclude that ethics is an essential dimension of implementation of
first-trimester risk assessment for trisomy 21.

[Chervenak
FA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Chervenak+FA"%5BAuthor%5D),
[McCullough
LB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="McCullough+LB"%5BAuthor%5D).
Implementation of first-trimester risk assessment for trisomy 21:
ethical considerations. Am J Obstet Gynecol. 2005 Jun;192(6):1777-81.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15970806&query_hl=1>

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

The 'process' Dr. Gilson describes above has taken years at our Indian
Health system facility and is very dependent on excellent personnel who
are willing to make a long term commitment. The 'process' requires extra
education, training, and an ongoing effort at quality assurance
documentation from the whole team. Anywhere along that timeline,
personnel turnover can jeopardize all your previous efforts.

ACOG Comm. Opinion No 296 states:

Although first-trimester screening for Down syndrome and trisomy 18 is
an option, it should be offered only if the following criteria can be
met:

1.  Appropriate ultrasound training and ongoing quality monitoring
    programs are in place.

2.  Sufficient information and resources are available to provide
    comprehensive counseling to women regarding the different screening
    options and limitations of these tests.

3.  Access to an appropriate diagnostic test is available when screening
    test results are positive.

If nothing else, you facility should be using the second trimester serum
'quad' screen, as opposed to the former 'triple' screen. Here a few
resources to help you evaluate the steps in this process.

First-trimester screening for fetal aneuploidy. ACOG Committee Opinion
No. 296. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2004;104:215--17

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15229041&dopt=Abstract>

**Prenatal Genetic Screening -- Serum and Ultrasound**

Perinatology Corner Module (free CME or just a great resource)

<http://www.ihs.gov/MedicalPrograms/MCH/M/TM01.cfm>

**Fetal Medicine Foundation Certification**

<http://www.fetalmedicine.com/nuchal.htm>

#### Primary Care Discussion Forum {#primary-care-discussion-forum .Style-Heading-4-+-Arial-14-pt-Underline}

**November 1, 2005**\
**Morbidity and Mortality Rounds - Web Based\***

**Rectal bleeding: Is it hemorrhoids? Moderator: Terry Cullen**

-   40 year old American Indian female presents to a remote ambulatory
    care clinic with intermittent blood in her stool for the last 3
    months.

-   She has had chronic constipation.

-   She believes that the blood is due to her hemorrhoids.

\***Goals of Web Based Morbidity and Mortality Rounds in Indian Health**

-Create a forum to discuss primary care M&M cases within the I/T/U
settings

-Cases will create a forum to discuss quality of care and patient safety

-Recognize and discuss the unique and ubiquitous constraints within the
Indian Health system

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

Subscribe to the Primary Care listserv

<http://www.ihs.gov/generalweb/helpcenter/helpdesk/index.cfm?module=listserv&option=subscribe&newquery=1>

Unsubscribe from the Primary Care listserv

<http://www.ihs.gov/generalweb/helpcenter/helpdesk/index.cfm?module=listserv&option=unsubscribe&newquery=1>

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

**STD Corner - Laura** **Shelby, STD Director, IHS**

**Evaluating a teen STD prevention Web site**

PURPOSE: Teens are at higher risk than other age groups for acquiring
sexually transmitted diseases (STDs) because of biological and
behavioral risk factors, but they have few STD prevention resources.
Little is known about how teens use the Internet to seek this
information. A pilot study was conducted to measure audience and
information-seeking characteristics of the
[www.iwannaknow.org](http://www.iwannaknow.org/) Web site.

CONCLUSIONS: Methods and findings will assist researchers, Web site
developers, and health educators to refine these evaluation methods,
develop effective Web sites, and tailor STD prevention messages by age
group and gender. The Internet is a cost-effective method for educating
teens and those who care for or work with teens about STD risks and
prevention, however, more research is needed to assess the behavioral
effects of online interventions.

Gilbert LK, Temby JR, Rogers SE. Evaluating a teen STD prevention Web
site. J Adolesc Health. 2005 Sep;37(3):236-42.    

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16109344&query_hl=1>

**Screening for sexually transmitted diseases in non-traditional
settings: a personal view**

We conducted a literature search to review studies that presented
quantitative data on sexually transmitted disease (STD) screening in
non-traditional settings in the United States. We examined the studies
for evidence of the feasibility of screening, population size reached,
acceptability, yield, and potential for contributing to STD control. We
found 17 studies in jails, eight in emergency room, five in schools and
15 in other community settings. Jail-based and emergency room-based STD
screenings have the highest yields and the largest numbers screened and
thus hold significant promise as settings for routine STD screening.
More research needs to be done in school and community settings to
better identify their potential.

[Cohen
DA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Cohen+DA"%5BAuthor%5D),
et al Screening for sexually transmitted diseases in non-traditional
settings: a personal view Int J STD AIDS. 2005 Aug;16(8):521-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16105185&query_hl=1>

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

**Q. Should we do a test of cure for Chlamydia in pregnancy? If so,
when?**

A. Yes, you should do a test of cure in pregnancy. See the details below

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ChlamyTOC9205.doc>

####  {#section-21 .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}

**Reduce insulin resistance during pregnancy**

Insulin resistance during pregnancy can lead to gestational diabetes,
which affects about 5-10 per cent of pregnancies. According to the
American Diabetes Association, about a third of women who suffered from
gestational diabetes during pregnancy develop type 2 diabetes in the
following years.

Blood levels of the vitamin-like substance L-carnitine are already
significantly reduced by the 12th week of pregnancy, and are reduced
further before birth.

Researchers at the University of Vienna have found that lower
L-Carnitine plasma levels lead to a down-regulation of the expression of
certain enzymes involved in fatty acid metabolism, namely CPT1, CPT2 and
CRAT. When the relative mRNA abundances of these enzymes are low,
however, the plasma levels of free fatty acids increase.

In the new study, taking a daily supplement of 2g of L-Carnipure
tartrate produced by the Swiss company Lonza was found to increase the
relative mRNA levels of these enzymes in pregnant women.

In three separate trials, more than 80 women in the 20th week of
pregnancy took a L-carnipure supplement in different doses until giving
birth. Only the 2g dose of L-Carnipure tartrate, which consists of 68
per cent L-Carnitine and 32 per cent L-tartaric acid, had an impact on
the fatty acid enzymes.

Lonza says there is increasing evidence that L-Carnitine may play an
important role during pregnancy, particularly in women following a
meat-reduced or vegetarian diet. These women may have a daily
L-Carnitine intake that is too low to meet the increased needs during
pregnancy.

Chemical Monthly, August 2005 (vol 136, pp1523-1533.

# Save the dates {#save-the-dates .Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5%)}

**National Indian Health Board: Youth and Tradition - Our Greatest
Resources**

-   October 16-19, 2005

-   Phoenix, AZ

-   Distinguished presenters and informative workshops

-   <http://www.nihb.org/staticpages/index.php?page=200403301344379533>

**Advances in Indian Health, 6^th^ Annual**

-   May 2-6, 2006

-   Albuquerque, NM

-   Save the dates brochure

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#May06>

**Native Peoples of North America HIV/AIDS Conference**

-   May 3--6, 2006

-   Anchorage, Alaska

-   Embracing Our Traditions, Values, and Teachings
    [www.embracingourtraditions.org](http://www.embracingourtraditions.org/)

-   [National Institutes of Health (NIH),
    DHHS](http://www.embracingourtraditions.org/conf_info.htm)
    <http://www.ou.edu/rec/pdf/Native_Fact_Sheet.pdf>

**ACOG 2006 Annual Clinical Meeting (ACM)**

-   May 6-10, 2006

-   Washington, DC

-   Save the dates brochure
    [http://www.acog.org/abstract%2Dsubmission/](http://www.acog.org/abstract-submission/)

**I.H.S. / A.C.O.G. Obstetric, Neonatal, and Gynecologic Care Course**

-   Tentative dates: September 17 -- 21, 2006

-   Location TBA

-   Contact <YMalloy@acog.org> or call Yvonne Malloy at 202-863-2580

```{=html}
<!-- -->
```
-   Last year's brochure link below (2005 Brochure) (PDF 145k)

-   <http://www.ihs.gov/MedicalPrograms/MCH/M/Documents/FinalACOGBrochure.pdf>

-   NEONATAL RESUSCITATION PROGRAM available

# What's new on the ITU MCH web pages? {#whats-new-on-the-itu-mch-web-pages .Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5%)}

**Maternal Morbidity in American Indian and Alaska Native Women,
2002-2004**

-   Stephen J. Bacak, Judith Thierry, Myra Tucker, Edna Paisano

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/MatMort81805.ppt>

**Comprehensive Cancer Control Web Site**

-   Cancerplan.org is a web site to assist tribes in community cancer
    plans.  Sponsored by American Cancer Society, CDC, and National
    Cancer Institute

<http://www.ihs.gov/MedicalPrograms/MCH/W/WHcancer.asp#cancerplan>

**HIV/AIDS among AI/AN**

-   Overall statistics of prevalence and incidence in the AI/AN
    population

<http://www.ihs.gov/MedicalPrograms/MCH/W/WHhiv.asp#HIVAIAN>

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-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5%)}

The **August 2005 OB/GYN CCC Corner** is available at:\
<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0805.cfm>

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

**Open access can work for any type of practice. It is the wave of the
future**

#### From your colleagues: page 7 {#from-your-colleagues-page-7 .Style-Heading-4-+-Arial-14-pt-Underline}

**Sandy Haldane:**

-New IHS Women's Health and Advanced Practice Nurse Consultants

#### -Public health approach to suicide prevention in an American Indian Tribal Nation {#public-health-approach-to-suicide-prevention-in-an-american-indian-tribal-nation .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Healthy Native Communities Fellowship accepting applications for 2006 {#healthy-native-communities-fellowship-accepting-applications-for-2006 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Cardiovascular Disease: The Kaw Nation and other minority populations  {#cardiovascular-disease-the-kaw-nation-and-other-minority-populations .Style-Heading-4-+-Arial-14-pt-Underline}

**Ruth Lagerberg:** Fetal cardiac echogenic foci on routine obstetric
sonogram

**Sheila Mahoney:** Cord clamping: early versus delayed

Chuck North: **Advances in Indian Health, 6^th^ Annual**

#### Miles Rudd: Relative value of physical exam of the breast as a screening tool {#miles-rudd-relative-value-of-physical-exam-of-the-breast-as-a-screening-tool .Style-Heading-4-+-Arial-14-pt-Underline}

#### Jennifer Retsinas: Uterine fibroids: uterine artery embolization {#jennifer-retsinas-uterine-fibroids-uterine-artery-embolization .Style-Heading-4-+-Arial-14-pt-Underline}

#### Phil Smith: New Outreach: Updated educational materials about the Prescription Drug Benefit {#phil-smith-new-outreach-updated-educational-materials-about-the-prescription-drug-benefit .Style-Heading-4-+-Arial-14-pt-Underline}

Judy Thierry:

-Many girls are at a literal standstill

-Trends and Regional Differences: Latest available

-Great resource: MCH Alert

-"Weaving WIC into Our Traditional Families"

-Child Protection Handbook 2004, IHS/BIA

**Carol Treat:** Brochure/support for sugar substitute and gestational
DM

#### Hot Topics:  {#hot-topics-2 .Style-Heading-4-+-Arial-14-pt-Underline}

##### Obstetrics: page 12

-Trial of Labor After Cesarean: Evidence based guidelines

-Time of birth and risk of neonatal death: 12-16% increase in mortality
at night

-Parietal peritoneum closure during cesarean delivery decreases
adhesions

-Aerobic training increases exercise capacity, overcoming negative
effects of pregnancy

-Pre-pregnancy obesity: Increasing excess risk of fetal death with
advancing gestation

-Screening asymptomatic, low-risk pregnant women for hepatitis C virus
not cost effective

And more....

**Gynecology: page 15**

-Ovarian conservation benefits survival in women when undergoing
hysterectomy

-Hysterectomy Associated With Earlier Onset of Menopause

-One in ten adult women perceives urinary incontinence to be barrier to
exercise

-Reclosure of the disrupted laparotomy wound is safe and successful in
over 80%

### -Cervical cytology screening and evaluation - Clinical Expert Series

And more....

**Child Health: page 16**

-AAP Releases Report on Excessive Sleepiness in Adolescents

\-[High-Grade Cervical Lesions Progress in Adolescents at Similar Rate
as in Adults\
](http://mp.medscape.com/cgi-bin1/DM/y/hq120G875W0Dzc0Gk8W0EZ)-Reducing
the Risk of SIDS Through Community Partnerships: Editorial

-Fetal Alcohol Spectrum Disorders

-Foreign Body Ingestion in Children

And more....

**Chronic Illness and Disease: page 17**

-Guidelines for Improving Vaccination Rates Among High-Risk Adults, CDC

-Bariatric Surgery Resolves Comorbid Conditions

-Tobacco Cessation: Kicking the Habit in Alaska

-Existing coronary heart disease is undiagnosed in half of women who
have a first heart attack

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

#### Features: page 17 {#features-page-17 .Style-Heading-4-+-Arial-14-pt-Underline}

#### American Family Physician {#american-family-physician-1 .Style-Heading-4-+-Arial-14-pt-Underline}

-Aspirin Prevents Stroke, but Not Cardiovascular Disease, in Women

-Intensive Diet-Behavior-Physical Activity Program for Obesity in
Children

-NSAIDs Alone or with Opioids as Therapy for Cancer Pain: Cochrane for
Clinicians

-Health Literacy: The Gap Between Physicians and Patients

American College of Obstetricians and Gynecologists

-Management of Endometrial Cancer ACOG Practice Bulletin

-Health Care for Homeless Women

-Two Major Women\'s Health Groups Call Attention to a Leading
Reproductive Cancer

**Agency for Healthcare Research and Quality**

-Despite revised guidelines, most OB/GYNs over-screen low-risk women for
cervical cancer

-Physician supply increases in States with caps on malpractice: greatest
impact in rural areas

-Women respond differently to medications than men, should be proactive
about medication use

-Efforts to help improve care for underserved patients: address
communication and respect

**Ask a Librarian**

The Known and the Unknown - Clinical Evidence Summarized

**Breastfeeding**

#### Fentanyl During Labor May Impede Establishment of Breastfeeding {#fentanyl-during-labor-may-impede-establishment-of-breastfeeding .Style-Heading-4-+-Arial-14-pt-Underline}

**Case Managers Corner (R.N.)**

Stress and verbal abuse in nursing

**CCC Corner, Last month's Digest**

#### Highlights include {#highlights-include-1 .Style-Heading-4-+-Arial-14-pt-Underline}

-USPSTF recommends that clinicians screen all pregnant women for HIV

-Simple Educational Handouts -- Kat Franklin, Sante Fe

-Elective Repeat Cesarean Delivery May Negatively Affect Neonatal
Outcomes

-Benzocaine spray does not offer effective pain control during per
endometrial biopsy

-OCPs are more effective than placebo for relieving dysmenorrhea in
adolescents

-Death rates for CVD are higher among AI/AN than other U.S. groups

-Pregnancy and Depression: What Women Need to Know

-What is an RN Case Manager?

-2 positive blood cultures found in a postpartum patient with a fever

-Benefits of low-fat dairy products on weight loss

-What Makes a Drug Over the Counter (OTC)? The case of Plan B

-Active management of the third stage of labor among American Indian
women

-Racial / Ethnic Disparities in Infant Mortality: No significant
improvement in AI / AN

-Use the talk / sing test during exercise during pregnancy

-Here is a good web based calcium screening tool

-Can chlamydia be stopped?

**Domestic Violence**

Developing Leaders in Violence Prevention -- Travel funding available

**Cultural Competency for Non-Native Advocates: Ending Violence Against
Native Women Training**

The 2006 PREVENT Institute:  Developing Leaders in Violence Prevention

**Elder Care News**

Toward optimal screening strategies for older women: Should cost matter
the most?

**Family Planning**

[Over-The-Counter Sales of Emergency Contraception Do Not Increase
Unsafe Sex](http://mp.medscape.com/cgi-bin1/DM/y/hq120G875W0Dzc0GlAH0EU)

**Frequently asked questions**

Q. Is there any help or assistance with infertility through the Indian
Health System?

**Indian Child Health Notes**

-Pediatric sleep apnea - you know more than you think

-Sleepy teenagers - they are not just slugs, they\'re victims of biology

-TB in AI/AN is down, but not out

**Information Technology**

-VHA Pharmacy Benefits Management (PBM) Strategic Healthcare Group page

-Free Online CME from Thomson Healthcare

International Health

-Increase the interdisciplinary and transdisciplinary focus in primary
health care research

-Unite For Sight\'s 3rd Annual International Health Conference

#### MCH Alert

New edition of the Women's Health Data Book Released

#### Medical Mystery Tour

Follow-up 2 positive blood cultures found in a postpartum patient with a
fever: The answer

#### Medscape

######### Eating Disorders and Body Image Distress in Women at Midlife - CME

**Menopause Management**

USPSTF Hormone Therapy for the Prevention of Chronic Conditions in
Postmenopausal Women

**Midwives Corner**

-Please help us build the Midwives Indian Health Patient Education
Resources page

-Women and Health Care: A National Profile

**Navajo News**

Is the patch more dangerous than the pill?

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

Publications and Materials -- Many Women's Health Topics

**Oklahoma Perspective**

Who do you contact in Oklahoma for MCH issues?

Osteoporosis

Ultralow-Dose Estradiol and BMD in Postmenopausal Women

Patient Education

-Brochure/support for sugar substitute and gestational DM

-What to Do If Your Child Swallows Something**?**

Perinatology Picks

#### -Glyburide for gestational diabetes in a large managed care organization  {#glyburide-for-gestational-diabetes-in-a-large-managed-care-organization .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Overweight and obese in gestational diabetes: the impact on pregnancy outcome {#overweight-and-obese-in-gestational-diabetes-the-impact-on-pregnancy-outcome .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Glargine use in pregnancy? {#glargine-use-in-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

Primary Care Discussion Forum

Appropriate use of narcotics for chronic non-malignant (non-cancer) pain

STD Corner

-Condom effectiveness for prevention of *Chlamydia trachomatis*
infection

-The percentage of male teens who reported ever having sexual
intercourse

-Prenatal screening and treatment needed to identify women with
asymptomatic chlamydia

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

-Women the stronger gender? Men more carbohydrate intolerant / less
physical endurance

-Teen Inactivity Leads to Obesity for Girls

-Relationship of Obesity and Fitness Level to Cardiovascular Risk and
Diabetes 

-New CERTs Program Brief on Women\'s Health Is Available

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

#### What's new on the ITU MCH web pages page 34

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/M/MCHdiscuss.asp>

9/10/05njm

[^1]: Goldhaber SZ. Pulmonary embolism. Lancet 2004;363:1295-1305.

[^2]: Chang J, Elam-Evans LK, Berg CJ, Herndon J, Flowers L, Seed KA, et
    al. Pregnancy-Related Mortality Surveillance - United States,
    1991-1999. Surveillance Summaries, February 21, 2003. MMWR
    2003;52(No SS-2):1-8.

[^3]: Farley TMM, Meirik O, Chang CL, Poulter NR. Combined oral
    contraceptives, smoking, and cardiovascular risk. J Epidemiol
    Community Health 1998;52:775-785.

[^4]: World Health Organization. Cardiovascular Disease and Steroid
    Hormone Contraception. Report of a WHO Scientific Group. Geneva
    1998; WHO Technical Report Series 877.