OB/GYN Chief Clinical Consultant's Corner

Volume 2, No. 9, September, 2004

**[Contents:]{.underline}**

**[Abstract of the Month]{.underline}:** **page 2**

Overview of the WISEWOMAN Projects: Health Promotion for Disadvantaged
Women

[From your colleagues:]{.underline} page 3

From Biennial Women's Health / MCH Meeting: Multiple slide sets
presented

**From George Gilson:** New Perinatology Corner module: Free CME / CEUs
from IHS - Preterm Labor and Preterm Premature Rupture of Membranes

From Sandy Haldane: Save the dates - AWHONN 2005 Convention **June
11-15, 2005 Salt Lake City, UT**

**From Steve Holve:** September Indian Child Health Notes

**From Jane Powers**: Office for Victims of Crime - Child Abuse Project

**From Lori de Ravello**: Focus groups of Y-K Delta Alaska Natives:
attitudes toward tobacco use and tobacco dependence interventions

**From Laura Shelby:** **CDC, Sexually Transmitted Disease Training
Log;** Starting a School-Based Chlamydia Screening and Treatment Program

From Judy Thierry: You Need to...Prepare for the Baby's Arrival- New
poster; Tobaccco Cessation PCC+ form available online; March of Dimes
PeriStats Web Site: Your online source for perinatal statistics; LEARN
about perinatal periods of risk and National Fetal and Infant Mortality
Review City MatCH / Healthy Start

**[Hot Topics:]{.underline}**

**Obstetrics:** **page 7**

Treatment for cervical intraepithelial neoplasia and risk of preterm
delivery; Outpatient cervical ripening: Successful; Use of Vitamins
Containing Folic Acid Among Women of Childbearing; Delaying Epidural Not
Necessary During Labor; Resistance exercise may help to avoid insulin
therapy for overweight women with GDM; Intracervical (rather than
posterior fornix) placement of dinoprostone decreases time to delivery;
**Venlafaxine Associated With Neonatal Complications**; Complementary
and alternative medicine for labor pain

**Gynecology:** **page 8**

LEEP - not the best for treating young women who have not completed
reproduction; JCAHO Sentinel events: Major issues -- Communication,
teamwork, and staff competency; Surgical Prophylaxis: Start early and
keep it simple; Start GYN prophylaxis 60 minutes prior to surgery;

GYN surgery involving the rectum or colon: Prophylaxis; Pelvic floor
physiotherapy is effective treatment for persistent postnatal SUI;
Estimating blood loss: can teaching significantly improve visual
estimation? High intrauterine pressure improves success in thermal
balloon endometrial ablation; Serious complications associated with
global endometrial ablation not yet reported;

Stress urinary incontinence affects one third of adult women and is
usually reduced or eliminated with either nonsurgical or surgical
therapy; Self-testing for human papillomavirus (HPV) DNA is feasible for
cervical cancer screening; Efficacy of Cone Biopsy of the Uterine Cervix
During Frozen Section for the Evaluation of Cervical Intraepithelial
Neoplasia Grade 3

**Child Health:** **page 11**

No benefit seen for suctioning meconium-stained newborns; Role of
vaginal douching in the reproductive health of adolescents and young
women; Whole environment intervention improves asthma associated
morbidity in children; SIDS Resource kits available; Protecting our
children from environmental hazards in the face of limited data

**Chronic Illness and Disease:** **page 12**

Tamoxifen for breast cancer prevention: a framework for clinical
decisions; New cholesterol guidelines pose a challenge for doctors and
patients; Broken Promises - What is the status of American Indian /
Alaska Native Health?

[Features:]{.underline} page 14

AFP: Misoprostol Therapy for Incomplete Abortion; Estrogen Sources Have
Similar Effects; Women Have Greater Analgesia from Butorphanol than
Morphine; Genital Herpes: Clinical Evidence Concise; Making Decisions
with Families at the End of Life

**ACOG:** Management of Postterm Pregnancy; Guidelines for Diagnostic
Imaging During Pregnancy

**AHRQ:** The Worst Headache: Web M + M; Treatment of high cholesterol
in women should be based on all risk factors for heart disease, not just
lipid levels; Child abuse is associated with increased risk of death in
young children with abdominal injuries; Women who undergo hysterectomy
for abnormal uterine bleeding report improved health-related quality of
life

**Breastfeeding:** Babies Were Born to Be Breastfed: Few Babies
Breastfed Long; Breastfeeding Protects Against Asthma and Atopy

**Domestic Violence:** Health Cares About Domestic Violence Day: October
13^th^; The Legacy of Child Maltreatment: Long-Term Health Consequences
for Women

**Elder Care News:** Effect of Raloxifene on the Incidence of Elevated
Low Density Lipoprotein

**Family Planning:** Emergency Contraception

**Frequently asked questions:** Should we perform routine urine dipstick
protein screening in our prenatal clinic?

**Hormone Replacement Update**: One our four women who attempt to stop
HRT are unsuccessful

**Information Technology:** Ten Questions to Ask Before Buying an
Electronic Medical Record

**International Health:** [Routine cervical cancer screening constitutes
nearly two thirds of total annual cervical HPV-related health care
costs](http://mdconsult.chtah.com/a/hBBJLAOAPMgn1ASgjDSAPMu5kLK/curb17);
Sprawl: The New Manifest Destiny? Health Effects

**MCH Alert:** New Report Maps Women's Health in the U.S.; A new
PeriStats database and Web interface increases access to detailed MCH
data in US; New ways to measure quality in Child Health Programs -
Toolbox, AHRQ

######### Medscape: Safety and Efficacy of Testosterone in Menopausal Women: Restoring Sexual Desire

**Office of Women's Health, CDC:** Can Changes in Sexual Behaviors Among
High School Students Explain the Decline in Teen Pregnancy Rates in the
1990s?

Osteoporosis: Vitamin D and Derivatives Should Not Be Administered
Concurrently With Doxercalciferol

**Patient Education:** Emergency Contraception; End-Of-Life Choices for
Families; Management of Gestational Diabetes Mellitus and Pharmacists\'
Role in Patient Education

**Primary Care Discussion Forum:** November 1, 2004: Violence against
Native women

**Barbara Stillwater, Alaska Diabetes Prevention and Control:** Weight
predicts diabetes; Soda Increases Risk of Diabetes 83%; New Diet
Guidelines Call for More Exercise and Grains; Diabetes Triples Risk of
Heart Failure for Women; Health Disparities among Minority and
Underserved Women**;** NIH: School Based Interventions to Prevent
Obesity

#### What's new on the ITU MCH web pages: page 21

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

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

# 

# [Abstract of the Month]{.underline}

**Overview of the WISEWOMAN Projects: Health Promotion for Disadvantaged
Women**

**-Features Alaska's Tribal Southcentral Foundation among other
recipients**\
\
BACKGROUND: Although historically Alaska Native women have had a
relatively low incidence of cardiovascular disease (CVD), this pattern
has changed dramatically in recent years. Alaska Native leaders have
identified decreasing cardiovascular risk as an intervention priority.
METHODS: From October 2000 to April 2001, Southcentral Foundation, an
Alaska Native-owned and managed health corporation in Anchorage,
conducted a pilot randomized controlled trial of a heart disease
prevention program tailored for Alaska Native women. The aim was to
assess feasibility and cultural acceptability and to develop enrollment
procedures. Of 76 women who enrolled, 44 were randomized to the
intervention group. Thirty-seven of 44 attended at least two
intervention sessions, 23 completed prequestionnaires and
postquestionnaires, and 27 returned for 12-month follow-up screening.
Thirty of 32 control group participants returned for 12-month follow-up
screening. The intervention included 12 weekly sessions on lifestyle
change and goal setting. At baseline and 12 months, participants\'
height, weight, resting blood pressure, fasting lipid levels, and blood
glucose were measured. At sessions 1 and 12, participants completed
assessments regarding diet, physical activity, tobacco use, and
psychosocial status.

RESULTS: At 12 weeks, significant improvements were noted in moderate
walking and physical activity self-efficacy. Also observed was
substantial movement from the contemplation and preparation stages to
the action stage regarding physical activity and heart-healthy eating.
CONCLUSIONS: Although the small sample size precludes drawing
conclusions about the intervention\'s effect, participants reported
lifestyle and psychosocial changes. The pilot study resulted in protocol
changes that improved the design and implementation of a subsequent
large-scale study.

Witmer JM, Hensel MR, Holck PS, Ammerman AS, Will JC. Heart disease
prevention for alaska native women: a review of pilot study findings. J
Womens Health (Larchmt). 2004 Jun;13(5):569-78.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15257848>

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

This is an example of how tribal initiated thoughts can successfully
partner with the research community. njm

The Supplement contains 15 scientific articles written by more than 50
CDC and collaborating scientists. The articles offer valuable insights
into the WISEWOMAN projects, health disparities issues, \"lessons
learned,\" and how-to guidance on programmatic issues such as cultural
adaptation of materials, cost-effectiveness evaluations, staff morale,
and partnering.

[CONCLUSIONS]{.underline}: The WISEWOMAN demonstration projects have
been successful at reaching financially disadvantaged and minority women
who are at high risk for chronic diseases. These projects face
challenges because they are generally implemented by safety net
providers who have limited resources and staff to conduct research and
evaluation. On the other hand, the findings from these projects will be
especially informative in reducing health disparities because they are
conducted in those settings where the most socially and medically
vulnerable women receive care.

Will JC, et al Health promotion interventions for disadvantaged women:
overview of the WISEWOMAN projects. J Womens Health (Larchmt). 2004
Jun;13(5):484-502.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15257842>

## From your colleagues:

#### [From the Biennial Women's Health/MCH meeting, ABQ]{.underline}

#### This meeting was a huge success: Here a few of the many talks

Go here to review these materials

<http://www.ihs.gov/MedicalPrograms/MCH/M/PROG01.cfm#MeetingLecNotes>

**J. Chris Carey , MD**

-   [Vaginal Infections and Preterm Labor: An
    update](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/VIPPRES2.PPT)
    (PPT 219k)

**Donald Clark, M.D., M.P.H.**

-   [Domestic Violence Screening and
    Assessment](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/CMEClinicalSkillsWithNotes.ppt)
    (PPT 1.5MB)

**Bonnie Duran M.D.**

-   Child Abuse and Neglect and Mental Disorders Among AI/AN women

[Part
1](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/Duran1.ppt)
(PPT 933k), [Part
2](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/Duran2.ppt)
(PPT 333k), [Part
3](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/Duran3.ppt)
(PPT 467k),

or [entire
presentation](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/DuranEntire.ppt)
(PPT 1.4 MB)

-   [Broken Promises: Evaluating the Native American Health Care System\
    U.S. Commission on Civil
    Rights](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/BrokenPromises.pdf)
    (PDF 676k)

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-   [Child maltreatment prevalence and mental disorder
    outcomes](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/ChildMaltr.pdf)
    among AI women in primary care (PDF 100k)

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-   [Prevalence and correlates of mental health
    disorders](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/PrevCorrelMent.pdf)
    among Native American women in primary care (PDF 184k)

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-   [Socioeconomic disparities in intimate partner violence against
    Native women: a cross sectional
    study](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/SocioEconDispar.pdf)
    (PDF 288k)

**Eve Espey, M.D.**

-   Birth Control and Breastfeeding: What is the evidence?\
    [Part 1](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/BC1.ppt)
    (PPT 790k),  [Part
    2](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/BC2.ppt) (PPT
    102k), and [Part
    3](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/BC3.ppt) (PPT
    602k)  

**Bruce Finke, M.D.**

-   [Care of the Older Native
    Woman](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/careOfOlderWoman04.ppt)
    (PPT 250k)

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-   [Osteoporosis Prevention (adapted from
    Zuni-Ramah)](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/Osteoporosis Prevention.doc)
    (DOC 24k)

```{=html}
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-   [Osteoporotic Fracture Prevention Algorithm:
    Whiteriver](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/fig2wrsualgorithm.xls)
    (XLS 24k)

**Fred Heidrich, M.D.**

-   [Osteoporosis from B to
    H](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/OsteoHeidrich.ppt)
    (PPT 2 MB)

**Ursula Knoki-Wilson, C.N.M.**

-   [Navajo Cultural Aspects of Obstetric
    Care](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/KeepingtheSacredinChildbirth.ppt)
    (PPT 4.5 MB)

-   If unable to download this large file (PowerPoint 4.5 MB) , then
    contact [Ursula M. Knoki-Wilson](mailto:Ursula.knoki-wilson@ihs.gov)
    CNM.

**Michele Lauria, M.D**.

-   [Emergency Delivery Simulations: How to
    DevelopTeamwork](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/Talk.ppt)
    (PPT 728k)

```{=html}
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-   [VBAC: Is There Such a Thing as Low
    Risk?](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/NewMexico.ppt)
    (PPT 1MB)

**Larry Leeman, M.D., M.P.H.**

-   [Obstetrical Perinatal Laceration: Anatomy, Prevention, and
    Repair](mailto:KBreckenridge@salud.unm.edu?Subject=Please send me a copy of Larry Leeman MD MPH Obstetrical Perinatal Laceration: Anatomy, Prevention, and Repair)

```{=html}
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```
-   [Labor Pain: Nature and
    Management](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/IHSPainHO.pdf)
    (PDF 352k)

**Rachel Locker MD**

-   [Domestic Violence: A Health Care Epidemic, Part
    1](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/AbqWorkshops1rachel.ppt)
    (PPT 171k)

```{=html}
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```
-   [Domestic Violence: A Health Care Epidemic, Part
    2](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/AbqWorkshops2rachel.ppt)
    (PPT 224k)

**Suzan Murphy, R.D., M.P.H., C.D.E., I.B.C.L.C.**

-   [Frequently Asked
    Questions](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/WhatMomMightSay-inservice.doc)
    (WORD 59k)

```{=html}
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-   [Breastfeeding: Congratulations
    Card](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/BFisNaturalBut--.doc)
    (WORD 351k)

**Donna Perry, M.D., F.A.A.P., F.S.A.M.**

-   [Proving Our Worth: Data Diving in RPMS -- Quality or
    Quagmire](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/provingOurWorth0804.ppt)
    (PPT 59k)

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-   [Adolescent Health: Consent, Confidentiality, and
    Conundrums](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/CONSENT, CONFIDENTIALITY AND CONUNDRUMS.ppt)
    (PPT 3.2 MB)

**Sharon Phelan, M.D.**

-   [Nausea and Vomiting in
    Pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/NVPhelan.ppt)
    (PPT 635 KB)

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-   [Tobacco Cessation in
    Pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CessationPhelan.ppt)
    (PPT 139 KB)

**Judy Thierry, D.O.**

-   [Births at IHS and Tribal Hospitals : 1992 --
    2001](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/IHSBirthstenyeartrend.ppt)
    (PPT 159k)

**[From George Gilson, Anchorage]{.underline}**

**There is a new Perinatology Corner module: Free CME / CEUs from IHS**

**Preterm Labor and Preterm Premature Rupture of Membranes**

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

#### [From Sandy Haldane, HQE]{.underline}

**Save the dates - AWHONN 2005 Convention** **June 11-15, 2005 Salt Lake
City, UT**

Contact <denises@awhonn.org> for questions

[From Steve Holve, Tuba City]{.underline}

**September Indian Child Health Notes**

The latest in child health notes for those who provide care for Alaska
Native and American Indian Children

This month a review of the new recommendations for the influenza vaccine
for children ages 6 months to 23 months and all of their household
contacts. What are effective strategies for delivering this vaccine to
so many in so short a time.

Plus a review of literature showing the effectiveness of the hepatitis A
vaccine in Native Americans. Go to:
[[http://www.ihs.gov/MedicalPrograms/MCH/C/documents/ICHN904.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/C/documents/ICHN904.doc)

**[From Jane Powers, Ft. Duchesne, Utah]{.underline}**

**Office for Victims of Crime - Child Abuse Project**

The Indian Health service and office for victims of crime child abuse
project is a coordinated effort between two government agencies (office
for victims of crime and Indian health service) to provide equipment,
training and resources to medical providers (doctors, nurse
practitioners, and physician assistants) within the Indian Health
service and tribal programs on the medical evaluation of child abuse.
The program is a two-year commitment and requires support from the
supervisor and participant and the employing agency. Year one consist of
an intense one-week didactic/classroom training, an image capture
device/software lab for documentation of medical examinations,
**[cultural awareness training]{.underline}**, and a mock trial of
various court cases scenarios. Every participant attends a one-week
hands on preceptorship with one of the expert faculty at that experts
site. Needed equipment for each site in funded by the project (except
for computers and internet access). Year two consist of mastering the
art of forensic documentation with the image capture device,
participation in Grand Rounds, development of site-specific policies and
procedures. All participants complete an advanced preceptorship and a
site visit by the project director is made. An award of completion is
given to successful participants and program resources continue to be
available to them. Past and current participants include:

Alaska -- Bethel, Dillingham, Kotzubue, Juneau

Arizona -- Whiteriver, Tuba City, San Carlos, Gila River

New Mexico -- ACL Hospital, Shiprock, Pine Hill, Gallup

North Dakota -- Belcourt

Michigan -- Keewenaw, Sault Ste. Marie

Montana -- Ft. Belknap, Ft. Peck, Crow Agency, Northern Cheyenne

Oklahoma -- Clinton

South Dakota -- Ft. Thompson, Wagner, Sisseton

Wyoming -- Ft. Washakie

For further information please contact: <Jane.Powers@ihs.gov> Office:
435-725-6839

CDR P. Jane Powers APRN, BC, FAANP

Ft. Duchesne Indian Health Center

P.O. Box 160

Ft. Duchesne, Utah 84026

Web site: [http://www.ovccap.ihs.gov](http://www.ovccap.ihs.gov/)

**[From Lori de Ravello, National EPI, Albuquerque]{.underline}**

**Focus groups of Y-K Delta Alaska Natives: attitudes toward tobacco use
and tobacco dependence interventions**

BACKGROUND: Tobacco dependence interventions developed for Alaska
Natives are virtually nonexistent. Alaska Natives residing on the
Yukon-Kuskokwim (Y\--K) Delta in southwestern Alaska use a unique form
of smokeless tobacco (ST) known as Iqmik. This study employed focus
group methodology to explore attitudes toward tobacco use and tobacco
dependence interventions among Alaska Natives residing on the Y-K Delta.
METHODS: Twelve focus groups of former and current tobacco users were
conducted in four villages in the Y-K Delta. Participants were 35 adults
(83% female) and 22 adolescents (27% female). Participants completed a
brief demographic and tobacco use history form. Statements from the
focus groups were transcribed for content coding and analysis of the
major themes. RESULTS: Use of Iqmik in the villages is thought to be
ubiquitous. Y-K Delta Alaska Natives are introduced to Iqmik at a very
young age. Iqmik is mostly used and prepared by young Alaska Natives and
adult women. There are few perceived adverse health effects of Iqmik or
other tobacco use. Although there is interest in stopping, there is a
perceived lack of availability of tobacco dependence interventions. The
major barriers to preventing the initiation of and stopping tobacco use
are the social acceptance and widespread use and availability of
tobacco.

CONCLUSION: The attitudes toward tobacco and identified barriers to
stopping will be useful in developing tobacco dependence interventions
for Alaska Natives

Renner CC et al Focus groups of Y-K Delta Alaska Natives: attitudes
toward tobacco use and tobacco dependence interventions.Preventive
Medicine.  38(4):421-31, 2004 Apr.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15020175>

**HRSA has just issued the Women\'s Health USA 2003 Data Book**. 

This publication is intended to be a concise reference with current data
on significant issues in women\'s health.  Included are data on
utilization of health service, behaviors such as drug and alcohol use,
special populations, and health indicators such as AIDS and STDs.  The
report is available at:  <http://www.hrsa.gov/womenshealth/databook.htm>

**[From Laura Shelby, Albuquerque]{.underline}**

**CDC, Sexually Transmitted Disease Training Log in**

Link to words 'Log in' (you can create your password and work on the
modules at the same sitting)
[[http://www2a.cdc.gov/STDTraining/Ready-To-Use/userLogin.asp]{.underline}](http://www2a.cdc.gov/STDTraining/Ready-To-Use/userLogin.asp)

**CDC, Other Online STD Training**

[[http://www.cdc.gov/std/training/onlinetraining.htm]{.underline}](http://www.cdc.gov/std/training/onlinetraining.htm)

**Starting a School-Based Chlamydia Screening and Treatment Program**

New publication - [www.etr.org](http://www.etr.org/)

**[From Judy Thierry, HQE]{.underline}**

**You Need to...Prepare for the Baby's Arrival- New poster now
available**

As part of a strategy to reduce the risk of Sudden Infant Death Syndrome
and the overall elevated infant mortality rates for American Indians and
Alaska Natives the Office of Minority Health has initiated this
campaign. The toll free number: 1-800-444-6472 can be used during 8:00
a.m. to 4:30 p.m. eastern time.   The following is a portion of the
text: 

-Never drink alcohol or use illegal drugs.

-There are no safe amounts of alcohol or illegal drugs.

-If you need help, there are places for you to go.

-See a healthcare provider.

-Start prenatal care the moment you find out you're pregnant. Don't miss
your prenatal visits---they're a way to help you and your baby stay
healthy.

-Set the rules for sleep time.  No matter what you've heard, always
place babies on their backs when they sleep.  Make this the rule for
grandparents and everyone who cares for the baby.

-Learn more about Sudden Infant Death Syndrome (SIDS).  For example,
babies who become overheated are at higher risk for SIDS or "crib
death."  So, don't put more than one layer of clothing or a single
blanket on your child.

-If you smoke, stop.  Smoking puts you and your baby at risk for many
health problems. -Secondhand smoke can also be dangerous.  So, ask your
friends and family not to smoke around you while you're pregnant or when
the baby comes home.

For further information call the toll free number or Dr. Judy Thierry,
MCH Coordinator for the Indian Health Service at 301-443-5070 or email
at <jthierry@hqe.ihs.gov>.  The poster can be down loaded and prints
nicely in color and or black and white

**Tobaccco Cessation PCC+ form available online**

You can modify this to fit the needs of your facility

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

**March of Dimes PeriStats Web Site: Your online source for perinatal
statistics.**

Developed by the March of Dimes Perinatal Data Center with funding from
the National Institutes of Health, PeriStats provides free access to
maternal & infant health-related data at the U.S., state, county, and
city level. Now with more than 60,000 graphs, maps, and tables,
PeriStats is your online source for perinatal data
[www.marchofdimes.com/peristats](http://www.marchofdimes.com/peristats)

For an overview of new features,
<http://www.marchofdimes.com/peristats/whatsnew.aspx?id=6>

**LEARN about perinatal periods of risk and National Fetal and Infant
Mortality Review**

**CityMatCH/Healthy Start**

PPOR Level 2: "Learning Network" Planning Brief

October 19 Implementation strategies, phone seminar

November 23    Evaluation and monitoring, phone seminar

December         Post meeting workshop w/MCH Epi Conference, Atlanta,
Georgia

                      December 10^th^ and 11th

January 17 Preconception health, phone seminar

February 15   Racial disparities, phone seminar

Seminars are currently scheduled for 12:00 pm Central Time

(1:00 pm Eastern Time, 10:00 am Pacific Time).

All date and times are tentative, CONTACT AMY Johnson

If you would like to be on the call <aljohnson@unmc.edu>

**[Hot Topics:]{.underline}**

**[Obstetrics]{.underline}**

**Treatment for cervical intraepithelial neoplasia and risk of preterm
delivery**

CONCLUSIONS: LEEP and laser cone treatments were associated with
significantly increased risk of pPROM. Careful consideration should be
given to treatment of CIN in women of reproductive age, especially when
treatment might reasonably be delayed or targeted to high-risk cases.

Sadler L, et al Treatment for cervical intraepithelial neoplasia and
risk of preterm delivery. JAMA. 2004 May 5;291(17):2100-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15126438>

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

For young women who have not yet completed reproduction, LEEP may not be
the best therapeutic option for treating CIN, especially of low
malignant potential. Women who clearly require surgical intervention may
be better served with a procedure such as cryotherapy

Also see Crane et al in Gynecology below njm

**Outpatient cervical ripening: Successful -- Small RCT**

CONCLUSION: A single 25-microg outpatient intravaginal dose of
misoprostol is effective in decreasing the interval to delivery in women
with unfavorable cervices at term

McKenna DS, Ester JB, Proffitt M, Waddell KR. Misoprostol outpatient
cervical ripening without subsequent induction of labor: a randomized
trial. Obstet Gynecol. 2004 Sep;104(3):579-84.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15339772&dopt=Abstract>

**[OB/GYN CCC Editorial comment:]{.underline}\
**Outpatient misoprostol has been used successfully in a tertiary care
Indian Health setting. This small RCT raises further questions as to its
utility in outlying Indian Health facilities, as was discussed at the
August IHS Women's Health Biennial Meeting. njm**\
**

**Use of Vitamins Containing Folic Acid Among Women of Childbearing Age
\-\-- 2004**

The fact that 40% of reproductive-age women are now consuming 400 *µ*g
of folic acid every day represents an important step toward meeting that
objective; however, the proportion of women not consuming a vitamin
containing folic acid is 60%, underscoring the need for continued public
health efforts to increase folic acid consumption. These percentages
only include supplementation from a vitamin containing folic acid and
not consumption of fortified foods. The reported increase in consumption
of a vitamin containing folic acid among women of childbearing age from
32% in 2003 to 40% in 2004 suggests a substantial change in behavior.
This change has not been previously observed in the March of Dimes
survey. Although this increase is encouraging, no clear rationale
explains the reported change, and results should be interpreted with
caution.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5336a6.htm>

**Delaying Epidural Not Necessary During Labor**

CONCLUSION: Our data support recent American College of Obstetricians
and Gynecologists guidelines that the restraining use of epidural
analgesia at \<4 cm of cervical dilation is unnecessary.

Vahratian A, et al. The effect of early epidural versus early
intravenous analgesia use on labor progression: a natural experiment. Am
J Obstet Gynecol. 2004 Jul;191(1):259-65.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15295376>

**Resistance exercise may help to avoid insulin therapy for overweight
women with GDM**

CONCLUSION: Resistance exercise training may help to avoid insulin
therapy for overweight women with gestational diabetes mellitus.
Randomized clinical trial\
Brankston GN, Mitchell BF, Ryan EA, Okun NB. Resistance exercise
decreases the need for insulin in overweight women with gestational
diabetes mellitus. Am J Obstet Gynecol. 2004 Jan;190(1):188-93

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14749658>

**Intracervical (rather than posterior fornix) placement of dinoprostone
decreases time to delivery** without increasing complications of labor
in mothers who respond to a single dose of the sustained-release
preparation. Perry MY, Leaphart WL. Randomized trial of intracervical
versus posterior fornix dinoprostone for induction of labor. Obstet
Gynecol. 2004 Jan;103(1):13-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14704238>

**Venlafaxine Associated With Neonatal Complications**

Neonates exposed to venlafaxine (Effexor and Effexor XR, made by Wyeth)
late in the third trimester may develop complications immediately upon
delivery and require prolonged hospitalization, respiratory support, and
tube feeding, according to a warning issued by MedWatch, the U.S. Food
and Drug Administration (FDA) safety information and adverse event
reporting program. The warning also applies to other serotonin and
norepinephrine reuptake inhibitors (SNRIs) and selective serotonin
reuptake inhibitors (SSRIs).

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

**Complementary and alternative medicine for labor pain: A systematic
review**

[Conclusion]{.underline} There is insufficient evidence for the efficacy
of any of the complementary and alternative therapies for labor pain,
with the exception of intracutaneous sterile water injections. For all
the other treatments described it is impossible to make any definitive
conclusions regarding effectiveness in labor pain control.

Huntley AL, Coon JT, Ernst E Complementary and alternative medicine for
labor pain: a systematic review. Am J Obstet Gynecol. 2004
Jul;191(1):36-44.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15295342>

**[Gynecology]{.underline}**

**LEEP - not the best for treating young women who have not completed
reproduction**

CONCLUSION: LEEP appears to be associated with subsequent preterm birth,
even when smoking status is matched. Studies with adequate sample size
are needed to further evaluate the relationship of LEEP and preterm
birth, controlling for potential confounders, including depth of the
tissue sample

[ACOG Clinical Review Editorial]{.underline}

Five studies with control groups met the criteria for review. For young
women who have not yet completed reproduction, LEEP may not be the best
therapeutic option for treating CIN, especially of low malignant
potential. Women who clearly require surgical intervention may be better
served with a procedure such as cryotherapy.

Crane JM. Pregnancy outcome after loop electrosurgical excision
procedure: a systematic review. Obstet Gynecol. 2003 Nov;102(5 Pt
1):1058-62.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14672487>

**JCAHO Sentinel events: Major issues -- Communication, teamwork, and
staff competency**

Root causes identified: In the 47 cases studied, communication issues
topped the list of identified root causes (72 percent), with more than
one-half of the organizations (55 percent) citing organization culture
as a barrier to effective communication and teamwork, i.e., hierarchy
and intimidation, failure to function as a team, and failure to follow
the chain-of-communication. Other identified root causes include: staff
competency (47 percent), orientation and training process (40 percent),
inadequate fetal monitoring (34 percent), unavailable monitoring
equipment and/or drugs (30 percent),
credentialing/privileging/supervision issues for physicians and nurse
midwives (30 percent), staffing issues (25 percent), physician
unavailable or delayed (19 percent), and unavailability of prenatal
information (11 percent).

<http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_30.htm>

**Surgical Prophylaxis: Start early and keep it simple**

For abdominal or vaginal hysterectomy, cefotetan is preferred, but
reasonable alternatives are cefazolin and cefoxitin . Metronidazole
monotherapy is included in the American College of Obstetricians and
Gynecologist\'s Practice Bulletin as an alternative for patients
undergoing hysterectomy, although it may be less effective as a single
agent for prophylaxis. In cases of
![](media/image1.png){width="9.375e-2in" height="0.15625in"}-lactam
allergy, the workgroup recommends the use of one of the following
regimens: clindamycin combined with gentamicin, aztreonam, or
ciprofloxacin; metronidazole combined with gentamicin or ciprofloxacin;
or clindamycin monotherapy. A single 750-mg dose of levofloxacin can be
substituted for ciprofloxacin.

     Patients undergoing cesarean section can be divided into low- and
high-risk groups for postoperative infection . High-risk patients
include those undergoing cesarean deliveries after rupture of the
membranes and/or onset of labor, as well as with emergency operations
for which preoperative cleansing may have been inadequate. Although
antimicrobial prophylaxis is recommended for both risk groups, the
benefits are greatest for high-risk patients. A narrow-spectrum
antimicrobial regimen similar to that recommended for hysterectomy
provides adequate prophylaxis \]. In the United States, the
antimicrobial is usually not administered until the umbilical cord is
clamped. Although there is no evidence to support the delay in
administration, it is standard practice and is preferred by
neonatologists because of concern of masking septic manifestations in
the neonate^.^

**Start GYN prophylaxis 60 minutes prior to surgery**

The consensus positions of Surgical Infection Prevention Guideline
Writers Workgroup (SIPGWW) meeting include that infusion of the first
antimicrobial dose should begin within 60 min before surgical incision
and that prophylactic antimicrobials should be discontinued within 24 h
after the end of surgery. This advisory statement provides an overview
of other issues related to antimicrobial prophylaxis, including specific
suggestions regarding antimicrobial selection.

Bratzler DW et al Antimicrobial prophylaxis for surgery: an advisory
statement from the National Surgical Infection Prevention Project. Clin
Infect Dis. 2004 Jun 15;38(12):1706-15.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15227616>

**GYN surgery involving the rectum or colon: Prophylaxis**

Antimicrobial prophylaxis for colorectal operations can consist of an
orally administered antimicrobial bowel preparation, a preoperative
parenteral antimicrobial, or the combination of both. Recommended oral
prophylaxis consists of neomycin plus erythromycin or neomycin plus
metronidazole, initiated no more than
18![](media/image2.png){width="8.333333333333333e-2in"
height="5.2083333333333336e-2in"}24 h before the operation, along with
administration of a mechanical bowel preparation. Cefotetan or cefoxitin
are recommended for parenteral prophylaxis and the combination of
parenteral cefazolin and metronidazole is also recommended as a
cost-effective alternative. Although a recent study suggests that the
combination of oral prophylaxis with parenteral antimicrobial
prophylaxis may result in lower SSI rates, this is not specified in any
published guideline. A survey of colorectal surgeons found that
combination oral and parenteral prophylaxis is common practice in the
United States . For patients with confirmed allergy or adverse reaction
to ![](media/image1.png){width="9.375e-2in" height="0.15625in"}-lactams,
use of one of the following regimens is recommended: clindamycin
combined with gentamicin, aztreonam, or ciprofloxacin; or metronidazole
combined with gentamicin or ciprofloxacin. A single 750-mg dose of
levofloxacin can be substituted for ciprofloxacin.

<http://www.journals.uchicago.edu/CID/journal/issues/v38n12/33257/33257.html>

**Pelvic floor physiotherapy is effective treatment for persistent
postnatal SUI: RCT**

CONCLUSION: Multimodal supervised pelvic floor physiotherapy is an
effective treatment for persistent postnatal stress urinary
incontinence.

Dumoulin C, et al. Physiotherapy for persistent postnatal stress urinary
incontinence: a randomized controlled trial. Obstet Gynecol. 2004
Sep;104(3):504-10\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15339760&dopt=Abstract>

**Estimating blood loss: can teaching significantly improve visual
estimation?**

CONCLUSION: Error in estimating blood loss is dependent on actual blood
loss volume. Medical students and experienced faculty demonstrate
similar errors, and both can be improved significantly with limited
instruction. This educational process may assist clinicians in everyday
practice to more accurately estimate blood loss and recognize patients
at risk for hemorrhage-related complications

Dildy GA 3rd, Paine AR, George NC, Velasco C. Estimating blood loss: can
teaching significantly improve visual estimation? Obstet Gynecol. 2004
Sep;104(3):601-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15339775&dopt=Abstract>

**High intrauterine pressure improves success in thermal balloon
endometrial ablation**

CONCLUSION(S): Maintaining high intrauterine pressure during the
treatment cycle and correction of the retroversion may help to improve
treatment success in thermal balloon endometrial ablation.

Lok IH, Leung PL, Ng PS, Yuen PM. Life-table analysis of the success of
thermal balloon endometrial ablation in the treatment of menorrhagia.
Fertil Steril. 2003 Nov;80(5):1255-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14607584>

**Serious complications associated with global endometrial ablation not
yet reported**

RESULTS: Traditional MEDLINE and bibliography searches yielded reports
of two cases of hemorrhage, one case of pelvic inflammatory disease, 20
cases of endometritis, two cases of first-degree skin burns, nine cases
of hematometra, and 16 cases of vaginitis and/or cystitis.

A search of the US Food and Drug Administration MAUDE database yielded
reports of 85 complications in 62 patients. These included major
complications: eight cases of thermal bowel injury, 30 cases of uterine
perforation, 12 cases in which emergent laparotomy was required, and
three intensive care unit admissions. One patient developed necrotizing
fasciitis and eventually underwent vulvectomy, ureterocutaneous ostomy,
and bilateral below-the-knee amputations. One of the patients with
thermal injury to the bowel died.

CONCLUSION: Use of the US Food and Drug Administration MAUDE database is
helpful in identifying serious complications associated with global
endometrial ablation not yet reported in the medical literature.

Gurtcheff SE, Sharp HT. Complications associated with global endometrial
ablation: the utility of the MAUDE database. Obstet Gynecol. 2003
Dec;102(6):1278-82.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14662215>

**Stress urinary incontinence affects one third of adult women and is
usually reduced or eliminated with either nonsurgical or surgical
therapy.**

Stress urinary incontinence, the complaint of involuntary leakage during
effort or exertion, occurs at least weekly in one third of adult women.
The basic evaluation of women with stress urinary incontinence includes
a history, physical examination, cough stress test, voiding diary,
postvoid residual urine volume, and urinalysis. Formal urodynamics
testing may help guide clinical care, but whether urodynamics improves
or predicts the outcome of incontinence treatment is not yet clear. The
distinction between urodynamic stress incontinence associated with
hypermobility and urodynamic stress incontinence associated with
intrinsic sphincter deficiency should be viewed as a continuum, rather
than a dichotomy, of urethral function. Initial treatment should include
behavioral changes and pelvic floor muscle training. Estrogen is not
indicated to treat stress urinary incontinence. Bladder training,
vaginal devices, and urethral inserts also may reduce stress
incontinence. Bulking agents reduce leakage, but effectiveness generally
decreases after 1--2 years. Surgical procedures are more likely to cure
stress urinary incontinence than nonsurgical procedures but are
associated with more adverse events. Based on available evidence at this
time, colposuspension (such as Burch) and pubovaginal sling (including
the newer midurethral synthetic slings) are the most effective surgical
treatments.

Nygaard IE, Heit M. Stress urinary incontinence. Obstet Gynecol. 2004
Sep;104(3):607-20.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15339776&dopt=Abstract>

**Self-testing for human papillomavirus (HPV) DNA is feasible for
cervical cancer screening**

[Conclusion:]{.underline} Self-assessment for HPV DNA is an easy,
feasible, and well-accepted method for HPV testing and for cervical
cancer screening in internal medicine outpatient clinics.

Kahn JA. Self-testing for human papillomavirus using a vaginal swab:
placing prevention of cervical cancer in the patient\'s hands. Ann
Oncol. 2004 Jun;15(6):847-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15151937>

**Efficacy of Cone Biopsy of the Uterine Cervix During Frozen Section
for the Evaluation of Cervical Intraepithelial Neoplasia Grade** 3

We retrospectively selected 22 cases in which patients with a
biopsy-proven diagnosis of cervical intraepithelial neoplasia grade 3
underwent cervical conization for frozen section (FS) evaluation
followed by hysterectomy at the University of California Irvine Medical
Center, Orange, during the August 1995 to September 9, 2001. All slides
from FS and permanent section (PS) and hysterectomy specimens were
reviewed. FS diagnoses were compared with those of previous biopsies,
PS, and hysterectomy specimens. The PS correlated with FS in all cases
but 1. Appropriate surgery was performed for all patients based on FS
diagnosis. The McNemar test was used to compare the results of FS and
PS, with a 2-sided P value of 1.0 and a c coefficient of 0.7755 with a
95% confidence level, indicating that the 2 groups were not
significantly different. FS evaluation of cervical conization is as
efficacious and accurate as evaluation of regular specimens in providing
information for the appropriateness of same-day surgery.

[Conclusion:]{.underline} We recommend that entire tissue be submitted
for FS to avoid sampling errors and to increase diagnostic accuracy. Gu
M, Lin F. Efficacy of cone biopsy of the uterine cervix during frozen
section for the evaluation of cervical intraepithelial neoplasia grade
3. Am J Clin Pathol. 2004 Sep;122(3):383-8

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15362368>

**[Child Health]{.underline}**

**No benefit seen for suctioning meconium-stained newborns: RCT**

INTERPRETATION: Routine intrapartum oropharyngeal and nasopharyngeal
suctioning of term-gestation infants born through MSAF does not prevent
MAS. Consideration should be given to revision of present
recommendations.

Vain NE, et al Oropharyngeal and nasopharyngeal suctioning of
meconium-stained neonates before delivery of their shoulders:
multicentre, randomised controlled trial. Lancet. 2004 Aug
14;364(9434):597-602.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15313360>

**Role of vaginal douching in the reproductive health of adolescents and
young women**

\"The initiation and maintenance of douching behavior in young women is
a complicated behavior influenced by many factors, including family,
sexual partners, body image, and advertising, among many others,\"

\* Numerous studies have shown that douching is prevalent and often
begins in adolescence.

\* Motivation for the initiation and maintenance of douching appears
complex and presents challenges to intervention efforts. Recent studies
implicate high-risk sexual behaviors as motivators for sustaining
douching behavior.

\* Douching has been implicated in numerous adverse reproductive health
outcomes such as pelvic inflammatory disease, ectopic pregnancy, reduced
fertility, and bacterial vaginosis. However, most studies linking
douching to adverse reproductive health outcomes are case control
studies; thus the causal relationship between douching and these
outcomes remains unknown.

\* Recent publications involving participants from developing countries
seem to indicate that vaginal douching under certain circumstances may
be harmless or even beneficial.

The authors note that although \"the need for prospective longitudinal
studies of the effects of douching was recognized decades ago . . . very
little advancement has been published in recent decades"

Simpson T, Merchant J, Grimley DM, et al. 2004. Vaginal douching among
adolescent and young women: More challenges than progress. Journal of
Pediatric and Adolescent Gynecology 17(4):249-255
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15288026>

**Whole environment intervention improves asthma associated morbidity in
children**

-The intervention group reported significantly fewer asthma symptoms
during both the intervention year and the follow-up year. The greater
reduction in asthma-related symptoms in the intervention group occurred
within 2 months after randomization and was sustained for the 2 years of
the study.

-Levels of cockroach allergens and dust-mite allergens in the bedroom
decreased in both groups over the course of the study; however, greater
reductions occurred in the intervention group.

-Relationships between the reduction in the levels of dust mite
allergens and improvements in reported asthma-associated morbidity were
similar in both groups.

\"We have shown that remediation strategies can be implemented that
result in both sustained reductions in indoor allergen levels and
sustained improvements in reported asthma-associated morbidity in this
high-risk population,\" conclude the authors.

Morgan WJ, Crain EF, Gruchalla RS, et al. 2004. Results of a home-based
environmental intervention among urban children with asthma. New England
Journal of Medicine 351(11):1068-1080.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15356304>

**SIDS Resource kits available**

If you are in need of a SIDS resourse kit(s) please go to the
[www.cjsids.com](http://www.cjsids.com/) web site

there are about 1000 left - they are free and take 3 weeks to deliver.

**Protecting our children from environmental hazards in the face of
limited data**

\-[Low-dose exposure is not necessarily safe
exposure](http://www2.us.elsevierhealth.com/scripts/om.dll/serve?action=searchDB&searchDBfor=art&artType=fullfree&id=as0022347604003816#head1%23head1)

\-[No evidence of harm is not equivalent to evidence of no
harm](http://www2.us.elsevierhealth.com/scripts/om.dll/serve?action=searchDB&searchDBfor=art&artType=fullfree&id=as0022347604003816#head2%23head2)

\-[Taking
action](http://www2.us.elsevierhealth.com/scripts/om.dll/serve?action=searchDB&searchDBfor=art&artType=fullfree&id=as0022347604003816#head3%23head3)

Shea KM  Protecting our children from environmental hazards in the face
of limited data-a precautionary approach is needed. J Pediatr. 2004
Aug;145(2):145-7\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15289755>

or full text

[www2.us.elsevierhealth.com/scripts/om.dll/serve?action=searchDB&searchDBfor=art&artType=fullfree&id=as0022347604003816](http://www2.us.elsevierhealth.com/scripts/om.dll/serve?action=searchDB&searchDBfor=art&artType=fullfree&id=as0022347604003816)

**[Chronic disease and Illness]{.underline}**

**Tamoxifen for breast cancer prevention: a framework for clinical
decisions**

CONCLUSION: Tamoxifen chemoprevention is cost-effective for women aged
40-50 years who are at significant breast cancer risk. Whether this
holds true for older women depends on the initial breast cancer risk,
fear of breast cancer, and presence of the uterus.

Cykert S, Phifer N, Hansen C. Tamoxifen for breast cancer prevention: a
framework for clinical decisions. Obstet Gynecol. 2004 Sep;104(3):433-42

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15339751&dopt=Abstract>

**New cholesterol guidelines pose a challenge for doctors and patients**

The Adult Treatment Panel III (ATP III) of the National Cholesterol
Education Program issued an evidence-based set of guidelines on
cholesterol management in 2001. Since the publication of ATP III, 5
major clinical trials of statin therapy with clinical end points have
been published. These trials addressed issues that were not examined in
previous clinical trials of cholesterol-lowering therapy. The present
document reviews the results of these recent trials and assesses their
implications for cholesterol management. Therapeutic lifestyle changes
(TLC) remain an essential modality in clinical management. The trials
confirm the benefit of cholesterol-lowering therapy in high-risk
patients and support the ATP III treatment goal of low-density
lipoprotein cholesterol (LDL-C) \<100 mg/dL. They support the inclusion
of patients with diabetes in the high-risk category and confirm the
benefits of LDL-lowering therapy in these patients. They further confirm
that older persons benefit from therapeutic lowering of LDL-C. The major
recommendations for modifications to footnote the ATP III treatment
algorithm are the following. In high-risk persons, the recommended LDL-C
goal is \<100 mg/dL, but when risk is very high, an LDL-C goal of \<70
mg/dL is a therapeutic option, ie, a reasonable clinical strategy, on
the basis of available clinical trial evidence. This therapeutic option
extends also to patients at very high risk who have a baseline LDL-C
\<100 mg/dL. Moreover, when a high-risk patient has high triglycerides
or low high-density lipoprotein cholesterol (HDL-C), consideration can
be given to combining a fibrate or nicotinic acid with an LDL-lowering
drug. For moderately high-risk persons (2+ risk factors and 10-year risk
10% to 20%), the recommended LDL-C goal is \<130 mg/dL, but an LDL-C
goal \<100 mg/dL is a therapeutic option on the basis of recent trial
evidence. The latter option extends also to moderately high-risk persons
with a baseline LDL-C of 100 to 129 mg/dL. When LDL-lowering drug
therapy is employed in high-risk or moderately high-risk persons, it is
advised that intensity of therapy be sufficient to achieve at least a
30% to 40% reduction in LDL-C levels. Moreover, any person at high risk
or moderately high risk who has lifestyle-related risk factors (eg,
obesity, physical inactivity, elevated triglycerides, low HDL-C, or
metabolic syndrome) is a candidate for TLC to modify these risk factors
regardless of LDL-C level. Finally, for people in lower-risk categories,
recent clinical trials do not modify the goals and cutpoints of therapy

Grundy SM et al. Implications of recent clinical trials for the National
Cholesterol Education Program Adult Treatment Panel III guidelines.
Circulation. 2004 Jul 13;110(2):227-39.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15249516&dopt=Abstract>

**Broken Promises - What is the status of American Indian / Alaska
Native Health?\
**The U.S. Commission on Civil Rights has issued a follow-up report to
its \"Quiet Crisis\" report from last year that focused on the lack of
federal funding addressing unmet needs in Indian Country. The new
report, entitled \"Broken Promises: Evaluating the Native American
Health Care System,\" is now available on the Commission\'s website at
[[http://www.usccr.gov/]{.underline}](http://www.usccr.gov/)

-In the end, as a result of our examination of the Native American
health care system and the nature of historical relationship between
tribes and the federal government, it is possible to reduce this report
to a single compelling observation. That observation is that persistent
discrimination and neglect continue to deprive Native Americans of a
health system sufficient to provide health care equivalent to that
provided to the vast majority of Americans.\"

-The report examines: health disparities in Indian Country; social and
cultural barriers that limit access to care and contribute to the
disparities; financial barriers; and proposed legislation changes. In
the chapter on legislative changes, the report finds that reauthorizing
the Indian Health Care Improvement Act would provide the \"most promise
for improving the lives of Native Americans\" (p. 121) and recommends
the passage of the reauthorization as \"a priority item on the
legislative agenda.\"

##### Features

## American Family Physician\*\*

###### Patient-Oriented Evidence that Matters (POEMS)\*

**Misoprostol Therapy for Incomplete Abortion**

[Clinical Question:]{.underline} Which regimen of misoprostol is more
effective for the treatment of incomplete abortion among women who would
otherwise undergo surgical evacuation?

[Bottom Line:]{.underline} A single 600-mcg dose of oral misoprostol
results in completion of a first-trimester abortion within one week in
two thirds of cases. A two-dose regimen is not significantly more
effective. Misoprostol also may prove useful in women with a diagnosis
of missed abortion. A placebo-controlled trial is needed. (Level of
Evidence: 1b-)

[**http://www.aafp.org/afp/20040915/tips/23.html**](http://www.aafp.org/afp/20040915/tips/23.html)

Estrogen Sources Have Similar Effects

[Clinical Question]{.underline}: Are commonly used estrogens equally
safe and effective in the treatment of menopausal hot flushes?

###### [Bottom Line:]{.underline} Commonly used estrogens, including oral conjugated equine estrogen, and oral or transdermal 17b-estradiol, are equally safe and effective in the treatment of menopausal hot flushes. This analysis did not include phytoestrogens because no direct comparisons have been made with standard estrogen replacement. (Level of Evidence: 1a)

<http://www.aafp.org/afp/20040815/tips/13.html>

**Women Have Greater Analgesia from Butorphanol than Morphine**

[Clinical Question]{.underline}: Do women and men react differently to
different analgesics?

[Bottom Line:]{.underline} This preliminary study found that women seem
to respond slightly better to butorphanol than to morphine. This
difference may extend to other mixed-action opioids, such as pentazocine
and nalbuphine. (Level of Evidence: 1b)

<http://www.aafp.org/afp/20040915/tips/22.html>

**\*POEM Rating system**: <http://www.infopoems.com/levels.html> **POEM
Definition:** <http://www.aafp.org/x19976.xml>

\*\* The AFP sites will sometimes ask for a username and password.
Instead just 'hit; cancel on the pop up password screen, and the page
you are requesting will come up without having to enter a username and
password.

Genital Herpes: Clinical Evidence Concise, A Publication of BMJ
Publishing Group

<http://www.aafp.org/afp/20040901/bmj.html>

**Making Decisions with Families at the End of Life**

<http://www.aafp.org/afp/20040815/719.html>

##### ACOG

**Management of Postterm Pregnancy**

**Practice Bulletin** NUMBER 55, SEPTEMBER 2004

Postterm pregnancy, by definition, refers to a pregnancy that has
extended to or beyond 42 weeks of gestation (294 days, or estimated date
of delivery \[EDD\] +14 days). Accurate pregnancy dating is critical to
the diagnosis. The term \"postdates\" is poorly defined and should be
avoided. Although some cases of postterm pregnancy likely result from an
inability to accurately define the EDD, many cases result from a true
prolongation of gestation. The reported frequency of postterm pregnancy
is approximately 7%.

Accurate assessment of gestational age and diagnosis of postterm
gestation, as well as recognition and management of risk factors, may
reduce the risk of adverse sequelae. Antenatal surveillance and
induction of labor are 2 widely used strategies that theoretically may
decrease the risk of an adverse fetal outcome; maternal risk factors for
postterm pregnancy also should be considered. The purpose of this
document is to examine the evidence and provide recommendations about
these 2 management strategies.

**Summary of Recommendations**

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

-   Women with postterm gestations who have unfavorable cervices can
    either undergo labor induction or be managed expectantly.

-   Prostaglandin can be used in postterm pregnancies to promote
    cervical ripening and induce labor.

-   Delivery should be effected if there is evidence of fetal compromise
    or oligohydramnios.

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

-   Despite a lack of evidence that monitoring improves perinatal
    outcome, it is reasonable to initiate antenatal surveillance of
    postterm pregnancies between 41 weeks (287 days; EDD +7 days) and 42
    weeks (294 days; EDD +14 days) of gestation because of evidence that
    perinatal morbidity and mortality increase as gestational age
    advances.

-   Many practitioners use twice-weekly testing with some evaluation of
    amniotic fluid volume beginning at 41 weeks of gestation. A
    nonstress test and amniotic fluid volume assessment (a modified BPP)
    should be adequate.

-   Many authorities recommend prompt delivery in a postterm patient
    with a favorable cervix and no other complications.

Management of postterm pregnancy. ACOG Practice Bulletin No. 55.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2004;104:639--46.

Non-ACOG Members

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15339790>

ACOG Members

<http://www.acog.org/publications/educational_bulletins/pb055.cfm>

**Guidelines for Diagnostic Imaging During Pregnancy**

Committee Opinion Number 299, September 2004

ABSTRACT: Undergoing a single diagnostic X-ray procedure does not result
in radiation exposure adequate to threaten the well-being of the
developing preembryo, embryo, or fetus and is not an indication for
therapeutic abortion. When multiple diagnostic X-rays are anticipated
during pregnancy, imaging procedures not associated with ionizing
radiation, such as ultrasonography and magnetic resonance imaging,
should be considered. Additionally, it may be helpful to consult an
expert in dosimetry calculation to determine estimated fetal dose. The
use of radioactive isotopes of iodine is contraindicated for therapeutic
use during pregnancy. Other radiopaque and paramagnetic contrast agents
have not been studied in humans, but animal studies suggest that these
agents are unlikely to cause harm to the developing human fetus.
Although imaging techniques requiring these agents may be diagnostically
beneficial, these techniques should be used during pregnancy only if
potential benefits justify potential risks to the fetus.

Non-ACOG Members

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15339791>

ACOG Members

<http://www.acog.org/publications/committee_opinions/co299.cfm>

##### AHRQ

**The Worst Headache: Web M + M\
**[A woman presents with a sudden onset headache, felt to be another
migraine. However, when her physician follows up with her by phone, the
line goes dead. EMTs find her
unconscious.](http://www.webmm.ahrq.gov/cases.aspx?ic=69)

<http://www.webmm.ahrq.gov/cases.aspx?ic=69>

**Treatment of high cholesterol in women should be based on all risk
factors for heart disease, not just lipid levels**
<http://www.ahrq.gov/research/jul04/0704RA2.htm#head1>

**Child abuse is associated with increased risk of death in young
children with abdominal injuries**
<http://www.ahrq.gov/research/jul04/0704RA12.htm#head4>

**Women who undergo hysterectomy for abnormal uterine bleeding report
improved health-related quality of life**
<http://www.ahrq.gov/research/jul04/0704RA13.htm#head1>

##### Breastfeeding

**Babies Were Born to Be Breastfed: Few Babies Breastfed Long Enough**
[\
]{.underline}This is the first national public health campaign for
breastfeeding since 1911. It emphasizes the health consequences of not
breastfeeding. Through a series of eye-catching images that subtly mimic
the appearance of breasts, print ads in the campaign advise mothers that
breastfeeding will help reduce their children\'s risk of ear infections,
respiratory illness, obesity and other health risks.
<http://www.4woman.gov/breastfeeding/> and
<http://www.cdc.gov/breastfeeding/nis_data/>

**Breastfeeding Protects Against Asthma and Atopy**

CONCLUSIONS: Less exclusive breastfeeding leads to increases in child
asthma and atopy and a higher BMI is a risk factor for asthma.

Oddy WH et al. The relation of breastfeeding and body mass index to
asthma and atopy in children: a prospective cohort study to age 6 years.
Am J Public Health. 2004 Sep;94(9):1531-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15333310>

**[Domestic Violence]{.underline}**

**Health Cares About Domestic Violence Day: October 13^th^**

HCADV Day is a nationally recognized awareness-raising day that takes
place annually on the second Wednesday of October---this year on October
13^th^. Sponsored by the Family Violence Prevention Fund, a national
non-profit organization working to eliminate domestic violence, HCADV
Day aims to reach members of the healthcare community and educate them
about the critical importance of assessing for domestic violence, as
well as the long term health implications of domestic violence and
lifetime exposure to violence.

If you would like any assistance in your planning of this day, please
contact Anna Marjavi at the Family Violence Prevention Fund
(415-252-8900, <anna@endabuse.org>).  Also note that the enclosed
Organizing Packet is available online in PDF version:
[www.endabuse.org/hcadvd](http://www.endabuse.org/hcadvd).

To receive a hard copy of the organizing packet, please contact Anna at
<anna@endabuse.org>

Further information about domestic violence within American Indian/
Alaska Native communities is available at 
<http://www.ihs.gov/MedicalPrograms/MCH/W/DV00.cfm>

**The Legacy of Child Maltreatment: Long-Term Health Consequences for
Women**

Arias I. The legacy of child maltreatment: long-term health consequences
for women. J Womens Health (Larchmt). 2004 Jun;13(5):468-73

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15257839>

**[Elder Care News]{.underline}**

**Effect of Raloxifene on the Incidence of Elevated Low Density
Lipoprotein (LDL)**

CONCLUSIONS: In postmenopausal women with osteoporosis not taking
concurrent lipid-lowering therapy, raloxifene significantly reduced the
incidence of LDL-C \> or = 160 mg/dL and significantly increased the
proportion achieving LDL-C goals for lipid-lowering compared with
placebo. Whether these and other effects of raloxifene on cardiovascular
risk markers will improve cardiovascular outcomes requires further
study. Cox DA, et al. Effect of raloxifene on the incidence of elevated
low density lipoprotein (LDL) and achievement of LDL target goals in
postmenopausal women. Curr Med Res Opin. 2004 Jul;20(7):1049-55.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15265250>

**[Family Planning]{.underline}**

**Emergency Contraception**

<http://www.aafp.org/afp/20040815/707.html>

**Emergency Contraception: An Ongoing Debate -- AFP**

<http://www.aafp.org/afp/20040815/editorials.html>

**EC: Patient Education**

<http://www.aafp.org/afp/20040815/717ph.html>

**[Frequently asked questions]{.underline}**

**Q. Should we perform routine urine dipstick protein screening in our
prenatal clinic?**

A. No, the urine dipstick tests are not sensitive, nor specific enough
to suggest for routine screening for pre-eclampsia. There is more to the
story, though.

The old prenatal systems included performing routine urine dipstick
screening for pre-eclampsia and diabetes on all prenatal patients at all
visits. Upon further review by the 1989 PHS Expert Panel on the Content
of Prenatal Care neither of those two disorders were well screened by
urine dipstick testing.

Urinary protein dipstick values do not correlate well with 24-hour
urinary collection protein excretion values in hypertensive pregnant
women (Mercer, Kuo, Waugh). In one systematic review including six
studies, the posttest probability for urine dipstick of
![](media/image3.png){width="8.333333333333333e-2in"
height="9.236111111111112e-2in"}1+ for predicting 24-hour urine protein
excretion ![](media/image3.png){width="8.333333333333333e-2in"
height="9.236111111111112e-2in"}300 mg ranged from 53 to 86 percent, and
was 23 to 40 percent when the dipstick was negative or trace (Waugh).
Thus, a negative dipstick does not necessarily exclude significant
proteinuria while many women with positive tests do not have it.
However, urine dipstick values of 3+ and 4+ are more helpful as, in one
series, all but 9 percent of patients with these dipstick values
excreted at least 3.5 g of protein per day (Mercer).

Another approach is to limit initial clinic screening pre-eclampsia
screening to patients at higher risk, e.g., BP greater then 140/90 mm
Hg, or mean arterial pressure greater than 105 mm Hg, symptoms of
pre-clampsia, multiple gestation, symptoms of UTI, or chronic
hypertension currently on hypertension medication. Screening of this
high risk group could be performed by either a classic dipstick, or a
total protein to creatinine ratio.

In any case, the best screen for pre-eclampsia remains a casual BP
reading performed in a sitting position after appropriate rest. (See
Guidelines below)

**References**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8296815&dopt=MEDLINE>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15051572&dopt=Abstract>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6656849>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9397097>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11641656>

**Guidelines**

<http://www.ihs.gov/NonMedicalPrograms/nc4/Documents/HYPERT12004.doc>

**[Hormone Replacement Update]{.underline}**

**One our four women who attempt to stop HT are unsuccessful**

CONCLUSION: Approximately one quarter of women who try to stop report
that they are unable to discontinue postmenopausal hormone therapy,
primarily because they develop troublesome withdrawal symptoms.
Effective approaches to reducing hormone therapy withdrawal symptoms
should be a priority for future research.

Grady D, Ettinger B, Tosteson AN, Pressman A, Macer JL. Predictors of
difficulty when discontinuing postmenopausal hormone therapy. Obstet
Gynecol. 2003 Dec;102(6):1233-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14662209>

# [Information Technology]{.underline}

**Ten Questions to Ask Before Buying an Electronic Medical Record
(EMR)**

An increasing number of practices are adopting EMRs and the
\$526-million-a-year industry is growing at about 8% annually. About 15%
to 22% of practices have adopted EMRs, but the percentage of individual
physicians who actually use the systems is lower.

1\. What are the options? You can choose to go paperless in a day or to
automate records in stages based on practice needs and vendor
experience.\
2. Can the new EMR system be integrated into existing practice
management systems?\
3. What are the additional costs? Training, additional hardware, and
computer updates are all necessary expenses, but might not be included
in initial price.\
4. How will this be financed? How you plan to finance the cost of an EMR
system will influence negotiations with the vendor.\
5. What is the backup plan if the EMR is unavailable? \"This is
something you need to plan for in advance,\" Dr. James said.\
6. Do you need the EMR to be able to exchange data with outside
companies and other physician practices?\
7. How much training is needed to get the system operational?\
8. Can physician input be included in the creation of EMR templates and
alerts?\
9. Do you have complete ownership of patient records under the EMR
contract? If not, the vendor may be able to resell any information
either in an identified or de-identified way to a third party.\
10. Who will be the practice\'s point person on EMR issues? Appointing a
system administrator to act as the liaison between office staff and the
vendor is a good way to keep current on any problems or questions.

<http://home.mdconsult.com/das/stat/view/40965568-2/pers?nid=143363&sid=0&pos=practmgmt>

# [International Health Update]{.underline}

[**Routine cervical cancer screening constitutes nearly two thirds of
total annual cervical HPV-related health care
costs**](http://mdconsult.chtah.com/a/hBBJLAOAPMgn1ASgjDSAPMu5kLK/curb17)

CONCLUSION: These are the first direct estimates of both individual and
population level costs of cervical human papillomavirus-related disease
in a general US health care setting. Routine cervical cancer screening
comprises nearly two thirds of total annual cervical human
papillomavirus-related health care costs, with 10% of expenditures
dedicated to the treatment of invasive cervical cancer, 17% to the
management of cervical precancers, and 9% to dealing with false-positive
Papanicolaou test results.

Insinga RP, Glass AG, Rush BB. The health care costs of cervical human
papillomavirus\--related disease. Am J Obstet Gynecol. 2004
Jul;191(1):114-20.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15295351>

**Sprawl: The New Manifest Destiny? Health Effects**

Urban sprawl is having profound impacts on human health and
environmental quality, yet it has been only relatively recently that
sprawl has been well defined and studied. One area of particular recent
interest is the link between sprawl and obesity. Civil planners and
others are advocating such alternatives as smart growth and urban growth
boundaries to keep sprawl in check while offering more opportunities for
residents to enjoy physical activity, but their efforts can often be met
with resistance from previously enacted zoning ordinances

Schmidt CW. Sprawl: the new manifest destiny? Environ Health Perspect.
2004 Aug;112(11):A620-7\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15289182>

#### [MCH Alert]{.underline}

**New Report Maps Women's Health in the U.S.**

The Women\'s Health and Mortality Chartbook is a statistical resource on
women\'s health in each of the states, the District of Columbia, and
Puerto Rico. The chartbook, produced by the U.S. Department of Health
and Human Services\' Office on Women\'s Health, was developed to provide
a collection of current state data on critical issues relevant to women.
A total of 27 featured health indicators highlight some key
women\'s-health-related issues that are measured regularly at the state
level. The chartbook contains U.S. maps for each featured health
indicator; women\'s health profiles for each of the 52 geographic areas
presented; and information on data sources, terminology, and analytic
issues. It is intended for use by policymakers and program managers at
the federal and state levels to identify key health issues in each
state, and it may also stimulate readers to ask new questions. The
chartbook is available at
[[http://www.cdc.gov/nchs/datawh/statab/chartbook.htm]{.underline}](http://www.cdc.gov/nchs/datawh/statab/chartbook.htm).

Data files may be downloaded from the National Center for Health
Statistics\' Web site at
[[http://www.cdc.gov/nchs/healthywomen.htm]{.underline}](http://www.cdc.gov/nchs/healthywomen.htm)

**A new PeriStats database and Web interface increases access to
detailed MCH data in US**

The new Web site represents the first milestone of a partnership between
the March of Dimes Perinatal Data Center, the National Library of
Medicine, and the New York Academy of Medicine to increase access to
city, county, state, and national perinatal data and to improve the
utility of PeriStats. More than 50,000 graphs, maps, and tables have
been added to the PeriStats system to date. Future efforts will include
integrating access to relevant biomedical literature.

The Web site is intended to be used for fact-finding, regional health
assessments, grant writing, policy development, lectures, and
presentations. An overview of the new features is available at
[[http://www.marchofdimes.com/peristats/whatsnew.aspx?id=6]{.underline}](http://www.marchofdimes.com/peristats/whatsnew.aspx?id=6).

The PeriStats Web site is available at
[[http://www.marchofdimes.com/peristats]{.underline}](http://www.marchofdimes.com/peristats).

**New ways to measure quality in Child Health Programs - Toolbox, AHRQ**

Child Health Care Quality Toolbox (formerly Child Health Toolbox)
contains concepts, tips, and tools for evaluating the quality of health
care for children. The redesigned toolbox, a product of the Agency for
Health Care Research and Quality, enables users to download to their
desktops all sections of the toolbox, including a new section on mental
health measures. Other sections include information on uses of quality
measurement, established child health care quality measures, emerging
quality measures, choosing quality measures, how to develop quality
measures, and resources. The toolbox is available at
[[http://www.ahrq.gov/chtoolbx]{.underline}](http://www.ahrq.gov/chtoolbx)

#### [Medscape\*]{.underline}

######### Safety and Efficacy of Testosterone in Menopausal Women: Restoring Sexual Desire

######### [**http://www.medscape.com/viewprogram/3138?src=mp**](http://www.medscape.com/viewprogram/3138?src=mp) (CME)

######### 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.

**[Office of Women's Health, CDC]{.underline}**

**Can Changes in Sexual Behaviors Among High School Students Explain the
Decline in Teen Pregnancy Rates in the 1990s?**

This recent article published in the Journal of Adolescent Health
explores the national decline in teen pregnancy and birth rates.
Overall, 53% of the decline in pregnancy rates can be attributed to
decreased sexual experience and 47% to improved contraceptive use. These
data suggest that both delayed initiation of sexual intercourse and
improved contraceptive practice contributed equally to declines in
pregnancy rates among high school-aged teens during the 1990s. *Journal
of Adolescent Health* 2004 Aug;35(2):80--90.

<http://download.journals.elsevierhealth.com/pdfs/journals/1054-139X/PIIS1054139X0400134X.pdf>

**[Osteoporosis]{.underline}**

**Vitamin D and Derivatives Should Not Be Administered Concurrently With
Doxercalciferol (Hectorol)** The FDA approved revisions to the safety
labeling for doxercalciferol capsules (Hectorol, made by Bone Care) to
include several precautions. Pharmacologic doses of vitamin D and its
derivatives should not be administered concurrently with doxercalciferol
because it is a precursor to a potent metabolite (1α, 25 (OH)~2~D~2~ )
of vitamin D~2~, and additive effects as well as hypercalcemia may
result. If hypercalcemia occurs, the dose of doxercalciferol and/or
calcium-containing binders should be decreased.

Uncontrolled serum phosphorus exacerbates secondary hyperparathyroidism
and can lessen the effectiveness of doxercalciferol in reducing blood
parathyroid hormone levels. If hyperphosphatemia occurs, the dose of
doxercalciferol should be decreased and/or the dose of phosphate binders
increased. <http://www.fda.gov/>

**[Patient Information]{.underline}**

**Emergency Contraception**

<http://www.aafp.org/afp/20040815/717ph.html>

**End-Of-Life Choices for Families**

<http://www.aafp.org/afp/20040815/725ph.html>

**Management of Gestational Diabetes Mellitus and Pharmacists\' Role in
Patient Education**

CONCLUSION: GDM can have serious effects if not treated properly. A
major part of managing GDM involves educating the patient about diet,
exercise, blood glucose self-monitoring, and insulin
self-administration.

Evans E, Patry R Management of gestational diabetes mellitus and
pharmacists\' role in patient education. Am J Health Syst Pharm. 2004
Jul 15;61(14):1460-5.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15332693>

**[Primary Care Discussion Forum]{.underline}**

**November 1, 2004: Violence against Native women**

Moderator: Terry Cullen

This discussion will include the scope of violence against Native women,
tools for patient evaluation, best practice policies and procedures,
plus ideas about available resources.

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

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

Subscribe to the Primary Care listserv

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

Unsubscribe from the Primary Care listserv

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

**[Barbara Stillwater, Alaska State Diabetes Program]{.underline}**

**Weight predicts diabetes**

CONCLUSIONS: Although BMI and physical inactivity are independent
predictors of incident diabetes, the magnitude of the association with
BMI was greater than with physical activity in combined analyses. These
findings underscore the critical importance of adiposity as a
determinant of diabetes. Weinstein AR, et al Relationship of physical
activity vs body mass index with type 2 diabetes in women. JAMA. 2004
Sep 8;292(10):1188-94.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15353531>
and

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15353537>

**Soda Increases Risk of Diabetes 83%**

CONCLUSION: Higher consumption of sugar-sweetened beverages is
associated with a greater magnitude of weight gain and an increased risk
for development of type 2 diabetes in women, possibly by providing
excessive calories and large amounts of rapidly absorbable sugars.

Schulze MB et al Sugar-sweetened beverages, weight gain, and incidence
of type 2 diabetes in young and middle-aged women. JAMA. 2004 Aug
25;292(8):927-34.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15328324>

**New Diet Guidelines Call for More Exercise and Grains\
**The federal advisory panel was offering its final recommendations for
making the government\'s food pyramid a better guide to proper eating.
Not just any bread will do: Americans need more fiber, and whole wheat
is better than white bread for getting it. For more details\
<http://www.health.gov/dietaryguidelines/dga2005/report>

**Diabetes Triples Risk of Heart Failure for Women**

CONCLUSIONS: We identified 9 predictors of heart failure in
postmenopausal women with coronary disease. Diabetes was the strongest
risk factor, particularly when poorly controlled or with concomitant
renal insufficiency or obesity

Bibbins-Domingo K et al Predictors of heart failure among women with
coronary disease. Circulation. 2004 Sep 14;110(11):1424-30.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15353499>

**Health Disparities among Minority and Underserved Women**\
The purpose of this initiative is to stimulate research aimed at
reducing health disparities among racial/ethnic minority and underserved
women. More specifically, this initiative seeks applications for:
Investigators responding to this announcement should focus on enhancing
the body of knowledge of a variety of factors (e.g., social, economic,
demographic, community, societal, personal, cultural) influencing the
health promoting and health compromising behaviors of racial and ethnic
minority women and underserved women and their subpopulations.

APPLICATION RECEIPT DATE(S): Multiple dates, see announcement

<http://grants.nih.gov/grants/guide/pa-files/PA-04-153.html>

**NIH: School Based Interventions to Prevent Obesity; PA-04-145**\
This program announcement (PA) encourages the formation of partnerships
between academic institutions and school systems in order to develop and
implement controlled, school-based intervention strategies designed to
reduce the prevalence of obesity in childhood.  This initiative also
encourages evaluative comparisons of different intervention strategies,
as well as the use of methods to detect synergistic interactions between
different types of interventions.
[http://grants.nih.gov/grants/guide/pa-files/PA-04-145.html](http://www.magnetmail.net/ls.cfm?r=12268528&sid=248943&m=52219&u=AHA_HFSF_1&s=http://grants.nih.gov/grants/guide/pa-files/PA-04-145.html)

##### What's new on the ITU MCH web pages?

#### From the Biennial Women's Health/MCH meeting, ABQ - This meeting was a huge success: Here a few of the many talks Go here to review these materials

<http://www.ihs.gov/MedicalPrograms/MCH/M/PROG01.cfm#MeetingLecNotes>

**There is a new Perinatology Corner Module: Free CME / CEUs from IHS**

**Preterm Labor and Preterm Premature Rupture of Membranes**

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

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>

### **[Save the dates]{.underline}**

**20th Annual Midwinter Conference**

-   For providers caring for Native women and children

-   February 25 - 27, 2005 **Final dates**

-   Telluride, CO
    <http://www.ihs.gov/MedicalPrograms/MCH/M/ConfDnlds/Tellurideagenda10-2004.doc>

-   Contact Alan Waxman <awaxman@salud.unm.edu>

**\
17th Annual IHS Research Conference: International Meeting on Inuit and
Native American Child Health: Innovations in clinical care and
research**

> April 29-May 1, 2005, Seattle, WA

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

Did you miss something in the last OB/GYN Chief Clinical Consultant
Corner?

The **August 2004 OB/GYN CCC Corner** is available at:

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCCorner81804.doc>

**[Contents:]{.underline}**

**[Abstract of the Month]{.underline}: page 2**

Estrogen Therapy May Adversely Affect Global Cognitive Function

[From your colleagues:]{.underline} page 4

From Burt Attico: Making a Difference in Cambodia

From Terry Cullen: *UpToDate* Version 12.2 Now Available

**From Barbara Fine:** Call for Papers - American Indian & Alaska Native
Health Care Needs

**From Sandra Haldane:** Farewell to Barbara Fine, Women's Health
Consultant; National Alaska Native American Indian Nurses Association
Annual Summit; Nursing Education Loan Repayment Program**;** Writer\'s
Mentoring Program; Genomics and the Public Health in the 21st Century

From Steve Holve: August Indian Child Health Notes

From Rose Knox: Breastfeeding women not to use domperidone, to increase
milk production\*

**From Chuck North:** Number needed to Treat (NNT), Number needed to
Screen (NNS)

**From Ty Reidhead:** Online access to online journals that are
available at the Parklawn Library

From Lois Steel: Policy for the Group B strep in pregnancy

From Judy Thierry: Need data to help inform our legislative colleagues
about Indian Country;

How Schools Work and How to Work with Schools on Public Health Issues;
Managing Child/Adolescent Behavioral Health Problems; School based
health: How would that work in Indian Country? Knowledge path edition
about asthma in children and adolescents; American Indian Children who
receive care in the Indian Health Service have a 10% higher Immunization
rate; Psychotropic drugs in pediatric population in ITU system

**[Hot Topics:]{.underline}**

**Obstetrics:** **page 10**

Pregnancy Rates decreased by 10% decrease in 10 years for the United
States; Intensive Management of Gestational Diabetes: Cochrane for
Clinicians; [Preterm Birth as a Social Disease; Congenital Syphilis
\-\-- United States, 2002; Dystocia and Augmentation of Labor: Practice
Guidelines](http://mdconsult.chtah.com/a/hBA3EUBAPMgn1ARsVeZAPMu5kXl/curb179)

[**Gynecology: page
11**](http://mdconsult.chtah.com/a/hBA3EUBAPMgn1ARsVeZAPMu5kXl/curb179)

[**Despite Guidelines, Pap Smears in Women Without a Cervix Very
Common;**](http://mp.medscape.com/cgi-bin1/DM/y/hhjh0G875W0Dzc0F3Zm0AC)
Have you ever tried to learn any new technique? How many till you are
competent? Clinical examination vs. dynamic magnetic resonance imaging
in vaginal vault prolapse; MRI Helpful for Deep Pelvic Endometriosis;
Asymptomatic women show pelvic floor nerve injury after uncomplicated
deliveries; Uterine myomas: an overview of development, clinical
features, and management; Significance of a negative loop
electrosurgical cone biopsy for high-grade dysplasia; The Visit Before
the Morning After; Treating Female Infertility and Improving IVF
Pregnancy Rates: Manual Physical Therapy; Increases in
Fluoroquinolone-Resistant Neisseria Gonorrhoeae: Implications for Women;
Genetic Testing for Breast and Ovarian Cancer Susceptibility: Consumer
Marketing,

**Child Health: page 13**

Educate the educators, er...providers; Ano-genital warts in children:
Sexual abuse or not? Exposure of underage girls to alcohol advertising
is substantial and increasing; What does SIDS really mean? Racial/Ethnic
Disparities in Neonatal Mortality; Violence-Related Behaviors Among High
School Students; Great Beginnings: Transform care in your hospital\'s
newborn nursery; Funding for prevention and treatment of childhood
obesity in primary care settings; Vision and school health fact sheet;
Gowning in Newborn and Special-Care Nurseries; Screening and Behavioral
Counseling Interventions in Primary Care to Reduce Alcohol Misuse;
**Alert: Paxil and Wellbutrin warnings;** Materials on Child
Maltreatment

**Chronic Illness and Disease: page 15**

Overview of the WISEWOMAN Projects: Health Promotion for Disadvantaged
Women-Featuring Alaska's Tribal Southcentral Foundation among other
recipients; Irritable Bowel Syndrome - An Evidence-Based Approach to
Diagnosis; Insulin for Type 2 Diabetes: Rescue, Augmentation, and
Replacement of Beta-Cells; HIV Counseling, Testing, and Referral

[Features:]{.underline} page 16

**AFP:** Progesterone Intrauterine System for Menorrhagia; PAPNET vs.
Manual Reading of Pap Smears; Useful Signs and Symptoms in the
Evaluation of Vaginitis; Effect of Fetal Fibronectin on Preterm Labor;
Three Days of Ciprofloxacin for UTI in Older Women; Tai Chi May Improve
Symptoms of Osteoarthritis; Exemestane vs. Tamoxifen After Breast
Cancer; No Link Between Breast Cancer and Abortion; Antihistamines for
the Common Cold? Diagnosis and Management of Galactorrhea

**ACOG:** Nonmedical Use of Obstetric Ultrasonography ; Prenatal and
Preconceptional Carrier Screening for Genetic Diseases

**AHRQ:** Bowel Prep -- AHRQ Web M + M

**Breastfeeding:** Tom Hale\'s response to FDA warning of domperidone;
Counseling for Breastfeeding: Case Study; Seeking to support
breastfeeding (breastpump procurement) at your area or service unit?

**Domestic Violence:** Funding available: OJJDP Program Announcement for
the Safe Start Program

**Elder Care News:** Women with Heart Disease; Omega-3 Fatty Acids

**Frequently asked questions:** Where can I get some funds for a
project?

**Hormone Replacement Update**: NAMS Releases Position Statement on the
Treatment of Vasomotor Symptoms Associated with Menopause: Practice
Guidelines; The Menopause Moment

**Information Technology:** HEALTHeFORCES™   Walter Reed: Women\'s
health and prevention; New web site address the health concerns of
American Indians and Alaska Natives

**International Health**; [Health Canada\'s First Nations and Inuit
Health Branch](http://www.hc-sc.gc.ca/fnihb/)**;** DHHS Afghan Family
Health Book Launch Invitation; Polio experts warn of largest epidemic in
recent years, as polio hits Darfur

**MCH Alert:** Depression among female adolescents, may be higher than
previous estimates

**Medscape**: Female Interstitial Cystitis: Chronic Pelvic Pain,
Diagnosis and Misdiagnosis

**Office of Women's Health, CDC**: Healthy Women: State Trends in Health
and Mortality

**Osteoporosis:** Longer-Term Data Confirm Raloxifene Reduces the Risk
of Breast Cancer in Older Women

**Patient Education:** Your Insulin Therapy; HIV Infection-How to Lower
Your Risk; Galactorrhea: What You Should Know About It?

**Primary Care Discussion Forum:** Violence against Native women:
November 1, 2004

##### Barbara Stillwater, Alaska Diabetes Prevention and Control: Exploratory Grant Program in Diabetes Endocrinology and Metabolism Release

**What's new on the ITU MCH web pages:** **page 24**

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@anmc.org>

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>

9/21/04