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OB/GYN Chief Clinical Consultant's Corner

Volume 4, No. 11, November 2006

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

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

Regular Cola Intake Reduces Bone Mineral Density in Women

#### From your colleagues page 8 {#from-your-colleagues-page-8 .Style-Heading-4-+-Arial-14-pt-Underline}

Carolyn Aoyama

-Learn Quick Health Data Online with us                         
                                                     

-New Women's Health Work Group Forming: Looking for interested
volunteers

Burt Attico

Remembering Bill Carlile

Scott Giberson

#### Funding Opportunity: Alcohol Abuse and HIV/AIDS {#funding-opportunity-alcohol-abuse-and-hivaids .Style-Heading-4-+-Arial-14-pt-Underline}

Wanda Jones

Hyperemesis gravidum can be devastating to women

Brenda Neufeld

#### Fish Intake, Contaminants, and Human Health {#fish-intake-contaminants-and-human-health .Style-Heading-4-+-Arial-14-pt-Underline}

Chuck North

Interested in a New England winter experience? Here is a great TDY

Ron Pust

At Highest Risk: Birthing in the Andes

Judy Thierry

-AI/AN Candidates in college are encouraged to apply -- deadline 15
December 2006

-SIDS: Train the Trainer Sessions available

-Archived METH Web cast available 

-Perinatal oral health screening: Provider response and interface with
oral health care

**Dawn Wyllie**

#### -Perinatal depression evidence based care {#perinatal-depression-evidence-based-care .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Many other Depression resources  {#many-other-depression-resources .Style-Heading-4-+-Arial-14-pt-Underline}

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

##### Obstetrics page 14

-Magnesium sulfate tocolysis: time to quit

-Uterine rupture cannot be predicted with any combinations of clinical
factors

-Drugs for treatment of very high blood pressure during pregnancy:
Dealer's choice

-VBAC is safer than repeat cesarean delivery if patient has had a prior
vaginal delivery

-Sphincter injuries: Overlap repair lower risks for fecal urgency and
anal incontinence

and more....

**Gynecology page 19**

-'No touch' hysteroscopy much better tolerated

-Hot water bottles do work: Active Warming Cuts Pelvic Pain in
Pre-hospital Setting 

-Early catheter removal post-op: Early ambulation and early discharge

## -Abnormal Uterine Bleeding: A Management Algorithm: Evidenced-Based Clinical Medicine

-Suppressive Therapy for Recurrent Bacterial Vaginosis Reduces
Recurrences

and more....

**Child Health page 21**

-Early adolescents worry more as they age. . . .

-Overweight Adolescent Girls Have Increased Mortality Risk

-Adolescent overweight and obesity: Effect of maternal smoking during
pregnancy

-Public Cost of Adolescent Childbearing- By the Numbers

-Dietary calcium intervention in adolescent mothers increases bone
mineralization

and more....

**Chronic Illness and Disease page 23**

-Health Behaviors among American Indian/Alaska Native Women, 1998--2000
BRFSS

-Raloxifene did not significantly affect the risk of CHD

-Rifampin Has Improved Adherence, Less Toxicity Than Isoniazid for
Latent Tuberculosis 

-Prophylactic Surgery Reduces Ovarian Cancer Risk

-Seasonal Affective Disorder

and more....

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

American College of Obstetricians and Gynecologists page 28

-Umbilical Cord Blood Gas and Acid-Base Analysis

-Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a
Vital Sign

-Overweight Adolescent: Prevention, Treatment, and Obstetric--
Gynecologic Implications

-Breast Concerns in the Adolescent

-Using Preimplantation Embryos for Research

##### American Family Physician

No Stirrups Preferred for Pelvic Examinations

**Agency for Healthcare Research and Quality**

-Over 1 million U.S. babies are delivered by Cesarean delivery

-Bone protection shifted to nonestrogen anti-osteoporosis medicine after
WHI

**Ask a Librarian**

Want to keep up with evidence-based medicine?

**Breastfeeding**

-It is official, breastfeeding counts

#### -Breast-Feeding Protects Against Obesity in Children of Diabetic, Overweight Mothers {#breast-feeding-protects-against-obesity-in-children-of-diabetic-overweight-mothers .Style-Heading-4-+-Arial-14-pt-Underline}

-Herbal Medicines in Pregnancy and Lactation

-Infants Born During Who Were Ever Breastfed, by Race / Ethnicity of
Mother

**CCC Corner Digest**

\-[Routine HIV Screening in 13- 64 year olds: Scott
Giberson](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_AOM.cfm)

\-[40 years in partnership: American Academy of Pediatrics and Indian
Health](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Coll.cfm)

\-[Can a 29% Cesarean Delivery Rate Possibly Be
Justified?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_HT.cfm#ob)

\-[Out with Clomid? Here come the Aromatase inhibitors for ovulation
induction](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_HT.cfm#gyn)

\-[Fetal injury at cesarean delivery: Indication and type of uterine
incision](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_HT.cfm#child)

\-[Aspirin to Prevent Heart Attack and Stroke: What's the Right Dose?
160
mg/day](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_HT.cfm#chrIll)

\-[Postcoital Bleeding and Cervical Cancer Risk only
1/220](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#afp)

\-[Amnioinfusion Does Not Prevent Meconium Aspiration
Syndrome](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#acog)

\-[Exercise and Pregnancy; Preclampsia Drugs; Calcium
Supplementation](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#AskLib)

\-[Do you have breastfeeding questions? The new IHS Breast feeding site
has the
answers](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#breast)

\-[Ortho Evra Patch Linked to Risk for Venous
Thromboembolism](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#fp)

\-[New Breastfeeding Web Page for the Indian Health
System](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#webSite)

\-[Maternal survival worldwide: consensus and
controversies](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#ih)

\-[The words 'bizarre' and 'atypia' in the same pathology report
sentence...hmmm....](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#mmtour)

\-[External Fetal Monitors - Can you kick the
habit?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#MidWives)

\-[Asthma in
Pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#okie)

\-[Fracture risk among First Nations
people](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#oste)

\-[A.) Fetal Lung Maturity B.) Blood test for pre-eclampsia? C.)  Fish
oil for the
brain](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#periPicks)

\-[Causes of Type 2 Diabetes: Old and New
Understandings](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#pcf)

\-[Prevalence of HPV Infection among Men: A Systematic Review of the
Literature](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#std)

\-[No improvement in fetal outcome, increased maternal morbidity: Who
pays for
this?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#stillW)

\-[Special Care Clinic -- Phoenix Indian Medical
Center](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#new)

\-[Heard about prenatal and postpartum care? Here is something on
Internatal
Care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#new)

**Domestic Violence**

-Measuring Intimate Partner Violence Victimization and Perpetration

-CDC Reports Prevalence of Dating Violence in High School Students

**Elder Care News**

-Diagnosis of Acute Abdominal Pain in Older Patients

-Indian Health Service History Project

**Family Planning**

-Maximizing access to EC not affect incidence of either pregnancy or
STIs

-EC: Progesterone receptor modulator CDB-2914 as effective as
levonorgestrel

-Monophasic oral contraceptives preferred over biphasic for
contraception

#### -One year\'s supply of OCPs: Higher continuation, improved screening, and lowered costs {#one-years-supply-of-ocps-higher-continuation-improved-screening-and-lowered-costs .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

-Check out our new IHS STD website

-New web site focuses on the history and legacy of maternal child health

**Frequently asked questions**

Is an informed consent necessary for all x-rays in pregnant women?

**Indian Child Health Notes**

-Tall Girls: When being tall was a disease - how culture shapes and
defines medical care

-Viral gastroenteritis in AI/AN children - do we have more than everyone
else? Surprising findings

-Prevalence of mental health disease in AI/AN children

**Information Technology**

-Telehealth Opportunity: Do you need nutrition services at your site?

-AHRQ Launches Electronic Preventive Services Selector Tool for Primary
Care Clinicians

International Health

-Anthropology in the clinic: the problem of cultural competency and how
to fix it

-Cesarean Delivery: Both Overused and Underused in Developing Countries

-Risk of formula feeding to infants in sub-Saharan Africa: Need for
alternative strategies

#### MCH Alert

-Child Health USA 2005 Released

#### Medical Mystery Tour

#### The words 'bizarre' and 'atypia' in the same pathology report sentence...hmmm.... {#the-words-bizarre-and-atypia-in-the-same-pathology-report-sentencehmmm. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

**Menopause Management**

-High-Dose Gabapentin Equal to Estrogen for Hot Flashes: POEM

-Hormone Therapy in Postmenopausal and Perimenopausal Women

-Alendronate May Be Best Choice for Postmenopausal Osteoporosis

#### -Estrogen only trial WHI: Significantly lower rates of any arthroplasty {#estrogen-only-trial-whi-significantly-lower-rates-of-any-arthroplasty .Style-Heading-4-+-Arial-14-pt-Underline}

-Progestin in HRT Linked to Hearing Loss in Postmenopausal Women

and more....

**Midwives Corner**

-What Women Want

-Delayed cord clamping: Benefits in settings with high levels of
neonatal anemia

**Navajo News**

-Prevalence of diabetes: Diagnosed Diabetes Among AI/AN Aged \<35 Years

-Great, low-cost, fun CME opportunity

**Nurses Corner**

#### -Exclusively for Nurses: IHS has a Biomedical Librarian / Informationist dedicated to I/T/U {#exclusively-for-nurses-ihs-has-a-biomedical-librarian-informationist-dedicated-to-itu .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Executive Nurse Fellows Program, Robert Wood Johnson {#executive-nurse-fellows-program-robert-wood-johnson .Style-Heading-4-+-Arial-14-pt-Underline}

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

-Measuring HIV Risk in the U.S. Population Aged 15-44

-HPV and HPV Vaccine: Information for Healthcare (Revised)

**Oklahoma Perspective**

Preoperative Evaluation

Osteoporosis

Potassium Citrate Beneficial for Osteopenia

Patient Education

#### -November is National Diabetes Month: Focus on gestational diabetes (GDM) {#november-is-national-diabetes-month-focus-on-gestational-diabetes-gdm .Style-Heading-4-+-Arial-14-pt-Underline}

#### -It\'s Never Too Early to Prevent Diabetes: Tip Sheets for Women and Health Care Providers {#its-never-too-early-to-prevent-diabetes-tip-sheets-for-women-and-health-care-providers .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Be Prepared: The Boy Scout motto...er...the Maternity Care Provider
motto, too

-Adverse neonatal outcomes associated with antenatal dexamethasone vs
betamethasone

-Metformin Exposure During First Trimester Seen Safe for Fetus

-Predicting glyburide failure is difficult, not associated with adverse
pregnancy outcomes

-The current pregnancy loss rate after amniocentesis is closer to 1 in
1,600

-Treatment of periodontitis: Is it a case of association does not imply
causation ?

and more....

Primary Care Discussion Forum

Causes of Type 2 Diabetes: Old and New Understandings

STD Corner

-IHS Consent Form for an HIV Antibody Test is Hereby Cancelled

-Check out our new IHS STD website

-Adapting condoms to community values in Native American communities:
Snag bags

-Barriers to condom purchasing: Effects of product positioning on
reactions to condoms

#### -Interventions for Molluscum Contagiosum: Cochrane Briefs {#interventions-for-molluscum-contagiosum-cochrane-briefs .Style-Heading-4-+-Arial-14-pt-Underline}

and more....

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

-Gestational Diabetes Linked to High Prevalence of Periodontal Disease

-Physical activity before pregnancy or during pregnancy reduces
gestational diabetes

-Mothers with type 2 diabetes during pregnancy can transmit risk factors
to their children

-Does coffee reduce the risk of type 2 diabetes in individuals with
impaired glucose?

-Every kilogram of weight loss resulted in 16% reduction of diabetes
risk

and more....

###### Save the Dates: Upcoming events of interest page 58

#### What's new on the ITU MCH web pages page 59

-What medications, foods, and beverages irritate the bladder?

\-[CDC Compendium of Domestic Violence Assessment
Tools](http://www.ihs.gov/MedicalPrograms/MCH/V/DV01.cfm#Compendium)

\-[Compendium of State Laws](http://www.ucsf.edu/hivcntr/) Impacting HIV
Screening and Treatment

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

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

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

**Regular Cola Intake Reduces Bone Mineral Density in Women**

BACKGROUND: Soft drink consumption may have adverse effects on bone
mineral density (BMD), but studies have shown mixed results. In addition
to displacing healthier beverages, colas contain caffeine and phosphoric
acid (H3PO4), which may adversely affect bone.

OBJECTIVE: We hypothesized that consumption of cola is associated with
lower BMD.

DESIGN: BMD was measured at the spine and 3 hip sites in 1413 women and
1125 men in the Framingham Osteoporosis Study by using dual-energy X-ray
absorptiometry. Dietary intake was assessed by food-frequency
questionnaire. We regressed each BMD measure on the frequency of soft
drink consumption for men and women after adjustment for body mass
index, height, age, energy intake, physical activity score, smoking,
alcohol use, total calcium intake, total vitamin D intake, caffeine from
noncola sources, season of measurement, and, for women, menopausal
status and estrogen use.

RESULTS: Cola intake was associated with significantly lower (P \<
0.001-0.05) BMD at each hip site, but not the spine, in women but not in
men. The mean BMD of those with daily cola intake was 3.7% lower at the
femoral neck and 5.4% lower at Ward\'s area than of those who consumed
\<1 serving cola/mo. Similar results were seen for diet cola and,
although weaker, for decaffeinated cola. No significant relations
between noncola carbonated beverage consumption and BMD were observed.
Total phosphorus intake was not significantly higher in daily cola
consumers than in nonconsumers; however, the calcium-to-phosphorus
ratios were lower. CONCLUSIONS: Intake of cola, but not of other
carbonated soft drinks, is associated with low BMD in women. Additional
research is needed to confirm these findings.

[Tucker
KL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Tucker+KL"%5BAuthor%5D)
et al Colas, but not other carbonated beverages, are associated with low
bone mineral density in older women: The Framingham Osteoporosis Study.
[Am J Clin Nutr.](javascript:AL_get(this, 'jour', 'Am J Clin Nutr.');)
2006 Oct;84(4):936-42

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17023723>

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

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

### While regular cola consumption has many detrimental effects, e. g., obesity and dental caries just for starters, [Tucker KL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Tucker+KL"%5BAuthor%5D) et al now have added a new item to that list, bone loss in women. 

### 

### Below is further perspective from Loud and Gordon in October's [Arch Pediatr Adolesc Med.](javascript:AL_get(this, 'jour', 'Arch Pediatr Adolesc Med.');) on Adolescent Bone Health.

### 

### **Clinical Context**

Peak bone mass, which reaches its maximum between ages 20 to 29 years,
is a predictor of osteoporosis. Up to 60% of adult total bone mineral is
acquired during adolescence, according to Bonjour and colleagues in the
September 1991 issue of the Journal of Clinical Endocrinology and
Metabolism. Factors that affect bone health include the following: body
weight, exercise, medications, hormonal status, genetics, calcium,
vitamin D, general health, nutrition, and other lifestyle factors.

This review examines patients at risk for poor skeletal health, methods
for evaluation of skeletal status, indications for bone density
measurement, therapies for low BMD, and recommendations for physical
activity and nutrition in adolescents.

### **Study Highlights**

-   Conditions associated with poor bone health include chronic
    conditions, specific endocrinopathies, medium- to long-term use of
    certain medications, deleterious behaviors, and bone disease;
    position statements exist for the female athlete triad and cystic
    fibrosis.

-   Evaluation of skeletal status by BMD

    -   DEXA is the current standard; 2004 guidelines for children by
        the International Society for Clinical Densitometry included the
        following:

        -   Use BMD z scores to compare BMD of peers matched for age,
            sex, and ethnicity.

        -   Do not use T scores that compare bone density to peak bone
            mass.

        -   Preferred measurement sites are spine and total body.

        -   Standards for adjustments based on bone size, pubertal
            stage, skeletal maturity, or body composition vary.

        -   Measurements are not diagnostic of osteoporosis.

    -   QCT to measure volumetric BMD is the noninvasive gold standard
        but requires costly software, moderately high radiation dose,
        and has limited normative data; peripheral QCT of extremities
        uses less radiation.

    -   Quantitative ultrasound does not consistently correlate with
        DEXA or QCT but is portable, inexpensive, and radiation free.

-   Evaluation of skeletal status by bone strength

    -   Bone strength depends on bone mass, size, geometry, and
        microarchitecture.

    -   Methods include QCT, investigational magnetic resonance imaging
        to assess bone geometry and quality, and DEXA to estimate bone
        strength at hip.

-   Evaluation of skeletal status by bone turnover

    -   Serum and urinary markers can monitor treatment effects but not
        diagnose them.

    -   Calcium homeostasis measures can evaluate low BMD in conjunction
        with body mass index, medical history, and physical examination.

    -   Bone biopsy might be used in difficult cases.

-   Indications for bone density measurement have been published but are
    not evidence based.

    -   The Cystic Fibrosis Foundation recommends assessment and
        baseline DEXA scans from age 8 years.

    -   The British Paediatric and Adolescent Bone Group recommends bone
        density screening in teens at risk.

    -   The current authors recommend DEXA for those with chronic
        predisposing condition and multiple risk factors or strong
        family history of osteoporosis.

-   Medications to inhibit bone resorption and/or increase bone
    formation have variable efficacy and unknown effects.

    -   Bisphosphonates can treat osteogenesis imperfecta and cerebral
        palsy--related low bone mass and fractures, but they cross the
        placenta and persist in bone for years.

    -   Estrogen and/or progestin have variable effect on BMD in women
        with anorexia nervosa or hypothalamic amenorrhea but may be
        protective if they have extremely low body mass index.

    -   Insulin-like growth factor I alone or with oral contraceptive
        and androgen therapy are being studied.

-   Exercise interventions for all teens

    -   Exercise might be most beneficial during peak height velocity
        (ages 10 - 12 years in girls and ages 12 - 14 years in boys).

    -   The American College of Sports Medicine recommends 10 to 20
        minutes of high-intensity impact activities at least 3 days per
        week.

-   Nutrition interventions for all teens

    -   In 1977, the National Academy of Sciences recommended dietary
        calcium intake of 1300 mg/day for ages 9 to 18 years and 1000
        mg/day for ages 19 to 50 years.

    -   In 2003, the American Academy of Pediatrics recommended vitamin
        D 200 IU/day for all children from infancy to adolescence;
        high-risk adolescents (African-American children, residents of
        northern latitudes) might need higher doses, especially in the
        winter.

### **Pearls for Practice**

-   Conditions associated with poor bone health include chronic
    conditions, endocrinopathies, medium- to long-term use of certain
    medications, deleterious behaviors, and bone disease. Evaluation of
    BMD by QCT and DEXA must be adapted for children. Long-term effects
    of medication treatment need to be studied in adolescents.

-   Recommendations for all adolescents include exercise during peak
    height velocity, dietary calcium of 1300 mg/day for ages 9 to 18
    years and 1000 mg/day for ages 19 to 50 years, and vitamin D 200
    IU/day for all children; an optimal exercise regimen has not been
    determined.

Resources:

[Loud
KJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Loud+KJ"%5BAuthor%5D),
[Gordon
CM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Gordon+CM"%5BAuthor%5D).
Adolescent bone health. [Arch Pediatr Adolesc
Med.](javascript:AL_get(this, 'jour', 'Arch Pediatr Adolesc Med.');)
2006 Oct;160(10):1026-32

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17018461>

### 

### Bone Density Evaluation in Teens Prevents Future Osteoporosis, Medscape

<http://www.medscape.com/viewarticle/545997?sssdmh=dm1.222846&src=top10>

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

**Carolyn Aoyama, HQE**

**Learn Quick Health Data Online with us                         
                                                     **

Sign up for an 1 hour online DHHS Office on Women\'s Health training
session on using Quick Health Data Online   

                                      
                                                                 

This is an online database which includes comprehensive data for both
women and men from 1998-2004 on a variety of health topics including
infectious and chronic disease, access to care, mental health,
reproductive health, maternal health, violence and abuse, and illness
prevention.  Quick Health Data Online provides free access to
comparative, county-level health data for all 50 states, the District of
Columbia and U.S. territories and possessions.  The data can be
stratified by gender, race/ethnicity, and age concurrently.

The training session will show participants how to obtain national,
state, and county-level health statistics from the database including
statistics that are stratified by gender, race/ethnicity, and age. 
Users will also learn how to easily create tables, graphs and maps from
any data in the database.  The training session is approximately one
hour long and will take place via conference call.  Each participant
will need to be sitting in front of a computer with Internet Explorer
access.  Here is my quick table home town demographics:

We will be scheduling three training sessions.  The ideal training will
have 15 or so participants per date so each person will get adequate
personal assistance in using the database.  I will be coordinating the
training enrollment, so if you are interested in the training, please
email me your preference from the following three training dates:

Thursday, December 7 from 3:00-4:00 EST

Monday, December 11 from 3:00-4:00 EST

Wednesday, December 13 from 3:00-4:00 EST

My suggestion is to RSVP by November 23 (two week notice)

Contact Carolyn Aoyama to sign up:  <Carolyn.aoyama@ihs.gov>

**Quick Health Data Online                               
                                                                         **
[www.womenshealth.gov/quickhealthdata](http://www.womenshealth.gov/quickhealthdata)
 

           

**New Women's Health Work Group Forming: Looking for interested
volunteers**

I want people for whom women's health is their true calling -- people
who are passionate about some part of women's health care - to join me
in forming an IHS Workgroup on Women's Health.  There are people out
there who are local experts on mobilizing women to come in for their PAP
smears, or their mammograms.  There are others who care about access to
high quality behavioral health services for women.  Maternal/Child
Health advocates who are especially interested in the "M" in MCH would
be invaluable.  How about chronic disease, or other health issues?

I am interested in forming a Women's Health Workgroup with people who
would be willing to serve in an advisory capacity to me.  I value the
advice of IHS staff that are passionately interested in expanding
services that will improve access, quality and health outcomes of AI/AN
women.   One of the first things I want to work on is an IHS Women's
Health Strategic Plan.  Please email me if you would be interested in
serving in this advisory capacity.  I need your perspective, experience,
and ideas. <Carolyn.Aoyama@ihs.gov>

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

#### Burt Attico, Phoenix {#burt-attico-phoenix .Style-Heading-4-+-Arial-14-pt-Underline}

**Remembering Bill Carlile**

I found the notice about Bill Carlile in the AZ Republic.  One was
published on October 5 (abbreviated announcement), and another, an
obituary.  

 

William K. Carlile, M.D., was born March 8, 1926 in Philadelphia, PA to
William K. Carlile and Anna Mae Markee Carlile. He died at home in
Phoenix surrounded by family on October 3, 2006. Bill grew up in
Jenkintown, PA, attended the U.S. Naval Academy at Annapolis and Grove
City College in Pennsylvania and received his medical education at
Jefferson Medical College, Philadelphia, interning at St. Joseph\'s
Hospital in Lancaster. He received his training in Pediatrics at Mayo
Clinic, Rochester, MN and his Master of Public Health from the
University of Michigan. After a long and distinguished career in the
U.S. Public Health Service, Division of Indian Health, he retired in
Phoenix in 1978 as Maternal and Child Health Consultant with
responsibility for the program nationwide. He then served as
administrative director for the newborn transport program of the Arizona
Department of Health Services until retirement in 1986.

Published in The Arizona Republic on 10/19/2006.

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

#### Scott Giberson, HQE {#scott-giberson-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

#### Funding Opportunity: Alcohol Abuse and HIV/AIDS {#funding-opportunity-alcohol-abuse-and-hivaids-1 .Style-Heading-4-+-Arial-14-pt-Underline}

For your information: this Funding Opportunity Announcement (FAO) is
from NIAAA, not IHS HQ offices; however the topic was relevant and
intriguing. If you have any questions, please refer to the following
contacts. 

This Funding Opportunity Announcement (FOA) issued by the National
Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institutes
of Health, solicits Exploratory/Developmental Research Grant (R21)
applications from institutions/ organizations that propose to
investigate the effectiveness of structural interventions that reduce
the risk of HIV/AIDS transmission by changing the environment of alcohol
use. Although a variety of structural and environmental interventions
have been employed successfully to reduce other drinking-related
problems, there has been little research that extends such efforts into
the realm of HIV/AIDS risk reduction.

Fund Number: 3181\
Fund Title: Structural Interventions, Alcohol Use, and Risk of HIV/AIDS
(R21)

Application Due Date: 01/02/2007 Cycle III

#### Web Page: [**grants.nih.gov/grants/guide/pa-files/PA-07-005.html**](http://grants.nih.gov/grants/guide/pa-files/PA-07-005.html) {#web-page-grants.nih.govgrantsguidepa-filespa-07-005.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Wanda Jones, P-OHS {#wanda-jones-p-ohs .Style-Heading-4-+-Arial-14-pt-Underline}

**Hyperemesis gravidum can be devastating to women**

This article is a review of the incidence, characteristics, risk
factors, proposed causes, outcomes, treatment and nursing management of
nausea and vomiting of pregnancy. Despite the fact that it affects most
pregnant women to some degree, it is poorly understood and often poorly
treated. Specific suggestions for therapeutic interventions are
outlined.

[Davis
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Davis+M"%5BAuthor%5D).
Nausea and vomiting of pregnancy: an evidence-based review. [J Perinat
Neonatal
Nurs.](javascript:AL_get(this, 'jour', 'J Perinat Neonatal Nurs.');)
2004 Oct-Dec;18(4):312-28.

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15646303**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15646303) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids15646303 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### There\'s actually a foundation addressing this topic (HER Foundation, Hyperemesis Education and Research Foundation) {#theres-actually-a-foundation-addressing-this-topic-her-foundation-hyperemesis-education-and-research-foundation .Style-Heading-4-+-Arial-14-pt-Underline}

#### Hyperemesis Education and Research HER) Foundation {#hyperemesis-education-and-research-her-foundation .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.hyperemesis.org/**](http://www.hyperemesis.org/) {#httpwww.hyperemesis.org .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Brenda Neufeld, Sells {#brenda-neufeld-sells .Style-Heading-4-+-Arial-14-pt-Underline}

#### Fish Intake, Contaminants, and Human Health {#fish-intake-contaminants-and-human-health-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Here is an interesting article in case you haven\'t seen it\--reviews the data on fish oil and cognitive development, as well as other issues. It is from JAMA's Clinician's Corner {#here-is-an-interesting-article-in-case-you-havent-seen-it--reviews-the-data-on-fish-oil-and-cognitive-development-as-well-as-other-issues.-it-is-from-jamas-clinicians-corner .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Conclusions:** For major health outcomes among adults, based on both
the strength of the evidence and the potential magnitudes of effect, the
benefits of fish intake exceed the potential risks. For women of
childbearing age, benefits of modest fish intake, excepting a few
selected species, also outweigh risks.

Mozaffarian D, Rimm EB Fish Intake, Contaminants, and Human Health:
Evaluating the Risks and the Benefits JAMA. 2006;296:1885-1899.

<http://jama.ama-assn.org/cgi/content/short/296/15/1885>

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

#### Another aspect is the worry about mercury contamination: Not to worry with young fish {#another-aspect-is-the-worry-about-mercury-contamination-not-to-worry-with-young-fish .Style-Heading-4-+-Arial-14-pt-Underline}

The controversy continues, but some balance has begun to appear.
Meanwhile, the Hg levels in all species of wild salmon are quite low,
and any amount you want to eat is safe.  Halibut, with the exception of
the very largest fish, several hundred pounds, is also low.  Even the
largest halibut is not really that high, and you\'d have to eat many
pounds weekly to raise your blood Hg level to a level where infant
outcomes are affected, and you\'d have to do it constantly, as the
half-life is not that long. More definitive information will be
available after the first of the year.

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

**Other resources**

CONCLUSION: In an island state with high levels of fish consumption,
women were 3 times more likely to have elevated cord blood mercury
levels, compared with the national average.

[Sato
RL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Sato+RL"%5BAuthor%5D),
et al Antepartum seafood consumption and mercury levels in newborn cord
blood. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Jun;194(6):1683-8

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16635458>

Alaska Mercury Biomonitoring

<http://www.epi.alaska.gov/bulletins/docs/b2005_05.pdf>

Fish Oil To Be Given To Pregnant Women

A new study suggests that fish oil should be given to pregnant women in
order to boost the child\'s behavior and performance before they are
born and lowers the risk of the baby being born with cerebral palsy. The
fish oil supplements would not only benefit the unborn child, but the
mother as well.To read the full article, see:
<http://www.allheadlinenews.com/articles/7003942474>

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

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

**Interested in a New England winter experience? Here is a great TDY**

Hockey players, ice skaters, moose hunters and Francophiles please take
note.

Primary Care medical providers with IHS experience -- we are looking for
one or more officers to TDY to this facility to provide immediate
Federal presence on site until we are able to transition employees to
federal system, clear suitability requirements, etc.  If you are
available any time in the next three months for 2 or more weeks, and you
are interested in a New England winter experience (near Quebec, Canada),
please contact Dr. Kennon.

The Micmac Service Unit at Presque Isle, Maine is undergoing acute
transition from a long-standing ambulatory care, Tribally-operated
facility to a federally-operated facility. In the process it is
proceeding to comply with I.H.S. and federal requirements and
operational standards.

None of the presently employed staff have prior federal civil service or
PHS experience, and lack adequate background investigations or
clearances. Meeting that requirement is an operational necessity. In
addition, the facility is faced with adaptation of its policies,
practices and procedures to comply with the upcoming initiative for
AAAHC accreditation. Expertise and assistance in establishing and
implementing these at the outset will materially enhance quality of care
and proper training of on-site staff.

The facility has also faced a disruption in the services of its
part-time contracted physician, and clinical care services by the Family
Nurse practitioner, who, while very well trained and experienced,
currently lacks the mentorship, quality review and consultative benefits
of an appropriate credentialable health care provider.

Possible adaptation of the prior system to a more defined reliance on
medical priorities and appropriate procedures for contract health
service requests and referrals is also anticipated.

Roy S. Kennon, M.D. <roy.kennon@ihs.gov>

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

#### Ron Pust, Tucson {#ron-pust-tucson .Style-Heading-4-+-Arial-14-pt-Underline}

**At Highest Risk: Birthing in the Andes**

As part of a yearlong, journalistic Fulbright grant, Rebecca Rivas and a
small crew lived in some of the most inaccessible regions of the
southern Andes to study solutions to Peru\'s high maternal mortality.
The solutions to South America\'s second highest maternal death rates
are not easy when both the Andean traditions and international political
pressure are so strong. Peru has one of the highest proportions of
indigenous inhabitants in the Americas, roughly 50 percent.

The question that guided our study was: is there a bridge between
traditional and institutional birth?

We found a few select organizations and members of the Ministry of
Health trying to integrate the women\'s traditions with the public
health system. This proved to be the most effective way to unravel
Andean people\'s fear and distrust of Western medicine.

#### The products of the research year were a 45-minute documentary and a 3,000 word article on maternal health care in the high Peruvian Andes. [**http://www.der.org/films/resources/30_09_film_high_risk.pdf**](http://www.der.org/films/resources/30_09_film_high_risk.pdf) {#the-products-of-the-research-year-were-a-45-minute-documentary-and-a-3000-word-article-on-maternal-health-care-in-the-high-peruvian-andes.-httpwww.der.orgfilmsresources30_09_film_high_risk.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

For more information contact: Sonia Medina, Administrative Associate,
626-7083 or at <soniam@coph.arizona.edu>

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

**AI/AN Candidates in college are encouraged to apply -- deadline 15
December 2006**

The Henry J. Kaiser Family Foundation

1. Mid-career AI/AN health professionals: Fellowship program         

Work full-time for one year in a Congressional or Executive Branch
office, develop their research and analytic skills by writing a policy
paper as well as participate in seminars on health and welfare policy
issues, and meet with top health administrators, elected
representatives, Congressional staff, and experts from policy research
groups.

<http://www.kff.org/about/nativeamericanfellowships.cfm>

2\. College students: 

Barbara Jordan Health Policy Scholars Program, which annually provides
college students of color the opportunity to work in a congressional
office with major health policy responsibilities.     Link has details,
application and form for letter of recommendation

#### [**http://www.kff.org/about/jordanscholars.cfm**](http://www.kff.org/about/jordanscholars.cfm) {#httpwww.kff.orgaboutjordanscholars.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

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

**SIDS: Train the Trainer Sessions available**

Aberdeen Healthy Native Babies training is scheduled in Rapid City on
December 13 and 14, 2006. For questions, please contact:
<lneel@namsinc.org>

Lisa C. Neel, MPH

Native American Management Services, Inc.

6858 Old Dominion Drive, Suite 302

McLean, VA  22101

703-226-2061 (direct line)

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

**Archived METH Web cast available **

The September 26, 2006 HRSA / IHS meth webcast had about 750
participants!  The speakers shared their various experiences responding
to meth in their communities.  Stephanie Bryn, M.P.H., Moderator : US
Public Health Service, Director Injury and Violence Prevention, Health
Resources and Services Administration, MCHB, DCAFH\
CAPT Judith Thierry, D.O., M.P.H., Moderator : US Public Health Service,
Maternal and Child Health Coordinator, Indian Health Service The webcast
is archived for viewing at:
<http://www.mchcom.com/archivedWebcastDetailNewInterface.asp?aeid=400>
or [www mchcom.com]{.underline}

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

**Perinatal oral health screening: Provider response and interface with
oral health care**

Issue: IHS prenatal providers do not have a standardized approach to the
oral health screening and risk stratification of the prenatal/ perinatal
population.  Can the NYDOH Guidelines (august 2006) serve as a construct
for a standardized approach?

Current models:  Are there IHS programs that are working with the
perinatal population? Can they share their successes?  Is there
presentable data being generated?   

Opportunity: OB module and the E H R will assist in standardizing both
screening and documenting of perinatal oral health status (denominator,
prevalence) by directly asking mom's standardized questions. Medical
prenatal providers can stratify our perinatal population and refer
appropriately.  15K to 20K women come to IHS for prenatal care, ½
deliver at our facilities and 26K infants come back into our system by
age 1.  We have a magnitude of the population we can affect and two
people not just one.

"Do you have bleeding gums, toothache, cavities, and loose teeth, teeth
that do not look right or other problems in your mouth?"

"Have you had dental care in the last 6 months?"

Training for medical providers: What are the components of the oral
health exam that should be completed in the medico/clinical exam at the
first prenatal visit?

Again the OB module and E H R can assist. (Environmental prompts)

Todd Smith's periodontal disease slides provide an excellent review and
could serve as a module -- perhaps paired down for non-oral health
providers.  Bottom line: providers need to be knowledgeable to perform a
standard oral exam in a perinatal patient?

Working guidelines for medical providers and oral health providers:  

Referrals: When to refer, what is appropriate and helpful information
(HTN, GDM) that dentists/ hygienists want to see in a referral;
maintaining regional/local referral lists.

Health Ed: Agreed upon consistent and universal perinatal oral Health
education in the oral health department and in the medical exam room.  
Universal and client focused messages and interventions that can be
applied to all prenatal clients

            Daily flossing, bid brushing

            If free sugars, then with meals only

            Avoid carbonated drinks, no cigarettes, no alcohol, no rec
drugs

            Fruit, over fruit juice

            Xylitol gum, as prevention

            Q 6 month oral health visits

           

Oral health department care to prenatal patients, knowledgeable of safe
practices during first, second and third trimester:

Immediate treatment in 1st trimester

            Needed treatment in the 2nd

            Elective treatment pre and post partum

            Xrays with thyroid coverage and apron

            Medications -- lidocaine with epi

            Procedures

Next steps: Convene a group of interested medical and oral health/dental
providers by conference call to review the NYDOH Guidelines, discuss the
above points and come up with some recommendations for MCH and Oral
health Division.

#### Judith Thierry [**Judith.Thierry@ihs.gov**](mailto:Judith.Thierry@ihs.gov) {#judith-thierry-judith.thierryihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Dawn Wyllie, Bemidji Area {#dawn-wyllie-bemidji-area .Style-Heading-4-+-Arial-14-pt-Underline}

#### Perinatal depression evidence based care {#perinatal-depression-evidence-based-care-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### This 92 page narrative and twice again number of pages with references, glossary, tables, and appendices published in 2005 should be a ready reference for those of you who want to understand the research surrounding perinatal depression prevalence and screening. The methodology of the review is useful to consider when you review future studies.  {#this-92-page-narrative-and-twice-again-number-of-pages-with-references-glossary-tables-and-appendices-published-in-2005-should-be-a-ready-reference-for-those-of-you-who-want-to-understand-the-research-surrounding-perinatal-depression-prevalence-and-screening.-the-methodology-of-the-review-is-useful-to-consider-when-you-review-future-studies. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Conclusions:]{.underline} Although limited, the available research suggests that depression is one of the most common perinatal complications and that screening is feasible and fairly accurate. Studies with larger sample sizes with a greater racial and ethnic mix are needed. Researchers also need to determine whether screening itself leads to better access to proven treatment and improved outcome relative to usual care. {#conclusions-although-limited-the-available-research-suggests-that-depression-is-one-of-the-most-common-perinatal-complications-and-that-screening-is-feasible-and-fairly-accurate.-studies-with-larger-sample-sizes-with-a-greater-racial-and-ethnic-mix-are-needed.-researchers-also-need-to-determine-whether-screening-itself-leads-to-better-access-to-proven-treatment-and-improved-outcome-relative-to-usual-care. .Style-Heading-4-+-Arial-14-pt-Underline}

AHRQ report: Evidence Report/Technology Assessment Number 119 Perinatal
Depression: Prevalence, Screening Accuracy and Screening Outcomes
<http://www.ahrq.gov/clinic/tp/perideptp.htm>

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

#### Other Depression resources from Judy Thierry {#other-depression-resources-from-judy-thierry .Style-Heading-4-+-Arial-14-pt-Underline}

#### Depression -- focused on moms who present during a child health visit {#depression-focused-on-moms-who-present-during-a-child-health-visit .Style-Heading-4-+-Arial-14-pt-Underline}

In this 1 credit CME/CEU the following are discussed among many other
items

-Awareness and facilitating screening

-Parental depression is just not post partum

-Screening tools in the office

-PHQ2

-Edinburgh

<http://www.medscape.com/viewprogram/6101>  

**More on Depression from the Commonwealth Fund web site:**

Go to 'search' and type in 'depression'

PDF's, slides, brochures.

1.  Wallet guide

```{=html}
<!-- -->
```
1.  ppt - Feeling blue communication poster

2.  2 page guide for providers on "parenting for depression"

3.  Parent's frequently asked questions on screening

4.  Guide for parents -- when times are tough -- age specific guidance
    with child age groups

5.  Can a depressed parent be a good parent -- You bet!

6.  Tips on Healthy Parenting for mothers with depression

7.  why is parental depression an important issue

8.  ppt poster - facts on depression

9.  Summary of Brief Paper-Based Depression Screening Tools

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

**One minute questionnaire now being used in primary care settings**

It is sometimes referred to as PQ2

**Over the past two weeks, how often have you been bothered by any of
the following problems?**

**Little interest or pleasure in doing things.**

0 = Not at all

1 = Several days

2 = More than half the days

3 = Nearly every day

**Feeling down, depressed, or hopeless.**

0 = Not at all

1 = Several days

2 = More than half the days

3 = Nearly every day

**Total point score: \_\_\_\_**

**see the hyperlink\_\_\_\_\_\_\_\_\_\_**

<http://www.cmwf.org/usr_doc/PHQ2.pdf>    

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

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

**Magnesium sulfate tocolysis: time to quit**

Intravenous magnesium sulfate tocolysis remains a North American
anomaly. This therapy rose to prominence based on poor science and the
recommendations of authorities. However, a Cochrane systematic review
concluded that magnesium sulfate is ineffective as a tocolytic. The
review found no benefit in preventing preterm or very preterm birth.
Moreover, the risk of total pediatric mortality was significantly higher
for infants exposed to magnesium sulfate (relative risk 2.8; 95%
confidence interval 1.2--6.6). Given its lack of benefit, possible
harms, and expense, magnesium sulfate should not be used for tocolysis.
Any further use of magnesium sulfate for tocolysis should be restricted
to formal clinical trials with approval by an institutional review board
and signed informed consent for participants. Should tocolysis be
desired, calcium channel blockers, such as nifedipine, seem preferable.

[Grimes
DA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Grimes+DA"%5BAuthor%5D),
[Nanda
K](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Nanda+K"%5BAuthor%5D).
Magnesium sulfate tocolysis: time to quit. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Oct;108(4):986-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17012463&dopt=Abstract>

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

**Remove Magnesium Sulfate from your Facility's tocolysis Guidelines**

While this is not news, it is a good reminder that there never has been
good randomized data to support the use of magnesium sulfate for
tocolysis. In the acute setting [Nonsteroidal anti-inflammatory
agents](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=10546776&dopt=Abstract)
such as
[indomethacin](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6374098&query_hl=9)
have a better success rate, as measured by lowering the occurrence of
low birth weight and prolonging pregnancy.

Here is an excerpt from the **Perinatology Corner module on Tocolysis**

Tocolytics for the treatment of preterm labor have been extensively
studied, but have demonstrated little long term benefit. Most tocolytic
agents will reduce the risk of delivery within the first 48 hours, and
there are definite advantages to such delay. Nevertheless, no tocolytic
agent has consistently reduced the perinatal mortality rate, the
incidence of IRDS, or the number of low birth weight infants. This is
true for the [beta-mimetics (terbutaline,
ritodrine)](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10546776),
and the calcium channel blockers
([nifedipine](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8238157),
[magnesium
sulfate](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12519550)).
Maternal pulmonary edema has been associated with the prolonged use of
all these agents, especially in women carrying twins, those with
chorioamnionitis, and those subjected to enthusiastic hydration.
Neonatal neuromuscular blockade and difficult resuscitation may be
associated with excessive use of magnesium sulfate. Despite this agent
having been shown to be equivalent to placebo for tocolysis in the
meta-analysis data, it inexplicably remains the first-line tocolytic
agent in many institutions! The data is conflicting as to the
neuroprotective effect of magnesium sulfate, with both a lower and a
higher incidence of later cerebral palsy being reported in surviving
children. The meta-analysis data show a neutral effect.

[Nonsteroidal anti-inflammatory
agents](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=10546776&dopt=Abstract)
such as
[indomethacin](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6374098&query_hl=9)
have a better success rate, as measured by lowering the occurrence of
low birth weight and prolonging pregnancy. They suppress myometrial
prostaglandin production, the last step in the labor cascade. Earlier
retrospective reports demonstrated an association of indomethacin with
neonatal necrotizing enterocolitis, intraventricular hemorrhage, [patent
ductus
arteriosus](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8498410),
and
[oliguria](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2340255).
These findings were not confirmed when the RCT employing this agent were
subjected to meta-analysis. Likewise, [multivariate
analysis](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12825006&query_hl=5)
showed that these effects were not significantly associated with the
drug when outcomes were corrected for gestational age, the adverse
events being ascribed to immaturity, not to the therapy. A decision
analysis concluded that indomethacin tocolysis would result in a lower
total number of adverse neonatal outcomes compared to no tocolysis, when
restricted to a 48 hour course. Indomethacin is probably [the tocolytic
of
choice](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7369252&query_hl=9)
because of best efficacy and fewest maternal side effects. It may be
given as 50 mg orally q6h over 48 hours with a maximum dose of 400 mg.
Greatest benefit and safety is seen when it is given at less than 32
weeks, and it should not be given if there is pre-existing
oligohydramnios.

Women between 32-34 weeks, or those with a low AFI, may be more
prudently treated with terbutaline 0.25 mg subcutaneously q4h x 4-6
doses. Indomethacin, being administered orally, is somewhat slow acting,
so despite having the most evidence favoring its use, you may need to
overlap it, or combine it, with another agent initially. Experience with
parenteral nonsteroidal agents, such as ketorolac, or the newer
selective COX-2 inhibitors such as rofecoxib, is promising but limited.
Long-term oral tocolytics of any class really have no place in
contemporary obstetrics. It will usually (but not always!) be futile to
attempt to tocolyse women in active labor who are at greater than 5 cm
cervical dilation, and it will also be risky to attempt to transport
these women. Women with PPROM are usually not candidates for tocolysis,
however tocolysis may be crucial for transport to the site of delivery.

There are thus two important advantages to the use of tocolytic agents.
One is facilitating transport to a level III center for birth, an issue
of great significance in our rural-based Indian Health Service setting.
The other is buying time for the administration of [antenatal
corticosteroids](http://www.ihs.gov/MedicalPrograms/MCH/M/PTL_10.cfm).

**Tocolysis**

<http://www.ihs.gov/MedicalPrograms/MCH/M/PTL_9.cfm>

**Other preterm labor management**

<http://www.ihs.gov/MedicalPrograms/MCH/M/PTL_8.cfm>

**Perinatology Corner module on Preterm labor and PPROM**

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

Cox SM, Sherman ML, Leveno KJ Randomized investigation of magnesium
sulfate for prevention of preterm birth. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 1990
Sep;163(3):767-72

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=2206069>

The full text of the review is available in [The Cochrane
Library](http://www.thecochranelibrary.com/) (ISSN 1464-780X).

<http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions>

**Uterine rupture cannot be predicted with any combinations of clinical
factors**

RESULTS: We identified 134 cases of uterine rupture and 665 noncases. No
single individual factor is sufficiently sensitive or specific for
clinical prediction of uterine rupture. Likewise, the 2 clinical
predictive indices were neither sufficiently sensitive nor specific for
clinical use (receiver operating characteristic curve \[area under the
curve\] 0.67 and 0.70, respectively). CONCLUSION: Uterine rupture cannot
be predicted with either individual or combinations of clinical factors.
This has important clinical and medical-legal implications.

[Macones
GA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Macones+GA"%5BAuthor%5D),
et al Can uterine rupture in patients attempting vaginal birth after
cesarean delivery be predicted? [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Oct;195(4):1148-52.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17000247>

**Drugs for treatment of very high blood pressure during pregnancy:
Dealer's choice**

CONCLUSIONS: Until better evidence is available, the choice of
antihypertensive should depend on the clinician\'s experience and
familiarity with a particular drug, and on what is known about adverse
effects. Exceptions are diazoxide, ketanserin, nimodipine and magnesium
sulphate, which are probably best avoided.

Duley L, Henderson-Smart DJ, Meher S. Drugs for treatment of very high
blood pressure during pregnancy. Cochrane Database of Systematic Reviews
2006, Issue 3. Art. No.: CD001449. DOI: 10.1002/14651858.CD001449.pub2.

<http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions>

**VBAC is safer than repeat cesarean delivery if patient has had a prior
vaginal delivery**

CONCLUSION: Among VBAC candidates who have had a prior vaginal delivery,
those who attempt a VBAC trial have decreased risk for overall major
maternal morbidities, as well as maternal fever and transfusion
requirement compared with women who elect repeat cesarean delivery.
Physicians should make this more favorable benefit-risk ratio explicit
when counseling this patient subpopulation on a trial of labor.

[Cahill
AG](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Cahill+AG"%5BAuthor%5D),
et al. Is vaginal birth after cesarean (VBAC) or elective repeat
cesarean safer in women with a prior vaginal delivery? [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Oct;195(4):1143-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16846571>

**Sphincter injuries: Overlap repair lower risks for fecal urgency and
anal incontinence**

CONCLUSIONS: The limited data available show that compared to immediate
primary end-to-end repair of obstetric anal sphincter injuries, early
primary overlap repair appears to be associated with lower risks for
faecal urgency and anal incontinence symptoms. As the experience of the
surgeon is not addressed in the three studies reviewed, it would be
inappropriate to recommend one type of repair in favour of another.

Fernando R, Sultan AH, Kettle C, Thakar R, Radley S. Methods of repair
for obstetric anal sphincter injury. Cochrane Database of Systematic
Reviews 2006, Issue 3. Art. No.: CD002866. DOI:
10.1002/14651858.CD002866.pub2.

<http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions>

**Valacyclovir suppression significantly reduces HSV shedding and
cesarean delivery**

OBJECTIVE: To measure the efficacy of valacyclovir suppression in late
pregnancy to reduce the incidence of recurrent genital herpes in labor
and subsequent cesarean delivery.

CONCLUSION: Valacyclovir suppression after 36 weeks of gestation
significantly reduces HSV shedding and recurrent genital herpes
requiring cesarean delivery. LEVEL OF EVIDENCE: I.

Sheffield JS et al Valacyclovir prophylaxis to prevent recurrent herpes
at delivery: a randomized clinical trial. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Jul;108(1):141-7

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16816068>

**Penicillin Skin Testing Safe for Pregnant Women**

CONCLUSIONS: Penicillin skin testing can be performed safelyin pregnant
women and, if the results are negative, allows penicillins to be used
safely at delivery for GBS prophylaxis.

[Macy
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Macy+E"%5BAuthor%5D).
Penicillin skin testing in pregnant women with a history of penicillin
allergy and group B streptococcus colonization. [Ann Allergy Asthma
Immunol.](javascript:AL_get(this, 'jour', 'Ann Allergy Asthma Immunol.');)
2006 Aug;97(2):164-8

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16937745>

**Binge drinking: Nonclinical psychiatric disorders and traits in early
adulthood**

CONCLUSIONS: Prenatal exposure to alcohol may be a risk factor for
specific psychiatric disorders and traits in early adulthood, even in a
nonclinical group.

Barr HM Binge drinking during pregnancy as a predictor of psychiatric
disorders on the Structured Clinical Interview for DSM-IV in young adult
offspring. [Am J Psychiatry.  2006;
163(6):1061-5](http://www.medscape.com/medline/publicationbrowser/123?pmid=16741207)

<http://www.medscape.com/medline/abstract/16741207?cid=med&src=nlbest>

**Increased BMI before pregnancy result in perinatal complications, even
if not overweight**

BACKGROUND: Maternal obesity has been positively associated with risk of
adverse pregnancy outcomes, but evidence of a causal relation is scarce.
Causality would be lent support if temporal changes in weight affected
risk of adverse pregnancy outcomes

INTERPRETATION: These findings lend support to a causal relation between
being overweight or obese and risks of adverse pregnancy outcomes.
Additionally they suggest that modest increases in BMI before pregnancy
could result in perinatal complications, even if a woman does not become
overweight. Our results provide robust epidemiological evidence for
advocating weight loss in overweight and obese women who are planning to
become pregnant and, to prevent weight gain before pregnancy in women
with healthy BMIs.

Villamor E; Cnattingius S Interpregnancy weight change and risk of
adverse pregnancy outcomes: a population-based study
[Lancet.](javascript:AL_get(this, 'jour', 'Lancet.');) 2006 Sep
30;368(9542):1164-70

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17011943>

**Vaginal misoprostol to terminate non-viable pregnancies before 24
weeks**

CONCLUSIONS: Available evidence from randomised trials supports the use
of vaginal misoprostol as a medical treatment to terminate non-viable
pregnancies before 24 weeks. Further research is required to assess
effectiveness and safety, optimal route of administration and dose.
Conflicting findings about the value of mifepristone need to be resolved
by additional study.

Neilson JP, Hickey M, Vazquez J. Medical treatment for early fetal death
(less than 24 weeks). Cochrane Database of Systematic Reviews 2006,
Issue 3. Art. No.: CD002253. DOI: 10.1002/14651858.CD002253.pub3.

<http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions>

**2-hour partogram increases interventions without improving outcomes
versus 4 hour**

CONCLUSION: In this birth setting, for primigravid women selecting low
intervention care, the 2-hour partogram increases the need for
intervention without improving maternal or neonatal outcomes, compared
with the 4-hour partogram, advocated by the World Health Organization.

Lavender T; Alfirevic Z; Walkinshaw SEffect of different partogram
action lines on birth outcomes: a randomized controlled trial. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Aug;108(2):295-302.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16880298>

**Expectant and medical management of miscarriage: Significant economic
advantages**

RESULTS: There was no significant difference in the incidence of
gynaecological infection between groups. Expectant management retained
the highest probability of being the most cost-effective management
method at all willingness-to-pay thresholds of less than 70,000 pounds
for preventing one gynaecological infection. CONCLUSIONS: Expectant and
medical management of first-trimester miscarriage possess significant
economic advantages over traditional surgical management.

Petrou S; Trinder J; Brocklehurst P; Smith L Economic evaluation of
alternative management methods of first-trimester miscarriage based on
results from the MIST trial.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16827823>

**Induction of labor: Admission in the morning rather than admission in
the evening**

Women admitted in the morning were less likely to require oxytocin
infusion (morning admission 126 of 280 \[45.0%\] compared with evening
admission 184 of 340 \[54.1%\]; relative risk 0.83, 95% confidence
interval 0.70-0.97; P=.022). Nulliparous women admitted in the morning
were less likely to require operative vaginal birth (morning admission
10 of 62 \[16.1%\] compared

CONCLUSION: For women who require induction of labor, consideration
should be given to admission in the morning rather than admission in the
evening.

Dodd JM; Crowther CA; Robinson JS Morning compared with evening
induction of labor: a nested randomized controlled trial. A nested
randomized controlled trial. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Aug;108(2):350-60

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16880306>

**Prepregnancy Diet May Affect Risk for Gestational Diabetes**

CONCLUSIONS: These findings suggested that prepregnancy diet might be
associated with women\'s GDM risk. In particular, diet with low fiber
and high glycemic load was associated with an increased risk. Future
clinical and metabolic studies are warranted to confirm these findings.

[Zhang
C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Zhang+C"%5BAuthor%5D),
et al Dietary fiber intake, dietary glycemic load, and the risk for
gestational diabetes mellitus. [Diabetes
Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');) 2006
Oct;29(10):2223-30

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17003297>

**Routine prophylactic drugs in normal labor for reducing gastric
aspiration: No evidence**

CONCLUSIONS: There is no good evidence to support the routine
administration of acid prophylaxis drugs in normal labour to prevent
gastric aspiration and its consequences. Giving such drugs to women once
a decision to give general anaesthesia is made, is assessed in another
Cochrane review.

Gyte GML, Richens Y. Routine prophylactic drugs in normal labour for
reducing gastric aspiration and its effects. Cochrane Database of
Systematic Reviews 2006, Issue 3. Art. No.: CD005298. DOI:
10.1002/14651858.CD005298.pub2

<http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions>

**Marine oil, and other prostaglandin precursor, supplementation for
pregnancy uncomplicated by pre-eclampsia or intrauterine growth
restriction**

AUTHORS\' CONCLUSIONS: There is not enough evidence to support the
routine use of marine oil, or other prostaglandin precursor, supplements
during pregnancy to reduce the risk of pre-eclampsia, preterm birth, low
birthweight or small-for-gestational age.

Cochrane Database Syst Rev.  2006; 3:CD003402

<http://www.medscape.com/medline/abstract/16856006?cid=med&src=nlbest>

**Systematic review of the literature on postpartum care: effectiveness
of postpartum support to improve maternal parenting, mental health,
quality of life, and physical health.**

CONCLUSIONS: No randomized controlled trial evidence was found to
endorse universal provision of postpartum support to improve parenting,
maternal mental health, maternal quality of life, or maternal physical
health. There is some evidence that high-risk populations may benefit
from postpartum support.

[Shaw E; Levitt C; Wong S; Kaczorowski J;  Systematic review of the
literature on postpartum care: effectiveness of postpartum support to
improve maternal parenting, mental health, quality of life, and physical
health.](http://mp.medscape.com/cgi-bin1/DM/y/hBAl20Ou5N60Juv0HwMk0E4)
Birth. 2006 Sep;33(3):210-20.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16948721>

**Eclampsia increases with mild hypertension not given Mag SO~4~
prophylaxis**

CONCLUSION: Selective magnesium sulfate prophylaxis results in an
increased overall incidence of eclampsia because of more seizures in
women with nonsevere gestational hypertension who are not given
magnesium sulfate prophylaxis. LEVEL OF EVIDENCE: II-3

[Alexander
JM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Alexander+JM"%5BAuthor%5D),
et al Selective magnesium sulfate prophylaxis for the prevention of
eclampsia in women with gestational hypertension. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Oct;108(4):826-32.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17012442&dopt=Abstract>

**Fetal survival with preeclampsia improved in 35 years: Aggressive
clinical management**

CONCLUSIONS: Fetal survival in preeclamptic pregnancies has vastly
improved over the past 35 years in Norway, presumably because of more
aggressive clinical management. However, the relative risk of neonatal
death following a preeclamptic pregnancy has not changed over time.

Basso O; Rasmussen S; Weinberg CR; Wilcox AJ; Irgens LM; Skjaerven R
Trends in fetal and infant survival following preeclampsia. [JAMA.
 2006;
296(11):1357-62](http://www.medscape.com/medline/publicationbrowser/123?pmid=16985227) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16985227>

**Acceptance of a woman\'s right to refuse cesarean delivery is not
uniform**

CONCLUSION: Case law arising from a few countries (United States,
Canada, and the United Kingdom) and professional guidelines favoring
women\'s autonomy have not solved the underlying ethical conflict, and
in Europe acceptance of a woman\'s right to refuse cesarean delivery, at
least in emergency situations, is not uniform. Differing attitudes
between obstetricians from the eight countries may reflect diverse legal
and ethical environments. LEVEL OF EVIDENCE: III.

[Cuttini
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Cuttini+M"%5BAuthor%5D),
et al Patient Refusal of Emergency Cesarean Delivery: A Study of
Obstetricians\' Attitudes in Europe. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Nov;108(5):1121-1129.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17077233&dopt=Abstract>

**DX of appendicitis during pregnancy requires a high level of suspicion
and clinical skills**

CONCLUSIONS: The accurate diagnosis of appendicitis during pregnancy
requires a high level of suspicion and clinical skills, and not merely
relying on the classic signs and diagnostic testing. Primary care
providers play an important role in recognizing potential signs and
symptoms of appendicitis in pregnancy to initiate prompt action and
reduce negative maternal and fetal outcomes [Pastore
PA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Pastore+PA"%5BAuthor%5D),
[Loomis
DM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Loomis+DM"%5BAuthor%5D),
[Sauret
J](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Sauret+J"%5BAuthor%5D).
Appendicitis in pregnancy. [J Am Board Fam
Med.](javascript:AL_get(this, 'jour', 'J Am Board Fam Med.');) 2006
Nov-Dec;19(6):621-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17090795&dopt=Abstract>

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

'**No touch' hysteroscopy much better tolerated**

OBJECTIVE: To compare a \"no touch\" approach to diagnostic hysteroscopy
without anesthesia, speculum, tenaculum, or anesthesia versus
traditional diagnostic hysteroscopy after intracervical injection of
mepivacaine hydrochloride 3%..

CONCLUSION: Patients reported significantly less pain with the altered
approach to diagnostic hysteroscopy compared with patients undergoing
the traditional procedure with anesthesia. This new approach can
therefore be considered as a useful hysteroscopic technique

Sagiv R; Sadan O; Boaz M; Dishi M; Schechter E; Golan A. A new approach
to office hysteroscopy compared with traditional hysteroscopy: a
randomized controlled trial. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Aug;108(2):387-92

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16880310>

**Hot water bottles do work: Active Warming Cuts Pelvic Pain in
Pre-hospital Setting **

OBJECTIVE: To assess whether local active warming can lessen acute
pelvic pain of gynaecological origin compared with traditional methods
in a prehospital setting.

CONCLUSIONS: Local warming is an effective emergency care measure for
acute pelvic pain

[Bertalanffy
P](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Bertalanffy+P"%5BAuthor%5D)
et al Active warming as emergency interventional care for the treatment
of pelvic pain. [BJOG.](javascript:AL_get(this, 'jour', 'BJOG.');) 2006
Sep;113(9):1031-4

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16903842>

**Early catheter removal post-op: Early ambulation and early discharge**

BACKGROUND: A prospective, randomized study was used to assess whether
the immediate removal of an in-dwelling catheter after hysterectomy
affects the rate of recatheterization, symptomatic urinary tract
infections, time of ambulation, and hospital stay.

CONCLUSIONS: There could be an association between necessity of
recatheterization and the type of surgery (VH) or the type of anesthesia
(spinal). Despite recatheterization rate, early removal of in-dwelling
catheters immediately after uncomplicated hysterectomy seems to decrease
first ambulation time and hospital stay.

[Alessandri
F](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Alessandri+F"%5BAuthor%5D),
et al A prospective, randomized trial comparing immediate versus delayed
catheter removal following hysterectomy. [Acta Obstet Gynecol
Scand.](javascript:AL_get(this, 'jour', 'Acta Obstet Gynecol Scand.');)
2006;85(6):716-20

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16752265>

## Abnormal Uterine Bleeding: A Management Algorithm 

**Evidenced-Based Clinical Medicine**

The algorithm in this article is designed to help primary care
physicians manage abnormal uterine bleeding using strategies that are
consistent with the evidence as well as the actual practice of
gynecologists.

Abnormal uterine bleeding is a common problem, and its management can be
complex. Because of this complexity, concise guidelines have been
difficult to develop. We constructed a concise but comprehensive
algorithm for the management of abnormal uterine bleeding between
menarche and menopause that was based on a systematic review of the
literature as well as the actual management of patients seen in a
gynecology clinic. We started by drafting an algorithm that was based on
a MEDLINE search for relevant reviews and original research. We compared
this algorithm to the actual care provided to a random sample of 100
women with abnormal bleeding who were seen in a university gynecology
clinic. Discrepancies between the algorithm and actual care were
discussed during audiotaped meetings among the 4 investigators (2 family
physicians and 2 gynecologists). The audiotapes were used to revise the
algorithm. After 3 iterations of this process (total of 300 patients),
we agreed on a final algorithm that generally followed the practices we
observed, while maintaining consistency with the evidence. In clinic,
the gynecologists categorized the patient\'s bleeding pattern into 1 of
4 types: irregular bleeding, heavy but regular bleeding (menorrhagia),
severe acute bleeding, and abnormal bleeding associated with a
contraceptive method. Subsequent management involved both diagnostic and
treatment interventions, which often occurred simultaneously.

[Ely
JW](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ely+JW"%5BAuthor%5D),
et al Abnormal uterine bleeding: a management algorithm. [J Am Board Fam
Med.](javascript:AL_get(this, 'jour', 'J Am Board Fam Med.');) 2006
Nov-Dec;19(6):590-602.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17090792&dopt=Abstract>

Suppressive Therapy for Recurrent Bacterial Vaginosis Reduces
Recurrences

Oral or topical antibiotic treatment provides short-term cure rates for
more than 80 percent of women, but many still have recurrences. There
were 157 women who participated in the trial, and 88.2 percent responded
to initial therapy. During the 16-week maintenance phase, 13 women who
received intravaginal metronidazole had a recurrence of bacterial
vaginosis compared with 26 women in the placebo group (*P* = .001);
however, at the end of the study, 26 of the women who were given
metronidazole had recurrences compared with 33 women in the placebo
group (*P* = .02). At 16 weeks, the probability of maintaining a cure
was 39 percent for placebo and 70 percent for metronidazole.

[Conclusions:]{.underline} Suppressive therapy with twice-weekly
intravaginal metronidazole gel does reduce the recurrence of bacterial
vaginosis and is a well-tolerated therapy, but that vaginal candidiasis
is a common complication.

Sobel JD, et al. Suppressive antibacterial therapy with 0.75%
metronidazole vaginal gel to prevent recurrent bacterial vaginosis. Am J
Obstet Gynecol May 2006;194:1283-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16647911>

**Oral Contraceptive Combination Curbs Uterine Bleeding: RCT**

CONCLUSION: This randomized trial is limited by sample size but suggests
that both regimens may be effective and reasonably well tolerated. LEVEL
OF EVIDENCE: II-1.

[Munro
MG](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Munro+MG"%5BAuthor%5D),
et al Oral medroxyprogesterone acetate and combination oral
contraceptives for acute uterine bleeding: a randomized controlled
trial. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Oct;108(4):924-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17012455>

**Expectant management for 6 months is justified in couples with
unexplained subfertility**

INTERPRETATION: A large beneficial effect of intrauterine insemination
with controlled ovarian hyperstimulation in couples with unexplained
subfertility and an intermediate prognosis can be excluded. Expectant
management for 6 months is therefore justified in these couples.

Steures P et al Intrauterine insemination with controlled ovarian
hyperstimulation versus expectant management for couples with
unexplained subfertility and an intermediate prognosis: a randomised
clinical trial.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16844491>

**Presurgical infiltration of levobupivacaine reduces analgesic
consumption after surgery**

CONCLUSIONS: Our results suggest that presurgical infiltration of
levobupivacaine in addition to general anesthesia and standard analgesic
therapy significantly decreases the intensity of postsurgical pain,
especially for the first 12 h after surgery, and reduces analgesic
consumption after surgery.

Alessandri F; Lijoi D; Mistrangelo E; Nicoletti A; Ragni N Effect of
presurgical local infiltration of levobupivacaine in the surgical field
on postsurgical wound pain in laparoscopic gynecological surgery. [Acta
Obstet Gynecol
Scand.](javascript:AL_get(this, 'jour', 'Acta Obstet Gynecol Scand.');)
2006;85(7):844-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16817084>

**Prophylactic Oophorectomy in Young Women Carries Increased Mortality
Risk**

INTERPRETATION: Although prophylactic bilateral oophorectomy undertaken
before age 45 years is associated with increased mortality, whether it
is causal or merely a marker of underlying risk is uncertain.

[Rocca
WA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Rocca+WA"%5BAuthor%5D)
et al Survival patterns after oophorectomy in premenopausal women: a
population-based cohort study. [Lancet
Oncol.](javascript:AL_get(this, 'jour', 'Lancet Oncol.');) 2006
Oct;7(10):821-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17012044>

**Laser Treatment for PCOS Patients May Restore Fertility**

CONCLUSION: The ultrasound-guided transvaginal ovarian interstitial
laser treatment may be an effective new method to manage anovulation in
PCOS patients.

[Zhu
W](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Zhu+W"%5BAuthor%5D),
et al Ovarian interstitial YAG-laser: an effective new method to manage
anovulation in women with polycystic ovary syndrome. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Aug;195(2):458-63

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16890553>

**No improvement: Subcutaneous closure of vertical incisions with over 3
cm of subcut. fat**

RESULTS: Two hundred twenty-five patients were enrolled with 222
eligible for evaluation. Wound complications were observed in 34 (15.3%)
patients, and 25 of these women also had wound disruption. Overall wound
complication and wound disruption rates were not significantly different
between groups: suture (12.8%, 7.7%), drain (17.9%, 14.9%), control
(15.6%, 11.7%); P = .70 and P = .39, respectively.

CONCLUSION: Suture approximation or drainage of the subcutaneous tissues
of women with 3 cm or more subcutaneous fat measured in midline vertical
incisions resulted in no significant change in the incidence of overall
wound complications or superficial wound disruption.

Cardosi RJ; et al Subcutaneous management of vertical incisions with 3
or more centimeters of subcutaneous fat.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16796988>

**Laparoscopic colposuspension may be cost effective over 24 months
compared with open** At 24 months, the laparoscopic arm again had a
higher mean QALY score compared to the open surgery group. Thus,
assuming that beyond 6 months the laparoscopic colposuspension would not
lead to any significant additional costs compared with open
colposuspension, the ICER was reduced to pound 9300 at 24 months.
Extensive sensitivity analyses were carried out to test assumptions made
in the base case scenario. CONCLUSIONS: Laparoscopic colposuspension is
not cost effective when compared with open colposuspension during the
first 6 months following surgery, but it may be cost effective over 24
months.

Dumville JC; Manca A; Kitchener HC; Smith AR; Nelson L; Torgerson DJ;  
Cost-effectiveness analysis of open colposuspension versus laparoscopic
colposuspension in the treatment of urodynamic stress incontinence.
[BJOG.](javascript:AL_get(this, 'jour', 'BJOG.');) 2006
Sep;113(9):1014-22.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16956333>

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

**Early adolescents worry more as they age. . . .**

They also appear more likely to keep worries to themselves as they go
through this stage of development. Research has shown that adolescent
worry has been associated with several important behavioral and health
outcomes. Additionally, studies have shown that adolescents exhibit age-
and gender-related patterns with regard to the type and number of
reported worries, that the types of worries reported by adolescents vary
across time, and that certain worries seem to remain stable and highly
ranked by adolescents.

The authors found that

\* Adolescents worried weekly most about school grades and least about
their friends\' problems. There were no significant age or gender
differences for total weekly worrying.

\* Compared to boys, girls worried weekly more about fitting in at
school and about being out of shape or overweight, whereas boys were
more likely than girls to have weekly worries about their futures.

\* Older students had more weekly worries than younger students about
looks or appearance and about being out of shape or overweight. Compared
to the youngest students (age 9), the oldest students (age 13) also were
more likely to worry about problems at home and about their friends.

\* Adolescents who primarily talk to a parent when they are worried were
significantly less likely to worry about being liked or fitting in.

Those who said they usually keep their worries to themselves were at
greater risk than the referent category for weekly worries about grades.

\* Compared to those who turn to parents, those who turn to friends were
more likely to have weekly worries about their friends and about being a
failure or disappointing loved ones. Those who preferred the Internet
for information about what is worrying them were at greater risk for
weekly worries about their future but were less likely to worry weekly
about grades than those who turned to parents.

This study highlights the need to pay more attention to the ways
students attempt to cope with their worries . . . \[and\] points to an
opportunity to investigate the link between types of adolescent worries
and primary sources of worry information utilized by early adolescents.

Brown SL, Teufel JA, Birch DA, et al. 2006. Gender, age, and behavior
differences in early adolescent worry. Journal of School Health
76(8):430-437

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16978167>

#### [PEDS CCC Editorial comment:]{.underline} Steve Holve

**Can we develop counseling strategies that make worrying a positive
activity?**

This article highlights what we suspected; teenagers worry. As
healthcare providers what we need is a mechanism to make worrying
useful. We already know from behavioral studies that if a patient
doesn't see a condition as a problem than they are not ready to change.
However, when students do recognize a problem and worry (e.g. "Am I too
heavy?" or "Should I really be having sex with three different people?")
how can we best use that concern to help teens make healthier lifestyle
changes? We all know it is a big step from knowledge to action. It is
probably an even bigger step from worry to action. Can we develop
counseling strategies that make worrying a positive activity? My only
question.... is it as elusive as turning lead into gold?

Overweight Adolescent Girls Have Increased Mortality Risk

Childhood obesity is associated with obesity in adulthood, but it is not
known if being overweight in adolescence carries an independent risk for
premature death. Van Dam and colleagues conducted a prospective cohort
study to examine the relationship between body mass index (BMI) at 18
years of age and premature death in women.

[Conclusions:]{.underline} Being overweight at 18 years of age increases
the risk of premature death in women, an increase that is independent of
their adult weight or lifestyle factors. However, the study did not
evaluate information on causes of death, leaving the reasons for
increased mortality unclear. Given these findings, the authors recommend
that physicians emphasize the primary prevention of overweight in
children and adolescents.

Van Dam RM, et al. The relationship between overweight in adolescence
and premature death in women. Ann Intern Med July 18, 2006;145:91-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16847291>

**Adolescent overweight and obesity: Effect of maternal smoking during
pregnancy**

Adolescent body mass index and prevalences of overweight and obesity
were greater in offspring whose mothers had smoked during pregnancy than
in those whose mothers had never smoked. Body mass index and levels of
overweight and obesity among adolescent offspring whose mothers stopped
smoking during pregnancy but smoked at other times in the child\'s life
were similar to those among offspring whose mothers had never smoked.
These results were independent of a range of potentially confounding
factors and suggest a direct effect of maternal smoking during pregnancy
on adolescent overweight and obesity. They provide yet another incentive
for pregnant women to be persuaded not to smoke and for young women to
be encouraged to never take up smoking.

Al Mamun A; Lawlor DA; Alati R; O\'Callaghan MJ; Williams GM;
Najman JMDoes maternal smoking during pregnancy have a direct effect on
future offspring obesity? Evidence from a prospective birth cohort
study. [Am J Epidemiol.  2006;
164(4):317-25](http://www.medscape.com/medline/publicationbrowser/123?pmid=16775040) 

<http://www.medscape.com/medline/abstract/16775040?cid=med&src=nlbest>

**Public Cost of Adolescent Childbearing- By the Numbers**

The Public Costs of Teen Childbearing presents an update of the national
cost estimates for childbearing among adolescents ages 19 and younger,
as well as state-level cost estimates. The report, published and
disseminated by the National Campaign to Prevent Teen Pregnancy with
support from the William T. Grant Foundation and Pfizer, Inc., contains
information about the aggregate costs of adolescent childbearing to
adolescents and their families, the public sector, and society.

Other By the Numbers project resources include (1) a one-page summary of
key results, (2) a conference call transcript and audio recording, (3) a
resource for policymakers with ideas on how to improve the prospects of
children and families and reduce public sector costs associated with
adolescent childbearing, and (4) a resource with suggestions on how
practitioners and advocates can highlight state costs in their
communities. The resources are intended for use by practitioners,
policymakers, researchers, funders, and others concerned about
adolescent childbearing.
[[http://www.teenpregnancy.org/costs/default.asp]{.underline}](http://www.teenpregnancy.org/costs/default.asp)

**Dietary calcium intervention in adolescent mothers increases bone
mineralization**

CONCLUSION: Calcium diet supplemented with dairy products during
adolescent pregnancy resulted in higher maternal vitamin D and folate
serum levels and higher newborn weight and bone mineralization compared
with controls

Chan GM; McElligott K; McNaught T; Gill G. Effects of dietary calcium
intervention on adolescent mothers and newborns: A randomized controlled
trial. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Sep;108(3 Pt 1):565-71
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16946216>

**Program reduces parenting stress among both mothers and fathers of
preterm infants**

CONCLUSIONS: This early-intervention program reduces parenting stress
among both mothers and fathers of preterm infants to a level comparable
to their term peers. We are now studying whether this will result in
long-term beneficial effects.

Kaaresen PI; Rønning JA; Ulvund SE; Dahl LB A randomized, controlled
trial of the effectiveness of an early-intervention program in reducing
parenting stress after preterm birth.
[Pediatrics.](javascript:AL_get(this, 'jour', 'Pediatrics.');) 2006
Jul;118(1):e9-19

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16818541>

**Maternal Smoking During Pregnancy Substantially Raises Risk of SIDS**

We investigated the effect of maternal smoking during pregnancy on the
relative risk of sudden infant death syndrome (SIDS) by linking data
from Georgia birth and death certificates from 1997 to 2000. We
estimated the effect of misclassifying smokers as non-smokers and the
effect of being misclassified on SIDS rates, and we calculated the
fraction of cases caused by exposure. Of all SIDS cases, 21% were
attributable to maternal smoking; among smokers, 61% of SIDS cases were
attributable to maternal smoking. Maternal smoking during pregnancy is
associated with a significantly increased risk of SIDS.

[Shah
T](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Shah+T"%5BAuthor%5D),
et al Sudden infant death syndrome and reported maternal smoking during
pregnancy. [Am J Public
Health.](javascript:AL_get(this, 'jour', 'Am J Public Health.');) 2006
Oct;96(10):1757-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17008569>

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

**Health Behaviors among American Indian/Alaska Native Women, 1998--2000
BRFSS**

Background and objective: Minority populations, including American
Indians and Alaska Natives (AI/AN), in the United States generally
experience a disproportionate share of adverse health outcomes compared
with whites. The prevalence of risk behaviors associated with these
adverse health outcomes among AI/AN women is not well documented,
especially for those who live outside areas serviced by Indian Health
Service. We sought to describe the prevalence of selected health risk
behaviors among AI/AN women, document the disparities between AI/AN
women and all U.S. women, and demonstrate the efforts needed for AI/AN
women to reach Healthy People 2010 goals.

Methods: Age-adjusted prevalence estimates for selected sociodemographic
characteristics, current smoking, obesity, lack of leisure time physical
activity, and binge drinking were calculated using Behavioral Risk
Factor Surveillance System (BRFSS) data from 1998 to 2000, combined.
Comparisons were made between prevalence estimates for AI/AN women and
all women who participated in the BRFSS and Healthy People 2010 goals.

Results: The prevalences of current smoking (27.8%) and obesity (26.8%)
were significantly higher among AI/AN women than among all U.S. women.
AI/AN women did not meet Healthy People 2010 goals for current smoking,
obesity, leisure time physical activity, or binge drinking.

Conclusions: These data highlight both disparities in health risk
behaviors between AI/AN women and all U.S. women and improvements needed
for AI/AN women to meet Healthy People 2010 goals. This project
demonstrates the overwhelming need for culturally appropriate and
accessible prevention programs to address health risk behaviors
associated with the leading causes of death among urbanized AI/AN women.

Doshi SR, Jiles R. Health Behaviors among American Indian/Alaska Native
Women, 1998--2000 BRFSS, Journal of Women\'s Health Oct 2006, Vol. 15,
No. 8 : 919 -927

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17087615>

**Raloxifene did not significantly affect the risk of CHD**

**Clinical Question:** What is the effect of raloxifene (Evista) on the
risks of cardiovascular disease and breast cancer?

**Study Design:** Randomized controlled trial (double-blinded)

**Synopsis:** Previous studies have shown that raloxifene appears to
reduce the risk of breast cancer and also may have beneficial
cardiovascular effects. In the Raloxifene Use for The Heart (RUTH)
trial, 10,101 postmenopausal women 55 years or older with known
cardiovascular disease (or at high risk for it) were randomly assigned
to raloxifene 60 mg per day or placebo. Patients with recent myocardial
infarction, bypass surgery, or percutaneous coronary intervention were
excluded, as were women who had a history of cancer or venous
thromboembolism, recent unexplained uterine bleeding, heart failure,
liver or renal disease, or who had recently used estrogen or other sex
hormones.

The mean age of participants was 67 years, 84 percent were white, 10
percent had a family history of breast cancer, and approximately 40
percent had a five-year risk of breast cancer greater than 1.66 percent
(the usual cutoff for considering prophylactic therapy). Approximately
one half had a history of coronary artery disease, and 45 percent had
diabetes. Groups were balanced at the start of the study except for a
statistically significant difference in the cardiovascular risk score
(7.9 in the raloxifene group versus 7.8 in the placebo group); however,
it is unlikely that this small difference was clinically meaningful.
Women were monitored for a mean of 5.6 years, and each outcome was
confirmed by a committee blinded to treatment assignment.

There was no difference between groups in the risk of cardiovascular
events, death from coronary disease, or nonfatal myocardial infarction.
Among women taking raloxifene there was a trend toward more strokes
(0.95 versus 0.86 percent per year; *P* = .07) and a greater risk of
venous thromboembolism (0.39 versus 0.27 percent per year; *P* = .02;
number needed to harm = 833 per year). However, the risk of invasive
breast cancer was lower in the raloxifene group (0.15 versus 0.27
percent per year; *P* = .003; number needed to treat \[NNT\] = 833 per
year), as was the risk of clinical vertebral fracture (0.24 versus 0.37
percent per year; *P* = .007; NNT = 769). There was no difference in the
risk of clinical nonvertebral fracture or all-cause mortality.

**Bottom Line:** For every 1,000 women who take raloxifene for five
years, four or five additional strokes, six additional episodes of
venous thromboembolism, six fewer invasive breast cancers, and six or
seven fewer clinical vertebral fractures can be expected. The cost for
this treatment would be approximately \$1,000 per woman per year, for a
total cost of \$5,000,000 at current drug prices.

**(Level of evidence: 1b)**

Study Reference: Barrett-Connor E, et al., for the Raloxifene Use for
The Heart (RUTH) Trial Investigators. Effects of raloxifene on
cardiovascular events and breast cancer in postmenopausal women. N Engl
J Med July 13, 2006;355:125-37.

<http://www.aafp.org/afp/20061101/tips/21.html>

**Rifampin Has Improved Adherence, Less Toxicity Than Isoniazid for
Latent Tuberculosis **

CONCLUSIONS: Compared with a 9-month isoniazid regimen, a 4-month
rifampin regimen was associated with a higher percentage of patients
completing treatment and a lower percentage of patients with clinically
recognized adverse reactions. Additional studies are warranted to
determine efficacy and effectiveness of rifampin therapy for LTBI.

[Page
KR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Page+KR"%5BAuthor%5D),
et al Improved adherence and less toxicity with rifampin vs isoniazid
for treatment of latent tuberculosis: a retrospective study. [Arch
Intern Med.](javascript:AL_get(this, 'jour', 'Arch Intern Med.');) 2006
Sep 25;166(17):1863-70

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17000943>

Prophylactic Surgery Reduces Ovarian Cancer Risk

**Clinical Question:** Is prophylactic bilateral salpingo-oophorectomy
(BSO) effective for reducing the risk of ovarian, fallopian tube, and
peritoneal cancers in high-risk women?

**Study Design:** Nonrandomized controlled trial

**Synopsis:** Women with a mutation in the BRCA1 or BRCA2 gene are at an
increased risk of cancers of the ovary, fallopian tube, and peritoneum.
The effectiveness of prophylactic BSO to prevent these cancers is
uncertain. The investigators identified 1,828 women known to carry a
BRCA1 or BRCA2 mutation from an international registry of 32 centers in
Canada, the United States, Europe, and Israel. Patients initially free
of ovarian cancer were monitored from the date of study entry until a
diagnosis of ovarian cancer, fallopian tube cancer, peritoneal cancer,
death, or the date of most recent evaluation. Final diagnoses were
confirmed by review of medical records and pathology reports.

The mean age of the cohort at study entry was 47.3 years (range: 30 to
74 years). Of the 1,828 participants, 555 (30.4 percent) underwent
prophylactic BSO before study entry, and an additional 490 (38.5 percent
of remaining patients) underwent the procedure during the follow-up
period. Women who did and who did not undergo BSO were similar with
regard to history of breast cancer, parity, oral contraceptive use, and
hormone therapy. All women underwent periodic follow-up for a mean of
3.5 years. Among women with intact ovaries, 32 cancers were detected (29
ovarian, two fallopian tube, and one primary peritoneal). Of the 490
women undergoing prophylactic BSO during the follow-up period, 11 had
cancer at the time of surgery. Seven additional women undergoing the
procedure presented with primary peritoneal cancer during follow-up.

A multivariate statistical model controlling for age, country of origin,
gene type, history of breast cancer, oral contraceptive use, history of
breastfeeding, and parity estimated an 80 percent reduction in the risk
of cancer associated with prophylactic BSO (hazard ratio = 0.20; number
needed to treat to prevent one additional cancer every 3.5 years = 36;
95% confidence interval, 31 to 70).

**Bottom Line:** BSO is effective for reducing the risk of ovarian,
fallopian tube, and peritoneal cancers in high-risk women with a
mutation in the BRCA1 or BRCA2 gene. Thirty-six women will need to
undergo BSO to prevent one additional cancer every 3.5 years. It is
important to inform women who are considering this procedure that
recommendations are not based on a true randomized trial and that there
is insufficient information on the effects of surgery on long-term
morbidity and all-cause mortality.

**(Level of evidence: 2b)**

**Study Reference:** Finch A, et al., for the Hereditary Ovarian Cancer
Clinical Study Group. Salpingo-oophorectomy and the risk of ovarian,
fallopian tube, and peritoneal cancers in women with a BRCA1 or BRCA2
mutation. JAMA July 12, 2006;296:185-92.

<http://www.aafp.org/afp/20061101/tips/20.html>

**Seasonal Affective Disorder**

Patients with seasonal affective disorder have episodes of major
depression that tend to recur during specific times of the year, usually
in winter. Like major depression, seasonal affective disorder probably
is underdiagnosed in primary care settings. Although several screening
instruments are available, such screening is unlikely to lead to
improved outcomes without personalized and detailed attention to
individual symptoms. Physicians should be aware of comorbid factors that
could signal a need for further assessment. Specifically, some emerging
evidence suggests that seasonal affective disorder may be associated
with alcoholism and attention-deficit/hyperactivity disorder. Seasonal
affective disorder often can be treated with light therapy, which
appears to have a low risk of adverse effects. Light therapy is more
effective if administered in the morning. It remains unclear whether
light is equivalent to drug therapy, whether drug therapy can augment
the effects of light therapy, or whether cognitive behavior therapy is a
better treatment choice. Am Fam Physician 2006;74:1521-24.

<http://www.aafp.org/afp/20061101/1521.html>

Antidepressants in Older Persons - Cochrane Briefs

Clinical Question

Which antidepressants are effective and well tolerated in older persons
with depression?

Evidence-Based Answer

In older persons with depression, three classes of antidepressants are
equally effective: selective serotonin reuptake inhibitors (SSRIs),
tricyclic antidepressants, and tricyclic-like compounds. More patients
taking classic tricyclic antidepressants stopped their medications
because of adverse events than did those taking SSRIs. Tricyclic-like
medications had withdrawal rates similar to SSRIs, but the studies were
small. The strongest evidence supports using SSRIs as first-line
pharmacotherapy in older patients with depression.

Practice Pointers

Depression is estimated to affect 17 to 37 percent of the population
older than 55 years.1 Despite its high prevalence in a rapidly growing
segment of the U.S. population, depression still is underdiagnosed.2 In
older persons, it can be difficult to diagnose because medical illnesses
and dementia can cause symptoms of depression. In 2001, a Cochrane
review concluded that antidepressant medications are effective in older
patients and those with severe medical illness.1 However, choice of
medication in older patients must account for decreased renal and
hepatic function and the potential for adverse reactions and drug
interactions,2 and it depends on medical comorbidities and patient and
physician preference.

Mottram and colleagues reviewed the literature to determine which
antidepressants are effective and well tolerated in older patients. They
found 29 trials. Six trials, with a total of 843 participants, compared
all tricyclic antidepressants with all SSRIs. There was no difference in
effectiveness. Eleven trials (with 1,091 patients) measuring withdrawal
rates showed that patients taking SSRIs were less likely to withdraw
than patients taking tricyclic antidepressants, in general (relative
risk \[RR\] = 1.24; 95% confidence interval \[CI\], 1.04 to 1.47) and
because of side effects (RR = 1.30; 95% CI, 1.02 to 1.64). Patients
taking SSRIs also were less likely to withdraw than patients taking
tricyclic-like compounds, but the studies were small.

When starting antidepressant treatment in older patients, most family
physicians make a medication choice based on effectiveness and
tolerability. In most situations, SSRIs are the initial medication
chosen for major or minor depression because of their good effectiveness
and tolerable side-effect profile. In some situations, such as treatment
resistance or medical conditions that would benefit from a different
class of medications, comorbidities may dictate another choice (e.g.,
use of a tricyclic antidepressant in a patient with peripheral
neuropathy).

The Cochrane study reaffirms that patients will benefit from SSRIs, but
also that, if the situation is appropriate, tricyclic and atypical
antidepressants will benefit patients as well. If a patient is warned in
advance about potential side effects, withdrawal because of the side
effects may be less likely.

-Mottram P, et al. Antidepressants for depressed elderly. Cochrane
Database Syst Rev 2006;(1):CD003491.

-Wilson K, Mottram P, Sivanranthan A, Nightingale A. Antidepressants
versus placebo for the depressed elderly. Cochrane Database Syst Rev
2001;(1):CD000561.

-Institute for Clinical Systems Improvement. Major depression in adults
in primary care. Bloomington, Minn.: Institute for Clinical Systems
Improvement, 2006.

<http://www.aafp.org/afp/20061101/cochrane.html#c1>

Chronic Low Back Pain - Clinical Evidence Concise

What are the effects of oral drug treatments?

likely to be beneficial

**Analgesics.** One randomized controlled trial (RCT) showed that
tramadol (an opioid) decreased pain and increased function at seven
weeks compared with placebo. One RCT showed that tramadol plus
paracetamol (acetaminophen) decreased pain and increased function at
three months compared with placebo. One small RCT identified by a
systematic review showed that diflunisal increased the proportion of
persons who rated the treatment as good or excellent compared with
paracetamol.

**Antidepressants**. Two systematic reviews including almost the same
RCTs showed that antidepressants decreased pain compared with placebo,
but they showed no consistent difference in function. One RCT showed
that maprotiline increased pain relief compared with paroxetine.

**Nonsteroidal Anti-inflammatory Drugs.** One small RCT showed that
naproxen reduced pain compared with placebo. One systematic review and
one subsequent RCT showed no significant difference in symptoms among
different nonsteroidal anti-inflammatory drugs. One small RCT identified
by the review showed that diflunisal increased the proportion of persons
who rated the treatment as good or excellent compared with paracetamol.
Two RCTs showed that cyclooxygenase-2 inhibitors decreased pain and
improved function at four and 12 weeks compared with placebo, but the
effects were small.

trade-off between benefits and harms

**Muscle Relaxants.** Two RCTs identified by a systematic review showed
that tetrazepam reduced pain and increased overall improvement after 10
to 14 days compared with placebo. Two RCTs identified by a systematic
review showed that nonbenzodiazepines (flupirtine and tolperisone)
increased overall improvement at seven to 21 days but showed no
significant difference in pain. Adverse effects of muscle relaxants
include dizziness and drowsiness.

What are the effects of injection therapy?

unknown effectiveness

**Epidural Steroid Injections.** We found no systematic review or RCT
including persons with chronic low back pain who did not have sciatica.

**Local Injections.** One systematic review showed no significant
difference between local injections (anesthetic and corticosteroids) and
placebo in short-term pain relief.

likely to be ineffective or harmful

**Facet Joint Injections.** One RCT identified by a systematic review
showed no significant difference in pain relief and disability between
corticosteroid and saline injections after one and three months.

What are the effects of nondrug treatments?

beneficial

**Exercise.** One systematic review showed that exercise improved pain
and function compared with placebo or no treatment or other conservative
treatments.

**Intensive Multidisciplinary Treatment Programs (Evidence of Benefit
for Intensive Programs but None for Less-Intensive Programs).** One
systematic review showed that intensive (more than 100 hours of therapy)
multidisciplinary biopsychosocial rehabilitation with functional
restoration reduced pain and improved function compared with inpatient
or outpatient nonmultidisciplinary treatment or usual care. The review
showed no significant difference between less-intensive
multidisciplinary and nonmultidisciplinary treatments or usual care in
pain or function.

likely to be beneficial

**Acupuncture.** One systematic review provided limited evidence that
acupuncture improved short-term pain relief and function compared with
no treatment or sham therapy. The review provided insufficient evidence
on the effects of acupuncture compared with other conventional
therapies. It provided limited evidence that adding acupuncture to other
conventional therapies relieved pain and improved function better than
the conventional therapies alone.

**Back Schools.** One systematic review provided limited evidence that
back schools reduced pain and disability compared with inactive
treatments (i.e., waiting list control, placebo gel, or written advice)
or no treatment within six months, although results suggested that
benefits may not persist long term. Three RCTs, identified by the
review, that compared back schools with other treatments had mixed
results.

**Behavior Therapy.** One systematic review showed that behavior therapy
reduced pain and improved behavioral outcomes compared with no
treatment, placebo, or waiting list control. The review and one
subsequent RCT provided no evidence of a difference in functional
status, pain, or behavioral outcomes among different types of behavior
therapy. The review provided insufficient evidence to compare behavior
therapy with other treatments.

**Spinal Manipulative** **Therapy.** One systematic review showed that
spinal manipulative therapy reduced short- and long-term pain and
improved short-term function compared with sham therapy, but it showed
no significant difference in long-term function after six weeks. The
systematic review showed no significant difference in pain or function
between spinal manipulative therapy and general physician care, physical
therapy, exercise, or back school. Two subsequent RCTs comparing spinal
manipulation with exercise or no treatment showed that spinal
manipulation reduced pain at six to 12 months, but they showed different
results for function. One of the RCTs showed that spinal manipulation
increased the number of patients who returned to work at 12 months
compared with exercise therapy. Another subsequent RCT showed no
significant difference in pain or function between spinal manipulation
and exercise.

unknown effectiveness

**Electromyographic Biofeedback.** A systematic review of three small
RCTs showed no significant difference in pain relief or functional
status between electromyographic biofeedback and placebo or waiting list
control. The review provided insufficient evidence on the effects of
electromyographic biofeedback compared with other treatments.

**Lumbar Supports.** We found insufficient evidence on the effects of
lumbar supports.

**Massage.** One systematic review provided insufficient evidence on the
effects of massage compared with inactive treatments or other
treatments.

**Traction.** We found no RCTs on the effects of traction for chronic
low back pain.

**Transcutaneous Electrical Nerve Stimulation.** We found insufficient
evidence on the effects of transcutaneous electrical nerve stimulation
compared with placebo for chronic low back pain.

[***http://www.aafp.org/afp/20061101/bmj.html***](http://www.aafp.org/afp/20061101/bmj.html)
A Publication of BMJ Publishing Group

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

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

**Umbilical Cord Blood Gas and Acid-Base Analysis**

ABSTRACT: Umbilical cord blood gas and acid-base assessment are the most
objective determinations of the fetal metabolic condition at the moment
of birth. Moderate and severe newborn encephalopathy, respiratory
complications, and composite complication scores increase with an
umbilical arterial base deficit of 12--16 mmol/L. Moderate or severe
newborn complications occur in 10% of neonates who have this level of
acidemia and the rate increases to 40% in neonates who have an umbilical
arterial base deficit greater than 16 mmol/L at birth. Immediately after
the delivery of the neonate, a segment of umbilical cord should be
double-clamped, divided, and placed on the delivery table. Physicians
should attempt to obtain venous and arterial cord blood samples in
circumstances of cesarean delivery for fetal compromise, low 5-minute
Apgar score, severe growth restriction, abnormal fetal heart rate
tracing, maternal thyroid disease, intrapartum fever, or multifetal
gestation.

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

**Cord gases at cesarean delivery and vaginal birth: A best practice**

This is a best practice that Indian Health facilities should put into
all guidelines.

Umbilical cord blood gas and acid-base analysis. ACOG Committee Opinion
No. 348. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2006;108:1319--22.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17077266>

**Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a
Vital Sign**

ABSTRACT: Young patients and their parents often are unsure about what
represents normal menstrual patterns, and clinicians also may be unsure
about normal ranges for menstrual cycle length and amount and duration
of flow through adolescence. It is important to be able to educate young
patients and their parents regarding what to expect of a first period
and about the range for normal cycle length of subsequent menses. It is
equally important for clinicians to have an understanding of bleeding
patterns in girls and adolescents, the ability to differentiate between
normal and abnormal menstruation, and the skill to know how to evaluate
young patients' conditions appropriately. Using the menstrual cycle as
an additional vital sign adds a powerful tool to the assessment of
normal development and the exclusion of serious pathologic conditions.

Menstruation in girls and adolescents: using the menstrual cycle as a
vital sign. ACOG Committee Opinion No. 349. American Academy of
Pediatrics; American College of Obstetricians and Gynecologists. Obstet
Gynecol 2006;108:1323--8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17077267>

**Overweight Adolescent: Prevention, Treatment, and Obstetric--
Gynecologic Implications**

ABSTRACT: The number of overweight adolescents has grown to epidemic
proportions in the United States. Adolescent females who are overweight
have significant health sequelae. The American College of Obstetricians
and Gynecologists recommends that all adolescents be screened annually
for overweight by determining weight and stature, calculating a body
mass index for age percentile, and asking about body image and eating
patterns. Health care providers should promote healthy eating and
physical activity to adolescent patients and their parents during
routine preventive health care visits. Adolescents with a body mass
index greater than or equal to the 95th percentile for age should have
an in-depth dietary and health assessment to determine psychosocial
morbidity and risk for future cardiovascular disease.
Obstetrician--gynecologists are strongly encouraged to provide this
assessment. Additional research is needed to determine the most
appropriate approach for the successful prevention and treatment of
overweight adolescents. Until this research has been completed, it is
best to extrapolate an approach from data and studies pertaining to
children and adults, while remaining cognizant of the special needs that
surround adolescent growth and development. Sound nutritional
recommendations and regular physical activity are essential components
of prevention and treatment plans

The overweight adolescent: prevention, treatment, and
obstetric--gynecologic implications. ACOG Committee Opinion No. 351.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2006;108:1337--48.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17077269>

**Breast Concerns in the Adolescent**

ABSTRACT: Breast disease in the adolescent female encompasses an
expansive array of topics. Benign disease overwhelmingly dominates the
differential diagnosis and dictates a different protocol for care in the
adolescent compared with the adult patient to avoid inappropriately high
assessments of risk and unnecessary diagnostic procedures and surgery.
There also are emerging issues pertaining to the care of the adolescent
breast, such as breast augmentation, nipple piercing, and management of
the adolescent patient with a family history of breast cancer

Breast concerns in the adolescent. ACOG Committee Opinion No. 350.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2006;108:1329--36

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17077268>

**Using Preimplantation Embryos for Research**

ABSTRACT: Human embryonic stem cell research promises an increased
understanding of the molecular process underlying cell differentiation.
Transplantation of embryonic stem cells or their derivatives may, in the
future, offer therapies for human diseases. In this Committee Opinion,
the American College of Obstetricians and Gynecologists (ACOG) Committee
on Ethics presents an ethical framework for examining issues surrounding
research using preimplantation embryos and proposes ethical guidelines
for such research. The Committee acknowledges the diversity of opinions
among ACOG members and affirms that no physician who finds embryo
research morally objectionable should be required or expected to
participate in such research. The Committee supports embryo research
within 14 days after evidence of fertilization but limits it according
to ethical guidelines. The Committee recommends that cryopreserved
embryos be the preferred source for research but believes that the
promise of somatic cell nuclear transfer is such that research in this
area is justified. The Committee opposes reproductive cloning. Intended
parents for whom embryos are created should give informed consent for
the disposition of any excess embryos. The donors of gametes or somatic
cells used in the creation of such tissue should give consent for
donation of embryos for research. Abandoned embryos should not be
accepted for research. Potential research projects should be described
to potential donors as much as possible. Donation of embryos for stem
cell research requires specific consent. The Committee believes that
compensation for egg donors for research is acceptable, consistent with
American Society for Reproductive Medicine guidelines.

#### Using preimplantation embryos for research. ACOG Committee Opinion No. 347. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1305--17. {#using-preimplantation-embryos-for-research.-acog-committee-opinion-no.-347.-american-college-of-obstetricians-and-gynecologists.-obstet-gynecol-2006108130517. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17077265**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17077265) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17077265 .Style-Heading-4-+-Arial-14-pt-Underline}

##  {#section-18 .Style-Heading-2-+-14-pt}

## American Family Physician\*\* {#american-family-physician-1 .Style-Heading-2-+-14-pt}

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

No Stirrups Preferred for Pelvic Examinations

**Clinical Question:** Do women feel more comfortable and less
vulnerable if stirrups are not used as part of a speculum examination?

**Study Design:** Randomized controlled trial (nonblinded)

**Synopsis:** The embarrassment and fear of discomfort from the speculum
examination often prevent women from seeking routine cervical cancer
screening. One problem might be the use of stirrups to support the legs
of women undergoing a pelvic examination. Stirrups are commonly used in
the United States but are not routine in other countries. The authors of
this study evaluated whether the use of stirrups increased pain and the
feeling of vulnerability in 197 adult women presenting for a routine
examination.

The women were randomized to a speculum examination using stirrups or
one without stirrups. The stirrups were used to hold the legs at a 30-
to 45-degree angle off the table. Women in the no-stirrup group were
placed at the end of the table with their heels on the corners of the
fully deployed extension of a standard examination table. Women in both
groups were fully draped and underwent a standard pelvic examination
with the examiner obtaining a cervical smear.

Physical discomfort and sense of vulnerability, measured following the
examination using a 100-mm visual analog scale, were significantly lower
in the no-stirrup group: the mean physical discomfort score was 43
percent lower (17.2 versus 30.4), and the sense of vulnerability was 44
percent lower (13.1 versus 23.6). Sense of loss of control was not
significantly different between the two groups.

The quality of the smears was similar in the two groups. The researchers
did not report the comfort of the examiner with either method or how
they avoided having the speculum handle hit the table extension. The
study was unblinded because the women knew whether they were in stirrups
or not. Most of the women had already had one or more speculum
examinations; the study would have been more effective had they enrolled
women who had never had a pelvic examination using stirrups.

**Bottom Line:** To decrease discomfort and sense of vulnerability,
women undergoing a routine pelvic examination should be offered the
option of not using stirrups. On average, women will find this position
more comfortable and will feel less exposed.

**(Level of evidence: 1b)**

Study Reference: Seehusen DA, et al. Improving women\'s experience
during speculum examinations at routine gynaecological visits:
randomised clinical trial. BMJ July 22, 2006;333:171.
<http://www.aafp.org/afp/20061101/tips/18.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.

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

**Over 1 million U.S. babies are delivered by Cesarean delivery**

<http://www.ahrq.gov/research/sep06/0906RA17.htm>

**Bone protection therapy shifted from estrogen to nonestrogen
anti-osteoporosis medicine after publication of the Women\'s Health
Initiative study**

<http://www.ahrq.gov/research/sep06/0906RA5.htm>

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

**Want to keep up with evidence-based medicine?**

Got time to read 50,000 articles? No? Then take a look at Evidence-Based
Medicine. From the editorial offices of the British Medical Journal,
this journal provides information gleaned from over 100 journals.
Published 6 times a year, the most important and valid research articles
are presented. For example, here are two current articles that may be of
interest.

Physical exertion during pregnancy

1\. Physical exertion at work during pregnancy did not increase risk of
preterm delivery or fetal growth restriction. (Evidence-Based Medicine
2006; 11: 156). This prospective cohort study included 1,908 women over
16 years of age who were 24-29 weeks pregnant and stood long hours each
week, lifted heavy objects 13 times or more each week, worked nights or
worked greater than 46 hour weeks.

Continuous dose vs. 28 day OCs

2\. Review: 6 RCTs show similar efficacy and safety for continuous
dosing and 28 day combination contraceptive pills. (Evidence-Based
Medicine 2006; 11: 53). Randomized controlled trials compared continuous
or extended combination oral contraceptives with the traditional dosing
(21 days of pills) in women of reproductive age.

To find Evidence-Based Medicine on the HSR Library website, click ONLINE
JOURNALS found on the left panel of the homepage. Next click "E" to get
to all journals starting with "E" and scan down to the journal.

Would you like to have regular updates in your special interest from
Evidence-Based Medicine and other journals you select and have complete
control over your updates? Email me for an easy "Go By" for this. And as
always, if you need any information help, just email me at
cooperd@mail.nih.gov

##### 

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

**It is official, breastfeeding counts**

Obesity is a rapidly escalating problem that could greatly complicate
health care in the future. Finding effective ways that reduce obesity
and maintain healthy weight are major challenges for health care
providers and planners. But research suggests that there is hope -- in
numerous studies, breastfeeding has been linked with reduced obesity
risk throughout childhood and into early adulthood. Additionally,
breastfeeding exclusivity and duration are recognized to be inversely
related to obesity risk.

Given the current widespread obesity problem and the research that
breastfeeding can reduce obesity risk, a GPRA measure has been born.
Beginning in 2007, baseline breastfeeding data at specific ages will be
established in I.H.S. country -- with the goal of increasing
breastfeeding incidence and duration in the first year of life.

It will take numbers to establish baseline data and monitor early
feeding practice. The good news is that feeding choice data can now be
captured in RPMS *and* the questions are those already routinely asked
by providers in the patient's first year of life. Using a software patch
available to all service units, feeding choice can be indicated at
patient visits by PCC, PCC +, and E.H.R. in 2007, than inputted by data
entry, and tracked by a V-gen search.

The software patch allows any provider to check one of five feeding
choices - exclusively breastfeeding, mostly breastfeeding, ½ and ½ ,
mostly formula and exclusively formula. The possible confounders that
can also be tracked are parity, birth weight, mother's name/chart
number, when solids were started, when breastfeeding stopped, and when
regular formula feeding began.

I.H.S. has unique health care records -- often spanning entire
lifetimes. No other national health care environment provides care for
an individual from conception throughout their life. There are limitless
opportunities to learn from health behavior/management to improve life
long care. How early feeding choice impacts later years is only the
beginning.

Please watch for more information about the new GPRA measure and
objectives related to breastfeeding. Specific information will be
available soon at the I.H.S. MCH Breastfeeding web site,
[www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm](http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm)

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

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

#### Breast-Feeding Protects Against Obesity in Children of Diabetic, Overweight Mothers {#breast-feeding-protects-against-obesity-in-children-of-diabetic-overweight-mothers-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Breast-feeding was inversely associated with childhood obesity regardless of maternal diabetes status or weight status. These data provide support for all mothers to breast-feed their infants to reduce the risk for childhood overweight. {#conclusions-breast-feeding-was-inversely-associated-with-childhood-obesity-regardless-of-maternal-diabetes-status-or-weight-status.-these-data-provide-support-for-all-mothers-to-breast-feed-their-infants-to-reduce-the-risk-for-childhood-overweight. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Mayer-Davis EJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Mayer-Davis+EJ"%5BAuthor%5D), et al Breast-feeding and risk for childhood obesity: does maternal diabetes or obesity status matter? [Diabetes Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');) 2006 Oct;29(10):2231-7  {#mayer-davis-ej-et-al-breast-feeding-and-risk-for-childhood-obesity-does-maternal-diabetes-or-obesity-status-matter-diabetes-care.-2006-oct29102231-7 .Style-Heading-4-+-Arial-14-pt-Underline}

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17003298>

# 

**Herbal Medicines in Pregnancy and Lactation**

Just as with prescription drugs, natural health products can present
substantial risks and prompt the same areas of concern. Although some of
these effects may be life-threatening, current literature on these
important issues is scant. With the use of natural health products on
the rise, physicians require quality evidence with which to make
evidence-based decisions and provide answers to their patients. Herbal
Medicines in Pregnancy and Lactation focuses entirely on the
therapeutics, safety and risk information of herbs and supplements used
during pregnancy and lactation for obstetricians, maternal-fetal
medicine specialists, and primary care physicians.

Herbal Medicines in Pregnancy and Lactation\
[Edward
Mills](http://www.amazon.com/s/104-5419862-0403928?ie=UTF8&index=books&rank=-relevance%2C%2Bavailability%2C-daterank&field-author-exact=Edward Mills),
[Jean-Jacques
Dugoua](http://www.amazon.com/s/104-5419862-0403928?ie=UTF8&index=books&rank=-relevance%2C%2Bavailability%2C-daterank&field-author-exact=Jean-Jacques Dugoua),
[Dan
Perri](http://www.amazon.com/s/104-5419862-0403928?ie=UTF8&index=books&rank=-relevance%2C%2Bavailability%2C-daterank&field-author-exact=Dan Perri)

Publisher: Informa Healthcare (January 17, 2006) ISBN: 0415373921

<http://www.informahealthcare.com/>

# QuickStats: Percentage of Infants Born During 1990\--1993 and 1997\--2000 Who Were Ever Breastfed, by Race/Ethnicity of Mother \-\-- United States

![](media/image2.png){width="5.342361111111111in"
height="2.2194444444444446in"}

\* Excludes twins and higher-order multiple births.

The percentage of infants ever breastfed increased from 55% among those
born during 1990\--1993 to 67% among those born during 1997\--2000,
bringing the levels of breastfeeding initiation closer to the Healthy
People 2010 objective of 75% among mothers in all racial/ethnic groups.
Substantial progress toward meeting this goal has been observed among
Hispanic (75%) and non-Hispanic white (69%) mothers. In addition,
breastfeeding initiation nearly doubled among non-Hispanic black
mothers, from 25% of infants born during 1990\--1993 to 47% of infants
born during 1997\--2000.

SOURCE: Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility,
family planning, and reproductive health of U.S. women: data from the
2002 National Survey of Family Growth. Vital Health Stat 2005;23(25).

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5542a6.htm>

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

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

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

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

\-[Routine HIV Screening in 13- 64 year olds: Scott
Giberson](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_AOM.cfm)

\-[40 years in partnership: American Academy of Pediatrics and Indian
Health](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Coll.cfm)

\-[Can a 29% Cesarean Delivery Rate Possibly Be
Justified?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_HT.cfm#ob)

\-[Out with Clomid? Here come the Aromatase inhibitors for ovulation
induction](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_HT.cfm#gyn)

\-[Fetal injury at cesarean delivery: Indication and type of uterine
incision](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_HT.cfm#child)

\-[Aspirin to Prevent Heart Attack and Stroke: What's the Right Dose?
160
mg/day](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_HT.cfm#chrIll)

\-[Postcoital Bleeding and Cervical Cancer Risk only
1/220](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#afp)

\-[Amnioinfusion Does Not Prevent Meconium Aspiration
Syndrome](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#acog)

\-[Exercise and Pregnancy; Preclampsia Drugs; Calcium
Supplementation](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#AskLib)

\-[Do you have breastfeeding questions? The new IHS Breast feeding site
has the
answers](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#breast)

\-[Ortho Evra Patch Linked to Risk for Venous
Thromboembolism](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#fp)

\-[New Breastfeeding Web Page for the Indian Health
System](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#webSite)

\-[Maternal survival worldwide: consensus and
controversies](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#ih)

\-[The words 'bizarre' and 'atypia' in the same pathology report
sentence...hmmm....](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#mmtour)

\-[External Fetal Monitors - Can you kick the
habit?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#MidWives)

\-[Asthma in
Pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#okie)

\-[Fracture risk among First Nations
people](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#oste)

\-[A.) Fetal Lung Maturity B.) Blood test for pre-eclampsia? C.)  Fish
oil for the
brain](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#periPicks)

\-[Causes of Type 2 Diabetes: Old and New
Understandings](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#pcf)

\-[Prevalence of HPV Infection among Men: A Systematic Review of the
Literature](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#std)

\-[No improvement in fetal outcome, increased maternal morbidity: Who
pays for
this?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#stillW)

\-[Special Care Clinic -- Phoenix Indian Medical
Center](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#new)

\-[Heard about prenatal and postpartum care? Here is something on
Internatal
Care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#new)

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

#### Go here for the October highlights: {#go-here-for-the-october-highlights .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/06OctOL.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/06OctOL.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocuments06octol.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### Domestic Violence {#domestic-violence .Style-Heading-4-+-Arial-14-pt-Underline}

**Measuring Intimate Partner Violence Victimization and Perpetration**

This compendium provides researchers and prevention specialists with a
set of assessment tools with demonstrated reliability and validity for
measuring the self-reported incidence and prevalence of Intimate Partner
Violence victimization and perpetration. Although the compendium
includes more than 20 scales, it is not intended to be an exhaustive
listing of available measures. The information is presented to help
researchers and practitioners make informed decisions when choosing
scales to use in their work.

<http://www.cdc.gov/ncipc/dvp/Compendium/Measuring_IPV_Victimization_and_Perpetration.htm>

CDC Reports Prevalence of Dating Violence in High School Students

Programs that promote the prevention of dating violence should address
risk factors associated with victimization and help educate high school
students about healthy behaviors within dating relationships. The
Centers for Disease Control and Prevention (CDC) analyzed data from the
2003 Youth Risk Behavior Survey to determine the prevalence of dating
violence among high school students. The report, \"Physical Dating
Violence Among High School Students-United States, 2003,\" was published
in the May 19, 2006, issue of *Morbidity and Mortality Weekly Report*.

The study showed that 9 percent of the 14,956 high school students who
were surveyed had been victims of physical dating violence, and one in
11 high school students reported being a victim within the previous 12
months.

Thirty-four percent of all participants were currently sexually active;
9 percent had attempted suicide; 28 percent drank heavily; and 33
percent had been involved in physical fighting. The survey found that
students who were victims of dating violence were more likely to engage
in these risky behaviors compared with students who had never
experienced dating violence. Additionally, 14 percent of students with
self-reported grades of D\'s and F\'s experienced physical dating
violence victimization compared with only 6 percent of students with
self-reported grades of A\'s.

Appropriate intervention, such as referral for counseling, is more
likely if physicians ask teenage patients about their dating behaviors.
Therefore, family physicians should be aware of the prevalence of dating
violence and appropriately address the associated risky behaviors in
teenagers to help prevent further instances of violence.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5519a3.htm>

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

**Diagnosis of Acute Abdominal Pain in Older Patients**

Acute abdominal pain is a common presenting complaint in older patients.
Presentation may differ from that of the younger patient and is often
complicated by coexistent disease, delays in presentation, and physical
and social barriers. The physical examination can be misleadingly
benign, even with catastrophic conditions such as abdominal aortic
aneurysm rupture and mesenteric ischemia. Changes that occur in the
biliary system because of aging make older patients vulnerable to acute
cholecystitis, the most common indication for surgery in this
population. In older patients with appendicitis, the initial diagnosis
is correct only one half of the time, and there are increased rates of
perforation and mortality when compared with younger patients.
Medication use, gallstones, and alcohol use increase the risk of
pancreatitis, and advanced age is an indicator of poor prognosis for
this disease. Diverticulitis is a common cause of abdominal pain in the
older patient; in appropriately selected patients, it may be treated on
an outpatient basis with oral antibiotics. Small and large bowel
obstructions, usually caused by adhesive disease or malignancy, are more
common in the aged and often require surgery. Morbidity and mortality
among older patients presenting with acute abdominal pain are high, and
these patients often require hospitalization with prompt surgical
consultation. Am Fam Physician 2006;74:1537-44.
<http://www.aafp.org/afp/20061101/1537.html>

**Indian Health Service History Project**\
The Indian Health Service has initiated a project to document the 50
years of work since the federal health responsibilities for American
Indians and Alaska Natives was transferred to the US Public Health
Service. The project includes collecting historic documents, photos, and
oral histories relating to the history of the Indian Health Service. We
are researching records at the National Archives, Library of Congress,
National Library of Medicine, and university archives with Indian health
related records. The records tell a fascinating, but at times incomplete
story. Much of the work of the Indian Health Service was carried out in
distant, rural locations by government and tribal programs whose work
may not have reached the official record system.

We are interested in finding people who would be willing to share
photos, documents, and memories of their time in the Indian Health
Service. Do you have old photos, reports, or documents that you have
been saving for years, and are you unsure what to do with them? This is
your opportunity. If you are willing to share items from your time in
the Indian Health Service, we would like to hear from you. We can accept
the donation of items to add to our collection, or we can take them on
loan to return to you after viewing and copying.

If you are interested in this unique opportunity or have questions about
the project, please contact:\
CAPT Alan Dellapenna, Jr., <alan.dellapenna@ihs.gov> (301) 443-0097\
*\
*You can see some items related to the history of the Indian Health
Service on the IHS website; the items include the executive summary of
the history of the Indian Health Service, The First 50 Years of the
Indian Health Service: Caring and Curing, which can be viewed and
downloaded at <http://info.ihs.gov/>. Go to the grey box at the top of
the page and select "IHS Gold Book - Part 1" through "IHS Gold Book -
Part 4" A collection of historic IHS photos is located at
*<http://www.ihs.gov/publicinfo/photogallery/index.cfm>.* Follow the
instructions to view the photos in the collection.

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

**A strategy to maximize access to emergency contraceptive pills
increased use but did not affect incidence of either pregnancy or
sexually transmitted infections.**

CONCLUSION: This intensive strategy to enhance access to emergency
contraceptive pills substantially increased use of the method and had no
adverse impact on risk of sexually transmitted infections. However, it
did not show benefit in decreasing pregnancy rates. LEVEL OF EVIDENCE:
II-1.

[Raymond
EG](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Raymond+EG"%5BAuthor%5D),et
al Impact of Increased Access to Emergency Contraceptive Pills: A
Randomized Controlled Trial. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Nov;108(5):1098-1106.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17077230&dopt=Abstract>

**EC: Progesterone receptor modulator CDB-2914 as effective as
levonorgestrel**

CONCLUSION: CDB-2914 is at least as effective as levonorgestrel in
preventing pregnancies after unprotected intercourse and has a similar
side effect profile. LEVEL OF EVIDENCE: I.\
[Creinin
MD](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Creinin+MD"%5BAuthor%5D)
et al Progesterone Receptor Modulator for Emergency Contraception: A
Randomized Controlled Trial., [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Nov;108(5):1089-1097.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17077229&dopt=Abstract>

**Monophasic oral contraceptives preferred over biphasic for
contraception**

Conclusions: The trial found no important differences in bleeding
patterns between the biphasic and monophasic preparations studied. Since
no clear rationale exists for biphasic pills and since extensive
evidence is available for monophasic pills, the latter are preferred.

Van Vliet HAAM, Grimes DA, Helmerhorst FM, Schulz KF. Biphasic versus
monophasic oral contraceptives for contraception. Cochrane Database of
Systematic Reviews 2006, Issue 3. Art. No.: CD002032. DOI:
10.1002/14651858.CD002032.pub2.

<http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions>

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

#### Dispensing a year\'s supply of OCPs is associated with higher oral contraceptive continuation, improved reproductive health screening, and lower health care costs. {#dispensing-a-years-supply-of-ocps-is-associated-with-higher-oral-contraceptive-continuation-improved-reproductive-health-screening-and-lower-health-care-costs. .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Dispensing a year\'s supply of OCP cycles to women is associated with higher method continuation and lower costs than dispensing fewer cycles per visit. LEVEL OF EVIDENCE: II-2. {#conclusion-dispensing-a-years-supply-of-ocp-cycles-to-women-is-associated-with-higher-method-continuation-and-lower-costs-than-dispensing-fewer-cycles-per-visit.-level-of-evidence-ii-2. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Foster DG](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Foster+DG"%5BAuthor%5D), et al Number of oral contraceptive pill packages dispensed, method continuation, and costs. [Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006 Nov;108(5):1107-14 [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17077231&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17077231&dopt=Abstract) {#foster-dg-et-al-number-of-oral-contraceptive-pill-packages-dispensed-method-continuation-and-costs.-obstet-gynecol.-2006-nov10851107-14-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids17077231doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Check out our new IHS STD website**

From Lori de Ravello, National IHS STD Program

<http://www.ihs.gov/medicalprograms/epi/index.cfm?module=health_issues&option=std&cat=sub_0>

**New web site focuses on the history and legacy of maternal child
health**

MCH Timeline: History, Legacy, and Resources for Education and Practice
provides information on some of the most important events in the history
of maternal and child health (MCH) in the United States. The Web site,
developed by the Health Resources and Services Administration\'s
Maternal and Child Health Bureau (MCHB), displays a timeline of events
in MCH history from 1798 to the present. Events on the timeline may be
further explored by group (Public Health and Medicine, Government and
Policy), by topic (infant mortality, systems of care, performance and
accountability), by decade, or by title. Detailed narratives containing
images, historical perspectives, current issues, and related resources
are provided for select topics and events. The Web site is intended
primarily for use as an orientation tool for individuals new to the MCH
profession, MCHB grantees, and MCH students.
[[http://www.mchb.hrsa.gov/timeline]{.underline}](http://www.mchb.hrsa.gov/timeline)

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

**Q. Is an informed consent necessary for all x-rays in pregnant
women?**

A. No, not on routine diagnostic studies. High dose procedures are
treated case by case.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/XrayConsent11506.doc>

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

**Highlights November 2006**

-Tall Girls: When being tall was a disease - a look at how culture
shapes and defines medical care

-Viral gastroenteritis in AI/AN children - do we have more or less than
everyone else? Surprising findings.

\- Prevalence of mental health disease in AI/AN children

[[http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN1106.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN1106.doc)

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

**Telehealth Opportunity: Do you need nutrition services at your site?**

If your Service Unit, Hospital or Clinic is in need of nutrition
services or diabetes education services by a Registered
Dietitian/Certified Diabetes Educator, please consider an exciting and
innovative approach to providing these services through Telehealth.

If you currently have (or plan to soon have) teleconferencing
availability, the IHS Native American Cardiology Program would be
interested in potentially working in partnership with you to assist in
providing these services. If you are interested, please see the attached
documents.

For further information or questions, you may also directly contact our
program dietitian, Diane Phillips, RD, LD, CDE at
<diane.phillips@ihs.gov> or by phone at (928) 214-3920.

**AHRQ Launches Electronic Preventive Services Selector Tool for Primary
Care Clinicians**

A new Electronic Preventive Services Selector (*e*PSS) tool for primary
care clinicians to use when recommending preventive services for their
patients was launched at the National Prevention Summit in Washington,
DC, on October 26. The interactive tool is designed for use on a
personal digital assistant (PDA) or desktop computer to allow clinicians
to access the latest recommendations from the AHRQ-sponsored U.S.
Preventive Services Task Force. The *e*PSS is designed to serve as an
aid to clinical decision-making at the point of care and contains 110
recommendations for specific populations covering 59 separate preventive
services topics. The \'real time\' search function allows a clinician to
input a patient\'s age, gender, and selected behavioral risk factors,
such as whether or not they smoke, in the appropriate fields. The
software cross-references the patient characteristics entered with the
applicable Task Force recommendations and generates a report
specifically tailored for that patient. \"This Electronic Preventive
Services Selector will assist physicians in selecting the right
preventive service for the right patient in real time,\" said HHS
Secretary Mike Leavitt in announcing the tool. \"It will help us create
a culture of wellness; a society that thinks of staying healthy rather
than simply being treated after we\'re sick.\".
<http://epss.ahrq.gov/PDA/index.jsp>

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

**Anthropology in the clinic: the problem of cultural competency and how
to fix it**

The article I've chosen to review this month is not specifically about
international health. Instead, it's a relevant piece for anyone working
in cross-cultural settings -- or perhaps any clinical settings at all --
abroad or at home. Arthur Kleinman, the lead author, is a well known
medical anthropologist whose pioneering work on cultural variation and
"explanatory models" of disease was adapted into many medical and
nursing school curricula. In an article in last month's PLoS Medicine,
he critiques current models of "cultural competency" and suggests
alternatives for high-quality, culturally sensitive clinical care.

So what's wrong with the cultural competency model? Kleinman and his
co-author Benson see several problems. First, no rigorous research shows
it to improve clinical care, though training programs have been widely
implemented. Second -- and to the authors clearly more seriously --
"culture" itself becomes another area of technical skill for the
clinician, rather than the lived experience in which we (just as much as
our patients) are immersed. This approach allows us to overlook the
culture of biomedicine and its powerful effect on our interactions with
patients. Instead, culture becomes something that belongs to other
people, and that can be reduced to a bullet-point list of typical
traits, dos and don'ts, or barriers to care. Patients on the receiving
end of this approach, the authors note, may feel intruded upon,
stereotyped or stigmatized. Finally, as the authors illustrate through
several case examples, cultural features are simply not always central
to clinical problems of "compliance" or communication. Family issues,
personal concerns, and economic constraints may be much more salient in
any given situation.

The article is strong on the critique of cultural competency models, and
articulates succinctly several concerns that have been corridor talk in
medical and anthropological circles for some time. Where it is less
strong is in the matter of pragmatic solutions. Kleinman and Benson
agree that clinicians should try to be sensitive to culture, and suggest
that we attempt to see culture from a more anthropological perspective:
as a way of experiencing and interpreting the world that is flexible,
dynamic, and often highly variable among individuals, rather than static
and wholly predictable on the basis of ethnic group memberships. This
anthropological view should allow clinicians to determine what is at
stake for any given patient in the course of illness and its treatment.
To this end, they develop a six-step model for eliciting patients'
experience (what they call a mini-ethnography) that simply seems to me
impractical for the busy clinic setting in which most of us work.
Perhaps it might be usefully adapted for more prolonged encounters or
problem cases? Take a look and see what you think; you can find the
article at www.plosmedicine.org.

Kleinman A, Benson P Anthropology in the clinic: the problem of cultural
competency and how to fix it. PLoS Medicine 3(10):e294, October 2006

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17076546>

**Other:**

**Cesarean Delivery: Both Overused and Underused in Developing
Countries**

INTERPRETATION: In the poorest countries-mostly in sub-Saharan
Africa-large segments of the population have almost no access to
potentially life-saving caesareans, whereas in some mid-income countries
more than half the population has rates in excess of medical need. These
data deserve the immediate attention of policymakers at national and
international levels.

[Ronsmans
C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Ronsmans+C"%5BAuthor%5D),
et al Socioeconomic differentials in caesarean rates in developing
countries: a retrospective analysis.
[Lancet.](javascript:AL_get(this, 'jour', 'Lancet.');) 2006 Oct
28;368(9546):1516-23.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17071285>

**Risk of formula feeding to infants in sub-Saharan Africa: Need for
alternative strategies**

CONCLUSIONS: Breastfeeding with zidovudine prophylaxis was not as
effective as formula feeding in preventing postnatal HIV transmission,
but was associated with a lower mortality rate at 7 months. Both
strategies had comparable HIV-free survival at 18 months. These results
demonstrate the risk of formula feeding to infants in sub-Saharan
Africa, and the need for studies of alternative strategies.

Thior I et al Breastfeeding plus infant zidovudine prophylaxis for 6
months vs formula feeding plus infant zidovudine for 1 month to reduce
mother-to-child HIV transmission in Botswana: a randomized trial: the
Mashi Study. [JAMA.](javascript:AL_get(this, 'jour', 'JAMA.');) 2006 Aug
16;296(7):794-805

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16905785>

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

**Child Health USA 2005 Released**

Child Health USA 2005 is a compilation of secondary data for more than
50 health and health care indicators. The 2005 report, the 16th in an
annual series of reports from the Health Resources and Services
Administration\'s Maternal and Child Health Bureau (MCHB), provides both
graphical and textual summaries of data and addresses long-term trends
where applicable. Data are presented for the target populations of Title
V funding, including infants, children, adolescents, children with
special health care needs, and women of childbearing age. The report
addresses population characteristics, health status, and health services
financing and utilization. Progress toward meeting the goals of MCHB\'s
strategic plan is also discussed. The report is intended to provide
public health professionals and other individuals in the private and
public sectors with a snapshot of measures of children\'s health in the
United States.
[[http://mchb.hrsa.gov/mchirc/chusa_05/index.htm]{.underline}](http://mchb.hrsa.gov/mchirc/chusa_05/index.htm)

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

#### The words 'bizarre' and 'atypia' in the same pathology report sentence...hmmm.... {#the-words-bizarre-and-atypia-in-the-same-pathology-report-sentencehmmm.-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### To recap... {#to-recap .Style-Heading-4-+-Arial-14-pt-Underline}

#### We discussed a 53 yo G6 P5015 who presented to a field facility with ongoing menometrorrhagia despite conservative therapy with medroxyprogesterone 10 mg for 10 days a month for 3 months. Initial ultrasound revealed a 2.7 x 2.4 cm endometrial structure felt to be consistent with an endometrial polyp or a leiomyoma.  {#we-discussed-a-53-yo-g6-p5015-who-presented-to-a-field-facility-with-ongoing-menometrorrhagia-despite-conservative-therapy-with-medroxyprogesterone-10-mg-for-10-days-a-month-for-3-months.-initial-ultrasound-revealed-a-2.7-x-2.4-cm-endometrial-structure-felt-to-be-consistent-with-an-endometrial-polyp-or-a-leiomyoma. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The patient subsequently received an uncomplicated total vaginal hysterectomy with a left salpingo-oophorectomy. The patient was discharged on the second post operative day. {#the-patient-subsequently-received-an-uncomplicated-total-vaginal-hysterectomy-with-a-left-salpingo-oophorectomy.-the-patient-was-discharged-on-the-second-post-operative-day. .Style-Heading-4-+-Arial-14-pt-Underline}

The Pathologist's initially commented that evaluation revealed cytologic
atypia present throughout the neoplasm that was of a degenerative and
bizarre type. Occasional mitotic figures were identified. No tumor type
necrosis was seen. The increased cellularity was felt to be somewhat
increased over what one normally sees in a highly cellular leiomyoma.
The pathologic material was sent to a second facility for pathologic
re-evaluation and the above impression was confirmed.

####  {#section-28 .Style-Heading-4-+-Arial-14-pt-Underline}

#### What did you think this patient's diagnosis was?  {#what-did-you-think-this-patients-diagnosis-was .Style-Heading-4-+-Arial-14-pt-Underline}

The second pathologic evaluation revealed:

#### Submucosal atypical leiomyoma with features of symplastic leiomyoma, benign....deeply penetrating adenomyosiis. There was a comment that it was a symplastic leiomyoma, rather than a leiomyosarcoma.  It was unusually cellular for this enitity, prompting the staff to qualify it as an atypical symplastic leiomyoma, but it is placed in a benign category.  The term atypia underlined the need for follow-up.  {#submucosal-atypical-leiomyoma-with-features-of-symplastic-leiomyoma-benign.deeply-penetrating-adenomyosiis.-there-was-a-comment-that-it-was-a-symplastic-leiomyoma-rather-than-a-leiomyosarcoma.-it-was-unusually-cellular-for-this-enitity-prompting-the-staff-to-qualify-it-as-an-atypical-symplastic-leiomyoma-but-it-is-placed-in-a-benign-category.-the-term-atypia-underlined-the-need-for-follow-up. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-29 .Style-Heading-4-+-Arial-14-pt-Underline}

#### So, what is a symplastic leiomyoma? {#so-what-is-a-symplastic-leiomyoma .Style-Heading-4-+-Arial-14-pt-Underline}

The term symplastic just refers to pleomorphic, atypical, or bizarre
leiomyomas have a wider range of morphologic changes and mitotic
activity than previously documented. Grossly, nothing typically
distinguishes a symplastic leiomyoma from the usual type of leiomyoma.
Microscopically, there are foci of bizarre and pleomorphic tumor cells
with atypical nuclei.

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

This smooth-muscle tumor is defined by the presence of variable numbers
of smooth-muscle cells with multiple, gigantic nuclei with abundant
nuclear chromatin in an otherwise typical leiomyoma. Mitotic figures are
often lacking, but up to 7 per 10 hpf have been reported. They are,
however, never atypical.

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

#### What is the risk of recurrence? {#what-is-the-risk-of-recurrence .Style-Heading-4-+-Arial-14-pt-Underline}

#### All symplastic leimyomas are benign. The recognition of this leiomyoma variant is critical, as the marked nuclear atypia can lead to an incorrect diagnosis of leiomyosarcoma. These lesions have a high cure rate with surgery alone (only one of 46 patients failed in the Stanford series and are considered a variant of usual (benign) leiomyoma. {#all-symplastic-leimyomas-are-benign.-the-recognition-of-this-leiomyoma-variant-is-critical-as-the-marked-nuclear-atypia-can-lead-to-an-incorrect-diagnosis-of-leiomyosarcoma.-these-lesions-have-a-high-cure-rate-with-surgery-alone-only-one-of-46-patients-failed-in-the-stanford-series-and-are-considered-a-variant-of-usual-benign-leiomyoma. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### If your learning curve isn't steep enough at this point, then I just want to add this common sense truism...."the third time is a charm" {#if-your-learning-curve-isnt-steep-enough-at-this-point-then-i-just-want-to-add-this-common-sense-truism.the-third-time-is-a-charm .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### I was a little uneasy about the words ...'The atypia just underlines the need for follow-up'...because it was not clear what other follow-up might be needed for a benign lesion...so I requested the slides be sent to a third center for evaluation. {#i-was-a-little-uneasy-about-the-words-the-atypia-just-underlines-the-need-for-follow-upbecause-it-was-not-clear-what-other-follow-up-might-be-needed-for-a-benign-lesionso-i-requested-the-slides-be-sent-to-a-third-center-for-evaluation. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The third center's preliminary diagnosis is leiomyosarcoma and at this time the patient is being notified to return for computerized tomography of the chest, abdomen, and pelvis. {#the-third-centers-preliminary-diagnosis-is-leiomyosarcoma-and-at-this-time-the-patient-is-being-notified-to-return-for-computerized-tomography-of-the-chest-abdomen-and-pelvis. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The median age for women with leimyosarcoma (43-53 years) is somewhat lower than that for other uterine sarcomas, and premenopausal patients have a better chance of survival.  {#the-median-age-for-women-with-leimyosarcoma-43-53-years-is-somewhat-lower-than-that-for-other-uterine-sarcomas-and-premenopausal-patients-have-a-better-chance-of-survival. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-36 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The recurrence rate is based on the amount of mitotic activity: less than 5 mitotic figures per 10 high power fields is 98% 5 year survival; 5- 10 MF/ 10HPF is unpredictable at 42%; and greater than 10 is poor at 15%. {#the-recurrence-rate-is-based-on-the-amount-of-mitotic-activity-less-than-5-mitotic-figures-per-10-high-power-fields-is-98-5-year-survival-5--10-mf-10hpf-is-unpredictable-at-42-and-greater-than-10-is-poor-at-15. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-37 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Robboy, SJ et al Pathology and Pathophysiology of Uterine Smooth-Muscle Tumors [Environmental Health Perspectives Supplements Volume 108, Number S5, October 2000](http://www.ehponline.org/cgi-bin/findtoc2.pl?tocinfo=Environmental Health Perspectives Supplements@108@S5@2000) {#robboy-sj-et-al-pathology-and-pathophysiology-of-uterine-smooth-muscle-tumors-environmental-health-perspectives-supplements-volume-108-number-s5-october-2000 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ehponline.org/members/2000/suppl-5/779-784robboy/robboy-full.html**](http://www.ehponline.org/members/2000/suppl-5/779-784robboy/robboy-full.html) {#httpwww.ehponline.orgmembers2000suppl-5779-784robboyrobboy-full.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-38 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Classification, clinical manifestations, and staging of uterine sarcoma, UpToDate {#classification-clinical-manifestations-and-staging-of-uterine-sarcoma-uptodate .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.uptodateonline.com/utd/content/topic.do?topicKey=gyne_onc/2274&type=A&selectedTitle=1\~2**](http://www.uptodateonline.com/utd/content/topic.do?topicKey=gyne_onc/2274&type=A&selectedTitle=1~2) {#httpwww.uptodateonline.comutdcontenttopic.dotopickeygyne_onc2274typeaselectedtitle12 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-39 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Other Background on Leiomyosarcomas {#other-background-on-leiomyosarcomas .Style-Heading-4-+-Arial-14-pt-Underline}

#### Rapidly enlarging uterine neoplasms are often attributed to leiomyosarcomas, although most women with this finding do not have a sarcoma. This was illustrated in a study of 1332 women admitted to either of two community hospitals for hysterectomy or myomectomy for presumed uterine leiomyomas: the incidence of uterine sarcomas was extremely low (0.23 percent). Among the 341 women with a rapidly growing uterus by clinical or ultrasound examination, only one (0.27 percent) had a uterine sarcoma. Based upon these data, an increased risk of sarcoma among women with \"rapidly growing\" leiomyomas could not be substantiated. However, the diagnosis of a uterine sarcoma should be considered in postmenopausal women with a pelvic mass, abnormal bleeding, and pelvic pain in whom the incidence of sarcoma is higher (1 to 2 percent). Black women and women with a history of [tamoxifen](http://www.uptodateonline.com/utd/content/topic.do?topicKey=Drug_L_Z/254457&drug=true) use or pelvic radiation are also at increased risk of sarcoma formation. {#rapidly-enlarging-uterine-neoplasms-are-often-attributed-to-leiomyosarcomas-although-most-women-with-this-finding-do-not-have-a-sarcoma.-this-was-illustrated-in-a-study-of-1332-women-admitted-to-either-of-two-community-hospitals-for-hysterectomy-or-myomectomy-for-presumed-uterine-leiomyomas-the-incidence-of-uterine-sarcomas-was-extremely-low-0.23-percent.-among-the-341-women-with-a-rapidly-growing-uterus-by-clinical-or-ultrasound-examination-only-one-0.27-percent-had-a-uterine-sarcoma.-based-upon-these-data-an-increased-risk-of-sarcoma-among-women-with-rapidly-growing-leiomyomas-could-not-be-substantiated.-however-the-diagnosis-of-a-uterine-sarcoma-should-be-considered-in-postmenopausal-women-with-a-pelvic-mass-abnormal-bleeding-and-pelvic-pain-in-whom-the-incidence-of-sarcoma-is-higher-1-to-2-percent.-black-women-and-women-with-a-history-of-tamoxifen-use-or-pelvic-radiation-are-also-at-increased-risk-of-sarcoma-formation. .Style-Heading-4-+-Arial-14-pt-Underline}

Leiomyosarcomas account for one-third of uterine sarcomas. They appear
grossly as a large (\>10 cm) yellow or tan solitary mass with soft,
fleshy cut surfaces exhibiting areas of hemorrhage and necrosis. The
mass may bulge into the uterine cavity, but the epicenter is in the
myometrium.

Benign leiomyomas (fibroids) and leiomyosarcomas often coexist in the
same uterus. However, they are independent entities. Leiomyosarcomas are
much less common and not hormonally driven, and leiomyomas only rarely
(0.23 percent of cases in one large series degenerate into
leiomyosarcomas.

Microscopically, most leiomyosarcomas are overtly malignant, with
hypercellularity, coagulative tumor cell necrosis, abundant mitoses
(![](media/image3.png){width="8.333333333333333e-2in"
height="9.236111111111112e-2in"}10 to 20 per 10 high power fields
\[HPF\]), atypical mitoses, cytologic atypia, and infiltrative borders
([show histology
2A-B](http://www.uptodateonline.com/utd/content/image.do?imageKey=gyne_pix/leiomy6.htm~gyne_pix/leiomy7.htm)).
Occasionally diagnostic problems arise in smooth muscle tumors that are
less cellular, less atypical, and less mitotically active. These tumors
have more worrisome features than the usual leiomyoma, but do not meet
histologic criteria to render an unequivocal diagnosis of
leiomyosarcoma, and few of them behave like a leiomyosarcoma.

Many authors believe that mitotic activity is the single most reliable
indicator of malignant potential, although opinions vary as to the exact
level of mitotic activity required. A large retrospective study from
Stanford suggested the use of three main criteria (frequent mitotic
figures, significant nuclear atypia, presence of coagulative necrosis of
tumor cells) to assign a low-risk or high-risk designation to uterine
smooth muscle tumors that were difficult to classify, indicating a risk
of malignancy that is below or above 10 percent, respectively.

Using these criteria, they were able to characterize the 218 patients
with \"problematic\" uterine smooth muscle tumors according to their
clinical behavior.

Others classify leiomyomas with increased mitotic activity (ie, \>5
mitoses per 10 HPF, [show histology
3](http://www.uptodateonline.com/utd/content/image.do?imageKey=gyne_pix/mitotic_.htm))
but no marked cytologic atypia as \"mitotically active benign
leiomyomas\" only when they arise in women under the age of 35. These
leiomyoma are typically small, well-circumscribed, and almost always
behave in a benign fashion. Leiomyomas are more likely to have a high
mitotic count if they are excised during the secretory phase of the
menstrual cycle, during pregnancy, or when women are receiving exogenous
progestins.

In contrast, the clinical behavior of leiomyomas with increased mitotic
activity but no marked cytologic atypia is less certain in older women,
and the term \"smooth muscle tumor of uncertain malignant potential\"
(meaning that insufficient tumors have been studied to predict their
behavior) has been suggested. Most of these patients are treated with a
simple hysterectomy and they have a better prognosis than
leiomyosarcoma.

Myxoid leiomyosarcomas do not fit well into the Stanford scheme and are
classified separately. The dense myxoid appearance may obscure the
smooth muscle etiology of this tumor, the extent of nuclear
pleomorphism, and the true number of mitotic figures. Despite their
apparently bland features, these tumors behave in a highly malignant
manner, and should be considered high-grade leiomyosarcomas.

####  {#section-40 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

######### 

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

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

**Clinical Discussion Board Index, Medscape**

Hundreds of ongoing clinical discussions available

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

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

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

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

**Menopause Management**

High-Dose Gabapentin Equal to Estrogen for Hot Flashes: POEM

**Clinical Question:** Is high-dose gabapentin (Neurontin) as effective
as usual-dose estrogen for the treatment of postmenopausal hot flashes?

**Study Design:** Randomized controlled trial (double-blinded)

**Synopsis:** The authors recruited menopausal women 35 to 60 years of
age who each had at least 50 moderate to severe hot flashes weekly for
at least two months. Any treatments for hot flashes, including hormones,
were discontinued for at least one month before enrollment in the study.
Sixty women were randomized to gabapentin 2,400 mg daily, conjugated
equine estrogen 0.625 mg daily, or placebo. The gabapentin was titrated
over 12 days to a total of two 400-mg capsules three times daily.

Women recorded their hot flashes in a diary and indicated the severity
of each one on a visual analog scale (1 = mild, 4 = severe). The number
of hot flashes was multiplied by the severity of each over the course of
a week to obtain a composite hot flash score. The composite scores at 12
weeks were compared with baseline scores. The gabapentin group had a
mean reduction of 71 percent, the estrogen group had a mean reduction of
72 percent, and the placebo group\'s score dropped 54 percent (*P* \<
.017 for each active treatment versus placebo). There was no statistical
difference between the gabapentin and estrogen groups. Five women
dropped out during the study, including one in the gabapentin group
because of side effects.

**Bottom Line:** In this small study, high-dose gabapentin was as
effective as the usual dose of conjugated equine estrogens for the
treatment of menopausal vasomotor symptoms. Larger studies are needed to
confirm this result.

**(Level of evidence: 1b)**

**Study Reference:** Reddy SY, et al. Gabapentin, estrogen, and placebo
for treating hot flushes: a randomized controlled trial. Obstet Gynecol
July 2006;108:41-8.

<http://www.aafp.org/afp/20061101/tips/19.html>

Hormone Therapy in Postmenopausal and Perimenopausal Women

Clinical Scenario - Cochrane for Clinicians

A healthy 66-year-old woman has been taking combined continuous hormone
therapy for menopausal symptoms for six months. She asks for how long
she can safely continue taking the medication.

Clinical Question

In perimenopausal and postmenopausal women, is long-term, combined
continuous hormone therapy safe and effective?

Evidence-Based Answer

Relatively healthy women taking combined continuous hormone therapy have
higher risks of myocardial infarction and venous thromboembolism after
one year, stroke after three years, and breast cancer after five years.
In women who take hormone therapy continuously for five years, there is
a lower incidence of fractures and colon cancer. Although it may be
relatively safe and effective for short-term symptom control, hormone
therapy should not be given routinely for prevention or chronic disease
management.

-Farquhar CM, Marjoribanks J, Lethaby A, Lambets Q, Suckling JA, and the
Cochrane HT Study Group. Long term hormone therapy for perimenopausal
and postmenopausal women. Cochrane Database Syst Rev 2005;(3):CD004143.

-NHLBI advisory for physicians on the WHI trial of conjugated equine
estrogens versus placebo. Accessed September 27, 2006, at:
<http://www.nhlbi.nih.gov/whi/e-a_advisory.htm>.

-LaCroix AZ. Estrogen with and without progestin: benefits and risks of
short-term use. Am J Med 2005;118(12 suppl 2):79-87.

<http://www.aafp.org/afp/20061101/cochrane.html#c1>

**Alendronate May Be Best Choice for Postmenopausal Osteoporosis**

CONCLUSIONS: Patients receiving 70 mg OW alendronate had greater gains
in BMD, were more likely to maintain or gain BMD, and had greater
reductions in bone turnover markers than patients receiving 35 mg OW
risedronate after 24 months, with no differences in upper
gastrointestinal tolerability.

[Bonnick
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Bonnick+S"%5BAuthor%5D),
et al Comparison of weekly treatment of postmenopausal osteoporosis with
alendronate versus risedronate over two years. [J Clin Endocrinol
Metab.](javascript:AL_get(this, 'jour', 'J Clin Endocrinol Metab.');)
2006 Jul;91(7):2631-7

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16636120>

####  {#section-42 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Estrogen only trial WHI: Significantly lower rates of any arthroplasty {#estrogen-only-trial-whi-significantly-lower-rates-of-any-arthroplasty-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: These data suggest that hormone therapy may influence joint health, but this observed decrease in risk may be limited to unopposed estrogen and may possibly be more important in hip than in knee osteoarthritis. {#conclusion-these-data-suggest-that-hormone-therapy-may-influence-joint-health-but-this-observed-decrease-in-risk-may-be-limited-to-unopposed-estrogen-and-may-possibly-be-more-important-in-hip-than-in-knee-osteoarthritis. .Style-Heading-4-+-Arial-14-pt-Underline}

Cirillo DJ; Wallace RB; Wu L; Yood RA Effect of hormone therapy on risk
of hip and knee joint replacement in the Women\'s Health Initiative.
[Arthritis Rheum.  2006;
54(10):3194-204](http://www.medscape.com/medline/publicationbrowser/123?pmid=17009251) 

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17009251**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17009251) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17009251 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-43 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Progestin in HRT Linked to Hearing Loss in Postmenopausal Women {#progestin-in-hrt-linked-to-hearing-loss-in-postmenopausal-women .Style-Heading-4-+-Arial-14-pt-Underline}

#### These findings suggest that the presence of P as a component of HRT results in poorer hearing abilities in aged women taking HRT, affecting both the peripheral (ear) and central (brain) auditory systems, and it interferes with the perception of speech in background noise. {#these-findings-suggest-that-the-presence-of-p-as-a-component-of-hrt-results-in-poorer-hearing-abilities-in-aged-women-taking-hrt-affecting-both-the-peripheral-ear-and-central-brain-auditory-systems-and-it-interferes-with-the-perception-of-speech-in-background-noise. .Style-Heading-4-+-Arial-14-pt-Underline}

[Guimaraes
P](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Guimaraes+P"%5BAuthor%5D),
et al Progestin negatively affects hearing in aged women. [Proc Natl
Acad Sci U S
A.](javascript:AL_get(this, 'jour', 'Proc Natl Acad Sci U S A.');) 2006
Sep 19;103(38):14246-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16959884>

**Data insufficient to support any complementary and alternative therapy
for menopause Sx**

The most common symptoms related to menopause include hot flashes, night
sweats, vaginal dryness, and sleep disorders. These symptoms cause
approximately 40 percent of perimenopausal or menopausal women to seek
medical advice. The authors identified 1,432 trials that were reviewed.
Of those, 70 met the inclusion criteria for the study. Forty-eight of
the trials were biologically based therapies, nine were mind-body
therapies, one was a manipulative or body-based therapy, two were energy
therapies, and 10 were for whole medical systems. The studies concerning
biologic agents (see accompanying table) showed varying results. Four of
the 15 trials on phytoestrogens showed a benefit, and one of the four
trials on black cohosh showed a benefit. The studies concerning
mind-body, energy, manipulative and body-based, and whole medical
systems therapies showed little benefit in treating menopausal symptoms.

CONCLUSIONS: Even though some individual studies suggest some benefit to
complementary and alternative therapies for menopausal symptoms, there
are inadequate data to support the effectiveness of these therapies.
They add that many of these therapies need to be evaluated with rigorous
controlled trials to assess their effectiveness and safety.

Nedrow A; Miller J; Walker M; Nygren P; Huffman LH; Nelson HD
Complementary and alternative therapies for the management of
menopause-related symptoms: a systematic evidence review. [Arch Intern
Med.](javascript:AL_get(this, 'jour', 'Arch Intern Med.');) 2006 Jul
24;166(14):1453-65

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16864755>

####  {#section-44 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**What Women Want**

The Journal of Midwifery and Women's Health September/October issue has
two more wonderful qualitative research articles (see my review of
another in the October CCC Corner.) These two studies gather information
about women's experience in early labor at home and their perceptions
during pregnancy of what would be a good birthing experience. The sample
sizes are small and the populations specific, but the quotes ring with
the universal experience of pregnant and birthing women. For example,
Beebe's and Humphreys' interviews with nulliparous included these:

> "It's interesting because the contractions (that) were described to me
> in class, or the way I interpreted them, didn't feel the way I felt
> when I...it just felt more like cramps. I don't know, the two just
> didn't go together for me. They didn't' feel the way I was expecting
> them to."
>
> "My body was just moving me around"
>
> "The only thing I worried about was going to the hospital maybe too
> soon...I just thought it would be bad if we get there only to be told
> to go back home, It would be discouraging."

Melender's interviews produced these quotes about staff:

> "Of course I wish that ....mmmhh...the midwife would be a caring
> person who sees the patient as a human being and not just a
> patient...takes her character into account."
>
> "That the midwife would be a person who listens to you...and not such
> a difficult one (and describing what she meant by difficult:) well, if
> for example, I ask for something, she won't do it or if I ask for
> something, she'll snap at me....I mean that the atmosphere shouldn't
> be in any way tense or like that...I mean that the midwife and
> obstetrician should be nice."

These articles remind us to tune into what women are experiencing and
wanting. Beebe's and Humphreys' encourage us to be sensitive to what
women are going through before they come in to hospital\-- their doubt
about how to tell if they are in labor and the anxiety about and
disappointment in finding out that they are not in active labor. This
should inspire us to teach as clearly as possible what early and active
labor are like and to be readily available to provide reassurance,
guidance, support, and encouragement over the phone and during labor
checks. Melender's article reminds us of the importance of our
relationship with women in labor, for example, being kind, nice,
welcoming, empathetic, and accepting of her as she is, and how we can
create an atmosphere conducive to birthing by including things like an
unhurried atmosphere, normality, and security.

Expectations, perceptions, and management of labor in nulliparas prior
to hospitalization, Beebe, K, Humphreys, J. J Midwifery Women's Health.
2006 Sep-Oct;51(5):347-53.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16945782>

What constitutes a good childbirth? A qualitative study of pregnant
Finnish women Melender, H-L, [J Midwifery Women's
Health.](javascript:AL_get(this, 'jour', 'J Midwifery Womens Health.');)
2006 Sep-Oct;51(5):331-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16945780>

**Other**

**From Zelda Collett-Paule, CNM, ANMC**

**Delayed cord clamping: Benefits in settings with high levels of
neonatal anemia**

METHODS: This was a randomized, controlled trial performed in 2
obstetrical units in Argentina on neonates born at term without
complications to mothers with uneventful pregnancies.

CONCLUSIONS: Delayed cord clamping at birth increases neonatal mean
venous hematocrit within a physiologic range. Neither significant
differences nor harmful effects were observed among groups. Furthermore,
this intervention seems to reduce the rate of neonatal anemia. This
practice has been shown to be safe and should be implemented to increase
neonatal iron storage at birth.

[Ceriani Cernadas
JM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ceriani+Cernadas+JM"%5BAuthor%5D)
et al The effect of timing of cord clamping on neonatal venous
hematocrit values and clinical outcome at term: a randomized, controlled
trial. [Pediatrics.](javascript:AL_get(this, 'jour', 'Pediatrics.');)
2006 Apr;117(4)\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16567393&dopt=Abstract>

Here is except from the Cochrane Review in [preterm]{.underline} infants

Authors\' conclusions: Delaying cord clamping by 30 to 120 seconds,
rather than early clamping, seems to be associated with less need for
transfusion and less intraventricular haemorrhage. There are no clear
differences in other outcomes.

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

**Use caution when fixing a problem that is not broken**

Luckily the days of significant problems with neonatal anemia among
AI/AN are in the past. I say this because that era was also associated
morbidity and mortality rates that approached those still seen in the
lowest resource developing countries today.

Hence, for those of you who work in developing countries, Cernadas et al
adds a randomized controlled trial to the growing literature that had
previously been reported in pre-term infants. Currently in AI/AN we are
more likely to see problems associated with polycythemia, than
widespread neonatal anemia.

The key will be to rationally apply this practice in a setting where the
problem neonatal anemia does not exist because delay cord clamping can
be associated with adverse effects from the NeoReview listed below

1.) respiratory - grunting, tachypnea

2.) hyperviscosity / plethora - tachypnea, cyanosis, plethora, apnea,
neurologic depression, cardiomegaly, pulmonary congestion, edema,
pleural effusion, irritability

'Why is immediate clamping current practice? '

See 5 reasons stated on page 10 in the NeoReview referenced below

One would need a good indication to set up an AI/AN term infant for the
exchange transfusions, NICU admission to treat hyperviscosity syndrome.
There are indications for exposing term infants to that risk in those
areas of the developing world where early infant anemia is a public
health problem, just not in Indian Country at this time.

**On a somewhat related topic**

....but one that applies to maternal effect of placental management in
Stage III of labor, just not to [infant]{.underline} outcome... Soltani
H -- Cochrane Review

..... in term patients, there does appear to be some potential maternal
benefit from the use of placental cord drainage in terms of reducing the
length of the third stage of labour. More research is required to
investigate the impact of cord drainage on the management of the third
stage of labour.

[Authors\' conclusions:]{.underline} It is difficult to draw conclusions
from such a small number of studies, especially where the review
outcomes were presented in a variety of formats. However, there does
appear to be some potential benefit from the use of placental cord
drainage in terms of reducing the length of the third stage of labour.
More research is required to investigate the impact of cord drainage on
the management of the third stage of labour.

NB: The Soltani discussion refers to draining the blood out into a
basin, not draining the blood into a term infant.

**References**:

Rabe H, Reynolds G, Diaz-Rossello J. Early versus delayed umbilical cord
clamping in preterm infants. The Cochrane Database of Systematic Reviews
2004, Issue 4. Art. No.: CD003248.pub2. DOI:
10.1002/14651858.CD003248.pub2.

<http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions>

Soltani H, Dickinson F, Symonds I. Placental cord drainage after
spontaneous vaginal delivery as part of the management of the third
stage of labour. The Cochrane Database of Systematic Reviews 2005, Issue
4. Art. No.: CD004665.pub2. DOI: 10.1002/14651858.CD004665.pub2.

<http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions>

Phillip AG et al When should we clamp the umbilical cord? NeoReviews
Vol.5 No.4 2004 e142

<http://neoreviews.aappublications.org/cgi/content/extract/5/4/e142>

**Navajo News Jean Howe, Chinle**

**Prevalence of diabetes: Diagnosed Diabetes Among AI/AN Aged \<35
Years**

This report was based on a CDC analysis of Indian Health Service data
and revealed that the age-adjusted prevalence of diabetes among American
Indians and Alaska Natives (AI/AN) aged \<35 increased from 8.5 to 17.1
per 1000 among the 60% of AI/AN who use IHS facilities for care. The
analysis also indicated that the number of AI/AN aged \<35 with diabetes
diagnosed by IHS more than doubled in the decade under study (from 6,001
in 1994 to 12,313 in 2004). Importantly, the annual percentage change
(APC) of diagnosed diabetes was greatest among females aged 25-34 years
of age (9.1%).

The accompanying discussion notes that this dramatic increase could be
due to an increased incidence of diabetes or increased screening for
diabetes or both. As the editor points out, the extraordinary increase
in diabetes in reproductive age women is especially concerning as the
offspring of women with diabetes are at increased risk for having
diabetes themselves as well as for congenital anomalies and perinatal
morbidity and mortality. The long-term health consequences of
early-onset diabetes are particularly daunting.

![](media/image4.wmf){width="5.996527777777778in"
height="2.4409722222222223in"}

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5544a4.htm?s_cid=mm5544a4_e>

**Great, low-cost, fun CME opportunity**

The Telluride Conference, to be held on January 26-28, 2007

This is a great, low-cost, fun CME opportunity attended by many current
IHS providers and IHS alumni. Please share this announcement with anyone
who might be interested at your facilities.

Hope to see you there! <Jean.Howe@ihs.gov>

#### [**http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Jan07**](http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Jan07) {#httpwww.ihs.govmedicalprogramsmchfcn01.cfmjan07 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-45 .Style-Heading-4-+-Arial-14-pt-Underline}

**Nurses Corner, Sandra Haldane, HQE**

#### Exclusively for Nurses: IHS has a Biomedical Librarian / Informationist dedicated to I/T/U {#exclusively-for-nurses-ihs-has-a-biomedical-librarian-informationist-dedicated-to-itu-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Please pass this information on to all nursing staff.  IHS has a clinical Biomedical Librarian / Informationist dedicated to IHS (I/T/U) nursing staff.  Judith Welsh, RN, MLS is available via email on the global or per her contact phone below to assist nurses with literature searches or other NIH Library information needs.  IHS pays NIH Library yearly for the support of informationists so please take advantage of their assistance.  If you do a literature search and find that you need document retrieval because the Library does not carry the document, inter-library loans and retrieval are free of charge to you.  Please go to Judith's link below to access the NIH Library for searching and PLEASE call or email Judith should you require any assistance.  She will walk you through searches if need be and believe me she knows the in's and out's of searching the various databases. {#please-pass-this-information-on-to-all-nursing-staff.-ihs-has-a-clinical-biomedical-librarian-informationist-dedicated-to-ihs-itu-nursing-staff.-judith-welsh-rn-mls-is-available-via-email-on-the-global-or-per-her-contact-phone-below-to-assist-nurses-with-literature-searches-or-other-nih-library-information-needs.-ihs-pays-nih-library-yearly-for-the-support-of-informationists-so-please-take-advantage-of-their-assistance.-if-you-do-a-literature-search-and-find-that-you-need-document-retrieval-because-the-library-does-not-carry-the-document-inter-library-loans-and-retrieval-are-free-of-charge-to-you.-please-go-to-judiths-link-below-to-access-the-nih-library-for-searching-and-please-call-or-email-judith-should-you-require-any-assistance.-she-will-walk-you-through-searches-if-need-be-and-believe-me-she-knows-the-ins-and-outs-of-searching-the-various-databases. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Judith Welsh, RN, MLS [**welshju@ors.od.nih.gov**](mailto:welshju@ors.od.nih.gov) Health Services Research Library 10 Center Drive, Room 1L09B Bethesda, MD 20892-1150 Phone: 301.594.6211  {#judith-welsh-rn-mls-welshjuors.od.nih.gov-health-services-research-library-10-center-drive-room-1l09b-bethesda-md-20892-1150-phone-301.594.6211 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Executive Nurse Fellows Program, Robert Wood Johnson {#executive-nurse-fellows-program-robert-wood-johnson-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Below is information regarding the Robert Wood Johnson Executive Nurse
Fellow\'s Program. This program is exceptional at developing leadership
skills. Deadline for application is Feb. 2007.

Please take a look at the information and consider applying or passing
along to a colleague who is an up and coming executive health care
leader or should be. Thanks, Sandy

The National Program Office is pleased to announce the launch of the
online application for the 2007 cohort of the RWJ Executive Nurse
Fellows Program.

Details about the application process are available at the link below
and the deadline for completed online applications is February 1, 2007.
Please share this information with colleagues who you think would make
great Fellows.
[[http://futurehealth.ucsf.edu/Program/rwj/Default.aspx?tabid=339]{.underline}](http://futurehealth.ucsf.edu/Program/rwj/Default.aspx?tabid=339)

Contact Sally Durgan, 415-502-4594, <sdurgan@thecenter.ucsf.edu>

#### Robert Wood Johnson Executive Nurse Fellows Program home [[http://futurehealth.ucsf.edu/Program/rwj/]{.underline}](http://futurehealth.ucsf.edu/Program/rwj/) {#robert-wood-johnson-executive-nurse-fellows-program-home-httpfuturehealth.ucsf.eduprogramrwj .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-46 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Measuring HIV Risk in the U.S. Population Aged 15-44**

Results from Cycle 6 of the National Survey of Family Growth - This
report presents national estimates of the percentage and number of
persons in the U.S. population aged 15--44 who report behaviors that
place them at increased risk for acquiring or transmitting human
immunodeficiency virus, or HIV. The report also contains data on condom
use and HIV testing by persons who report risk behaviors. In addition,
estimates of self-reported risk for HIV from the Cycle 6 National Survey
of Family Growth are compared with data from other recent national
surveys. Overall, 8.9 percent of persons 15--44 years of age had engaged
in sexual behaviors in the past year that put them at increased risk of
HIV, and 1.5 percent had engaged in drug use behaviors that put them at
risk. In all, an estimated 9.9 percent engaged in either drug use or
sexual behavior that placed them at increased risk for HIV. Including
those who were treated for a sexually transmitted disease in the past
year, 11.9 percent of persons 15--44 years of age---13.0 percent males
and 10.8 percent of females---were at risk of HIV in 2002.

<http://www.cdc.gov/nchs/data/ad/ad377.pdf>

####  {#section-47 .Style-Heading-4-+-Arial-14-pt-Underline}

**HPV and HPV Vaccine: Information for Healthcare (Revised)**

This three page fact sheet provides information on provisional
recommendations, HPV vaccine safety, HPV vaccine efficacy, duration of
vaccine protection, HPV vaccine delivery, cost effectiveness, policies,
other vaccines in development, genital HPV infection, natural history of
HPV, HPV-associated disease, prevention of cervical cancer, and
additional sources of information.
<http://www.cdc.gov/std/HPV/hpv-vacc-hcp-3-pages.pdf>

####  {#section-48 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Preoperative Evaluation**

As we often deal with very healthy patients in our specialty, it is good
to remind ourselves that surgery, even in healthy patients, can have
serious consequences. Fortunately, the majority of the time healthy
patients have very uneventful surgical procedures, but occasionally what
we perceive as a healthy patient may have risk factors that may cause us
to take additional precautions prior to surgery. A preoperative
questionnaire can identify those at risk and can be as useful as a
detailed history and physical. A modified questionnaire

Do you feel unwell?

Have you ever had any serious illnesses in the past?

Do you get any more short of breath on exertions than other people of
your age?

Do you have any coughing?

Do you have any wheezing?

Do you have any chest pain on exertion (anginal type)?

Do you have any ankle swelling?

Have you taken any medicine or pills in the last 3 months including
excess alcohol?

Have you any allergies?

Have you had an anesthetic in the last 2 months?

Have you or your relatives had any problems with a previous anesthetic?

Observation of serious abnormality from "end of bed" which might affect
anesthetic?

What is the date of your last menstrual period?

Recommended lab tests for the preoperative evaluation of the healthy
patient include:

Pregnancy test

Hematocrit for surgery with expected major blood loss

> Serum creatinine if major surgery, hypotension expected, nephrotoxic
> drugs to be used or \>50 yrs

Other lab tests such as LFTs, routine UA, blood glucose have little if
any predictive value of pre or postoperative performance

EKGs should be obtained on: (within 1 month of surgery)

all women \>55 years,

> known cardiac disease,
>
> clinic eval. suggestive of cardiac disease, patient at risk of
> electrolyte abnormality,
>
> systemic disease associated with possible unrecognized heart disease
> (DM or HTN)

Chest x-ray (within 6 months of surgery) for patients over 60 years or
those with suspected cardiac or pulmonary disease.

(Adapted from Wilson, ME, Williams, MB, Baskett, PJ, et al, Br Med J
1980; 1:509)

**Preoperative evaluation of the healthy patient, UpToDate**

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=med_cons/6474>

**Estimation of cardiac risk prior to noncardiac surgery, UpToDate**

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=periart/7170>

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

**Potassium Citrate Beneficial for Osteopenia**

Twelve-month daily alkali therapy with potassium citrate supplements
resulted in a nearly 2% increase in lumbar spine and hip bone mineral
density (BMD) in a small randomized controlled trial of postmenopausal
women with osteopenia. These results suggest that citrate partially
reverses the high acidity of the modern Western diet and that this
promotes better skeletal health.

[Jehle
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Jehle+S"%5BAuthor%5D),
et al Partial neutralization of the acidogenic Western diet with
potassium citrate increases bone mass in postmenopausal women with
osteopenia. [J Am Soc
Nephrol.](javascript:AL_get(this, 'jour', 'J Am Soc Nephrol.');) 2006
Nov;17(11):3213-22

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17035614>

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

#### November is National Diabetes Month: Focus on gestational diabetes (GDM) {#november-is-national-diabetes-month-focus-on-gestational-diabetes-gdm-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### This is a particular kind of diabetes which can start during pregnancy. Research shows women who develop this condition have an increased risk for Type 2 diabetes in future years. Their babies are also at increased risk for developing diabetes as children or adolescents so gestational diabetes is an important public health issue. {#this-is-a-particular-kind-of-diabetes-which-can-start-during-pregnancy.-research-shows-women-who-develop-this-condition-have-an-increased-risk-for-type-2-diabetes-in-future-years.-their-babies-are-also-at-increased-risk-for-developing-diabetes-as-children-or-adolescents-so-gestational-diabetes-is-an-important-public-health-issue. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Here is a helpful newsletter from the University of Alaska Health Science Library {#here-is-a-helpful-newsletter-from-the-university-of-alaska-health-science-library .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.lib.uaa.alaska.edu/hsis/about/newsletters/Oct06.pdf**](http://www.lib.uaa.alaska.edu/hsis/about/newsletters/Oct06.pdf)  {#httpwww.lib.uaa.alaska.eduhsisaboutnewslettersoct06.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-49 .Style-Heading-4-+-Arial-14-pt-Underline}

#### It\'s Never Too Early to Prevent Diabetes: Tip Sheets for Women and Health Care Providers {#its-never-too-early-to-prevent-diabetes-tip-sheets-for-women-and-health-care-providers-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Gestational Diabetes Mellitus (GDM) is a significant risk factor for the
development of diabetes after a pregnancy.  Women with a history of GDM
have a 20-50% chance of developing type 2 diabetes five to 10 years
after the index pregnancy. 

The Diabetes Prevention Program's results suggest that type 2 diabetes
can be prevented or delayed.  These findings apply to many populations,
including women with a history of GDM.  Given these findings, NDEP
developed tip sheets to promote primary prevention efforts  and to
encourage lifestyle changes for women with a history of GDM and their
families. 

The tip sheets encourage women with a history of GDM to get tested for
diabetes; to lose at least 5-7% of their body weight; to be active for
30 minutes, 5 days a week; and to make healthy food choices for their
entire family.

The tip sheets are available in English and Spanish at: 
[www.ndep.nih.gov](../../../../../../../../%5C%5Cwww.ndep.nih.gov). 

You may also view the tip sheet below.

#### [**http://www.ndep.nih.gov/campaigns/SmallSteps/SmallSteps_nevertooearly.htm**](http://www.ndep.nih.gov/campaigns/SmallSteps/SmallSteps_nevertooearly.htm) {#httpwww.ndep.nih.govcampaignssmallstepssmallsteps_nevertooearly.htm .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-50 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Be Prepared: The Boy Scout motto...er...the Maternity Care Provider
motto, too**

CONCLUSION: These data demonstrate that most emergent cesarean
deliveries develop during labor in low-risk women and cannot be
anticipated by prelabor factors. The outcomes demonstrate that infants
are at risk in these clinical situations and suggest that strategies to
improve performance in these clinical situations are important.

[Lagrew
DC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Lagrew+DC"%5BAuthor%5D),
et al Emergent (crash) cesarean delivery: indications and outcomes. [Am
J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Jun;194(6):1638-43; discussion 1643

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16731082>

#### [Editorial comment:]{.underline} George Gilson, MFM, ANMC

**Emergency drills are a good thing..... for your L/D team, and for your
JCAHO accreditation**

Our system expends a large amount of time and effort on ACLS and NRP
that maternity care providers infrequently apply, yet 1:159 deliveries
is a \"crash section\" that we aren\'t prepared for, and subsequent
neonatal outcomes are often poor.

[Lagrew
DC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Lagrew+DC"%5BAuthor%5D),
et al, above, reviews the new \"15 minute rule\", skipping asepsis,
Foley, importance of the clinical team 'in house', that only 13% of them
were associated with VBAC attempts despite the disproportionately strict
VBAC recommendations from our professional organizations, need for staff
drills for cord prolapse, etc,\....a lot of practical information for
small and large facilities.

The Advanced Life Support in Obstetrics (ALSO) model could be helpful if
applied in this setting

<http://www.aafp.org/online/en/home/cme/aafpcourses/clinicalcourses/also.html>

**Adverse neonatal outcomes associated with antenatal dexamethasone vs
betamethasone**

RESULTS: A total of 3600 infants met entry criteria. Compared with no
antenatal steroids, there were trends for a reduced risk for PVL
associated with dexamethasone and betamethasone but no difference in
risk between dexamethasone and betamethasone. Dexamethasone reduced the
risk for IVH and severe IVH, compared with no antenatal steroid
exposure. Betamethasone reduced the risk for IVH, severe IVH, and
neonatal death, compared with no antenatal steroids. Compared with
betamethasone, dexamethasone had a statistically significant increased
risk for neonatal death. There were trends for greater risks associated
with dexamethasone compared with betamethasone for IVH and severe ROP.

CONCLUSIONS: Betamethasone was associated with a reduced risk for
neonatal death, with trends of decreased risk for other adverse neonatal
outcomes, compared with dexamethasone. It may be in the best interest of
neonates to receive betamethasone rather than dexamethasone when
available.

[Lee
BH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Lee+BH"%5BAuthor%5D),
et al Adverse neonatal outcomes associated with antenatal dexamethasone
versus antenatal betamethasone.
[Pediatrics.](javascript:AL_get(this, 'jour', 'Pediatrics.');) 2006
May;117(5):1503-10

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16651303>

**Metformin Exposure During First Trimester Seen Safe for Fetus**

After adjustment for publication bias, metformin was associated with a
statistically significant protective effect of 57%\" against major
malformations in the fetus. This study considered only major
malformations of the fetus. Other studies assessing the incidence of
spontaneous abortion, stillbirth, minor abnormalities, intrauterine
growth retardation and preterm labor still need to be conducted.
CONCLUSION(S): On the basis of the limited data available today, there
is no evidence of an increased risk for major malformations when
metformin is taken during the first trimester of pregnancy. Large
studies are needed to corroborate these preliminary results.

[Gilbert
C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Gilbert+C"%5BAuthor%5D),
[Valois
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Valois+M"%5BAuthor%5D),
[Koren
G](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Koren+G"%5BAuthor%5D).
Pregnancy outcome after first-trimester exposure to metformin: a
meta-analysis. [Fertil
Steril.](javascript:AL_get(this, 'jour', 'Fertil Steril.');) 2006
Sep;86(3):658-63.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16879826>

**Predicting glyburide failure is difficult, not associated with adverse
pregnancy outcomes**

RESULTS: Of the 235 gestational diabetics identified, 79% of the 101
A2DMs were successfully treated with glyburide as first-line therapy.
Those that failed had a higher mean glucose value on glucose challenge
test (GCT) (200.5 +/- 57.3 vs 176.6 +/- 33.8 mg/dL, P = .019) and were
more likely to have a GCT \> or = 200 mg/dL (45 vs 22%, P = .043). Only
GCT and GCT \> or = 200 mg/dL were predictive of failure.

CONCLUSION: Predicting glyburide failure is difficult, but failure does
not appear to be associated with increased adverse pregnancy outcomes.

[Rochon
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Rochon+M"%5BAuthor%5D),
et al Glyburide for the management of gestational diabetes: risk factors
predictive of failure and associated pregnancy outcomes. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Oct;195(4):1090-4.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17000241>

**The current pregnancy loss rate after amniocentesis is closer to 1 in
1,600**

CONCLUSION: The procedure-related fetal loss rate after midtrimester
amniocentesis performed on patients in a contemporary prospective
clinical trial was 0.06%. There was no significant difference in loss
rates between those undergoing amniocentesis and those not undergoing
amniocentesis. LEVEL OF EVIDENCE: II-2.

[Eddleman
KA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Eddleman+KA"%5BAuthor%5D),
et al Pregnancy Loss Rates After Midtrimester Amniocentesis. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Nov;108(5):1067-1072.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17077226&dopt=Abstract>

**Treatment of periodontitis: Is it a case of association does not imply
causation ?**

CONCLUSIONS: Treatment of periodontitis in pregnant women improves
periodontal disease and is safe but does not significantly alter rates
of preterm birth, low birth weight, or fetal growth restriction.

[Michalowicz
BS](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Michalowicz+BS"%5BAuthor%5D),
et al Treatment of periodontal disease and the risk of preterm birth. [N
Engl J Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2006 Nov
2;355(18):1885-94.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17079762&dopt=Abstract>

**Insulin drip versus rotation of IV fluids between glucose and
non-glucose containing fluids**

CONCLUSION: In patients with insulin requiring gestational diabetes,
intrapartum glycemic control may be comparable with a standard adjusted
insulin drip or a rotation of intravenous fluids between glucose and
non-glucose containing fluids.

Rosenberg VA; Eglinton GS; Rauch ER; Skupski DW Intrapartum maternal
glycemic control in women with insulin requiring diabetes: a randomized
clinical trial of rotating fluids versus insulin drip. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Oct;195(4):1095-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16893507>

**No Benefit for Delivering Twins by 38 Weeks\' Gestation**

CONCLUSION: This study suggests that the optimal date of delivery for
twins should be \<40 weeks of gestation; there was no compelling
evidence for delivering at \<38 weeks of gestation.

[Soucie
JE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Soucie+JE"%5BAuthor%5D),
et al Neonatal mortality and morbidity rates in term twins with
advancing gestational age. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Jul;195(1):172-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16579946>

**Diagnostic accuracy of noninvasive fetal Rh genotyping from maternal
blood**

CONCLUSION: The diagnostic accuracy of noninvasive fetal Rh
determination using maternal peripheral blood is 94.8%. Its use can be
applicable to Rh prophylaxis and to the management of Rh alloimmunized
pregnancies. Improvements of the technique and further study of
structure and rearrangements of the RhD gene may improve accuracy of
testing and enable large-scale, risk-free fetal RhD genotyping using
maternal blood.

[Geifman-Holtzman
O](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Geifman-Holtzman+O"%5BAuthor%5D),
et al Diagnostic accuracy of noninvasive fetal Rh genotyping from
maternal blood\--a meta-analysis. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Oct;195(4):1163-73

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17000250>

**Maternal exposure to low levels of ambient air pollution is associated
with preterm birth**

METHODS: Average maternal exposure estimates for ambient particulate
matter (PM(10) and bsp), ozone (O(3)) and nitrogen dioxide were
calculated over the first 3 months after last menstrual period (LMP) and
the last 3 months prior to birth (individually and combined as
trimesters).

RESULTS: Exposure to PM(10) and O(3) during trimester one was associated
with an increased risk of PTB (OR = 1.15, 95% CI 1.06-1.25 and OR =
1.26, 95% CI 1.10-1.45, respectively). The PM(10) exposure effect
associated with trimester one was strongly related to exposure during
the first month post-LMP (PM(10), month one; OR = 1.19, 95% CI
1.13-1.26).

CONCLUSION: These results suggest that maternal exposure to low levels
of ambient air pollution is associated with PTB.

Hansen C; Neller A; Williams G; Simpson R Maternal exposure to low
levels of ambient air pollution and preterm birth in Brisbane,
Australia. [BJOG.](javascript:AL_get(this, 'jour', 'BJOG.');) 2006
Aug;113(8):935-41

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16907939>

**Antenatal hydronephrosis as a predictor of postnatal outcome: Even
mild findings**

CONCLUSIONS: The findings of this meta-analysis can potentially be used
for prenatal counseling and may alter current postnatal management of
children with antenatal hydronephrosis. Overall, children with any
degree of antenatal hydronephrosis are at greater risk of postnatal
pathology as compared with the normal population. Moderate and severe
antenatal hydronephrosis have a significant risk of postnatal pathology,
indicating that comprehensive postnatal diagnostic management should be
performed. Mild antenatal hydronephrosis may carry a risk for postnatal
pathology, but additional prospective studies are needed to determine
the optimal management of these children. A well-defined prospective
analysis is needed to further define the risk of pathology and the
appropriate management protocols.

Lee RS; Cendron M; Kinnamon DD; Nguyen HT Antenatal hydronephrosis as a
predictor of postnatal outcome: a meta-analysis. [Pediatrics.  2006;
118(2):586-93](http://www.medscape.com/medline/publicationbrowser/123?pmid=16882811) 

<http://www.medscape.com/medline/abstract/16882811?cid=med&src=nlbest>

**With prior PTD, 17 hydroxyprogesterone caproate results in
cost-savings**

OBJECTIVE: To evaluate whether the use of 17alpha-hydroxyprogesterone
caproate for the prevention of recurrent preterm deliveries is
cost-effective.

CONCLUSION: Within our baseline assumptions, 17alpha-hydroxyprogesterone
caproate was associated with cost-savings when used for the prevention
of preterm deliveries in women with prior preterm deliveries.

[Odibo
AO](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Odibo+AO"%5BAuthor%5D),
et al 17alpha-hydroxyprogesterone caproate for the prevention of preterm
delivery: A cost-effectiveness analysis. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Sep;108(3 Pt 1):492-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16946206&dopt=Abstract>

**Impact of the recent randomized trials on the use of progesterone to
prevent preterm birth**

CONCLUSION: Although the use of progesterone to prevent PTB has
increased significantly since our last survey, there remain a
substantial number of nonusers. Among users, many are using it for
indications not yet proven in clinical trials. Current nonusers have
higher levels of concerns compared to nonusers in the first survey and
their major concern is the need for more data.

[Ness
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Ness+A"%5BAuthor%5D),
et al Impact of the recent randomized trials on the use of progesterone
to prevent preterm birth: a 2005 follow-up survey. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Oct;195(4):1174-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17000251>

**BV with Ureaplasma enhances risk of preterm delivery, SGA, and low
birth weight**

OBJECTIVE: To examine associations of vaginal Ureaplasma urealyticum
(UU) and bacterial vaginosis (BV) with preterm delivery (PTD), small for
gestational age (SGA), and low birth weight (LBW). CONCLUSION: This
analysis suggests that UU is independently associated with fetal growth
and LBW and that BV with UU may enhance the risk of these outcomes.

Vogel I; Thorsen P; Hogan VK; Schieve LA; Jacobsson B; Ferre CD The
joint effect of vaginal Ureaplasma urealyticum and bacterial vaginosis
on adverse pregnancy outcomes. [Acta Obstet Gynecol
Scand.](javascript:AL_get(this, 'jour', 'Acta Obstet Gynecol Scand.');)
2006;85(7):778-85.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16817073>

Do Antioxidants Prevent Preeclampsia?

Dysfunction in the antioxidant defenses has been suggested as an
important factor in the pathogenesis of preeclampsia. Patients were
randomized to receive vitamin C (1,000 mg) and vitamin E (400 IU) or
placebo daily, beginning between 14 and 22 weeks\' gestation.

There were no differences in the risks of preeclampsia or other primary
outcome measures between the supplementation and placebo groups.
Furthermore, among women who developed preeclampsia, there were no
differences between the two groups in the time of onset or the severity.
One limitation noted by the authors was that the trial participants had
a high dietary intake of vitamins C and E at baseline, so the results
may not be applicable to women with low dietary antioxidant intake.
Trials with women at increased risk of preeclampsia are ongoing.

**Conclusions:** The authors do not recommend vitamin C or E
supplementation to reduce preeclampsia or other serious outcomes.

Rumbold AR, et al., for the ACTS Study Group. Vitamins C and E and the
risks of preeclampsia and perinatal complications. N Engl J Med April
27, 2006;354:1796-806.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16641396>

**A single course of antenatal corticosteroids should be considered
routine for PTD**

AUTHORS\' CONCLUSIONS: The evidence from this new review supports the
continued use of a single course of antenatal corticosteroids to
accelerate fetal lung maturation in women at risk of preterm birth. A
single course of antenatal corticosteroids should be considered routine
for preterm delivery with few exceptions. Further information is
required concerning optimal dose to delivery interval, optimal
corticosteroid to use, effects in multiple pregnancies, and to confirm
the long-term effects into adulthood.

[Roberts
D](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Roberts+D"%5BAuthor%5D),
[Dalziel
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Dalziel+S"%5BAuthor%5D).
Antenatal corticosteroids for accelerating fetal lung maturation for
women at risk of preterm birth. [Cochrane Database Syst
Rev.](javascript:AL_get(this, 'jour', 'Cochrane Database Syst Rev.');)
2006 Jul 19;3:CD004454

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16856047>

**Vaginal birth after cesarean delivery in twin gestations: Similar
rupture rates as singletons**

CONCLUSION: Our study showed a significantly higher rate of uterine
rupture in the trial of labor group that is similar to the rates
reported for trial of labor after cesarean in singleton pregnancies.

[Ford
AA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Ford+AA"%5BAuthor%5D),
et al Vaginal birth after cesarean delivery in twin gestations: a large,
nationwide sample of deliveries. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Oct;195(4):1138-42

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17000246>

**Impact of time of day on cesarean complications**

CONCLUSION: Maternal and neonatal complications of cesarean delivery do
not increase with delivery during the night shift.

[Bailit
JL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Bailit+JL"%5BAuthor%5D),
et al The MFMU Cesarean Registry: impact of time of day on cesarean
complications. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Oct;195(4):1132-7

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16875648>

**Increasing birth weight relative to the first birth weight diminishes
the VBAC success**

CONCLUSION: For women with previous cesarean delivery for dystocia,
increasing birth weight in the subsequent trial of labor relative to the
first birth weight diminishes the chances of successful vaginal
delivery.

[Peaceman
AM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Peaceman+AM"%5BAuthor%5D),
et al The MFMU Cesarean Registry: impact of fetal size on trial of labor
success for patients with previous cesarean for dystocia. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Oct;195(4):1127-31

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17000245>

**Consider TOL for women undergoing preterm delivery with a history of
prior cesarean**

CONCLUSION: The likelihood of VBAC success after TOL in preterm
pregnancies is comparable to term gestations, with a lower risk of
uterine rupture. Perinatal outcomes are similar with preterm TOL and
RCD. TOL should be considered as an option for women undergoing preterm
delivery with a history of prior cesarean delivery.

[Durnwald
CP](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Durnwald+CP"%5BAuthor%5D),
et al The Maternal-Fetal Medicine Units Cesarean Registry: safety and
efficacy of a trial of labor in preterm pregnancy after a prior cesarean
delivery. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Oct;195(4):1119-26

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17000244>

**Aggressive potent glucocorticoids constitute the cornerstone of
management HELLP**

We recommend for the present that aggressively used potent
glucocorticoids constitute the cornerstone of management for patients
considered to have HELLP syndrome. Use of dexamethasone 12 mg IM q12h
for HELLP improves the platelet count. Nevertheless, giving steroids
does not prevent the serious sequelae of maternal death, abruption,
intracranial hemorrhage, hepatic hematoma, and perinatal outcome. The
advantage of a platelet count \>100.000 is that one can have regional
anesthesia and a vaginal delivery, but beyond that, steroids have little
impact.

[Martin JN
Jr](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Martin+JN+Jr"%5BAuthor%5D),
et al Understanding and managing HELLP syndrome: the integral role of
aggressive glucocorticoids for mother and child. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Oct;195(4):914-34

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16631593>

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

#### December 1, 2006

**Causes of Type 2 Diabetes: Old and New Understandings**

**Moderator: Ann Bullock M.D.**

In 2002, the International Diabetes Federation determined that the
medical literature supports 4 etiologies of type 2 diabetes:

\--Genetics

\--Fetal Origins

\--Lifestyle

\--Stress

**We will explore these issues**

-   Diabetes prevention programs focus on lifestyle modification---what
    might these programs look like if lifestyle is only one factor?

-   What else can be learned from the DPP (Diabetes Prevention Program)?

-   Pregnancy and early life risk factors

-   What are the particular roots of the diabetes and obesity epidemics
    in Indian Country

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

Subscribe to the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51>

Unsubscribe from the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51>

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

**STD Corner - Lori de Ravello, National IHS STD Program**

**IHS Consent Form for an HIV Antibody Test is Hereby Cancelled**

On September 22, 2006, the Center for Disease Control (CDC) issued
revised recommendations for HIV testing of adults, adolescents, and
pregnant women in health care settings. The recommendations for patients
in all health-care setting is that a separate written consent for HIV
testing should not be required; general consent for medical care should
be considered sufficient to encompass consent for HIV testing.  To
remove any barriers in implementing the CDC recommendations, IHS Form
509\*, previously required by the IHS as a separate and specific patient
consent form for an HIV antibody test, is hereby cancelled and no longer
recommended. If a facility chooses to implement these recommendations
and is within state guidelines, patients still must be informed orally
or in writing (and documented) that HIV testing will take place --
unless they decline the test (opt-out screening). Cancellation of Form
509 does not mean IHS mandates full implementation of CDC
recommendations. Rather, it has removed an existing form that may create
a barrier within IHS to implementing more streamlined processes for HIV
testing. Depending upon individual state guidelines and relationships,
local facilities may choose to fully or partially implement all or some
of CDC recommendations. More time is needed this year to assess how
these recommendations are adopted at the state level and how CDC will
identify and manage implementation barriers and challenges.

\*NOTICE OF HIV ANTIBODY TEST INFORMATION AND AUTHORIZATION FOR HIV
ANTIBODY TEST - IHS Form 509

If you should have questions regarding the CDC recommendations and/or
IHS policy and guidelines on HIV testing, please contact CDR Scott
Giberson, National IHS HIV/AIDS Principal Consultant, by phone at (301)
443-4644 or by e-mail at <Scott.Giberson@ihs.gov>

**Check out our new IHS STD website**

<http://www.ihs.gov/medicalprograms/epi/index.cfm?module=health_issues&option=std&cat=sub_0>

**Adapting condoms to community values in Native American communities:
Snag bags**

HIV/AIDS researchers working among Native Americans have consistently
noted resistance to discussions of sexuality and the distribution of
condoms. This resistance is inspired by long held values about shame and
public discussions of sexuality. Also, American Indians have been
reluctant to welcome public discussions of HIV/AIDS and sexuality from
external entities, such as governmental agencies. As a result, Native
peoples have some of the lowest documented condom use rates. However,
innovations in culturally integrating condoms and safe sex messages into
Native cultural ideals are proving beneficial. One such innovation is
the snag bag, which incorporates popular Native sexual ideology while
working within local ideals of shame to distribute condoms and safe sex
materials to sexually active young people and adults. Using snag bags as
an example, this research proposes that an effective approach to HIV
prevention among Native peoples is not cultural sensitivity but cultural
integration. That is, HIV prevention strategies must move beyond the
empty promise of merely culturally-sensitizing ideas about disease
cause. Instead of simply \'translating\' HIV/AIDS programming into
Native culture, prevention strategies must be integrated by Native
peoples into their own disease theories and contemporary

[Gilley
BJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Gilley+BJ"%5BAuthor%5D).
\'Snag bags\': Adapting condoms to community values in Native American
communities. [Cult Health
Sex.](javascript:AL_get(this, 'jour', 'Cult Health Sex.');) 2006
Nov-Dec;8(6):559-70.

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17050386**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17050386) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17050386 .Style-Heading-4-+-Arial-14-pt-Underline}

**Barriers to condom purchasing: Effects of product positioning on
reactions to condoms**

Correct and consistent condom use has been promoted as a method to
prevent sexually transmitted infections including HIV. Yet research has
repeatedly shown that people fail to use condoms consistently. One
influence on the pervasive lack of condom use that has received
relatively little attention is the context in which consumers are
exposed to condoms (i.e., how condoms are displayed in retail settings).
In this paper we present two studies explored variations in condom shelf
placement and its effects on people\'s condom attitudes and acquisition.
Study 1 explored the shelf placement of condoms in 59 retail outlets in
Connecticut, USA and found that condoms were typically located in areas
of high visibility (e.g., next to the pharmacy counter) and on shelves
adjacent to feminine hygiene and disease treatment products. In Study 2,
120 heterosexual undergraduate students at the University of Connecticut
were randomly assigned to evaluate condoms adjacent to sensual,
positive, neutral, or negative products and found that overall men
reported more positive attitudes and acquired more condoms when exposed
to condoms in a sensual context compared to women in the same condition.
Among women, condom attitudes were more positive in the context of
neutral products; condom acquisition was strongest for women exposed to
condoms in the positive aisles. These results suggest a gender-specific
approach to condom promotion. Implications of these studies for HIV
prevention, public health, and condom marketing strategies are
discussed.

[Scott-Sheldon
LA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Scott-Sheldon+LA"%5BAuthor%5D),
et al Barriers to condom purchasing: Effects of product positioning on
reactions to condoms Social Science & Medicine,   [Soc Sci
Med.](javascript:AL_get(this, 'jour', 'Soc Sci Med.');) 2006
Dec;63(11):2755-69.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16962220>

####  {#section-51 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Interventions for Molluscum Contagiosum: Cochrane Briefs {#interventions-for-molluscum-contagiosum-cochrane-briefs-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Clinical Question

Is there an effective treatment for molluscum contagiosum?

Evidence-Based Answer

There is insufficient evidence to determine whether treatments for
molluscum are effective.

Practice Pointers

Molluscum contagiosum, a poxvirus skin infection that largely affects
children and adolescents, presents as single or multiple painless white
papules with a central dimple. Lesions enlarge slowly and may reach a
diameter of 0.2 to 0.4 inches (5 to 10 mm) in six to 12 weeks. After
trauma, or spontaneously after several months, inflammatory changes
result in the production of pus, crusting, and eventual destruction of
the lesions. Most cases are self-limited and resolve within six to nine
months. Treatments include cryotherapy, expression or pricking with a
sterile needle, topical preparations (e.g., podofilox \[Condylox\],
liquefied phenol, tretinoin \[Retin-A\], cantharidin, potassium
hydroxide), and systemic treatment (e.g., cimetidine \[Tagamet\]).1

Five randomized controlled trials addressing the effectiveness of
different topical treatments for raised molluscum lesions were
identified. The participants included children, adolescents, and adults
with molluscum. Immunocompromised patients and those with genital
molluscum were excluded. The studies reported medium and long-term cure
rates, time to cure, and adverse effects for the following treatments:
povidone iodine plus salicylic acid (Keralyt); sodium nitrite plus
salicylic acid; potassium hydroxide; systemic cimetidine; and calcarea
carbonica (a homeopathic and impure form of calcium carbonate). No
studies examined cryotherapy or needle expression. The included studies
followed a total of 137 participants, with numbers of participants in
each study ranging from 20 to 38. Overall, these studies were limited by
small size and high drop-out rates, and some did not include an
intention-to-treat analysis.

Only one study showed a statistically significant difference in the rate
of complete cure in the treatment group. This study (n = 30)
demonstrated that treatment with 5% sodium nitrite coapplied daily with
5% salicylic acid under occlusion resulted in a significantly higher
rate of lesion cure after three months than treatment with salicylic
acid alone (12 out of 16 participants \[75 percent\] compared with three
out of 14 participants \[21 percent\], respectively \[number needed to
treat = 2\]). The mean number of treatment days was lower in the
treatment group than in the control group (38 versus 49 days,
respectively). Adverse effects of the sodium nitrite plus salicylic acid
treatment included brown staining of skin and irritation.

Another study (n = 35) found a shorter mean time to cure in the group
treated with iodine plus salicylic acid plaster compared with iodine
alone or salicylic plaster alone (26, 86, and 47 days, respectively).
There was no significant difference in complete cure rates between the
groups treated with 10% povidone iodine solution plus 50% salicylic acid
plaster compared with povidone iodine alone (100 versus 60 percent
\[risk ratio = 1.67; 95% confidence interval, 0.81 to 3.41\]). All
participants developed redness of the skin at the treatment site within
three to seven days after the start of the treatment.

The other three studies included in the review showed no significant
difference in complete cure or lesion improvement with the use of
topical 10% potassium hydroxide, systemic cimetidine, or calcarea
carbonica compared with the placebo groups.

In the absence of evidence about treatment effectiveness, many experts
recommend watchful waiting.

**-**van der Wouden JC, et al. Interventions for cutaneous molluscum
contagiosum. Cochrane Database Syst Rev 2006;(2):CD004767.

-Sladden MJ, Johnston GA. Common skin infections in children. BMJ
2004;329:95-9.

#### [**http://www.aafp.org/afp/20061101/cochrane.html#c1**](http://www.aafp.org/afp/20061101/cochrane.html#c1) {#httpwww.aafp.orgafp20061101cochrane.htmlc1 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-52 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-53 .Style-Heading-4-+-Arial-14-pt-Underline}

# Females Aged 15\--44 Years Ever Treated for Pelvic Inflammatory Disease, 2002

![](media/image5.png){width="5.102777777777778in" height="3.4375in"}

In 2002, the percentage of females aged 15\--44 years reporting that
they had ever been treated for PID varied by age at first vaginal
intercourse and by number of male sex partners in the preceding 12
months. Higher prevalence of PID treatment was reported among females
who had their first vaginal intercourse at younger ages, particularly
\<15 years, and among those who had greater numbers of male sex partners
in the preceding 12 months.

SOURCE: Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility,
family planning, and reproductive health of U.S. women: data from the
2002 National Survey of Family Growth. Vital Health Stat 2005;23(25).

#### [**http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5543a8.htm?s_cid=mm5543a8_e**](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5543a8.htm?s_cid=mm5543a8_e) {#httpwww.cdc.govmmwrpreviewmmwrhtmlmm5543a8.htms_cidmm5543a8_e .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-54 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Barbara Stillwater Alaska State Diabetes Program  {#barbara-stillwater-alaska-state-diabetes-program .Style-Heading-4-+-Arial-14-pt-Underline}

**Gestational Diabetes Linked to High Prevalence of Periodontal
Disease**

OBJECTIVE: We examined the relationship between periodontal disease and
different types of diabetes in pregnant and nonpregnant women. STUDY
DESIGN: This study was based on the data from the third National Health
and Nutrition Examination Survey (NHANES III), including 256 pregnant
and 4234 nonpregnant women. Women were classified into those with
gestational diabetes mellitus (GDM) in current pregnancy, with GDM in
previous pregnancy, and with type 1 or 2 diabetes. RESULTS: In pregnant
women, the prevalence of periodontitis was 44.8% in women with GDM and
13.2% in nondiabetic women, with adjusted odds ratio (aOR) of 9.11 (95%
confidence interval \[CI\] 1.11-74.9). In nonpregnant women, the
prevalence of periodontitis was 40.3% in women with type 1 or 2
diabetes, 25.0% in women with previous history of GDM, and 13.9% in
nondiabetic women, with aOR of 2.76 (1.03-7.35) for women with type 1 or
2 diabetes. CONCLUSION: We found an association between periodontal
disease and GDM.

#### [Editorial comment:]{.underline} Todd Smith, DDS, MSD IHS Periodontal Consultant

It is not surprising that there was a significant, positive association
between periodontitis and GDM. Both pregnancy and diabetes are
associated with increased inflammation in the gums and tissues
surrounding the teeth. The same microvascular changes occurring
throughout the body in patients with diabetes (ie formation of advanced
glycation end products, increased cross linking of collagen and
accumulation in blood vessel walls, vascular smooth muscle proliferation
with narrowing of the lumen, poor oxygenation and perfusion) occurs in
the periodontal tissues. Taylor (2004) reported in a review of 55
studies involving subjects with dm that there was consistent evidence of
greater periodontitis prevalence, incidence, severity, and progression.
This relationship appears to be bidirectional, with the chronic,
gram-negative anaerobic infection of periodontitis perpetuating a
systemic inflammatory state with a resultant increase in insulin
resistance and aggravation of glycemic control. This is supported in
treatment studies where treatment of periodontitis has been associated
with significant drops in HbA1c.

 

The same may be true for pregnancy and periodontitis. The systemic
inflammation associated with periodontitis, with bacteremia and
increases in PgE2, TNF-α, Il-1 and --6, and CRP, has been associated
with adverse pregnancy outcomes such as PTB, LBW, and preeclampsia
(Offenbacher, Jeffcoat, Boggess, Radnai, and others). Some studies have
demonstrated a decrease in prevalence of adverse pregnancy outcomes with
periodontal therapy during the second trimester; the most recent in the
NEJM did not. A larger multicenter periodontal treatment study with 1800
patients is ongoing and due to be published within 2 years. In the
meantime, if your patients are having trouble controlling their blood
sugar, or are pregnant, look in their mouths to see how healthy the gums
look. Expectant mothers should be counseled in the importance of oral
health, and referral to a dentist is strongly recommended.

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

**Diabetes can impair the healing process: May result in increased
periodontal disease**

There was a presentation / overview of studies on periodontal disease
and birth outcomes at the 2006 National Oral Health Conference.  The
summary was that studies are building the case for links of periodontal
disease and adverse birth outcomes.  The conclusion of the presenters
that we aren\'t quite yet in the position to make very strong statements
about causation but the studies have pointed to clear associations with
some evidence of biological plausibility and a couple of intervention
studies indicating that treatment of periodontal disease during
pregnancy can reduce the risk of adverse birth outcomes or the mother\'s
health (preeclampsia, preterm birth and low birth-weight). 

[Xiong
X](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Xiong+X"%5BAuthor%5D),
et al might assist in identification of women most at-risk.  Generally,
the indications are still not that diabetes causes periodontal disease. 
The model has generally been that diabetes can impair the healing
process so it is that aspect that can result in increased periodontal
disease.  It is clear that individuals with diabetes are at much greater
risk for periodontal disease and this study seems to support that is the
case even with gestational diabetes. 

 

It is hoped that NIH, CDC and others to be doing consensus conferences
over the next year or two for review of the studies and literature to
make more definitive statements about roles of periodontal disease in
relation to pregnancy and birth outcomes. 

**References:**

[Xiong
X](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Xiong+X"%5BAuthor%5D),
et al Periodontal disease and gestational diabetes mellitus. [Am J
Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Oct;195(4):1086-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16846573>

Taylor GW et al. Diabetes, periodontal diseases, dental caries, and
tooth loss: a review of the literature. Compendium of Contin Ed in Dent
2004. Mar;25(3):179-84, 186-8, 190

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15641324>

**Other Background:**

Southerland, Taylor, Offenbacher. Diabetes and Periodontal Infection:
Making the Connection. Clinical Diabetes. Fall 2005. Vol23, Issue 4.
171.

 

Offenbacher. Periodontal infection as a possible risk factor for preterm
low birth weight. J. Periodontol 1996. 67: 1103-1113.

Jeffcoat et al. Periodontal disease and preterm birth: Results of a
pilot intervention study. J Periodontol 2003; 74: 1214-1218

Boggess et al. Maternal periodontal disease is associated with increased
risk for preeclampsia. Obstet gynecol 2003; 101:227-231.

Radnai etal. A possible association between preterm birth and early
periodontitis. A pilot study. J Clin Periodontol 2004. Sep;31(9):736-41

**Physical activity before pregnancy or during pregnancy reduces
gestational diabetes**

CONCLUSION: Physical activity, especially vigorous activity before
pregnancy and at least light-to-moderate activity during pregnancy, may
reduce risk for abnormal glucose tolerance and GDM. LEVEL OF EVIDENCE:
II-2.

[Oken
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Oken+E"%5BAuthor%5D),
[Ning
Y](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ning+Y"%5BAuthor%5D),
[Rifas-Shiman
SL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Rifas-Shiman+SL"%5BAuthor%5D),
[Radesky
JS](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Radesky+JS"%5BAuthor%5D),
[Rich-Edwards
JW](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Rich-Edwards+JW"%5BAuthor%5D),
[Gillman
MW](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Gillman+MW"%5BAuthor%5D).
Associations of physical activity and inactivity before and during
pregnancy with glucose tolerance. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Nov;108(5):1200-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17077243&dopt=Abstract>

**Mothers with type 2 diabetes during pregnancy can transmit risk
factors to their children**\
Type 2 diabetes is the result of both genetic and environmental factors.
Fetal exposure to maternal diabetes is associated with a higher risk of
abnormal glucose homeostasis in offspring beyond that attributable to
genetic factors, and therefore, may participate in the excess of
maternal transmission of type 2 diabetes.

A MEDLINE search covering the period from 1960--2005. In studies
performed in children and adolescents suggest that offspring who had
been exposed to maternal diabetes during fetal life exhibit higher
prevalence of impaired glucose tolerance and markers of insulin
resistance. Recent studies that directly measured insulin sensitivity
and insulin secretion have shown an insulin secretory defect even in the
absence of impaired glucose tolerance in adult offspring. In animal
models, exposure to a hyperglycemic intrauterine environment also led to
the impairment of glucose tolerance in the adult offspring. These
metabolic abnormalities were transmitted to the next generations,
suggesting that in utero exposure to maternal diabetes has an epigenetic
impact. At the cellular level, some findings suggest an impaired
pancreatic ß-cell mass and function. Several mechanisms such as defects
in pancreatic angiogenesis and innervation, or modification of parental
imprinting, may be implicated, acting either independently or in
combination.

Therefore it was concluded that, fetal exposure to maternal diabetes may
contribute to the worldwide diabetes epidemic. Public health
interventions targeting high-risk populations should focus on long-term
follow-up of subjects who have been exposed in utero to a diabetic
environment and on a better glycemic control during pregnancy.\
[Fetita
LS](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Fetita+LS"%5BAuthor%5D),
et al Consequences of Fetal Exposure to Maternal Diabetes in Offspring
Journal of Clinical Endocrinology & Metabolism Vol. 91, No. 10 3718-3724

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16849402&dopt=Abstract>

**Does coffee reduce the risk of type 2 diabetes in individuals with
impaired glucose?**

In a large study, current and past coffee consumption reduced the risk
for type 2 diabetes by 60% compared with those who did not drink coffee.

RESULTS: Past and current coffee drinkers had a reduced risk of incident
diabetes (odds ratio 0.38 \[95% CI 0.17-0.87\] and 0.36 \[0.19-0.68\],
respectively) compared with those who never drank coffee. CONCLUSIONS:
This study confirms a striking protective effect of caffeinated coffee
against incident diabetes and extends these findings to incident
diabetes based on OGTT independent of multiple plausible confounders.

[Smith
B](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Smith+B"%5BAuthor%5D),
et al Does coffee consumption reduce the risk of type 2 diabetes in
individuals with impaired glucose? [Diabetes
Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');) 2006
Nov;29(11):2385-90

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17065672>

**Every kilogram of weight loss resulted in 16% reduction of diabetes
risk**

Among participants in the intensive lifestyle intervention arm of the
Diabetes Prevention Program, weight reduction had the strongest effect
on reduction of diabetes risk compared with diet and physical activity.
The Diabetes Prevention Program (DPP) reported a 58% reduction in the
incidence of diabetes over almost three years in \[participants\]
treated with an intensive lifestyle intervention compared with
participants treated with placebo.

[Hamman
RF](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Hamman+RF"%5BAuthor%5D),
et al Effect of weight loss with lifestyle intervention on risk of
diabetes.

[Diabetes Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');)
2006 Sep;29(9):2102-7

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16936160>

[**New Measure Predicts Blood Glucose Variability in Diabetics\
**](http://mp.medscape.com/cgi-bin1/DM/y/hBCAp0Ou5N60Dzc0H2WM0Eb)Traditionally,
statistical estimation of glycemic variability includes computing
standard deviation of glucose readings or related statistics (eg, M
value, mean amplitude of glucose excursions, and so forth). We advocate
an alternative approach using risk measures of variability, which have
substantial clinical and numerical advantages. In addition, continuous
glucose monitoring (CGM) data have clinically important inherent
temporal structure that should be taken into consideration. Thus,
temporal variability methods are discussed for the analysis and
interpretation of CGM output. [Kovatchev
BP](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Kovatchev+BP"%5BAuthor%5D).
Is glycemic variability important to assessing antidiabetes therapies?
[Curr Diab Rep.](javascript:AL_get(this, 'jour', 'Curr Diab Rep.');)
2006 Nov;6(5):350-6

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17076995>

**Racial/Ethnic and Socioeconomic Differences in Multiple Risk Factors
for Heart Diseases and Stroke in Women: Behavioral Risk Factor
Surveillance System, 2003**\
Heart disease and stroke are among the leading causes of death in women.
The risk of heart disease and stroke can be reduced by controlling risk
factors such as high blood pressure, high cholesterol, diabetes,
smoking, obesity and physical inactivity.  This CDC study shows that
over a third of U.S. women have two or more of these risk factors with
significant disparities among socioeconomic and racial/ethnic groups.
Those who were older, less educated, unemployed, and with a lower income
were more likely to have multiple risk factors. Black and Native
American women were at increased risk, while Hispanic women were at
lower risk, compared to white women. To decrease the disproportionate
burden of multiple risk factors on minority populations, public health
programs should focus on improving identification and treatment of
affected women and promote policy and lifestyle changes conducive to
cardiovascular health.

Hayes DK, et al Racial/Ethnic and Socioeconomic Differences in Multiple
Risk Factors for Heart Diseases and Stroke in Women: Behavioral Risk
Factor Surveillance System, 2003. Journal of Women's Health
<http://www.liebertonline.com/jwh>

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

**22nd Annual Midwinter Indian Health OB/PEDS Conference**

-   For providers caring for Native women and children

-   January 26-28, 2007

-   Telluride, CO

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

**TeenScreen Conference: Second Annual**

-   March 14 and 15, 2007

-   Washington D.C.

-   Contact <TSConference@childpsych.columbia.edu>

**2nd** **International Meeting on Indigenous Child Health**

-   April 20-22, 2007

-   Montreal, Quebec, Canada

-   Solutions, not Problems

-   Joint meeting of IHS, AAP-CONACH, First Nations and several other
    stakeholders

-   <http://www.aap.org/nach/2InternationalMeeting.htm>

**2007 Indian Health MCH and Women's Health National Conference**

-   August 15 -17, 2007

-   Albuquerque, NM

-   THE place to be for anyone involved in care of AI/AN women, children

-   Internationally recognized speakers

-   Save the dates. Details to follow

-   Want a topic discussed? Contact <nmurphy@scf.cc>

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

**What medications, foods, and beverages irritate the bladder?**

<http://www.ihs.gov/MedicalPrograms/MCH/W/documents/BLADDERIRRITANTS.doc>

[**CDC Compendium of Domestic Violence Assessment
Tools**](http://www.ihs.gov/MedicalPrograms/MCH/V/DV01.cfm#Compendium)

<http://www.ihs.gov/MedicalPrograms/MCH/V/DV01.cfm#Compendium>

**[Compendium of State Laws](http://www.ucsf.edu/hivcntr/) Impacting HIV
Screening and Treatment**

<http://www.ihs.gov/MedicalPrograms/MCH/W/stdHiv.cfm#PregScrn>

There are several upcoming **Conferences**

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

and **Online CME/CEU resources**, etc....

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN13.cfm>

and the latest **Perinatology Corners** (free online CME from IHS) are
at

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

...or just take a look at the **What's New** page

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

# Did you miss something in the last OB/GYN Chief Clinical Consultant Corner? {#did-you-miss-something-in-the-last-obgyn-chief-clinical-consultant-corner .Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5%)}

#### The October 2006 OB/GYN CCC Corner is available at: {#the-october-2006-obgyn-ccc-corner-is-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn1006.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

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

CDC Advocates for Routine Voluntary Testing of HIV

####  {#section-55 .Style-Heading-4-+-Arial-14-pt-Underline}

#### From your colleagues page 8 {#from-your-colleagues-page-8-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Carolyn Aoyama

Grants for Nursing

Jim Galloway

Do you need nutrition services at your site?

Sunnah Kim, AAP (with comments by Elaine Locke, ACOG)

Forty years in partnership: the American Academy of Pediatrics and
Indian Health

Judy Thierry

-Smoking Cessation for Pregnancy and Beyond

-Northern Plains Tobacco Prevention Project -- Smoke Free Families
Campaign

-Latest AI/AN birth and fertility data from NCHS, 2004

-Literature on feeding beliefs and attitudes in AIAN/indigenous
populations requested

-Release of IDEA 2004 Part B Regulations Links to forms and tool kits
for IEPS FSPs

**Myra Tucker, CDC**

Analyzing and Mapping Health Inequities to Impact Policies for
Eliminating Disparities

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

##### Obstetrics page 12

-Can a 29% Cesarean Delivery Rate Possibly Be Justified?

-Stricter VBAC Guideline Does Not Improve Mortality

-Dose-response pattern in the risk of previa, with increasing number of
cesarean deliveries

-12 and 24 hours of MgSO4: Similar course in postpartum mild
preeclampsia

-Oral misoprostol Can Reduce PPH When Given Prophylactically

and more.....

**Gynecology** page 15

-A new era in ovulation induction: Aromatase inhibitors

-Preventing Postoperative Nausea and Vomiting

-Flexible-dosing with anticholinergics: Simple and effective for
overactive bladder

-HPV and HPV Vaccine: Information for Healthcare and for the general
public

-MR imaging: Excellent at excluding appendicitis in pregnancy when not
visualized at US

**Child Health** page 16

# -Fetal injury at cesarean delivery: Related to the indication and type of uterine incision

-Youth Exposure to Alcohol Advertising on Radio

-YOUTH: 3 complementary resources: Needs based...asset
mapping...resiliency...

-TeenScreen Conference: Second Annual

# -Adolescent Death Rates by Race/Ethnicity and Sex

**Chronic Illness and Disease** page 18

-Aspirin to Prevent Heart Attack and Stroke: What's the Right Dose? 160
mg/day

-Benefits of Eating Fish Greatly Outweigh the Risks

-Daily Weighing and Quick Action Keeps Pounds Off, Study Shows

-F as in Fat and Failing: How Obesity Policies are Failing in America,
2006

-Regular exercise and keeping weight in check decreases breast-cancer
risk factors

and more.....

#### Features page 21 {#features-page-21 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician

-Postcoital Bleeding and Cervical Cancer Risk

-Metformin May Help Children Lose Weight

-Lubiprostone (Amitiza) for Chronic Idiopathic Constipation

American College of Obstetricians and Gynecologists

-Amnioinfusion Does Not Prevent Meconium Aspiration Syndrome

-Postpartum Hemorrhage (Technical Bulletin)

-Vulvodynia

**Agency for Healthcare Research and Quality**

-What processes are in place for same last name awareness?

-Do Not Resuscitate in the OR, but What About Afterwards?

-Prevalence, impact, and disclosure of domestic violence among women

-Premature infants born at 30 to 34 wks gestation suffer substantial
problems

-Bariatric obesity surgery complication rates are higher over time

and more.....

**Ask a Librarian**

Updated Cochrane Systematic Reviews....

-Aerobic Exercise and Pregnancy

-Calcium Supplementation Safe and Cheap

-Preclampsia Drugs: No Clear Choice

**Breastfeeding**

Do you have breastfeeding questions? The new Breast feeding site has the
answers

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

#### Lactation Support in the Indian Health Workplace: New Circular {#lactation-support-in-the-indian-health-workplace-new-circular .Style-Heading-4-+-Arial-14-pt-Underline}

**CCC Corner Digest**

#### September 2006 Highlights included: {#september-2006-highlights-included .Style-Heading-4-+-Arial-14-pt-Underline}

-FDA OTC Access for Plan B for 18 and Older: A 'Catch-22' for AI/AN
patients?

-USPSTF Best Practices -- Breast and Cervical Cancer Screening, plus
Helpful Tips

-Cesarean delivery: Increased risks versus vaginal delivery -- 4
articles

-See and treat: HPV positive, HSIL cytology, and a HG impression at
2^nd^ colposcopy

-Metformin Useful for Treating PCOS in Adolescents

-Varenicline was significantly more efficacious for smoking cessation

-Human Papillomavirus Vaccination: ACOG Committee Opinion

-Engorgement -- It only feels like it is going to last forever

-Adolescent perception of sexual abstinence: A complete disconnect

-HIV Management System, v1.0 -- National Release

-Health care and indigenous peoples: the other side of the planet

-First trimester screening: How would you counsel this patient?

-Postpartum Care: Still the neglected step child of perinatal services?

-Implanon- A single rod contraceptive implant...

-Harm Resulting from Inappropriate Telephone Triage in Primary Care

-How important is maternal intratpartum glucose to neonatal
hypoglycemia?

-Must Honor Advance Directives -- Palliative Medicine's Role in the
Continuity of Care

-Sexual Education / HIV Education and youth

-Weight Loss Should be the Primary Intervention for Risk of Diabetes

**Domestic Violence**

A must WEB site for CHILD Abuse care and practice info

**Elder Care News**

-Palliative Care Training

-How is the Indian Health System providing palliative and end-of-life
care?

-The Last Hours of Living: Practical Advice for Clinicians

**Family Planning**

#### Ortho Evra Patch Linked to Risk for Venous Thromboembolism {#ortho-evra-patch-linked-to-risk-for-venous-thromboembolism .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

New Breastfeeding Web Page for the Indian Health System

**Frequently asked questions**

-Is my first trimester patient always hyperthyroid if her labs are
abnormal?

**Indian Child Health Notes**

-Early prednisone therapy in Henoch-Schonlein purpura

-Physician documentation of neonatal risk assessment for perinatal
infections.\
-The Alaska Hib type b experience: lessons in controlling a
vaccine-preventable disease

**Information Technology**

New patient wellness handout

International Health

Maternal survival worldwide: consensus and controversies

and

An Entire Issue of Can J Public Health Dedicated to Health Policy

#### MCH Alert

-What is the contribution of preterm birth to infant mortality rates?

-Increased efforts are needed for states to achieve all eight HP 2010
objectives

-Portal to Maternal and Child History Materials

-Children's Opportunity Depends on Their Parent's Opportunity

#### Medical Mystery Tour

#### The words 'bizarre' and 'atypia' in the same pathology report sentence...hmmm.... {#the-words-bizarre-and-atypia-in-the-same-pathology-report-sentencehmmm.-2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

**Menopause Management**

# -Associations between night sweats and other sleep disturbances

# -Combination Estrogen-Progestin Hormone Prescribed by Age Group

-Unopposed Estrogen Therapy Increases Breast Cancer Risk

**Midwives Corner**

-External Fetal Monitors -- Can you kick the habit?

-EMTALA language changes addresses certification of false labor

**Navajo News**

-Great, low-cost, fun CME opportunity

**Nurses Corner**

-Improving Perinatal Outcomes: Reliably Using Elective Induction and
Labor Augmentation

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

-Preconception Care: Science, Practice, Challenges and Opportunities

-October is Breast Cancer Awareness Month

**Oklahoma Perspective**

-Asthma in Pregnancy

Osteoporosis

Fracture risk among First Nations people

Patient Education

Assessment of Adult Health Literacy

-Is patient education really working? GDM patients smoke more and eat
less vegetables

-HPV Vaccine: What You Need to Know

#### -Stress: How to Cope with Life's Challenges {#stress-how-to-cope-with-lifes-challenges .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Anxiety and Panic: Getting Control over Your Feelings {#anxiety-and-panic-getting-control-over-your-feelings .Style-Heading-4-+-Arial-14-pt-Underline}

and more.....

Perinatology Picks

-Fetal Lung Maturity Assessment

-Can a blood test predict pre-eclampsia? And will it help us?

-Fish oil for fetal brain development, hypertensive disorders, and
depression?

-Maternal oxygen administration for fetal distress

-A nuchal translucency measurement where there is no benefit from first
trimester screening

and more.....

Primary Care Discussion Forum

Causes of Type 2 Diabetes: Old and New Understandings

STD Corner

-Prevalence of HPV Infection among Men: A Systematic Review of the
Literature

-FDA Approves the First Once-a-Day Three-Drug Combination Tx of HIV-1\
-NIH launches new HIV Vaccine awareness campaign

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

### -No improvement in fetal outcome, plus increased maternal morbidity: Who pays for this? 

-Who Responds to Glyburide for Gestational Diabetes?

-Nearly one out of two women with gestational diabetes also have
periodontal disease

-Mothers Who Gain Weight Between Pregnancies Experience Pregnancy
Complications

-The growing trends in maternal obesity

and more.....

###### Save the Dates: Upcoming events of interest page 50

#### What's new on the ITU MCH web pages page 51

The past CCC Corners are archived at:

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN01.cfm#top>

The CCC Corner is good way to inform ITU providers about recent updates,
while decreasing the number of e-mail messages.

Let me know if you want to add something to next month's CCC Corner at
<nmurphy@scf.cc>

or 907 729 3154 (with voicemail)

\*The opinions expressed in the OB/GYN CCC Corner are strictly those of
the authors, and not necessarily those of the Indian Health System, or
the author of this newsletter. If you have any comments, please share
them by joining the Primary Care Discussion Forum where this topic was
recently discussed. To join the Primary Care Listserv, click on
'Subscribe' here
<http://www.ihs.gov/MedicalPrograms/MCH/F/MCHdiscuss.cfm>

11/12/06