06/14/08 jeh

**News Flash: International, Multidisciplinary Indigenous Women's and
Children's Health Conference, March 2009, Albuquerque, NM**

**Women's Health March 4-6, 2009**

**Children's Health March 6-8, 2009**

**(The 6^th^ is an overlap day with both groups participating)**

**See "From Your Colleagues" for initial announcement and mark your
calendar now!**

![](media/image1.jpeg){width="6.000694444444444in" height="1.11875in"}

 

Chief Clinical Consultant's Corner

Volume 6, No. 7, 2008

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

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

#### -Does a PICC line facilitate treatment of hyperemesis gravidarum? {#does-a-picc-line-facilitate-treatment-of-hyperemesis-gravidarum .Style-Heading-4-+-Arial-14-pt-Underline}

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

Scott Giberson

-IHS HIV Program and the Native Capacity Building Assistance Network
sign MOU

-Grant opportunities

Steve Holve

-3rd International Meeting on Indigenous Child Health: Many Voices Into
One Song

Elaine Locke and Yvonne Malloy

-ACOG Committee on American Indian Affairs

-Haffner Native Women's Health Award

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

September 14-18, 2008; Salt Lake City, Utah

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

##### Obstetrics

-Prophylactic antibiotics improve outcomes with 3^rd^ and 4^th^ degree
repair

-Episiotomy increases obstetric laceration risk with subsequent
pregnancies

-Maternal Obesity associated with increased risk of neural tube defects

-Diagnostic accuracy of urinary spot protein:creatinine ratio

## -Cochrane Review: Dietary advice in pregnancy for preventing gestational diabetes mellitus.

**Gynecology**

\- No increased risk with Misoprostol for early pregnancy failure
despite previous uterine surgery

\- Cessation of douching may decrease incidence of bacterial vaginosis

\- Green Tea Extract for treatment of external anogenital warts

\- Only 1 in 10 EDs provide comprehensive medical care for victims of
sexual assault

\- Women with epilepsy often at risk for unintended pregnancy

**Child Health**

-Hypothermia therapy after traumatic brain injury in children not
helpful

## -Obesity and type 2 diabetes risk in midadult life: the role of childhood adversity

-Nearly 1 in 10 Girls Engages in Frequent Binge Eating or Purging

-Irregular menses linked to vomiting

-Ocular Trauma Due to a Water-Bottle Cap

**Chronic Illness and Disease**

-Intensive Glucose Control Does Not Prevent Major Cardiovascular Events
in Type 2 Diabetes

-A collaborative approach to diabetes care in community health centers
can improve care

-Patient factors account for most of the variance in blood sugar levels
among adults with diabetes

-Antidepressants and therapy may be cost-effective for patients with
unexplained symptoms

-Light and Melatonin May Reduce Dementia Symptoms

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

American College of Obstetricians and Gynecologists

\- Medical Management of Ectopic Pregnancy

\- Ethical Issues in Genetic Testing

\- Direct-to-Consumer Marketing of Genetic Testing

\- Professional Liability and Gynecology-Only Practice

\- New interactive site for clinicians serving women with disabilities

##### American Family Physician

\- Food Allergies: Detection and Management

**Agency for Healthcare Research and Quality**

-"Real Men Wear Gowns"

**Ask a Librarian**

\- Health education materials available online in a variety of languages

**Behavioral Health Insights**

\- Chronic Pain Management 101 -- Saying No to Patients

**Breastfeeding**

\- A new look at what works to support breastfeeding in hospitals

\- Recall of Mommy's Bliss Nipple Cream

**CCC Corner Digest**

-Did you miss something? A link to last month's issue

**Domestic Violence**

\- WHO study links domestic violence and poor health; DV an urgent
global health priority

**Elder Care News**

\- Several factors can quickly identify mortality risk among frail
elderly persons

###################### -Living wills should be updated as preferences for change with health status {#living-wills-should-be-updated-as-preferences-for-change-with-health-status .unnumbered}

**Family Planning**

## -Injectable contraception: what should the longest interval be for reinjections?

## -Depo Now: preventing unintended pregnancies among adolescents and young adults

**Featured Website**

\- IHS Head Start Oral Health Resources

**Frequently asked questions**

\- Progesterone for the Prevention of Recurrent Spontaneous Preterm
Birth

**Indian Child Health Notes**

-Cardiovascular Evaluation and Monitoring of Children and Adolescents
with Heart Disease Receiving Medications for ADHD

-Teens and Vaccines; How are we doing?

-Pertussis-Associated Hospitalizations in American Indian and Alaska
Native Infants

**Information Technology**

-New RPMS Scheduling Package Released

-PCC+ v2.6 (Well Child Module) Released

International Health

-New evidence on lead's long-term effects

#### MCH Alert

-AAP Releases Statement on Strategies to Improve Adolescent Health Care

-Report Presents Findings from the 2007 National Youth Risk Behavior
Survey

-Panel Reviews National Study on Environmental and Genetic Effects on
Health in Children\
-Bright Futures for Women's Health and Wellness Releases new Tools on
Emotional Health

#### MCH Headlines

-Bright Futures Web Site Updated

-Resources and Guidance for Fatherhood Programs (10 Promising Practices)

-Now Available: Baby Oral Health Program

-Child Maltreatment Institute: Enhancing Leadership for Child
Maltreatment Prevention

#### Medical Mystery Tour

-A diabetic patient who is finally losing weight

#### Medscape

#### - A sample of recent free CME offerings and other resources on Medscape: {#a-sample-of-recent-free-cme-offerings-and-other-resources-on-medscape .Style-Heading-4-+-Arial-14-pt-Underline}

**Menopause Management**

\- Low-Dose Estradiol Spray to Treat Vasomotor Symptoms

**Midwives Corner**

-Centering Pregnancy Training

**Navajo News**

-Forty one (41) Indian Health Care Providers complete SANE/SAFE course
in Window Rock

**Nurses Corner**

-What Is Forensic Nursing?

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

-Development of ACIP Recommendations for Vaccination during Pregnancy
and Breastfeeding

-Healthy Eating Index (HEI) Scores among Adults, 60 Years of Age and
Over

-HIV/AIDS Surveillance Slide Sets

**Oklahoma Perspective**

-ACOG Committee on Indian Affairs Site Visit

Osteoporosis

\- New evidence that Calcium supplementation may work, at least while
you take them...

Patient Education

-New offerings from the AAFP

Perinatology Picks

-Longer PROM associated with more infections

-Cesarean Delivery does not improve outcome in very low birthweight
vertex fetuses

-Clostridium difficile-associated diarrhea: an emerging threat to
pregnant women

-Mycophenolate mofetil (MMF) may be linked to congenital anomalies

Primary Care Discussion Forum

-New Topic coming soon

STD Corner

## -Chlamydia Positivity in American Indian/Alaska Native Women Screened in Family Planning Clinics, 1997-2004

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

\- Stretching exercises may reduce risk of pre-eclampsia during
pregnancy

**Women's Health Headlines**

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

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

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

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

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

**Does a PICC line facilitate treatment of hyperemesis gravidarum?**

OBJECTIVE: The objective of the study was to evaluate the use of
interventions such as a peripherally inserted central catheters (PICC)
line or nasogastric (NG)/nasoduodenal (ND) tube with the use of
medications alone in the management of pregnancies with hyperemesis.
STUDY

DESIGN: Subjects were identified with confirmed intrauterine pregnancy,
admitted with hyperemesis gravidarum (HEG) between 1998 and 2004.
Medical records were then abstracted for information with regard to
therapy. Subjects were assigned on the basis of the management plan:
medication alone, PICC line, or NG/ND tube. Outcomes were compared
between groups.

RESULTS: Ninety-four patients met study criteria and had complete
outcome data available. Of those, 33 had a PICC line placed (35.1%), 19
had a NG/ND placed (20.2%), and 42 were managed with medication alone
(44.7%). These groups were similar with respect to gestational age at
delivery, Apgar score, and mean birthweight. Maternal complications were
significantly higher among those with PICC lines. Of patients managed
with PICC lines, 66.4% (P \< .001) required treatment for infection,
thromboembolism, or both. Adjusted odds ratio for a PICC line
complication was 34.5 (5.09, 233.73).

CONCLUSION: Maternal complications associated with PICC line placement
are substantial despite no difference in neonatal outcomes, suggesting
that the use of PICC lines for treatment of HEG patients should not be
routinely used.

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

**66.4% of women managed with a PICC line required treatment for
thromboembolism or infection, or both**

Holmgren et al conclude that enteral feeding for women with hyperemesis
gravidarum is safer than parenteral feeding and is accepted by patients.
Obstetricians should make every effort to use enteral feeding for women
with hyperemesis gravidarum and persistent weight loss.

For a more complete discussion about management options for hyperemesis
gravidarum, please review the answer to this month's Medical Mystery
Tour. Another possible resource can be found in T. Murphy Goodwin, MD's
OBG Management discussion, link below.

Holmgren et al expands on the observations of previous authors who have
pointed out the numerous complications of PICC line access for
parenteral nutrition during pregnancy. The vast majority of such
interventions during pregnancy are for the diagnosis of HEG.

That some form of nutritional supplementation is needed for women who
experience persistent weight loss with hyperemesis is clear. Although it
is rare, maternal mortality still does occur and comes almost
exclusively from this group of women. The same is true for major
maternal morbidity such as Wernicke's encephalopathy.

Fetal effects such as growth restriction are limited to women who have
HEG who also lose weight. Apart from growth restriction, which can be
recognizable at birth, substantial data in both humans and experimental
animals suggest adverse consequences later in life as a result of
maternal calorie restriction for even a few months of pregnancy.

Interestingly, in this study, there were no SGA infants in either the
group treated with medication alone or the group managed with NG/ND tube
placement.

[Main complications are thrombosis, infection]{.underline}

The major complications of peripheral and central venous access for
nutrition in pregnancy are thrombosis and infection, and the prevalence
is now well established to be around 50%. Maternal death from
complications of line access has also been reported.

[A confirmation of case reports and small series]{.underline}

This study is important because it represents the largest report of
women who have received total nutritional support via an enteral feeding
tube. Previous reports were limited to single cases or small series.

There is little evidence indicating that the better safety record of
enteral feeding and greater efficacy compared with parenteral feeding
via a PICC line have led to increased usage. In our own survey of 792
women who self-reported hyperemesis gravidarum from 2000 to 2004, 16.7%
reported parenteral nutrition, compared with only 2.3% who reported
enteral tube feeding. It is hoped that this study will help reverse this
ratio.

Have you taken advantage of the free Perinatology Corner CME / CEU
Module we offer on this topic? If not, this next part is definitely low
hanging fruit. Just go to this module, review the material, answer a few
quick questions, hit the submit button and voila free CME
credits.....plus the module offers a great set of materials for future
reference.

**Resources:**

Nausea and Vomiting in Pregnancy: Perinatology Corner Module

<http://www.ihs.gov/MedicalPrograms/MCH/M/PNC/NVP01.cfm>

Holmgren C, Aagaard-Tillery KM, Silver RM, Porter TF, Varner M.
Hyperemesis in pregnancy: an evaluation of treatment strategies with
maternal and neonatal outcomes. Am J Obstet Gynecol.
2008;198:56.e1--56.e4

<http://www.ncbi.nlm.nih.gov/pubmed/18166306>

Goodwin TM. Does a PICC line facilitate treatment of hyperemesis
gravidarum?

OBG Management May 2008 · Vol. 20, No. 05

<http://www.obgmanagement.com/article_pages.asp?aid=6143>

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

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

One of the guiding principles of the IHS HIV/AIDS Strategic Plan is to
improve the collaborative nature and transparency of the program to
maximize effectiveness. That said, we would like to share two recent
announcements:

 

In April 2008, the **IHS HIV Program and the Native Capacity Building
Assistance Network (CBA),** comprised of the Center for Applied Studies
in American Ethnicity (CASAE), the Intertribal Council of Arizona (ITCA)
and the National Native American AIDS Prevention Center (NNAAPC)
**signed a Memorandum of Understanding (MOU)** to continue open
communications and collaborate to raise awareness and mutually augment
efforts. This partnership demonstrates mobilization of both the Native
community and IHS for HIV prevention efforts.

 

**NNAAPC is offering and funding** **regional training grants** to host
trainings on a variety of HIV-related topics. This NNAAPC initiative
will assist communities in capacity-building efforts from readiness to
grant writing. Additional information is available from NNAAPC at:
[http://www.nnaapc.org/programs/regionaltraininggrants.htm](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.nnaapc.org/programs/regionaltraininggrants.htm)

 

#### Steve Holve, Tuba City {#steve-holve-tuba-city .Style-Heading-4-+-Arial-14-pt-Underline}

**3rd International Meeting on Indigenous Child Health: Many Voices Into
One Song**

**March 6-8, 2009 Albuquerque, NM**

Join the Canadian Paediatric Society and the American Academy of
Pediatrics, in cooperation with the Indian Health Service and the First
Nations Inuit Health Branch, Health Canada, for the 3rd International
Meeting on Indigenous Child Health. Child health providers and
researchers dedicated to working with

American Indian, Alaska Native, First Nations, Inuit, and Métis children
and families are encouraged to attend. Participants will have the
opportunity to share model programs and research, and develop practical
skills that can be utilized in community settings.

For updated conference information, visit
[www.cps.ca](http://www.cps.ca/) or
[www.aap.org/nach](http://www.aap.org/nach). The AAP direct conference
link can be found at
<http://www.aap.org/nach/3InternationalMeeting.html>.

This is the third conference with the US and Canada. The past two have
been terrific and this conference will also be great. Block off the time
for next Spring.

#### Elaine Locke and Yvonne Malloy, ACOG {#elaine-locke-and-yvonne-malloy-acog .Style-Heading-4-+-Arial-14-pt-Underline}

**"For American Indians, healthcare needs grow, money doesn't"**

Indian Health staff were featured in an [ACOG Today]{.underline} article
about American Indian and Alaska Native women's health care and the
longstanding IHS/ACOG collaboration. The article pointed out the limited
funding that IHS receives and the challenges encountered in providing
care to a largely rural population with limited resources. The full
front-page article, with lovely photos and quotes from several leaders
in Indian Women's Health, is available at the link below:

[http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Indian%20Health%20Services%20may%2008.pdf](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Indian Health Services may 08.pdf)

### **Haffner Native Women's Health Award** 

The ACOG Committee on American Indian Affairs is raising money for a new
award that would recognize an individual who has made a major
contribution to improving the health care of American Indians/Alaska
Natives. The William H.J. Haffner American Indian/Alaska Native Women's
Health Award is named after ACOG Fellow Dr. Haffner, an ob-gyn professor
at the Uniformed Services University of the Health Sciences, Bethesda,
MD. Dr. Haffner worked for the federal Indian Health Service for many
years and has been involved with ACOG's Indian health programs since
their inception.

To donate to the Haffner Award Fund, please make checks out to \"ACOG\"
and mail to Yvonne Malloy, ACOG, 409 12th St. SW, Washington, DC 20024

[http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Indian%20health%20award.doc](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Indian health award.doc)

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

**September 14-18, 2008; Salt Lake City, Utah**

This annual women's health update for Nurses, Advanced Practice
Clinicians, and physicians provides a four-day schedule of lectures,
workshops, hands-on sessions, and team building. The large
interdisciplinary faculty collaborates to teach clinical and practical
topics as they apply in Indian health settings. Many faculty members are
your colleagues in IHS and Tribal facilities; private sector faculty
also bring a wide range of experience providing Indian health care.
Learn the latest evidence-based approaches to maternal and child health
services, and share problems and solutions with your colleagues from
across Indian country. The course can also serve as a good foundation
for professionals who are new to women's health care or new to the
Indian health system.

In addition to the basic course, you may sign up for the Neonatal
Resuscitation Program, and come away with your certificate from this
convenient pre-course program. The opportunity to fulfill continuing
education requirements in a concentrated format is significant: With the
optional NRP, we can document your participation in seven half-days of
education.

Sign up early! You'll have first chance for support from your facility
and coverage for your time in Salt Lake City. Getting these benefits
lined up takes time, so don't delay and miss out! In addition, early
registration holds your place, and puts you in line for possible
availability of scholarship funds.

Watch your mail for the course brochure and registration form, or
download it from here:

<http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm?module=08&option=9#top>

For more information on the Postgraduate Course or other Indian Health
programs please contact <ymalloy@acog.org>; 800-673-8444, ext 2580; or
visit the ACOG website, [www.acog.org](http://www.acog.org/); under
\"Women's Issues,\" click on \"Indian Health Service\"

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

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

## Antibiotic Prophylaxis for Prevention of Postpartum Perineal Wound Complications

### **A Randomized Controlled Trial** 

OBJECTIVE: To estimate whether prophylactic antibiotics at the time of
repair of third- or fourth-degree perineal tears after vaginal delivery
prevent wound infection and breakdown.

METHODS: This was a prospective, randomized, placebo-controlled study.
Patients who sustained third- or fourth-degree perineal tears after a
vaginal delivery were recruited for the study. Each patient was given a
single intravenous dose of a second-generation cephalosporin (cefotetan
or cefoxitin) or placebo before repair of third- or fourth-degree
perineal tears. Obstetricians and patients were blinded to study drug.
The perineum was inspected for evidence of infection or breakdown at
discharge from the hospital and at 2 weeks postpartum. Primary end
points were gross disruption or purulent discharge at site of perineal
repair by 2 weeks postpartum.

RESULTS: One hundred forty-seven patients were recruited for the study.
Of these, 83 patients received placebo and 64 patients received
antibiotics. Forty patients (27.2%) did not return for their 2-week
appointment. Of the patients seen at 2 weeks postpartum, 4 of 49 (8.2%)
patients who received antibiotics and 14 of 58 (24.1%) patients who
received placebo developed a perineal wound complication (*P*=.037).
There were no differences between groups in parity, incidence of
diabetes, operative delivery, or third-degree compared with
fourth-degree lacerations.

CONCLUSION: By 2 weeks postpartum, patients who received prophylactic
antibiotics at the time of third- or fourth-degree laceration repair had
a lower rate of perineal wound complications than patients who received
placebo.

Duggal N, Mercado C, Daniels K, Bujor A, Caughey AB, El-Sayed YY.
Antibiotic Prophylaxis for Prevention of Postpartum Perineal Wound
Complications: A Randomized Controlled Trial. Obstet Gynecol. 2008
Jun;111(6):1268-1273. <http://www.ncbi.nlm.nih.gov/pubmed/18515507>

CCC Editorial Comment:

Avoidance of episiotomy is associated with the lowest rates of 3^rd^ and
4^th^ degree lacerations but will not eliminate all such events; when
they happen, antibiotic prophylaxis may prevent further complications.

## Episiotomy and Increase in the Risk of Obstetric Laceration in a Subsequent Vaginal Delivery

OBJECTIVE: To examine whether episiotomy at first vaginal delivery
increases the risk of spontaneous obstetric laceration in the subsequent
delivery.

METHODS: A review was conducted of women with consecutive vaginal
deliveries at Magee-Womens Hospital between 1995 and 2005, using the
Magee Obstetrical Maternal and Infant database. The primary exposure of
interest was episiotomy at first vaginal delivery. Multivariable
polytomous logistic regression modeling of potential risk factors was
used to estimate odds ratios (ORs) for obstetric laceration in the
second vaginal delivery.

RESULTS: A total of 6,052 patients were included, of whom 47.8% had
episiotomy at first delivery. Spontaneous second-degree lacerations at
the time of second delivery occurred in 51.3% of women with history of
episiotomy at first delivery compared with 26.7% without history of
episiotomy (*P*\<.001). Severe lacerations (third or fourth degree)
occurred in 4.8% of women with history of episiotomy at first delivery
compared with 1.7% without history of episiotomy (*P*\<.001). Prior
episiotomy remained a significant risk factor for second-degree (OR
4.47, 95% confidence interval 3.78--5.30) and severe obstetric
lacerations (OR 5.25, 95% confidence interval 2.96--9.32) in the second
vaginal delivery after controlling for confounders. Based on these
findings, for every four episiotomies not performed one second-degree
laceration would be prevented. To prevent one severe laceration,
performing 32 fewer episiotomies is required.

CONCLUSION: Episiotomy at first vaginal delivery increases the risk of
spontaneous obstetric laceration in the subsequent delivery. This
finding should encourage obstetric providers to further restrict the use
of episiotomy.

Alperin M, Krohn MA, Parviainen K. Episiotomy and Increase in the Risk
of Obstetric Laceration in a Subsequent Vaginal Delivery. Obstet
Gynecol. 2008 Jun;111(6):1274-1278.
<http://www.ncbi.nlm.nih.gov/pubmed/18515508>

**Maternal Obesity associated with increased risk of neural tube
defects**

We conducted a metaanalysis of published evidence on the relationship
between maternal obesity and the risk of neural tube defects (NTDs).
Eligible studies were identified from 3 sources: (1) PubMed search of
articles that were published from January 1980 through January 2007, (2)
reference lists of publications that were selected from the PubMed
search, and (3) reference lists of review articles on obesity and
maternal outcomes that were published from January 2000 through January
2007. Twelve studies met inclusion criteria. A Bayesian random effects
model was used for the metaanalysis and metaregression. Unadjusted odds
ratios for an NTD-affected pregnancy were 1.22 (95% CI, 0.99-1.49), 1.70
(95% CI, 1.34-2.15), and 3.11 (95% CI, 1.75-5.46) among overweight,
obese, and severely obese women, respectively, compared with
normal-weight women. None of the study characteristics included in the
metaregression analysis affected the results significantly. Maternal
obesity is associated with an increased risk of an NTD-affected
pregnancy.

## Rasmussen SA, Chu SY, Kim SY, Schmid CH, Lau J. Maternal obesity and risk of neural tube defects: a metaanalysis. **Am J Obstet Gynecol. 2008 Jun;198(6):611-9.** 

## [**http://www.ncbi.nlm.nih.gov/pubmed/18538144**](http://www.ncbi.nlm.nih.gov/pubmed/18538144) 

## 

## Diagnostic accuracy of urinary spot protein:creatinine ratio for proteinuria in hypertensive pregnant women: systematic review

OBJECTIVE: To review the spot protein:creatinine ratio and
albumin:creatinine ratio as diagnostic tests for significant proteinuria
in hypertensive pregnant women.

DESIGN: Systematic review.

DATA SOURCES: Medline and Embase, the Cochrane Library, reference lists,
and experts. Review methods Literature search (1980-2007) for articles
of the spot protein:creatinine ratio or albumin:creatinine ratio in
hypertensive pregnancy, with 24 hour proteinuria as the comparator.
RESULTS: 13 studies concerned the spot protein:creatinine ratio (1214
women with primarily gestational hypertension). Nine studies reported
sensitivity and specificity for eight cut-off points, median 24 mg/mmol
(range 17-57 mg/mmol; 0.15-0.50 mg/mg). Laboratory assays were not well
described. Diagnostic test characteristics were recalculated for a
cut-off point of 30 mg/mmol. No significant heterogeneity in cut-off
points was found between studies over a range of proteinuria. Pooled
values gave a sensitivity of 83.6% (95% confidence interval 77.5% to
89.7%), specificity of 76.3% (72.6% to 80.0%), positive likelihood ratio
of 3.53 (2.83 to 4.49), and negative likelihood ratio of 0.21 (0.13 to
0.31) (nine studies, 1003 women). Two studies of the spot
albumin:creatinine ratio (225 women) found optimal cut-off points of 2
mg/mmol for proteinuria of 0.3 g/day or more and 27 mg/mmol for
albuminuria.

CONCLUSION: The spot protein:creatinine ratio is a reasonable
\"rule-out\" test for detecting proteinuria of 0.3 g/day or more in
hypertensive pregnancy. Information on use of the albumin:creatinine
ratio in these women is insufficient.

Côté AM, Brown MA, Lam E, von Dadelszen P, Firoz T, Liston RM, Magee LA.
Diagnostic accuracy of urinary spot protein:creatinine ratio for
proteinuria in hypertensive pregnant women: systematic review. BMJ. 2008
May 3;336(7651):1003-6. Epub 2008 Apr 10.

<http://www.ncbi.nlm.nih.gov/pubmed/18403498>

## Cochrane Review: Dietary advice in pregnancy for preventing gestational diabetes mellitus.

BACKGROUND: Gestational diabetes mellitus (GDM) is a form of diabetes
that occurs during pregnancy which can result in significant adverse
outcomes for mother and child both in the short and long term. The
potential for adverse outcomes, in addition to the increasing prevalence
of gestational diabetes worldwide, demonstrates the need to assess
strategies, such as dietary advice, that might prevent gestational
diabetes.

OBJECTIVES: To assess the effects of dietary advice in preventing
gestational diabetes mellitus. SEARCH STRATEGY: We searched the Cochrane
Pregnancy and Childbirth Group\'s Trials Register (January 2008) and
reference lists of retrieved articles.

SELECTION CRITERIA: Quasi-randomised and randomised studies of dietary
intervention for preventing glucose intolerance in pregnancy.

DATA COLLECTION AND ANALYSIS: Two review authors independently conducted
data extraction and quality assessment. We resolved disagreements
through discussion or through a third author.

MAIN RESULTS: Three trials (107 women) were included in the review. One
trial (25 pregnant women) analysed high-fibre diets with no included
outcomes showing statistically significant differences. Two trials (82
pregnant women) assessed low glycaemic index (LGI) versus high glycaemic
index diets for pregnant women. Women on the LGI diet had fewer large
for gestational age infants (one trial; relative risk (RR) 0.09, 95%
confidence interval (CI) 0.01 to 0.69), infants with lower ponderal
indexes (two trials; weighted mean difference (WMD) -0.18, 95% CI -0.32
to -0.04, random-effects analysis) and lower maternal fasting glucose
levels (two trials; WMD -0.28 mmol/L 95% CI -0.54 to -0.02,
random-effects model). Results for women on the LGI diet on neonatal
birth weight were not conclusive under a random-effects model (two
trials; WMD -527.64 g, 95% CI -1119.20 to 63.92); however, on a
fixed-effect model, women on the LGI diet gave birth to lighter babies
(two trials; WMD -445.55 g, 95% CI -634.16 to -256.95). High
heterogeneity was observed between the trials in most results and both
were relatively small trials. One of these trials also included a
standard exercise regimen for all participants. AUTHORS\' CONCLUSIONS:
While a low glycaemic index diet was seen to be beneficial for some
outcomes for both mother and child, results from the review were
inconclusive. Further trials with large sample sizes and longer follow
up are required to make more definitive conclusions. No conclusions
could be drawn from the high-fibre versus control-diet comparison since
the trial involved did not report on many of the outcomes we
prespecified.

Tieu J, Crowther CA, Middleton P. Dietary advice in pregnancy for
preventing gestational diabetes mellitus. Cochrane Database Syst Rev.
2008 Apr 16;(2):CD006674.

<http://www.ncbi.nlm.nih.gov/pubmed/18425961>

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

**No increased risk with Misoprostol for treatment of early pregnancy
failure in women with previous uterine surgery**

OBJECTIVE: Misoprostol use in early pregnancy may incur a risk of
uterine rupture in women with previous uterine surgery. STUDY DESIGN: We
analyzed 488 women who received misoprostol 800 microg vaginally in a
study that evaluated medical and surgical management of early pregnancy
failure. Subjects received a repeat misoprostol dose if expulsion was
not confirmed 2 days after treatment. We compared efficacy,
acceptability, and safety in subjects with a history (n = 78 women) or
absence (n = 410 women) of uterine surgery, defined as cesarean delivery
or myomectomy. RESULTS: Expulsion rates after a single misoprostol dose
(69% vs 72%; P = .64) and overall success at 30 days (82% vs 85%; P =
.50) were comparable. Pain, bleeding, complications, and acceptability
did not differ. No uterine ruptures occurred (95% CI, 0, 3.8%).
CONCLUSION: Misoprostol treatment for early pregnancy failure had
similar success, acceptability, and complications in women with and
without previous uterine surgery.

Chen BA, Reeves MF, Creinin MD, Gilles JM, Barnhart K, Westhoff C, Zhang
J; National Institute of Child Health and Human Development Management
of Early Pregnancy Failure Trial. Misoprostol for treatment of early
pregnancy failure in women with previous uterine surgery. Am J Obstet
Gynecol. 2008 Jun;198(6):626.e1-5. Epub 2008 Feb 15.

<http://www.ncbi.nlm.nih.gov/pubmed/18279821>

**Cessation of douching may decrease incidence of bacterial vaginosis**

OBJECTIVE: The objective of the study was to evaluate the risk for
bacterial vaginosis (BV) in a douching cessation trial.

STUDY DESIGN: Thirty-nine reproductive-age women who reported use of
douche products were enrolled into a 20-week study consisting of a 4
week douching observation (phase I) followed by 12-weeks of douching
cessation (phase II). In phase III, participants then chose to resume
douching or continue cessation for the remaining 4 weeks. Self-collected
vaginal samples were obtained twice weekly in the first 16 weeks, and 1
sample was collected during week 20 (1107 samples total). BV was
diagnosed by Nugent score of 7 or greater. Conditional logistic
regression was used to evaluate douching cessation on the risk of BV.

RESULTS: The adjusted odds ratio (aOR) for BV in the douching cessation
phase, as compared with the douching-observation phase was 0.76 (95%
confidence interval \[CI\], 0.33 to 1.76). Among women who reported
their primary reason for douching was to cleanse after menstruation, BV
was significantly reduced in douching cessation (aOR:0.23; 95% CI, 0.12
to 0.44).

CONCLUSION: Vaginal douching cessation may reduce the risk for BV in a
subset of women.

Brotman RM, Ghanem KG, Klebanoff MA, Taha TE, Scharfstein DO, Zenilman
JM.

## The effect of vaginal douching cessation on bacterial vaginosis: a pilot study. **Am J Obstet Gynecol. 2008 Jun;198(6):628.e1-7. Epub 2008 Mar 4. <http://www.ncbi.nlm.nih.gov/pubmed/18295180>**

**Green Tea Extract for treatment of external anogenital warts**

OBJECTIVE: To estimate the clinical efficacy of topical sinecatechins, a
defined green tea extract, in the treatment of external genital and
perianal warts.

METHODS: This was a randomized, double-blind, vehicle-controlled trial
involving 502 male and female patients aged 18 years and older, with
2-30 anogenital warts ranging from 12 to 600 mm(2) total wart area.
Patients applied sinecatechins ointment 15% or 10% or vehicle (placebo)
three times daily for a maximum of 16 weeks or until complete clearance
of all warts, followed by a 12-week treatment-free follow-up to assess
recurrence.

RESULTS: Complete clearance of all baseline and newly occurring warts
was obtained in 57.2% and 56.3% of patients treated with sinecatechins
ointment 15% and 10%, respectively, compared with 33.7% for vehicle
(both P\<.001). Significance was observed at weeks 4 and 6 and all
subsequent visits. Numbers needed to treat were 4.3 and 4.4. Partial
clearance rates of at least 50% were reported for 78.4% and 74.0% of
patients in the sinecatechins ointment 15% and 10% groups compared with
51.5% of vehicle patients. During follow-up, recurrence of any wart was
observed in 6.5%, 8.3%, and 8.8% in the sinecatechins ointment 15%
group, sinecatechins ointment 10% group, and vehicle patients,
respectively. A total of 3.7%, 8.3%, and 0.0% developed new warts,
respectively. A total of 87.7% and 87.3% of patients in the
sinecatechins ointment 15% and 10% groups, and 72.1% of vehicle patients
experienced application site reactions; 49.2%, 46.2%, and 65.4% of
those, respectively, were mild or moderate. CONCLUSION: Topical
sinecatechins ointments 15% and 10% are effective and well-tolerated in
the treatment of anogenital warts.

Tatti S, Swinehart JM, Thielert C, Tawfik H, Mescheder A, Beutner KR.
Sinecatechins, a Defined Green Tea Extract, in the Treatment of External
Anogenital Warts: A Randomized Controlled Trial. Obstet Gynecol. 2008
Jun;111(6):1371-1379. <http://www.ncbi.nlm.nih.gov/pubmed/18515521>

**An Illinois survey demonstrates only 1 in 10 Emergency Departments
provides comprehensive medical care for victims of sexual assault**

BACKGROUND: Sexual assault is a major public health problem affecting 17
million women in the United States. Hospital emergency departments (EDs)
are often the primary point of care for these women. We propose the
concept of \"comprehensive medical care management\" (CMCM) at the
primary point of care for victims of sexual assault. The objectives of
this study were (a) to describe medical care services provided to sexual
assault victims presenting at the EDs in Illinois hospitals, and (b) to
identify the percentage of hospitals that always provide all 10 elements
of CMCM.

STUDY DESIGN: This is a cross-sectional prevalence study. A 14-item
phone survey was administered to 187 eligible EDs in Illinois from July
to September 2004. Outcome measures were the percentages of EDs that
provide the elements of CMCM: (a) acute medical care; (b) history and
physical exam; (c and d) acute and long-term rape crisis counseling; (e
and f) prophylactic and therapeutic sexually transmitted infection (STI)
management; (g and h) prophylactic and therapeutic HIV management; and
(I and j) counseling and provision of emergency contraception.

RESULTS: An 83% response rate of eligible emergency rooms provided the
following data: while 100% of emergency rooms provide acute medical care
upon presentation, two thirds provide rape crises counseling, two thirds
provide STI management, 4 of 10 report counseling and provision of
emergency contraceptives, and only 28.2% provide HIV management. About 1
in 10 (9.6%) provides all elements of CMCM.

CONCLUSION: Although there are recommendations from various medical
organizations for all 10 elements of CMCM for victims of sexual assault,
very few hospitals provide CMCM. Improvements must be made to provide
quality comprehensive care for victims of sexual assault.

## Patel A, Panchal H, Piotrowski ZH, Patel D. Comprehensive medical care for victims of sexual assault: a survey of Illinois hospital emergency departments. **Contraception. 2008 Jun;77(6):426-30. Epub 2008 Apr 10. <http://www.ncbi.nlm.nih.gov/pubmed/18477492>** 

**Despite increased pregnancy-related risks, women with epilepsy often
at risk for unintended pregnancy**

BACKGROUND: Women with epilepsy experience more pregnancy-related risks
than do their healthy peers. Guidelines recommend highly effective
contraception. However, their contraceptive practices remain unknown.

STUDY DESIGN: We conducted a cross-sectional questionnaire study among
reproductive-age women (18-44 years) with epilepsy presenting for
routine, outpatient visits to an urban, academic medical center. Our
questionnaire, in English or Spanish, included demographic
characteristics, reproductive history, antiepileptic drug use, sexual
behavior and contraception.

RESULTS: Participants had a mean age of 32 years (S.D.=8), 32% spoke
Spanish and described themselves as Hispanic. Participants reported a
wide range of educational attainment, insurance payor and income.About
half of the participants reported at least one pregnancy, and 50% of the
181 pregnancies reported were unplanned. Among the 53% who reported
intercourse in the last month, 74% used contraception, 15% were
pregnant, 5% did not want to use contraception, 3% sought pregnancy and
3% had hysterectomy. Of those using contraception, 53% used highly
effective methods (sterilization, intrauterine device, hormonal pill,
patch and injection), and 47% used less effective methods (condom,
withdrawal, rhythm and spermicide). Among the 21 participants using
hormonal methods, six concomitantly took enzyme-inducing antiepileptic
drugs potentially increasing susceptibility to pregnancy.

DISCUSSION: In this sample of women with epilepsy about half reported
prior pregnancies; 50% were unplanned. Of those using contraception,
only 53% used a highly effective method. Future studies should determine
generalizability of these findings and explore reasons for inadequate
family planning in women with epilepsy.

Davis AR, Pack AM, Kritzer J, Yoon A, Camus A. Reproductive history,
sexual behavior and use of contraception in women with epilepsy.
Contraception. 2008 Jun;77(6):405-9. Epub 2008 Apr 18.
<http://www.ncbi.nlm.nih.gov/pubmed/18477488>

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

**Hypothermia therapy after traumatic brain injury in children does not
improve neurologic outcomes and may increase mortality**

BACKGROUND: Hypothermia therapy improves survival and the neurologic
outcome in animal models of traumatic brain injury. However, the effect
of hypothermia therapy on the neurologic outcome and mortality among
children who have severe traumatic brain injury is unknown. METHODS: In
a multicenter, international trial, we randomly assigned children with
severe traumatic brain injury to either hypothermia therapy (32.5
degrees C for 24 hours) initiated within 8 hours after injury or to
normothermia (37.0 degrees C). The primary outcome was the proportion of
children who had an unfavorable outcome (i.e., severe disability,
persistent vegetative state, or death), as assessed on the basis of the
Pediatric Cerebral Performance Category score at 6 months.

RESULTS: A total of 225 children were randomly assigned to the
hypothermia group or the normothermia group; the mean temperatures
achieved in the two groups were 33.1+/-1.2 degrees C and 36.9+/-0.5
degrees C, respectively. At 6 months, 31% of the patients in the
hypothermia group, as compared with 22% of the patients in the
normothermia group, had an unfavorable outcome (relative risk, 1.41; 95%
confidence interval \[CI\], 0.89 to 2.22; P=0.14). There were 23 deaths
(21%) in the hypothermia group and 14 deaths (12%) in the normothermia
group (relative risk, 1.40; 95% CI, 0.90 to 2.27; P=0.06). There was
more hypotension (P=0.047) and more vasoactive agents were administered
(P\<0.001) in the hypothermia group during the rewarming period than in
the normothermia group. Lengths of stay in the intensive care unit and
in the hospital and other adverse events were similar in the two groups.

CONCLUSIONS: In children with severe traumatic brain injury, hypothermia
therapy that is initiated within 8 hours after injury and continued for
24 hours does not improve the neurologic outcome and may increase
mortality.

## Hutchison JS, et al. Hypothermia therapy after traumatic brain injury in children. **N Engl J Med. 2008 Jun 5;358(23):2447-56.** [**http://www.ncbi.nlm.nih.gov/pubmed/18525042**](http://www.ncbi.nlm.nih.gov/pubmed/18525042) 

## Obesity and type 2 diabetes risk in midadult life: the role of childhood adversity

OBJECTIVE: Child abuse has been associated with poorer physical health
in adulthood, but less is known about childhood adversity more broadly,
including neglect and family problems, or the pathways from adversity to
adult disease. We have examined how different stressful emotional or
neglectful childhood adversities are related to adiposity and glucose
control in midadulthood, taking into account childhood factors, and
whether the relationships are mediated by adult health behaviors and
socioeconomic position.

METHODS: This was a prospective longitudinal study of 9310 members of
the 1958 British birth cohort who participated in a biomedical interview
at 45 years of age. Primary outcomes consisted of continuous measures of
BMI, waist circumference, and glycosylated hemoglobin at 45 years and
categorical indicators: total obesity (BMI \> or = 30), central obesity
(waist circumference: \> or = 102 cm for men and \> or = 88 cm for
women), and glycosylated hemoglobin level of \> or = 6. RESULTS: The
risk of obesity increased by 20% to 50% for several adversities
(physical abuse, verbal abuse, witnessed abuse, humiliation, neglect,
strict upbringing, physical punishment, conflict or tension, low
parental aspirations or interest in education, hardly takes outings with
parents, and father hardly reads to child). Adversities with the
strongest associations with adiposity (eg, physical abuse) tended to be
associated with glycosylated hemoglobin levels of \> or = 6, but in most
cases associations were explained by adjustment for adulthood mediators
such as adiposity. Effects of other adversities reflecting less severe
emotional neglect and family environment were largely explained by
childhood socioeconomic factors.

CONCLUSIONS: Some childhood adversities increase the risk of obesity in
adulthood and thereby increase the risk for type 2 diabetes. Research is
needed to understand the interrelatedness of adversities, the social
context of their occurrence, and trajectories from adversity to adult
disease.

## Thomas C, Hyppönen E, Power C. Obesity and type 2 diabetes risk in midadult life: the role of childhood adversity. **Pediatrics. 2008 May;121(5):e1240-9.** 

<http://www.ncbi.nlm.nih.gov/pubmed/18450866>

**Nearly 1 in 10 Girls Engages in Frequent Binge Eating or Purging**

OBJECTIVE: To identify predictors of becoming eating disordered among
adolescents. DESIGN: Prospective cohort study. SETTING: Self-report
questionnaires.

SUBJECTS: Girls (n = 6916) and boys (n = 5618), aged 9 to 15 years at
baseline, in the ongoing Growing Up Today Study (GUTS). Main Exposures
Parent, peer, and media influences.

MAIN OUTCOME MEASURES: Onset of starting to binge eat or purge (ie,
vomiting or using laxatives) at least weekly. RESULTS: During 7 years of
follow-up, 4.3% of female subjects and 2.3% of male subjects (hereafter
referred to as \"females\" and \"males\") started to binge eat and 5.3%
of females and 0.8% of males started to purge to control their weight.
Few participants started to both binge eat and purge. Rates and risk
factors varied by sex and age group (\<14 vs \> or =14 years). Females
younger than 14 years whose mothers had a history of an eating disorder
were nearly 3 times more likely than their peers to start purging at
least weekly (odds ratio, 2.8; 95% confidence interval, 1.3-5.9);
however, maternal history of an eating disorder was unrelated to risk of
starting to binge eat or purge in older adolescent females. Frequent
dieting and trying to look like persons in the media were independent
predictors of binge eating in females of all ages. In males, negative
comments about weight by fathers was predictive of starting to binge at
least weekly.

CONCLUSIONS: Risk factors for the development of binge eating and
purging differ by sex and by age group in females. Maternal history of
an eating disorder is a risk factor only in younger adolescent females.

Field AE, Javaras KM, Aneja P, Kitos N, Camargo CA Jr, Taylor CB, Laird
NM. Family, peer, and media predictors of becoming eating disordered.
Arch Pediatr Adolesc Med. 2008 Jun;162(6):574-9.
<http://www.ncbi.nlm.nih.gov/pubmed/18524749>

I**rregular menses linked to vomiting**

PURPOSE: Using data from an eating disorders screening initiative
conducted in high schools across the United States, we examined the
relationship between vomiting frequency and irregular menses in a
nonclinical sample of adolescent females.

METHODS: A self-report questionnaire was administered to students from
U.S. high schools participating in the National Eating Disorders
Screening Program in 2000. The questionnaire included items on frequency
of vomiting for weight control in the past 3 months, other eating
disorder symptoms, frequency of menses, height, and weight.
Multivariable regression analyses were conducted using data from 2791
girls to estimate the risk of irregular menses (defined as menses less
often than monthly) associated with vomiting frequency, adjusting for
other eating disorder symptoms, weight status, age, race/ethnicity, and
school clusters.

RESULTS: Girls who vomited to control their weight one to three times
per month were one and a half times more likely (risk ratio \[RR\] =
1.6; 95% confidence interval \[CI\] = 1.2-2.2), and girls who vomited
once per week or more often were more than three times more likely (RR =
3.2; 95% CI = 2.3-4.4), to experience irregular menses than were girls
who did not report vomiting for weight control. Vomiting for weight
control remained a strong predictor of irregular menses even when
overweight and underweight participants were excluded.

CONCLUSIONS: Our study adds to the evidence that vomiting may have a
direct effect on hormonal function in adolescent girls, and that
vomiting for weight control may be a particularly deleterious component
of eating disorders.

Austin SB, Ziyadeh NJ, Vohra S, Forman S, Gordon CM, Prokop LA, Keliher
A, Jacobs D.

## Irregular menses linked to vomiting in a nonclinical sample: findings from the National Eating Disorders Screening Program in high schools. **J Adolesc Health. 2008 May;42(5):450-7. Epub 2008 Mar 4.** [**http://www.ncbi.nlm.nih.gov/pubmed/18407039**](http://www.ncbi.nlm.nih.gov/pubmed/18407039) 

**Ocular Trauma Due to a Water-Bottle Cap**

A New England Journal of Medicine "Images in Clinical Medicine" presents
a case of adolescent eye injury associated with crushing plastic water
bottles.

<http://content.nejm.org/cgi/content/full/358/21/2265>

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

**Intensive Glucose Control Does Not Prevent Major Cardiovascular Events
in Type 2 Diabetes**

Two recent studies published in the NEJM addressing intensive glucose
control in adults with type 2 diabetes failed to demonstrate a decrease
in major cardiovascular events, although the second study did show a
decrease in nephropathy.

**ACCORD Study Abstract:**

BACKGROUND: Epidemiologic studies have shown a relationship between
glycated hemoglobin levels and cardiovascular events in patients with
type 2 diabetes. We investigated whether intensive therapy to target
normal glycated hemoglobin levels would reduce cardiovascular events in
patients with type 2 diabetes who had either established cardiovascular
disease or additional cardiovascular risk factors.

METHODS: In this randomized study, 10,251 patients (mean age, 62.2
years) with a median glycated hemoglobin level of 8.1% were assigned to
receive intensive therapy (targeting a glycated hemoglobin level below
6.0%) or standard therapy (targeting a level from 7.0 to 7.9%). Of these
patients, 38% were women, and 35% had had a previous cardiovascular
event. The primary outcome was a composite of nonfatal myocardial
infarction, nonfatal stroke, or death from cardiovascular causes. The
finding of higher mortality in the intensive-therapy group led to a
discontinuation of intensive therapy after a mean of 3.5 years of
follow-up.

RESULTS: At 1 year, stable median glycated hemoglobin levels of 6.4% and
7.5% were achieved in the intensive-therapy group and the
standard-therapy group, respectively. During follow-up, the primary
outcome occurred in 352 patients in the intensive-therapy group, as
compared with 371 in the standard-therapy group (hazard ratio, 0.90; 95%
confidence interval \[CI\], 0.78 to 1.04; P=0.16). At the same time, 257
patients in the intensive-therapy group died, as compared with 203
patients in the standard-therapy group (hazard ratio, 1.22; 95% CI, 1.01
to 1.46; P=0.04). Hypoglycemia requiring assistance and weight gain of
more than 10 kg were more frequent in the intensive-therapy group
(P\<0.001).

CONCLUSIONS: As compared with standard therapy, the use of intensive
therapy to target normal glycated hemoglobin levels for 3.5 years
increased mortality and did not significantly reduce major
cardiovascular events. These findings identify a previously unrecognized
harm of intensive glucose lowering in high-risk patients with type 2
diabetes.

## The Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of Intensive Glucose Lowering in Type 2 Diabetes. **N Engl J Med. 2008 Jun 12;358(24):2545-2559. Epub 2008 Jun 6.** 

PubMed Abstract: <http://www.ncbi.nlm.nih.gov/pubmed/18539917>

Free Full Text:
<http://content.nejm.org/cgi/content/full/358/24/2545?query=TOC>

**ADVANCE Study Abstract:**

BACKGROUND: In patients with type 2 diabetes, the effects of intensive
glucose control on vascular outcomes remain uncertain. METHODS: We
randomly assigned 11,140 patients with type 2 diabetes to undergo either
standard glucose control or intensive glucose control, defined as the
use of gliclazide (modified release) plus other drugs as required to
achieve a glycated hemoglobin value of 6.5% or less. Primary end points
were composites of major macrovascular events (death from cardiovascular
causes, nonfatal myocardial infarction, or nonfatal stroke) and major
microvascular events (new or worsening nephropathy or retinopathy),
assessed both jointly and separately.

RESULTS: After a median of 5 years of follow-up, the mean glycated
hemoglobin level was lower in the intensive-control group (6.5%) than in
the standard-control group (7.3%). Intensive control reduced the
incidence of combined major macrovascular and microvascular events
(18.1%, vs. 20.0% with standard control; hazard ratio, 0.90; 95%
confidence interval \[CI\], 0.82 to 0.98; P=0.01), as well as that of
major microvascular events (9.4% vs. 10.9%; hazard ratio, 0.86; 95% CI,
0.77 to 0.97; P=0.01), primarily because of a reduction in the incidence
of nephropathy (4.1% vs. 5.2%; hazard ratio, 0.79; 95% CI, 0.66 to 0.93;
P=0.006), with no significant effect on retinopathy (P=0.50). There were
no significant effects of the type of glucose control on major
macrovascular events (hazard ratio with intensive control, 0.94; 95% CI,
0.84 to 1.06; P=0.32), death from cardiovascular causes (hazard ratio
with intensive control, 0.88; 95% CI, 0.74 to 1.04; P=0.12), or death
from any cause (hazard ratio with intensive control, 0.93; 95% CI, 0.83
to 1.06; P=0.28). Severe hypoglycemia, although uncommon, was more
common in the intensive-control group (2.7%, vs. 1.5% in the
standard-control group; hazard ratio, 1.86; 95% CI, 1.42 to 2.40;
P\<0.001).

CONCLUSIONS: A strategy of intensive glucose control, involving
gliclazide (modified release) and other drugs as required, that lowered
the glycated hemoglobin value to 6.5% yielded a 10% relative reduction
in the combined outcome of major macrovascular and microvascular events,
primarily as a consequence of a 21% relative reduction in nephropathy.

## The ADVANCE Collaborative Group. Intensive Blood Glucose Control and Vascular Outcomes in Patients with Type 2 Diabetes. **N Engl J Med. 2008 Jun 12;358(24):2560-2572. Epub 2008 Jun 6.**

PubMed Abstract:<http://www.ncbi.nlm.nih.gov/pubmed/18539916>

Free Full Text: <http://content.nejm.org/cgi/content/full/358/24/2560>

Commentary on both articles in the New England Journal of Medicine:

<http://content.nejm.org/cgi/content/full/358/24/2630>

<http://content.nejm.org/cgi/content/full/358/24/2633>

<http://content.nejm.org/cgi/content/full/358/24/2537>

**A collaborative approach to diabetes care in community health centers
can improve care and be cost-effective**

OBJECTIVE: To estimate the incremental cost-effectiveness of improving
diabetes care with the Health Disparities Collaborative (HDC), a
national collaborative quality improvement (QI) program conducted in
community health centers (HCs).

DATA SOURCES/STUDY SETTING: Data regarding the impact of the Diabetes
HDC program came from a serial cross-sectional follow-up study (1998,
2000, 2002) of the program in 17 Midwestern HCs. Data inputs for the
simulation model of diabetes came from the latest clinical trials and
epidemiological studies.

STUDY DESIGN: We conducted a societal cost-effectiveness analysis,
incorporating data from QI program evaluation into a Monte Carlo
simulation model of diabetes. Data COLLECTION/EXTRACTION METHODS: Data
on diabetes care processes and risk factor levels were extracted from
medical charts of randomly selected patients.

PRINCIPAL FINDINGS: From 1998 to 2002, multiple processes of care (e.g.,
glycosylated hemoglobin testing \[HbA1C\] \[71\--\>92 percent\] and ACE
inhibitor prescribing \[33\--\>55 percent\]) and risk factor levels
(e.g., 1998 mean HbA1C 8.53 percent, mean difference 0.45 percent \[95
percent confidence intervals -0.72, -0.17\]) improved significantly.
With these improvements, the HDC was estimated to reduce the lifetime
incidence of blindness (17\--\>15 percent), end-stage renal disease
(18\--\>15 percent), and coronary artery disease (28\--\>24 percent).
The average improvement in quality-adjusted life year (QALY) was 0.35
and the incremental cost-effectiveness ratio was \$33,386/QALY.

CONCLUSIONS: During the first 4 years of the HDC, multiple improvements
in diabetes care were observed. If these improvements are maintained or
enhanced over the lifetime of patients, the HDC program will be
cost-effective for society based on traditionally accepted thresholds.

## Huang ES, Zhang Q, Brown SE, Drum ML, Meltzer DO, Chin MH. The cost-effectiveness of improving diabetes care in U.S. federally qualified community health centers. **Health Serv Res. 2007 Dec;42(6 Pt 1):2174-93; discussion 2294-323. <http://www.ncbi.nlm.nih.gov/pubmed/17995559>** 

####  {#section-2 .Style-Heading-4-+-Arial-14-pt-Underline}

**Patient factors, not physician or clinic factors, account for most of
the variance in blood sugar levels among adults with diabetes**

**From ARHQ:** This study supports the hypothesis that medication
intensification may be the final common pathway that leads to better
glycemic control.

**Abstract:**

INTRODUCTION: We studied variance in glycated hemoglobin (HbA1c) values
among adults with diabetes to identify variation in quality of diabetes
care at the levels of patient, physician, and clinic, and to identify
which levels contribute the most to variation and which variables at
each level are related to quality of diabetes care.

METHODS: Study subjects were 120 primary care physicians and their 2589
eligible adult patients with diabetes seen at 18 clinics. The dependent
variable was HbA1c values recorded in clinical databases. Multivariate
hierarchical models were used to partition variation in HbA1c values
across the levels of patient, physician, or clinic and to identify
significant predictors of HbA1c at each level.

RESULTS: More than 95% of variance in HbA1c values was attributable to
the patient level. Much less variance was seen at the physician and
clinic level. Inclusion of patient and physician covariates did not
substantially change this pattern of results. Intensification of
pharmacotherapy (t = -7.40, P \< .01) and patient age (t = 2.10, P \<
.05) were related to favorable change in HbA1c. Physician age, physician
specialty, number of diabetes patients per physician, patient
comorbidity, and clinic assignment did not predict change in HbA1c
value. The overall model with covariates explained 11.8% of change in
HbA1c value over time.

CONCLUSION: These data suggest that most variance in HbA1c values is
attributable to patient factors, although physicians play a major role
in some patient factors (e.g., intensification of medication). These
findings may lead to more effective care-improvement strategies and
accountability measures.

AHRQ commentary at: <http://www.ahrq.gov/research/jun08/0608RA12.htm>

## 

Abstract and PubMed citation at: O\'Connor PJ, Rush WA, Davidson G,
Louis TA, Solberg LI, Crain L, Johnson PE, Whitebird RR. Variation in
quality of diabetes care at the levels of patient, physician, and
clinic. Prev Chronic Dis. 2008 Jan;5(1):A15. Epub 2007 Dec 15.
<http://www.ncbi.nlm.nih.gov/pubmed/18082004>

**Antidepressants and therapy may be cost-effective for patients with
medically unexplained symptoms**

**From ARHQ:** Individuals complaining of physical problems for which
there is little or no disease explanation (somatization) make up 5 to 10
percent of primary care patients. These individuals, many of whom are
depressed, often embark on a quest to find a disease that they fear but
do not have. This typically results in numerous laboratory tests and
consultations, as well as treatments of nonexistent conditions. Not only
is this a costly enterprise, but physicians often ignore these
patients\' emotional distress, note Michigan State University
researchers. They hypothesized that use of antidepressants and
cognitive-behavioral therapy, combined with a focus on a strong
provider-patient relationship, may be of some help to these patients.

**Abstract:**

OBJECTIVE: This study sought to determine whether an intervention for
patients with medically unexplained symptoms in primary care reduced
total costs, components of cost, and longer-term costs and whether it
led to decreased service use outside the health maintenance organization
(HMO).

METHODS: A randomized controlled trial involving 206 patients with
medically unexplained symptoms was conducted in a staff-model HMO. The
protocol emphasized the provider-patient relationship and included
cognitive-behavioral therapy and pharmacological management. Cost data
for medical treatments were derived from the HMO\'s electronic database.
Patients were interviewed about work days lost and out-of-pocket
expenses for medical care outside the HMO. RESULTS: The difference in
total costs (\$1,071) for the 12-month intervention was not significant.
The treatment group had significantly higher costs for antidepressants
than the usual-care group (\$192 higher) during the intervention, and a
larger proportion received antidepressants. The intervention group used
less medical care outside the HMO and missed one less work day per month
on average (1.23 days), indicating a slight improvement in productivity,
but the difference was not significant. The between-group difference in
estimated total cost was smaller in the year after the intervention
(difference of \$341) but were not significant.

CONCLUSIONS: The total costs for the intervention group were not
significantly different, but the group had greater use of
antidepressants. Coupled with findings of improved mental health
outcomes for this group in a previous study, the results indicate that
the intervention may be cost-effective. The longer-term impact needs to
be further studied.

AHRQ commentary at: <http://www.ahrq.gov/research/jun08/0608RA18.htm>

Abstract and PubMed citation at: Luo Z, Goddeeris J, Gardiner JC, Smith
RC. Costs of an intervention for primary care patients with medically
unexplained symptoms: a randomized controlled trial. Psychiatr Serv.
2007 Aug;58(8):1079-86. <http://www.ncbi.nlm.nih.gov/pubmed/17664519>

**Light and Melatonin May Reduce Dementia Symptoms**

Resynchronizing patients\' circadian rhythms with light and melatonin
may have a \"modest benefit\" on their dementia symptoms.

CONTEXT: Cognitive decline, mood, behavioral and sleep disturbances, and
limitations of activities of daily living commonly burden elderly
patients with dementia and their caregivers. Circadian rhythm
disturbances have been associated with these symptoms. OBJECTIVE: To
determine whether the progression of cognitive and noncognitive symptoms
may be ameliorated by individual or combined long-term application of
the 2 major synchronizers of the circadian timing system: bright light
and melatonin.

DESIGN, SETTING, AND PARTICIPANTS: A long-term, double-blind,
placebo-controlled, 2 x 2 factorial randomized trial performed from 1999
to 2004 with 189 residents of 12 group care facilities in the
Netherlands; mean (SD) age, 85.8 (5.5) years; 90% were female and 87%
had dementia. INTERVENTIONS: Random assignment by facility to long-term
daily treatment with whole-day bright (+/- 1000 lux) or dim (+/- 300
lux) light and by participant to evening melatonin (2.5 mg) or placebo
for a mean (SD) of 15 (12) months (maximum period of 3.5 years).
CONCLUSIONS: Light has a modest benefit in improving some cognitive and
noncognitive symptoms of dementia. To counteract the adverse effect of
melatonin on mood, it is recommended only in combination with light.

Riemersma-van der Lek RF, Swaab DF, Twisk J, Hol EM, Hoogendijk WJ, Van
Someren EJ. Effect of bright light and melatonin on cognitive and
noncognitive function in elderly residents of group care facilities: a
randomized controlled trial. JAMA. 2008 Jun 11;299(22):2642-55.

<http://www.ncbi.nlm.nih.gov/pubmed/18544724>

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

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

**ACOG Practice Bulletin No. 94: Medical Management of Ectopic
Pregnancy**

**Overview:** In the United States, ectopic pregnancy accounts for 2% of
all first-trimester pregnancies and 6% of all pregnancy-related deaths;
it is the leading cause of maternal death in the first trimester. Early
detection of ectopic pregnancy can lead to successful management without
surgery. Methotrexate, a folic acid antagonist, can be used successfully
to treat early, nonruptured ectopic pregnancy. The purpose of this
document is to review the risks and benefits of the use of methotrexate
in the management of ectopic pregnancy.

**Summary of Recommendations and Conclusions:**

**The following conclusion is based on good and consistent evidence
(Level A):**

-   In comparing systemic methotrexate with tube-sparing laparoscopic
    surgery, randomized trials have shown no difference in overall tubal
    preservation, tubal patency, repeat ectopic pregnancy, or future
    pregnancies.

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

-   An increase in serum hCG of less than 53% in 48 hours confirms an
    abnormal pregnancy.

-   With an hCG level of 5,000 mIU/mL or higher, multiple doses of
    methotrexate may be appropriate.

-   Methotrexate can be considered in those women with a confirmed, or
    high clinical suspicion of, ectopic pregnancy who are
    hemodynamically stable with an unruptured mass.

-   Failure of the hCG level to decrease by at least 15% from day 4 to
    day 7 after methotrexate administration is considered treatment
    failure requiring therapy with either additional methotrexate
    administration or surgical intervention.

-   Posttreatment hCG levels should be monitored until a nonpregnancy
    level is reached.

**The following conclusion is based primarily on consensus and expert
opinion (Level C):**

-   If the initial hCG level is less than 200 mIU/mL, 88% of patients
    experience spontaneous resolution.

ACOG Practice Bulletin No. 94: Medical Management of Ectopic Pregnancy.
Obstet Gynecol 2008 111: 1479-1485.
<http://www.ncbi.nlm.nih.gov/pubmed/18515537>

**ACOG Committee Opinion No. 410: Ethical Issues in Genetic Testing**

**Abstract:** Genetic testing is poised to play an increasing role in
the practice of obstetrics and gynecology. To assure patients of the
highest quality of care, physicians should become familiar with the
currently available array of genetic tests and the tests' limitations.
Clinicians should be able to identify patients within their practices
who are candidates for genetic testing. Candidates will include patients
who are pregnant or considering pregnancy and are at risk for giving
birth to affected children as well as gynecology patients who, for
example, may have or be predisposed to certain types of cancer. The
purpose of this Committee Opinion is to review some of the ethical
issues related to genetic testing and provide guidelines for the
appropriate use of genetic tests by obstetrician--gynecologists. Expert
consultation and referral are likely to be needed when
obstetrician--gynecologists are confronted with these issues.

ACOG Committee Opinion No. 410: Ethical Issues in Genetic Testing.

Obstet Gynecol 2008 111: 1495-1502.
<http://www.ncbi.nlm.nih.gov/pubmed/18515541>

**ACOG Committee Opinion No. 409: Direct-to-Consumer Marketing of
Genetic Testing**

**Abstract:** Marketing of genetic testing, although similar to
direct-to-consumer advertising of prescription drugs, raises additional
concerns and considerations. These include issues of limited knowledge
among patients and health care providers of available genetic tests,
difficulty in interpretation of genetic testing results, lack of federal
oversight of companies offering genetic testing, and issues of privacy
and confidentiality. Until all of these considerations are addressed,
direct or home genetic testing should be discouraged because of the
potential harm of a misinterpreted or inaccurate result.

ACOG Committee Opinion No. 409: Direct-to-Consumer Marketing of Genetic
Testing.

Obstet Gynecol 2008 111: 1493-1494.
<http://www.ncbi.nlm.nih.gov/pubmed/18515540>

**ACOG Committee Opinion No. 408: Professional Liability and
Gynecology-Only Practice**

**Abstract:** Fellows of the American College of Obstetricians and
Gynecologists may choose to limit the scope of their practices to
gynecology. The College considers early pregnancy care (often up to
12--14 weeks of gestation) to be within the scope of gynecology and
gynecologic practice. Liability insurers who provide coverage for
"gynecology-only" practices should provide coverage for clinical
practice activities that involve the management of early pregnancy and
its complications.

ACOG Committee Opinion No. 408: Professional Liability and
Gynecology-Only Practice.

Obstet Gynecol 2008 111: 1491.
<http://www.ncbi.nlm.nih.gov/pubmed/18515539>

**New interactive site for clinicians serving women with disabilities**

ACOG has released a recorded slide program, ***Reproductive Health
Care for Women with Disabilities**,* which assists women\'s health care
clinicians with office skills to assist with their care of women with
physical, developmental or sensory disabilities
giving specific information for reproductive health care.  Available now
are the first 2 parts of a six part series:

[Part
1](http://www.acog.org/departments/womenWithDisabilities/ReproHealthCare.ppt)
includes an *overview* of the program, *The Scope of Disability in
Women, Sexuality*, and *Psychosocial Issues*. 

[Part
2](http://www.acog.org/departments/womenWithDisabilities/RoutineGynHealthCare.ppt)
includes *The GYN Examination* and* GYN Health Screening.*

This program was recorded by Raymond L Cox, Jr., MD, MBA, FACOG and
Caroline Signore, MD, MPH, FACOG. Elisabeth Quint, MD, FACOG served as
faculty chair.

<http://streaming.acog.org/WomenWithDisabilities/>

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

**Food Allergies: Detection and Management**

ABSTRACT: Family physicians play a central role in the suspicion and
diagnosis of immunoglobulin E-mediated food allergies, but they are also
critical in redirecting the evaluation for symptoms that patients are
falsely attributing to allergies. Although any food is a potential
allergen, more than 90 percent of acute systemic reactions to food in
children are from eggs, milk, soy, wheat, or peanuts, and in adults are
from crustaceans, tree nuts, peanuts, or fish. The oral allergy syndrome
is more common than anaphylactic reactions to food, but symptoms are
transient and limited to the mouth and throat. Skin-prick and
radioallergosorbent tests for particular foods have about an 85 percent
sensitivity and 30 to 60 percent specificity. Intradermal testing has a
higher false-positive rate and greater risk of adverse reactions;
therefore, it should not be used for initial evaluations. The
double-blind, placebo-controlled food challenge remains the most
specific test for confirming diagnosis. Treatment is through recognition
and avoidance of the responsible food. Patients with anaphylactic
reactions need emergent epinephrine and instruction in
self-administration in the event of inadvertent exposure. Antihistamines
can be used for more minor reactions.

Kurowski K, Boxer RW, Food Allergies: Detection and Management, **Am Fam
Physician**. 2008;77(12):1678-1686, 1687-1688.
[**http://www.aafp.org/afp/20080615/1678.html**](http://www.aafp.org/afp/20080615/1678.html)

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

**"Real Men Wear Gowns"**

The Agency for Healthcare Research and Quality (AHRQ) has joined with
the Advertising Council to launch a national public service campaign
designed to raise awareness among middle-aged men about the importance
of preventive medical testing. The new campaign---\"Real Men Wear
Gowns\"---tells men over 40 to learn which preventive screening tests
they need to get and when they need to get them. According to AHRQ\'s
Medical Expenditure Panel Survey, men are 25 percent less likely than
women to have visited the doctor within the past year and are 38 percent
more likely than women to have neglected their cholesterol tests. Data
from the Centers for Disease Control and Prevention indicate that men
are 1.5 times more likely than women to die from heart disease, cancer,
and chronic lower respiratory diseases.

The campaign encourages men to visit a comprehensive Web site,
[www.ahrq.gov/realmen/](http://www.ahrq.gov/realmen/). The site provides
the recommended ages for preventive testing (as well as a list of
tests), a quiz designed to test knowledge of preventive health care,
tips for talking with the doctor, a glossary of consumer health terms,
and links to online resources where men can find more medical
information.

#### 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}

**Health education materials available online in a variety of
languages**

Sally J. Bremner, Health Sciences Librarian of the Alaskan Health
Sciences Information Service, provided information on an exciting new
service offered by the National Library of Medicine on MedlinePlus.
Follow the link below to check out the searchable offerings:

##### [**http://www.nlm.nih.gov/medlineplus/languages/languages.html**](http://www.nlm.nih.gov/medlineplus/languages/languages.html) 

##### Behavioral Health Insights Peter Stuart, IHS Psychiatry Consultant

**Chronic Pain Management 101 -- Saying No to Patients**

Vignette: Ms. Howard has been followed in your clinic for several years
for a variety of complaints including chronic neck and arm pain. She has
a history of rotator cuff surgery which did not improve substantially
her pain status. Her rehab participation could be characterized by the
words "erratic to none." She also has a history of periodic drinking
episodes, depression and several overdoses while intoxicated, and
previous tolerance development to narcotics and drug-seeking behavior.
She is involved in a chaotic relationship. You do believe she has some
physiologic basis for her pain but her compliance with your
recommendations is erratic at best and you have on several occasions
assisted her in detoxing from narcotics only to have her go to another
provider and be restarted on them. She can be quite dramatic when
claiming to suffer from pain and has accused you previously of "not
doing enough to help me with my pain." She is also on an antidepressant
and gabapentin and cannot tolerate NSAIDs due to GI complications. You
have a pain contract in place.

She presents today telling you she needs a refill of her Percocet 1 week
before they were supposed to run out. She has been taking "1 or 2 extra
a day because I was cleaning house last week and twisted my shoulder
again." She has a fairly recent history of prior "lost meds" that she
has been counseled on in line with the pain treatment contract she
signed. She appears mildly anxious and exhibits some discomfort with the
shoulder even when non-obtrusively observed. The daily quantity is
sufficient enough that you are concerned about withdrawal symptoms.

(At this point most providers start grinding their teeth) How do you
approach her? Turf her to the psychiatrist or chronic pain committee (if
you're fortunate enough to have either?) What about her current needs?

In the murky world of real human beings, this amalgam of physical,
social and emotional issues is not uncommon. The patient is likely to
genuinely need some type of pain management, but is clearly out of
control of her life and her self-care. She has demonstrated concerning
tolerance development and there certainly is an addiction component
active. She is clearly stepping outside of the boundaries set by the
treatment contract. What is a reasonable goal here? Do we, as providers,
have a commitment to provide compassionate and effective care no matter
what the circumstances? If so, what exactly does that look like in this
case? Is the appropriate overall approach "Harm Reduction" or
"Abstinence-Based" or something else?

For me in situations like this it is helpful to go back to some basic
clinical principles: First, that the overall clinical situation always
trumps any absolute clinical rules about specific issues (i.e. if the
pain contract says "no more meds after you lose an RX"). Borrowing a
little from rabbinic tradition, each patient presents a unique set of
predispositions, current symptoms and possible outcomes that require the
provider to exercise discernment and judgment in determining what the
appropriate course of action is.

For this patient, that means understanding that my goal is long-term
pain relief and life management -- the path I'm looking for keeps the
patient in my practice, but also provides enough incentive for her to
make some necessary changes for her benefit. Second, sometimes the right
answer is "No". As physicians, the principles of beneficence and minimal
malfeasance are in play here. She is presenting in a situation where
contingency management can be helpful in shifting behavior. In this case
it might be worth using the positive contingency of getting her pain
meds to decrease her discomfort both from withdrawal symptoms and pain
in order to get her attending rehab and counseling. The challenge here
is often a systems one -- lack of access to these services at the time
of presentation. \*\*If the system is broken and doesn't work well -- it
is incredibly important to acknowledge that reality.\*\*

An appointment in rehab is available in 3 days time. In order to involve
her in the process you negotiate with her to walk to rehab, schedule the
appointment in person, and return to your office at which time you will
provide her with an Rx for the 3 days. Further refills will be
contingent on showing up at rehab and will be filled [after]{.underline}
she has her rehab appointment. Here is where saying "no med refill until
. . ." can be very important.

Alternatively, you believe the big issue here is that she is not
managing her meds appropriately (she is not following the contract, you
have given her prior "chances" to learn the system, the system has done
its part by providing her with the full Rx when she comes in, and is
available to her if she has been debating about increasing her dose at
home). In this case, the challenge becomes saying "No" without breaking
the treatment relationship.

Third, "No" can be said in a supportive way. The principles for saying
"No" in a supportive way are as follows: 1) Start with empathizing and
putting yourself in the patient's shoes, for example "I hear from what
you're saying and can see by looking at you that you are very
uncomfortable right now, and I'm guessing you're also worried about what
withdrawal is going to be like if you don't get something. Is that close
to what's going on?" 2) Align yourself alongside the patient and look at
the problem together and the potential consequences of different
approaches together, for example "Help me look at the options from your
perspective. First option -- I just refill the meds, no further
questions asked, what happens then? And after that? And what's happened
before when we've done that? And how was that experience? Second option
-- I tell you no more meds . . . (repeat) Third option -- can you think
of a third option? " 3) Summarize the options preferably using similar
language to the patient, 4) tell the patient what you personally are
comfortable doing and why, and 5) acknowledge that the patient may
angry, frustrated, annoyed, scared, etc. and that you appreciate and
understand that response and will continue working with them on their
care.

Part 4 is the most difficult part because it is where you may be
choosing an option different than the one the patient prefers. It is
very important to be prepared for strong reactions. In Ms. Howard's case
she initially tells you to "F\*\*\* off -- I'll just go somewhere else
then." You reply, "Yes, I think I'd be upset and scared too, and at the
same time I hope you will continue to work with me." If the strong
feelings can be safely tolerated and tested with the patient you have
just successfully improved the relationship bond with the patient and
the ability of the patient to tolerate further conflict with you -- for
the best interest of the patient.

In summary, the key ingredients here are an ability to see the big
picture with the patient, to align yourself alongside the patient rather
than against, and to support movement towards health sometimes by
setting firm limits and boundaries but always in a context of compassion
and caring. What else does this approach require? Time and focused
attention . . .and if you can't hold the system accountable for
providing these basic human needs, you're not going to get far in
holding the patient accountable.

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

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

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

**A new look at what works to support breastfeeding in hospitals**

June 13, 2002, Centers for Disease Control and Prevention (CDC)
published in its weekly Morbidity and Mortality Weekly Report (MMWR),
"Breastfeeding-Related Maternity Practices at Hospitals and Birth
Centers -- United States, 2007." The article is the result of the first
national Maternity Practices in Infant Nutrition and Care (mPINC --
called "m-pink") survey. The survey used questions from 7 categories of
practice that are known to support breastfeeding, such as those found in
the Ten Steps for Baby Friendly Hospitals. The categories and typical
questions were:

1.  Labor and delivery -- Do mothers and newborns routinely experience
    skin-to-skin contact and early breastfeeding initiation?

2.  Breastfeeding assistance -- Is assessment, recording and instruction
    provided to new families on infant feeding? For example, are
    pacifiers not provided to breastfeeding infants?

3.  Mother- newborn contact -- Is the separation of mother and newborn
    avoided?

4.  Newborn feeding practices -- What and how breastfed babies are fed
    while in the hospital or birthing center? For example, is
    supplementation common and why?

5.  Breastfeeding support after discharge -- Are resources provided for
    the new family when they are discharged? Where can they go for
    assistance if problems or concerns arise?

6.  Nurse/birth attendant breastfeeding training and education -- What
    kind of breastfeeding support training and on-going education does
    staff receive?

7.  Structural and organizational factors related to breastfeeding --

    a.  Does the facility have a breastfeeding policy and how is it
        communicated to staff?

    b.  Is there support for breastfeeding employees?

    c.  Does the facility receive free infant formula?

    d.  Is prenatal breastfeeding education available?

    e.  Is there coordination of lactation care?

The survey was mailed to 3,143 hospitals and 138 birth centers - of
these, 2,690 hospitals and 121 birthing centers responded. The survey
was structured to be completed by the person most knowledgeable of the
facility's intra-partum practices related to breastfeeding. To encourage
true answers to survey questions, the responders and their
administration were assured that their location and name would be kept
confidential. The only potential identifier was the name of the state
where the facility was located. The data was summarized by state and
region.

The results of the survey were based on a maximum score of 100. For each
category from above, the mean subscale scores from highest to lowest
was:

80. 2\. Breastfeeding assistance

77 4. Newborn feeding practices

70 3. Mother-newborn contact

66. 7\. Structural and organizational factors related to breastfeeding

```{=html}
<!-- -->
```
60. 1\. Labor and delivery

```{=html}
<!-- -->
```
51. 6\. Nurse/birth attendant breastfeeding training and education

40 5. Breastfeeding support after discharge

State survey results strongly correlated with their breastfeeding
prevalence rates. This suggests that where there are more
evidenced-based breastfeeding support maternity practices in place,
there are positive impacts on breastfeeding. Unfortunately, the reverse
is also true.

For more information the survey project and survey questions, please see
[www.cdc.gov/mmwr](http://www.cdc.gov/mmwr)

June 13, 2008/vol 57/No. 23, and
[www.cdc.gov/mpinc](http://www.dcd.gov/mpinc)

CDC, Breastfeeding-Related Maternity Practices at Hospitals and Birth
Centers \-\-- United States, 2007 MMWR Weekly, June 13, 2008 /
57(23);621-625.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5723a1.htm>

**Recall of Mommy's Bliss Nipple Cream**

FDA informed consumers not to use or purchase Mommy\'s Bliss Nipple
Cream, marketed by MOM Enterprises, Inc., because the product contains
potentially harmful ingredients that may cause respiratory distress or
vomiting and diarrhea in infants. The product is promoted to nursing
mothers to help soothe and heal dry or cracked nipples. Potentially
harmful ingredients in the product are chlorphenesin and phenoxyethanol.
Chlorphenesin relaxes skeletal muscle and can depress the central
nervous system and cause slow or shallow breathing in infants.
Phenoxyenthanol, a preservative that is primarily used in cosmetics and
medications, can also depress the central nervous system and may cause
vomiting and diarrhea, which can lead to dehydration in infants. Mothers
and caregivers should seek immediate medical attention if their child
shows signs and symptoms of a decrease in appetite, difficulty in
awakening, limpness of extremities or a decrease in an infant\'s
strength of grip and a change in skin color.

Read the entire 2008 MedWatch Safety Summary, including a link to the
FDA News Release regarding this issue at:
[http://www.fda.gov/medwatch/safety/2008/safety08.htm#Bliss](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.fda.gov/medwatch/safety/2008/safety08.htm%23Bliss)

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

####  {#section-7 .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}

#### <http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm#jun08>  {#httpwww.ihs.govmedicalprogramsmchmob.cfmjun08 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-8 .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-9 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Domestic Violence Denise Grenier, Tucson / Rachel Locker, Warm Springs {#domestic-violence-denise-grenier-tucson-rachel-locker-warm-springs .Style-Heading-4-+-Arial-14-pt-Underline}

**WHO study links domestic violence and poor health; DV an urgent global
health priority**

BACKGROUND: This article summarises findings from ten countries from the
WHO multi-country study on women\'s health and domestic violence against
women.

METHODS: Standardised population-based surveys were done between 2000
and 2003. Women aged 15-49 years were interviewed about their
experiences of physically and sexually violent acts by a current or
former intimate male partner, and about selected symptoms associated
with physical and mental health. The women reporting physical violence
by a partner were asked about injuries that resulted from this type of
violence.

FINDINGS: 24,097 women completed interviews. Pooled analysis of all
sites found significant associations between lifetime experiences of
partner violence and self-reported poor health (odds ratio 1.6 \[95% CI
1.5-1.8\]), and with specific health problems in the previous 4 weeks:
difficulty walking (1.6 \[1.5-1.8\]), difficulty with daily activities
(1.6 \[1.5-1.8\]), pain (1.6 \[1.5-1.7\]), memory loss (1.8
\[1.6-2.0\]), dizziness (1.7 \[1.6-1.8\]), and vaginal discharge (1.8
\[1.7-2.0\]). For all settings combined, women who reported partner
violence at least once in their life reported significantly more
emotional distress, suicidal thoughts (2.9 \[2.7-3.2\]), and suicidal
attempts (3.8 \[3.3-4.5\]), than non-abused women. These significant
associations were maintained in almost all of the sites. Between 19% and
55% of women who had ever been physically abused by their partner were
ever injured.

INTERPRETATION: In addition to being a breach of human rights, intimate
partner violence is associated with serious public-health consequences
that should be addressed in national and global health policies and
programmes.

## Ellsberg M, Jansen HA, Heise L, Watts CH, Garcia-Moreno C; WHO Multi-country Study on Women\'s Health and Domestic Violence against Women Study Team. Intimate partner violence and women\'s physical and mental health in the WHO multi-country study on women\'s health and domestic violence: an observational study. **Lancet. 2008 Apr 5;371(9619):1165-72.** **<http://www.ncbi.nlm.nih.gov/pubmed/18395577>** 

#### Elder Care News Bruce Finke, Elder Care Initiative {#elder-care-news-bruce-finke-elder-care-initiative .Style-Heading-4-+-Arial-14-pt-Underline}

**Several factors can quickly identify mortality risk among frail
elderly persons living in the community**

The Agency for Healthcare Research and Quality provides the following
synopsis of a study that was partially funded through AHRQ:

Community-based long-term care programs such as PACE (Program of
All-Inclusive Care for the Elderly) can help frail, chronically ill
elderly people who would ordinarily enter nursing homes stay in the
community. Asking about certain risk factors during routine clinical
care can identify which of these frail community-dwelling elderly are at
risk of dying, according to a new study.

The researchers predicted time to death using data on risk factors
(demographic characteristics, coexisting medical conditions, and
functional status), which they obtained from a geriatric assessment
performed at the time of study enrollment. The risk scoring system
scored male sex as 2 points; age 75-84, 2 points; 85 and older, 3
points; dependence for help with toileting, 1 point; dependence for
partial or full help with dressing, 1 and 3 points, respectively;
cancer, 2 points; congestive heart failure, 3 points; chronic
obstructive pulmonary disease, 1 point; and renal insufficiency, 3
points.

In the validation group, respective 1 and 3-year mortality rates were 7
and 18 percent in the lowest risk group (0-3 points), 11 and 36 percent
in the middle-risk group (4-5 points), and 22 and 55 percent in the
highest-risk group (more than 5 points). The eight-variable index is
easy to use and includes variables that can be obtained in the course of
a routine clinical exam.

The ability of the index to predict mortality risk among the frail
elderly reinforces the importance of considering multiple domains in
assessing the prognosis of older patients.

The AHRQ summary is available at:
<http://www.ahrq.gov/research/jun08/0608RA10.htm>.

Abstract and PubMed Citation at: Carey EC, Covinsky KE, Lui LY, Eng C,
Sands LP, Walter LC. Prediction of mortality in community-living frail
elderly people with long-term care needs. J Am Geriatr Soc. 2008
Jan;56(1):68-75. Epub 2007 Nov 20.
<http://www.ncbi.nlm.nih.gov/pubmed/18031487>

###################### **Living wills should be updated, since preferences for life-prolonging treatments change when health status changes** {#living-wills-should-be-updated-since-preferences-for-life-prolonging-treatments-change-when-health-status-changes .unnumbered}

**Abstract:**

As a substantial body of research attests, the acceptability of
life-prolonging treatment (e.g., tube feeding) tends to be greater among
people in worse health than among healthier ones. Because a decision for
or against a life-prolonging treatment represents a choice between two
prospects-life (usually in poor health) and death-we propose a decision
model, Prospect Theory, as a theoretical account of this phenomenon.
Prospect Theory postulates that pairs of distant prospects are less
distinguishable than pairs of closer ones. Thus, to healthy individuals,
the prospects of death and life in poor health would both be remote, and
therefore, the distinction between them, small. To less healthy
individuals, however, the difference between the same pairs of prospects
would appear greater, and therefore, life-prolonging treatment may be
more acceptable. In a cross-sectional study of 304 community-dwelling
people, aged 60 years and over in the Philadelphia area, USA,
preferences for 4 life-prolonging treatments in 9 health scenarios were
examined in relation to participants\' current health, operationalized
as number of deficits in physical functioning. As predicted, less
healthy people expressed stronger preferences for all life-prolonging
treatments compared with healthier ones, with differences greatest in
the worse-health scenarios. Preferences also varied by health scenario,
with any treatment preferred in the better health scenarios. Treatment
preferences did not differ by type of treatment, depressed mood or any
demographic characteristic except race, with African-Americans
expressing stronger treatment preferences. Implications for advance care
planning are discussed.

## Winter L, Parker B. Current health and preferences for life-prolonging treatments: an application of prospect theory to end-of-life decision making. **Soc Sci Med. 2007 Oct;65(8):1695-707. Epub 2007 Jul 25. <http://www.ncbi.nlm.nih.gov/pubmed/17655996>** 

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

## Injectable contraception: what should the longest interval be for reinjections?

BACKGROUND: Progestin-only injectable contraceptives continue to gain in
popularity, but uncertainty remains about pregnancy risk among women
late for reinjection. The World Health Organization (WHO) recommends a
\"grace period\" of 2 weeks after the scheduled 13-week reinjection.
Beyond 2 weeks, however, many providers send late clients home to await
menses. STUDY DESIGN: A prospective cohort study in Uganda, Zimbabwe and
Thailand followed users of depot-medroxyprogesterone acetate (DMPA) for
up to 24 months. Users were tested for pregnancy at every reinjection,
allowing analysis of pregnancy risk among late comers. RESULTS: The
analysis consists of 2290 participants contributing 13,608 DMPA
intervals. The pregnancy risks per 100 women-years for \"on time\"
\[0.6; 95% confidence interval (CI), 0.33-0.92\], \"2-week grace\" (0.0;
95% CI, 0.0-1.88) and \"4-week grace\" (0.4; 95% CI, 0.01-2.29)
injections were low and virtually identical.

CONCLUSION: Extending the current WHO grace period for DMPA reinjection
from 2 to 4 weeks does not increase pregnancy risk and could increase
contraceptive continuation.

Steiner MJ, Kwok C, Stanback J, Byamugisha JK, Chipato T, Magwali T,
Mmiro F, Rugpao S, Sriplienchan S, Morrison C. Injectable contraception:
what should the longest interval be for reinjections? Contraception.
2008 Jun;77(6):410-4. Epub 2008 Apr 10.

#### <http://www.ncbi.nlm.nih.gov/pubmed/18477489>  {#httpwww.ncbi.nlm.nih.govpubmed18477489 .Style-Heading-4-+-Arial-14-pt-Underline}

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

## Depo Now: preventing unintended pregnancies among adolescents and young adults

PURPOSE: We compared the immediate administration of DMPA (Depo Now) to
the immediate use of short-term hormonal methods that served as a
\"bridge method\" until later DMPA initiation. We examined whether Depo
Now, as compared to initiating with a bridge method (pills, transdermal
patch, or vaginal ring), resulted in greater DMPA continuation at six
months. METHODS: Young women aged 14 to 26 years seeking to use DMPA
were randomized (nonblinded) after meeting eligibility criteria to
either the Depo Now (n = 101) or bridge method (n = 232) group. Depo Now
subjects received their first injection of DMPA at the conclusion of
their first visit provided each was medically suitable and had a
negative urine pregnancy test regardless of menstrual cycle day. Those
assigned to the bridge method group were allowed to choose their
starting contraceptive method and it was provided at the first visit.
All subjects were told to return to the clinic in 21 days to repeat the
urine pregnancy test, and among those who were assigned to use a bridge
method, to receive their first injection of DMPA. All subjects were
followed to their third injection, or about 6 months later.

RESULTS: Those randomized to a bridge method were 1.8 (1.1, 2.9) times
more likely than Depo Now subjects to return for their 21-day repeat
pregnancy test, but only 55% (n = 125) of these young women actually
received their first DMPA injection. Continuation rates at the third
injection were 29.7% (n = 30) for those in the Depo Now group and 21.1%
(n = 49) for those assigned to the bridge method (p = .09). Three
factors were significantly associated with adherence to the third
injection: randomized to Depo Now group, knowing more women who use
DMPA, and returning to clinic for the 21-day repeat pregnancy test
visit. Finally, 28 pregnancies were diagnosed during the study period,
and those in the bridge method group were almost 4.0 (1.2, 13.4) times
more likely to be diagnosed with a pregnancy than those in the Depo Now
group. CONCLUSIONS: Immediate administration of DMPA is associated with
improved adherence to DMPA continuation and fewer pregnancies.

Rickert VI, Tiezzi L, Lipshutz J, León J, Vaughan RD, Westhoff C. Depo
Now: preventing unintended pregnancies among adolescents and young
adults. J Adolesc Health. 2007 Jan;40(1):22-8.
<http://www.ncbi.nlm.nih.gov/pubmed/17185202>

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

#### CCC Editorial Comment: {#ccc-editorial-comment .Style-Heading-4-+-Arial-14-pt-Underline}

#### The first article provides reassurance that a woman who is late, even as late as four weeks, for her scheduled Depo-Provera injection faces a low risk of unintended pregnancy and should receive the next injection without additional barriers. The second article provides more support for a "quick start" approach to Depo-Provera initiation. A "quick start" protocol can also be used for resuming Depo Provera use for those who are more than 2 to 4 weeks past the recommended date for their next dose. {#the-first-article-provides-reassurance-that-a-woman-who-is-late-even-as-late-as-four-weeks-for-her-scheduled-depo-provera-injection-faces-a-low-risk-of-unintended-pregnancy-and-should-receive-the-next-injection-without-additional-barriers.-the-second-article-provides-more-support-for-a-quick-start-approach-to-depo-provera-initiation.-a-quick-start-protocol-can-also-be-used-for-resuming-depo-provera-use-for-those-who-are-more-than-2-to-4-weeks-past-the-recommended-date-for-their-next-dose. .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

**IHS Head Start Oral Health Resources**

The IHS Head Start Program has developed a Best Practices document and
Toolkit to assist in work with AI/AN Head Start Programs and those who
visit the website will find many resources to assist in their work with
Head Start, specifically AI/AN Head Start Programs.

 

[http://www.ihs.gov/NonMedicalPrograms/HeadStart/index.cfm?module=fa_oralhealth_dc](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.ihs.gov/NonMedicalPrograms/HeadStart/index.cfm?module=fa_oralhealth_dc)

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

**Progesterone for the Prevention of Recurrent Spontaneous Preterm
Birth**

**Q.** My patient is asymptomatic with a documented history of one prior
spontaneous preterm birth at 33 weeks who is now 18 weeks gestation by a
good LMP and an ultrasound at 12 weeks. Should she be give progesterone
therapy?

**A.** Yes, but first make sure she agrees to return for weekly till 36
weeks of pregnancy.

Background

The incidence of preterm birth has risen progressively over the last
decade from 9% to 12% of all births in the United States. Preterm birth
is the second leading cause of infant mortality in this country and a
significant proportion of survivors have residual disabilities. Despite
multiple trials of tocolytics, antibiotics, and other preventive
strategies, no effective method of preventing preterm birth has been
found.

Recently, prophylactic treatment of high risk women with a history of
one or more prior spontaneous preterm births with progestational
compounds have demonstrated efficacy (1, 2). A prior meta-analysis (3)
has also demonstrated a significant reduction in the rate of preterm
delivery with the use of 17 alpha hydroxyprogesterone caproate (17P).
The American College of Obstetrics and Gynecology (ACOG) has recommended
that when progesterone is used, it be restricted to women with a
documented history of a previous spontaneous birth at less than 37 weeks
of gestation (4). Extensive experience with progesterone has shown it
not to be a teratogen (5), and its use in this protocol will not involve
administering it during organogenesis in the first trimester.

As a referral center, ANMC renders care to a large number of women who
have experienced preterm birth, and an effective preventive treatment
would be most advantageous to this population. Referral of these women
and/or their infants to Level III centers for delivery and prolonged
level III newborn intensive care generates significant expenditures for
the institution that could be avoided by prevention of the problem.

Eligible Patients:

1)  Asymptomatic women with a documented history of one or more prior
    spontaneous preterm births (less than 35 weeks gestation) who are
    identified prior to 20 weeks gestation, who are dated by ultrasound
    prior to 20 weeks, and who agree to return for weekly injections
    from 16 weeks (may enroll up to 20 weeks) to 36 weeks of pregnancy.

2)  Consult with Maternal Fetal Medicine to establish eligibility and
    monitor outcomes.

Ineligible Patients:

1)  Women with a history of prior preterm birth due to a known cause
    such as a uterine malformation or cervical insufficiency requiring
    cervical cerclage.

2)  Women who present with symptoms of preterm labor (symptomatic
    uterine contractions, short cervix on ultrasound, uterine bleeding,
    ruptured membranes) after 20 weeks gestation.

3)  Women with a multi-fetal gestation.

4)  Women with a known fetal anomaly.

5)  Women with a prior indicated preterm birth (as a result of severe
    preeclampsia, placenta previa, fetal demise, or threatening maternal
    medical illness).

Drug Treatment Protocol:

1)  Weekly intramuscular injection of 17-hydroxyprogesterone caproate
    (17P) 250 mg\* from 16 through 36 weeks of gestation.

2)  Fetal growth ultrasounds every 4 weeks while the patient is being
    treated.

Outcomes for Quality Assurance:

1)  Incidence of preterm birth prior to 35 weeks.

2)  Infant weights and Apgar scores.

3)  Incidence of preterm labor requiring inpatient treatment but not
    resulting in preterm birth.

4)  Any adverse maternal effects while receiving the therapy.

**[CCC Editorial Comment:]{.underline}**

**Short cervix, multiple gestation, preterm labor**

There is as yet no consistent evidence that this drug is effective in
women with preterm labor, a short cervix, or other high risk conditions
(6). On the other hand, progesterone supplementation did NOT reduce the
rate of preterm birth in multiple gestations randomly assigned to
receive this therapy (7).

References:

1)  Meis PJ, et al. Prevention of recurrent preterm delivery by 17 alpha
    hydroxyprogesterone caproate. N Engl J Med 2003; 348:2379-85.
    <http://www.ncbi.nlm.nih.gov/pubmed/12802023>

2)  Da Fonseca EB, et al. Prophylactic administration of progesterone by
    vaginal suppository to reduce the incidence of spontaneous preterm
    birth in women at increased risk: A randomized placebo-controlled
    double-blind study. Am J Obstet Gynecol 2003; 188:419-24.

3)  Keirse MJ. Progestogen administration in pregnancy may prevent
    preterm delivery. Brit J Obstet Gynaecol 1990; 97:149-57.

4)  ACOG Committee Opinion No.291. Use of progesterone to prevent
    preterm birth. Obstet Gynecol 2003; 102:1115-6.

5)  Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation.
    6^th^ edition, 2002, page 674. Lippincott Williams and Wilkins.
    Philadelphia.

6)  Meis PJ. 17 hydroxyprogesterone for the prevention of preterm
    delivery. Obstet Gynecol 2005 May;105(5):1128-35.

7)  Rouse DJ et al. A trial of 17 alpha-hydroxyprogesterone caproate to
    prevent prematurity in twins. N Engl J Med. 2007 Aug
    2;357(5):454-61.<http://www.ncbi.nlm.nih.gov/pubmed/17671253>

\*Available through many pharmacies as 10mL vials (250mg/mL) at a cost
of approximately \$120/vial (if \>6 vials are ordered). Be sure to check
out availability before you discuss the possible therapy with your
patient.

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

# Quote of the month: "If you rest, you rust." Helen Hayes

**Articles of Interest**

**Cardiovascular Monitoring of Children and Adolescents with Heart
Disease**

**Receiving Medications for Attention Deficit/Hyperactivity Disorder: A
Scientific**

**Statement from the American Heart Association Council on
Cardiovascular Disease in the Young Congenital Cardiac Defects Committee
and the Council on Cardiovascular Nursing**

*Circulation* 2008;117;2407-2423; originally published online Apr 21,
2008;

[[http://circ.ahajournals.org/cgi/content/full/CIRCULATIONAHA.107.189473/DC1]{.underline}](http://circ.ahajournals.org/cgi/content/full/CIRCULATIONAHA.107.189473/DC1)

**Cardiovascular Monitoring and Stimulant Drugs for Attention-Deficit
Hyperactivity Disorder - Policy Statement of the American Academy of
Pediatrics**

Published online on May 28, 2008

<http://www.aap.org/new/ecg-adhd.htm>

**American Academy of Pediatrics/American Heart Association
Clarification of Statement on Cardiovascular Evaluation and Monitoring
of Children and Adolescents with Heart Disease Receiving Medications for
ADHD**

Published online on June 3, 2008

<http://americanheart.mediaroom.com/index.php?s=43&item=422>

In late April the American Heart Association (AHA) released new
guidelines for children receiving stimulant medication for Attention
Deficit Hyperactivity Disorder (ADHD) The AHA recommended that all
children beginning treatment with stimulant medications, and those
already on stimulant medication, should have an electrocardiogram (ECG)
to search for occult heart disease that could place them at increased
risk for sudden cardiac death. This recommendation caused anxiety in
many parents and frustration in many psychiatrists and pediatricians.

The AHA recommendation has significant procedural and financial
implications. It is estimated that 2.5 million children are receiving
stimulant medication now. Obtaining an ECG on each one would entail
significant costs. For some patients a further barrier was the
suggestion that the ECG should be reviewed by a practitioner experienced
in reading pediatric ECG. This would limit the reading of these studies
to pediatric cardiologists and a small subset of pediatricians.

Within a month the American Academy of Pediatrics (AAP) fired back. The
AAP published its own policy statement on stimulants and ADHD on May 28,
2008. Highlights included.

-   Sudden Cardiac Death (SCD) in persons taking medications for ADHD is
    a rare event occurring at rates no higher than in the general
    population of children and adolescents

-   Stimulant medication can cause mild elevations of blood pressure and
    heart rate but there is no evidence they increase the risk of SCD

-   There is no evidence that the routine use of ECG screening before
    beginning medication for ADHD treatment would prevent SCD.

-   Substantial evidence exists concerning the efficacy and safety of
    ADHD treatment with stimulant medications.

-   Requiring an ECG before stimulant treatment could create a barrier
    to timely therapy. Limiting children's access to effective treatment
    for ADHD could have serious implications, because there are
    substantial risks of not treating ADHD.

The AAP recommended that the cardiac evaluation of children taking
stimulant medication should not change from their previous policy in
2000. The recommendations were as follows:

1\. The AAP continues to recommend a careful assessment of all children,
including those starting stimulants, using a targeted cardiac history
(e.g., patient history of previously detected cardiac disease,
palpitations, syncope, or seizures; a family history of sudden death in
children or young adults; hypertrophic cardiomyopathy; long QT syndrome)
and a physical examination, including a careful cardiac examination.

2\. Given current evidence, the AAP encourages primary care and
subspecialty physicians to continue currently recommended treatment for
ADHD, including stimulant medications, without obtaining routine ECGs or
routine subspecialty cardiology evaluations for most children before
starting therapy with these medications.

To resolve confusion between the two professional societies the AAP and
AHA issued a joint statement on June 3, 2008. The relevant portion is
listed below:

-   Obtaining a patient and family health history and doing a physical
    exam focused on cardiovascular disease risk factors are recommended
    by the AAP and AHA for assessing patients before treatment with
    drugs for ADHD.

-   It is reasonable for a physician to consider obtaining an ECG as
    part of the evaluation of children being considered for stimulant
    drug therapy, but this should be at the physician's judgment, and it
    is not mandatory to obtain one.

-   Treatment of a patient with ADHD should not be withheld because an
    ECG is not done

**Pediatric Chief Clinical Consultant Editorial Comment:**

The AAP statement of May 28, 2008 is reasonable guidelines that
practitioners should embrace. Patients should be screened by history for
potential cardiac risk factors and have a physical exam that focuses on
cardiovascular system. Patients with known or suspected heart disease
may need an ECG and further specialty evaluation.

**Infectious Disease Updates** Rosalyn Singleton, MD

**Teen Vaccines: How are we doing?**

Since 2005, three new vaccines have been licensed and recommended
specifically for teens: Tdap, HPV and meningococcal conjugate vaccine.

-   Tdap -- for 11-18 year olds with [\>]{.underline}5 years since last
    Td vaccine,

-   HPV -- 3 doses for 9-26 year old females

-   Meningococcal conjugate (Menactra®, MCV4) -- for 11-18 year olds

CDC published the first estimates of national vaccination coverage among
teens aged 13-17 years in U.S.-2006 in Aug. 2007
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5634a3.htm> Among 13-17 year
olds, 10.8% had received 1 dose of Tdap and 60.1% had received 1 dose of
Td or Tdap since age 10 years; 11% had received meningococcal vaccine.
According to recent CDC data, 23% of females aged 13-17 years had
received 1+ doses of HPV vaccine.

Indian Health Service started reporting Adolescent Immunization rates
for American Indian and Alaska Native adolescents 13-17 years of age
from IHS/contract facilities in 12/31/07. Adolescent coverage data from
12/31/07 and 3/31/08 are presented here:

![](media/image2.wmf){width="5.001388888888889in" height="3.74375in"}

Comments: The initial Indian Health Service adolescent vaccine coverage
rates for new vaccines compare favorably with national coverage rates;
however, the national rates reflect an earlier time period. These rates
reflect a robust delivery system; however, it will be challenging to
administer 2^nd^ and 3^rd^ doses in a timely manner to teens. Providers
can pull up lists of teens due for their 2^nd^ or 3^rd^ HPV doses in the
RPMS Immunization Package by running a list of girls who have "received
HPV vaccine" and are "due for HPV vaccine".

**Recent literature on American Indian/Alaskan Native Health** Michael
L. Bartholomew, MD

**Pertussis-Associated Hospitalizations in American Indian and Alaska
Native Infants**

Before the introduction of the pertussis vaccine in the 1940s, the US
incidence of pertussis was approximately 150 cases per 100,000
population or roughly 175,000 cases per year^1^. By the 1980-90's the
incidence declined to approximately 1 case per 100,000 population. Since
1980, the incidence of pertussis has steadily increased. Waning immunity
in the adolescent and adult populations are felt to be contributing
factors to this increase^2^.

This study investigates the burden of pertussis in American Indian and
Alaska Native (AI/AN) infants from 1980 to 2004 and 2000 to 2004 through
the analysis of discharge/hospitalization data from the Indian Health
Service (IHS)/Tribal health care system. Infant pertussis
hospitalizations were examined by sex, age group (infants less than 6
months and 6-11 months) and IHS region (Northern Plains, Southern
Plains, Southwest, and Alaska). Rates of infant pertussis
hospitalizations for 2000-2004 were compared to the pertussis
hospitalizations of the general U.S. infant population in 2003.

In IHS, there were 483 infant pertussis hospitalizations between 1980
and 2004. This equals an annual pertussis hospitalization rate of 132.7
per 100,000 AI/AN infants (95% CI = 121.3 to 145.2). The highest numbers
of hospitalizations were in infants less than 6 months of age (427
hospitalizations); equaling a rate of 234.5 per 100,000 infants. Rates
in males and females were similar by age. The Southwest region had the
highest rate (187.9 per 100,000) of pertussis hospitalizations as
compared to Alaska (92.0), Northern Plains (103.3) and the Southern
Plains (87.8).

In comparison, the average annual pertussis hospitalization rate for
AI/AN between 2000 and 2004 was higher than the 2003 general US infant
population pertussis hospitalization rate (100.5 vs. 67.7).
Additionally, Alaska (156.9) and Southwest (130.9) regions had higher
hospitalization rates than the Northern (59.1) and Southern (59.2)
Plains during the same time period.

The authors concluded that the burden of pertussis is greatest in AI/AN
infants less than 6 months of age predominantly those residing in the
Southwest and Alaska regions. Despite levels of immunization rates equal
or slightly less than the general population, environmental and social
influences likely contribute to the higher disease burden in the AI/AN
population; similar to what is seen with respiratory syncytial virus
infections in Alaska Native infants^3^. Prevention of pertussis by
timely administration of DTaP at 6 to 8 weeks of age and promotion of
Tdap vaccination in adults and adolescents are strongly encouraged.

Murphy TV, Syed SB, Holman RC, Haberling DL, Singleton RJ, Steiner CA,
Paisano EL, Cheek JE. Pertussis-Associated Hospitalizations in American
Indian and Alaska Native Infants. *J Pediatr*. 2008;152:839-43.
<http://www.ncbi.nlm.nih.gov/pubmed/18492528>

References:

1.  Centers for Disease Control and Prevention.
    <http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/pert.pdf>

2.  American Academy of Pediatrics. Pertussis. In: Pickering LK, Baker
    CJ, Long SS, McMillan JA, eds. *Red Book: 2006 Report of the
    Committee on Infectious Diseases.* 27^th^ ed. Elk Grove Village, IL:
    American Academy of Pediatrics; 2006:498-520.

3.  Holman RC, Curns AT, Cheek JE, Bresee JS, Singleton RJ, Carver K,
    Anderson LJ. Respiratory syncytial virus hospitalizations among
    American Indian and Alaska Native infants and the general United
    States infant population. *Pediatrics* 2004 Oct;114(4):e437-44.
    <http://www.ncbi.nlm.nih.gov/pubmed/15466069>

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

**New RPMS Scheduling Package Released**

The Indian Health Service Office of Information Technology and the
Clinical Scheduling for Windows Application Team announce the following
application release: Clinical Scheduling for Windows, v2.0 (RPMS
namespace: BSDX) A release notice from the IHS Office of Information
Technology has been sent to all RPMS site managers, and site managers
are advised to notify users once the application has been installed.\
\
GUI Scheduling is a supplement to the character based RPMS PIMS
Scheduling package allowing the user a fast and easy approach to
scheduling and managing appointments.  Users of this package will be
able to enjoy color-coded appointment types and view clinics side by
side to see what times are available for scheduling.  The package
supports most of the daily scheduling activities including Rescheduling,
Cancellations, Check-In and Walk-ins.  Displaying and printing Clinic
Schedules, Reminder Letters, Cancellation Letters and Patient Letters
are also available.  The current release fixes a number of issues with
version 1.0 that limited the application\'s usability and deployment.\
\
Thank you to the following beta test sites for their assistance with
this release. \
·         Chemawa Indian Health Center (Western Oregon Service Unit)\
·         Fort Peck Service Unit (Poplar, Montana)\
·         Warm Springs Health & Wellness Center (Warm Springs, Oregon)\
·         WW Hastings (Tahlequah, Oklahoma)\
\
For user support please contact the RPMS help desk at support@ihs.gov or
call (888) 830-7280.

**PCC+ v2.6 (Well Child Module) Released**

**Introduction**

The PCC+ v2.6 Well Child Module (WCM) will become an "add-on module" to
the current version of PCC+. The objective of the Well Child Module is
to use information technology to standardize well child care throughout
the Indian Health Service and to lay the groundwork for the inclusion of
age-specific guidelines and reminders for well child care into the
Electronic Health Record (EHR). The well child module is designed to be
in compliance with a set of national guidelines and standards that were
provided by a group of senior pediatricians in the IHS. As a rule,
guidelines and standards are taken from nationally recognized sources
such as Bright Futures, the American Academy of Pediatricians, the Ages
and Stages Child Monitoring Program, and the IHS Patient Education
advisory group.

 

**Background**

Well Child care is one of the most common yet clinically complex
services. Typically, the well child "record" is captured on a series of
special encounter forms with each form corresponding to a specific age
from birth through adolescence. Each form contains age-specific
guidelines for developmental screening, anticipatory guidance,
examinations, immunizations, nutritional counseling, and patient
education. The ideal situation is that children are scheduled for well
child appointments and the forms correspond to the age(s) of the child
being seen however; experience tells us that this type of precision is
rarely, if ever achieved.

 

The objectives of the PCC+ Well Child Module are to:

-   Standardize well child care throughout the IHS

-   Present the correct age-specific guidelines to the provider at the
    time of encounter using current nationally recognized guidelines

-   Enable the components of the Well Child Module to be incorporated
    and presented in a multi-modal format so that it can be used by the
    Electronic Health Record (EHR), PCC+ and Health Summary.

 In addition to the objectives above, hybrid components will be
available that will enable providers to enter well child information
(i.e. ASQ scores) directly into the RPMS system via a desktop module.

 

**Features of the new Well Child Module (WCM)**

1.) [Knowledgebase and Knowledgebase Manipulator]{.underline}

From the moment a child is born until age 21, there are thousands of
age-specific guidelines and reminders that apply to well child care. The
PCC+ WCM contains a knowledgebase in RPMS that serves as a repository
for age-specific guidelines and reminders. The Knowledgebase Manipulator
is a tool used by WCM that will enable providers to edit the
knowledgebase and to determine exactly which age-specific guidelines and
reminders will be displayed on PCC+ encounter forms and in the near
future, the HER application.

2.) [ASQ Screening]{.underline}

The Ages and Stages questionnaire is a commercial instrument for
monitoring childhood development (0 to 5). The ASQ contains a set of 19
age-specific questionnaires for the child's parent to answer. The
questionnaire is then scored by well child care personnel and results
are entered into the RPMS system, either by data entry personnel or via
a WCM GUI application at the point of care. ASQ results are stored as
"measurements" in RPMS and are displayed on the new Well Child Health
Summary.

3.) [Informal Development Screening]{.underline}

For sites that are not able to conduct ASQ screening on every visit, the
WCM can be configured to display representative milestones from the
Denver Developmental Screening Test (DDST) and these milestones will
display on the PCC+ encounter form. The child's age determines exactly
which milestones will display as well as the percentage of children at
that age who are expected to pass a particular milestone.

4.) [Intervention Reminders]{.underline}

Special exams and interventions are due throughout childhood. The WCM
will provide the following age-specific exams and reminders:

-   Special risk exams, such as TB screening.

-   Age-specific exams, such as strabismus and scoliosis.

-   General screening exams such as lead levels.

-   Autism screening questions.

-   Immunizations, past immunization given (history), and forecasting
    lists will be automatically generated by WCM & displayed on the
    encounter form.

5.) [Anticipatory guidance]{.underline}

Anticipatory guidance is a cornerstone of well child care. There are
literally thousands of age-specific topics, general patient education
topics, and nutrition counseling topics available for display. Using the
Knowledgebase Manipulator the WCM will enable providers to display only
topics and standards they choose to display on encounter forms. Topics
include substance abuse, behavioral health, community interaction, oral
health, etc...

6.) [PCC+ Growth Grids]{.underline}

Users of traditional PCC+ have been able to display growth grids and
immunization lists. PCC+ 2.6 will continue to print the grids and lists
to be used as patient handouts.

7.) [Data Entry Mnemonic]{.underline}

Since the new WCM captures new data elements, it will increase the
workload of data entry personnel. To compensate, the new WCM includes a
new "intelligent" mnemonic that will be synchronized with the actual
patient visit. Using the new "WCE" mnemonic, only information that is
specifically associated with a well child visit will present to the data
entry clerk, thus increasing the efficiency of data entry personnel.

8.) [New Well Child Health Summary component]{.underline}

The new Well Child Health Summary component will display age-specific
guidelines and reminders specific to Well Child care.

 

**Summary of the new Well Child Module (SCM)**

The new version of PCC+ will include a Well Child Module that is
intended to standardize well child care in the IHS and lay the
groundwork for inclusion of well child care age-specific guidelines and
reminders into the EHR application. The WCM leverages the power of
information technology and automated decision support in two specific
ways to:

-   Capture and encapsulate data gathered during well child care
    encounters that previously was only collected piecemeal over an
    extended amount of time.

-   Customize and present age-specific guidelines and reminders to the
    pediatrician at the time of encounter.

 

Several other validated screening tools exist such as the Arizona PEDS®
instruments used by pediatricians in Arizona. New autism screening tools
(i.e. mCHAT®) are also becoming available. We intend to add these
screening options to future versions of the WCM.

  

Acknowledgements go to many and include the test sites:

Southern Indian Health Council in Alpine, CA

SEARHC in Sitka, AK & Juneau, AK (both sites participated)

Cherokee Indian Hospital Authority in Cherokee, NC - first test site

For more information on the WCM, please contact Clarence Smiley at
<clarence.smiley@ihs.gov>

 

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

**New evidence on lead's long-term effects**

Lead has been back in the news lately. A potent neurotoxin, lead damages
the brain by altering neurotransmitter release in a way that leads to
accelerated apoptosis (cell death). It is a known toxin for adults, but
appears to be a particularly bad actor in the developing brain. Though
it hasn't typically been a problem in the rural parts of Indian country,
urban AI/AN people living in dilapidated housing stock are at risk for
chronic lead toxicity. Two new articles based on longitudinal research
from the Cincinnati Lead Study (CLS) may heighten the stakes of the
debate over acceptable childhood lead levels.

The CLS birth cohort was recruited in the womb between 1979 and 1984
from urban inner-city neighborhoods known to have high lead levels.
These children got detailed exposure histories from the prenatal period
on, frequent neuropsychiatric exams and serum lead levels, and have now
been followed into young adulthood. One of the two new reports shows a
small but significant correlation between childhood lead levels and
adult arrest records in this cohort. After careful adjusting for
potential confounders, John Wright and colleagues found that for every 5
mcg/dl increase in prenatal (maternal) and childhood blood lead, total
arrests and arrests for violent crime went up by roughly forty percent.
In the second report, Kim Cecil and colleagues used MRI to assess brain
volume in 157 members of the CLS cohort. Regression analysis
demonstrated a linear dose-dependent correlation between childhood serum
lead levels and reduction in adult brain volume, a result that was
highly statistically significant. Most interesting, the reduction was
specific to grey matter in the anterior cingulate cortex and portions of
the prefrontal cortex. (White matter and CSF volume were not affected.)
These are the regions responsible for judgment, focusing attention,
regulation of mood, and executive functions. Grey-matter volume loss in
these areas was also much more pronounced among men than women, even at
similar lead levels. This finding suggests a mechanism for the links
previously explored between childhood lead exposure and adult
anti-social behavior, criminal activity, and poor intellectual
performance.

Some of you may be scratching your heads over why this is an
international health problem. Unfortunately, the measures put in place
to mitigate lead toxicity in the United States years ago -- screening
programs, mandated transitions to unleaded gasoline, abolition of
lead-based paints and ceramic glazes -- never happened in much of the
Third World. In fact, some gasoline sold today in South America, the
Middle East and Africa has *more* lead additives than leaded gas in our
country ever did; paint sold for residences, toys, and playground
equipment still contains high levels of lead in Africa and several
countries in Asia. In Central and South America, unregulated industrial
processes are the major culprits. Some experts argue that an
unrecognized epidemic of low- to moderate-level lead poisoning is
occurring in much of the Third World, and a few small pilot studies of
lead levels tend to confirm this assessment. Improvements in screening,
policy and enforcement are urgent.

Cecil KM et al. Decreased brain volume in adults with childhood lead
exposure. PLoS Medicine 5(5):e112, 2008
<http://www.ncbi.nlm.nih.gov/pubmed/18507499>

Wright JP et al. Association of prenatal and childhood blood lead
concentrations with criminal arrests in early adulthood. PLoS Medicine
5(5):e101, 2008 <http://www.ncbi.nlm.nih.gov/pubmed/18507497>

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

**American Academy of Pediatrics Releases Statement on Strategies to
Improve Adolescent Health Care**\
Achieving Quality Health Services for Adolescents provides
recommendations and criteria for assessing the quality of adolescent
health care and discusses the need for comprehensive efforts to improve
the quality of primary care delivered to adolescents in the United
States. The policy statement, developed by the American Academy of
Pediatrics\' Committee on Adolescents, focuses on quality issues that
relate to staying healthy \-- preventive care themes. Topics include\
adolescent health status and risky behaviors, primary care access and
utilization, access to quality care for adolescents, emerging quality
measures for adolescent care, and opportunities and challenges for
primary care. Conclusions and recommendations are included. The policy\
statement is available at:
[http://aappolicy.aappublications.org/cgi/content/full/pediatrics;121/6/1263](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://aappolicy.aappublications.org/cgi/content/full/pediatrics;121/6/1263).

**Report Presents Findings from the 2007 National Youth Risk Behavior
Survey**\
\"Since 1991, the prevalence of many health-risk behaviors among
students nationwide has decreased. However, many students continue to
engage in behaviors that place them at risk for the leading causes of
mortality and morbidity,\" state the authors of a report published on
June 6, 2008, in MMWR Surveillance Summaries. The national Youth Risk
Behavior Survey (YRBS) is the primary source of data to measure 15
Healthy People 2010 objectives and three leading health indicators. This
report provides the 2010 target and data from the 2007 national YRBS for
all 15 objectives.\
\
The Youth Risk Behavior Surveillance System (YRBSS) includes a national
school-based survey conducted by the Centers for Disease Control and
Prevention and state and local school-based surveys conducted by state
and local education and health agencies. This report summarizes results
from the national survey, 39 state surveys, and 22 local surveys
conducted among students in grades 9-12 during 2007.\
\
The authors found that

-   Among students in grades 9-12 nationwide during 2007, 11% had never
    or\
    rarely worn a seatbelt when riding in a car driven by someone else.

-   During the 30 days before the survey, 29% of students had ridden in
    a\
    car or other vehicle driven by someone who had been drinking
    alcohol.

-   18% had carried a weapon, and more than 5% had not gone to school\
    because they felt they would be unsafe at school or on their way to
    or\
    from school.

-   During the 12 months before the survey, almost 7% of students had\
    attempted suicide. In addition, 75% had ever drunk alcohol, and
    more\
    than 4% had ever used methamphetamines.

-   About 48% of students had ever had sexual intercourse, 35% were\
    currently sexually active, and more than 38% of currently sexually\
    active students had not used a condom during last sexual
    intercourse.

-   Twenty percent of students had smoked cigarettes during the 30 days\
    before the survey, 35% had watched television 3 or more hours per
    day on\
    an average school day, and 13% were obese.

-   During the 7 days before the survey, almost 79% of students had not\
    eaten fruits and vegetables five or more times per day, about 34%
    had\
    drunk soda or pop at least one time per day, and more than 65% had
    not\
    met recommended levels of physical activity.

The authors conclude that \"more effective school health programs and
other policy and programmatic interventions are needed to reduce risk
and improve health outcomes among youth.\"\
\
Eaton DK, Kann L, Kinchen S, et al. 2008. Youth risk behavior
surveillance \-- United States, 2007. MMWR Surveillance Summaries
57(SS04):1-131. Available at:
[http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5704a1.htm](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5704a1.htm).\
\
More information is available from the following MCH Library resource:\
[http://www.mchlibrary.info/guides/schoolhealth.html](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.mchlibrary.info/guides/schoolhealth.html)

**Panel Reviews National Study Plan on Environmental and Genetic Effects
on Health in Children**\
The National Children\'s Study Research Plan: A Review presents a
scientific assessment of a national longitudinal study to examine the
effects of environmental influences (including chemical, biological, and
psychosocial) on the health and development of approximately 100,000
children across the United States, following them from before birth
until age 21. The report, published by the National Academies Press, is
based on a review conducted by the National Research Council in
collaboration with the Institute of Medicine to ensure that the National
Children\'s Study (NCS) is scientifically rigorous and is being carried
out with the best available methods. Topics include NCS goals,
conceptual framework, and core hypotheses; priority outcome and exposure
measures; study design, data collection, and analysis; ethical
procedures and community engagement; and conclusions and
recommendations. An executive summary, references, and biographical
sketches of the review panel members are included. The report is
available at
[http://www.nap.edu/catalog.php?record_id=12211](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.nap.edu/catalog.php?record_id=12211)
(requires sign-in for free PDF download).

The National Children's Study, to be conducted in selected counties
across the U.S., includes several counties with significant Native
American representation. The National Children's Study website can be
reviewed at: <http://www.nationalchildrensstudy.gov/>

**Bright Futures for Women's Health and Wellness Releases new Tools on
Emotional Health**\
The Bright Futures for Women's Health and Wellness (BFWHW) series
includes new tools to address the connection between women\'s mental and
physical well-being and encourage better health across the lifespan. The
tools, produced by the Health Resources and Services Administration\'s
Office of Women\'s Health, focus on three main concepts: appreciating
oneself, finding balance and purpose in life, and connecting with
others. Each tool is designed for a specific audience including women,
young women, community groups, and primary care health professionals.
All BFWHW tools are wellness-focused, gender-specific, and
evidence-based.\
\
New tools in the BFWH series are available from the MCH Library\'s Web
site as follows:\
\
- A Young Woman\'s Guide to Emotional Wellness\
[http://mchlibrary.info/BFWHW/BF_young_women_Revised_707.pdf](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://mchlibrary.info/BFWHW/BF_young_women_Revised_707.pdf)\
\
- A Woman\'s Guide to Emotional Wellness\
[http://mchlibrary.info/BFWHW/BF_Woman_revised_707.pdf](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://mchlibrary.info/BFWHW/BF_Woman_revised_707.pdf)\
\
- A Community Organization's Guide to Promoting Emotional Wellness\
[http://mchlibrary.info/BFWHW/BF_Community_Revised_707.pdf](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://mchlibrary.info/BFWHW/BF_Community_Revised_707.pdf)\
\
- A Health Care Provider\'s Guide to Promoting Women\'s Emotional
Wellness\
[http://mchlibrary.info/BFWHW/BF_Clinicians_Revised_707-2.pdf](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://mchlibrary.info/BFWHW/BF_Clinicians_Revised_707-2.pdf)\
\
A companion one-page flyer for health professionals to use in waiting
and exam rooms to support client-professional dialogue about emotional
wellness is also available
[http://mchlibrary.info/BFWHW/BF_Flyer.pdf](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://mchlibrary.info/BFWHW/BF_Flyer.pdf).\
\
Print copies from this series may be ordered from the HRSA Information
Center Web site at
[http://ask.hrsa.gov](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://ask.hrsa.gov).

**MCH Headlines Judy Thierry HQE**

**Bright Futures Web Site Updated**

The Bright Futures Web site has been renovated for the 3rd edition,
including free access to the Guidelines posted by chapter and
hyperlinked references. Bright Futures is a national health promotion
and disease prevention initiative that addresses children\'s health
needs in the context of family and community. In addition to use in
pediatric practice, many states implement Bright Futures principles,
guidelines and tools to strengthen the connections between state and
local programs, pediatric primary care, families, and local communities.
Whether you are a health care or public health professional, a parent,
or a child advocate, Bright Futures offers many different resources for
your use in improving and maintaining the health of all children and
adolescents. Access the site online at:
[http://brightfutures.aap.org](http://brightfutures.aap.org/).

**Resources and Guidance for Fatherhood Programs (10 Promising
Practices)**

An increasing number of programs focus on improving fathers\'
involvement with children and families. What features of fatherhood
programs really matter?  A new [[National Responsible Fatherhood
Clearinghouse
brief]{.underline}](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://rs6.net/tn.jsp?e=001JEHZJcn9W4_f36x2Me_D6ZCbSYr-FKfYWGP6elRr0Sdi8x6lm_um_ZO7cpyG4y9l9CqU8F7vaqwUxMH0FVmhjiH25lp2YkqirSfmmQjDCtCNtg3NBxFQKwiya-Y67hIFY8yVbGwLYimab2XQaStBJXhDFfHByPkcbMj2UVxXhF9IyNMtxah7REvGjcedap6ZS8AhsvetqOecEVJR158HIYZKZ_W3FbB9ls5kWcKSIryQXqoxun94bNOBTV2ApHwK9VMRXpMAC4H2cJW8rZU5esGfF1eXirEA8AMwCDn5aVAvVCRy2hT3XOuj7_Yq_7IMHUCBdGZfaSNP62mRtrl_WcamJif6A2-hsJvnneS9vv8iRfT2T9Kkfg96estxZ9Pe9lBr5Q1CKAcjc7e7cB4qgD-ojftG4P23jnrl2iYrj-v7FaqQpO4Jg7LQotXO77eDZgOU0AEe5o_74eFNM0nSmgoLYWGorG-GTF6B2jwn9yPt0dfKUsOeLb2mhwLdhZmQqAjdb1Uj0gzevZ6Yv63zEcgfXxEOvbx6o08YGdpIQ0wt4U2Q1Y0FDU0MVtuZUibli_SikWltkOo9_XChEZCvhZ_JPpFdtrgq)
authored by Child Trends examines experimental evaluations of fatherhood
and parenting programs to identify ten promising practices: 

-   Teaching methods and materials that are culturally appropriate for
    fathers being served.

-   Staff members who believe in the program and have relevant training
    and coaching.

-   A high staff-participant ratio.

-   One-on-one relationships between staff and participants.

-   Clear, specific program goals.

-   Theory-based approaches that have influenced parenting behaviors in
    other contexts.

-   Varied teaching methods that focus on fathers as individuals.

-   Sufficient time to complete important core program activities.

-   Incentives to engage fathers and families.

Additional resources at:

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

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

**Now Available: Baby Oral Health Program**

The Department of Pediatric Dentistry at the University of North
Carolina at Chapel Hill has developed an educational program titled Baby
Oral Health Program (BOHP). As part of this program, an infant and
toddler oral health kit has been developed to provide the entire dental
team with the necessary background information, technique demonstration
and educational materials to begin an effective BOHP as an extension to
its current practice. This preventive program promotes early oral health
values and the establishment of a dental patient for life. It is now
available to all dental practitioners.   This kit provides a hands-on
package that includes 1) a "how to do and why" DVD, 2) clinical forms
for the first dental visit, 3) resource handouts on this topic, and 4)
an **Educational Flip Chart outlining the important concepts that guide
 infant and toddler oral health education for caregivers in the dental
office.**  In addition, a two hour CE credit can be earned through
self-study of the BOHP Kit**©**. Information is available online at:
[www.bohp.unc.edu](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.bohp.unc.edu/)**.**
 

**Child Maltreatment Institute: Enhancing Leadership for Child
Maltreatment Prevention**

Apply now for PREVENT's upcoming state-of-the-art Child Maltreatment
Institute**.** Application deadline for is August 1, 2008. The Institute
will provide experienced, multi-organizational teams access to expert
faculty in child maltreatment and primary prevention and the opportunity
to network with other leaders from across the country. Trained coaches
will use an action learning approach to facilitate and support teams in
producing concrete outcomes such as:

-   a detailed, team-based 6-month action plan focused on developing an
    effective program that stimulates organizational and social change

-   a Logic Model that outlines the transition from the 6-month plan
    into a comprehensive primary prevention program over a 5-year period

-   a framework for program evaluation with measurable objectives

-   communication strategies and message development for media and
    legislative advocacy

-   approaches for achieving program sustainability

The PREVENT Child Maltreatment Institute consists of two (2) intensive
three-day, on-site sessions separated by six months of team project work
at home with an experienced coach.  The first three-day on-site session
will be November 16-19, 2008 at the Sheraton Chapel Hill Hotel, Chapel
Hill, North Carolina.  The second on-site session will be conducted in
May 2009. 

Multi-organizational teams of up to 6 people will be selected based on
their experience working together, demonstration of leadership in child
maltreatment prevention AND readiness to take an increased leadership
role in making social and organizational changes to prevent child
maltreatment. The Institute will cover lodging and most meals for up to
4 team members (up to 2 additional members are welcome but must cover
their own lodging; their meals will be provided by PREVENT). Selected
teams are responsible for travel and a one-time non-refundable \$750
team registration fee. For more information and to submit an
application, please see the attached flyer and visit
[http://prevent.unc.edu/education/](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://prevent.unc.edu/education/).

***The PREVENT Child Maltreatment Institute** is supported by the Doris
Duke Charitable Foundation and is operated by The University of North
Carolina Injury Prevention Research Center, a partner in the National
Training Initiative for Injury and Violence Prevention (NTI). PREVENT
was launched in 2003 with support from the National Center for Injury
Prevention and Control at CDC and has trained more than 900 violence
practitioners in 44 states in the primary prevention of different types
of violence.*

Medical Mystery Tour

**A diabetic patient who is finally losing weight**

As you may recall last month we discussed......

.... a 21 yo G1 P0 presents with persistent nausea and vomiting for 7
weeks. The patient was diagnosed with type 2 diabetes 4 years ago and
has had fair control with and an oral hypoglycemic agent. She stopped
her hypoglycemic when she learned she was pregnant. Her glucose has been
well controlled with diet and exercise during her pregnancy. The patient
has a history of migraine that often presents with concomitant nausea.

Exam reveals a 7 % loss from her pre-pregnancy body weight which she
states was without trying to lose weight. Otherwise the patient's fundus
is palpable 3 fingerbreadths below her umbilicus.

Laboratory evaluation reveals no evidence of urinary tract infection,
but she does have ketonuria.

Ultrasound confirms a single 16 week female fetus with normal amniotic
fluid and a Grade I anterior fundal placenta.

We established that pregnancy is not an ideal time for weight loss.
Significant weight loss should be confined to the preconception and
postpartum periods, but still had these two questions:

**To review:**

-   Some degree of nausea with or without vomiting occurs in most
    pregnancies, typically with onset at five to six weeks of gestation,
    then peaking at nine weeks, and usually abating by 16 to 18 weeks of
    gestation. Hyperemesis gravidarum represents the severe end of the
    spectrum of symptoms.

```{=html}
<!-- -->
```
-   The diagnosis of hyperemesis gravidarum is made clinically in a
    woman with onset of persistent vomiting accompanied by weight loss
    exceeding 5 percent of prepregnancy body weight and ketonuria in the
    first trimester, unrelated to other causes.

-   The standard initial evaluation of pregnant women with persistent
    vomiting includes measurement of weight, orthostatic blood
    pressures, serum free T4 concentration, serum electrolytes, urine
    ketones, and an ultrasound examination to exclude gestational
    trophoblastic disease and multiple gestation.

#1 What are some of the treatment options for this patient?

**Here are some basic treatment recommendations**

-   Women who are significantly dehydrated should receive intravenous
    fluids. We suggest a short period of gut rest during hydration,
    followed by reintroduction of oral intake with liquids and low fat
    foods.

```{=html}
<!-- -->
```
-   Women should try to become aware of and avoid environmental triggers
    and foods which might provoke their nausea and vomiting. Acupuncture
    and acupressure have not been shown to significantly reduce nausea
    and vomiting. However, given the absence of harm and the strong
    placebo effect, some patients may benefit from a trial of
    acupressure wrist bands.
    [Ginger](http://www.uptodateonline.com/online/content/topic.do?topicKey=nat_drug/52571&drug=true)
    also appears to have beneficial effects and ginger containing foods,
    such as ginger lollipops, may be helpful in women with mild nausea
    and vomiting.

-   Where available, pyridoxine-doxylamine succinate combination therapy
    is recommended for initial pharmacologic treatment of hyperemesis
    gravidarum. If this drug is not available, we suggest
    [pyridoxine](http://www.uptodateonline.com/online/content/topic.do?topicKey=drug_l_z/217142&drug=true),
    adding
    [doxylamine](http://www.uptodateonline.com/online/content/topic.do?topicKey=drug_a_k/187179&drug=true)
    succinate if pyridoxine alone is not effective.

```{=html}
<!-- -->
```
-   If nausea and vomiting persist,
    [promethazine](http://www.uptodateonline.com/online/content/topic.do?topicKey=drug_l_z/212504&drug=true)
    is also suggested.

-   [Corticosteroids](http://www.uptodateonline.com/online/content/topic.do?topicKey=drug_l_z/209553&drug=true)
    are not recommended for treatment of hyperemesis.

**#2 If conservative measures are successful, does a PICC line
facilitate treatment of hyperemesis gravidarum?**

**No.** In fact, it may be dangerous. In this study, 42 women
hospitalized with hyperemesis gravidarum (HEG) were assigned to
treatment with medication alone, 33 to a peripherally inserted central
catheter (PICC) line, and 19 to a nasogastric (NG) or nasoduodenal (ND)
tube. Of those managed with a PICC line, 66.4% (P\<.001) required
treatment for infection, thromboembolism, or both. In addition, neonatal
complications including small for gestational age (SGA), admission to
neonatal intensive care, termination of pregnancy because of HEG, and
fetal loss were increased in the women who had a PICC.

Have you taken advantage of the free CME we offer on this topic? If not,
this next part is definitely low hanging fruit. Just go to this module,
review the material, answer a few quick questions, hit the submit button
and voila free CME credits.....plus the module offers a great set of
materials for future reference.

**Nausea and Vomiting in Pregnancy**

<http://www.ihs.gov/MedicalPrograms/MCH/M/PNC/NVP01.cfm>

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

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

#### A sample of recent free CME offerings on Medscape: {#a-sample-of-recent-free-cme-offerings-on-medscape .Style-Heading-4-+-Arial-14-pt-Underline}

#### Female Sexual Dysfunction: A Clinical Update  {#female-sexual-dysfunction-a-clinical-update .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/14727**](http://www.medscape.com/viewprogram/14727)  {#httpwww.medscape.comviewprogram14727 .Style-Heading-4-+-Arial-14-pt-Underline}

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

############## Statement from USPSTF: Screening for Iron Deficiency Anemia \-- Including Iron Supplementation for Children and Pregnant Women  {#statement-from-uspstf-screening-for-iron-deficiency-anemia----including-iron-supplementation-for-children-and-pregnant-women .unnumbered}

#### [**http://cme.medscape.com/viewprogram/7033**](http://cme.medscape.com/viewprogram/7033)  {#httpcme.medscape.comviewprogram7033 .Style-Heading-4-+-Arial-14-pt-Underline}

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

############## Antibiotic Prophylaxis Reduces Risk for Postpartum Perineal Wound Complications   {#antibiotic-prophylaxis-reduces-risk-for-postpartum-perineal-wound-complications .unnumbered}

#### [**http://cme.medscape.com/viewarticle/575875**](http://cme.medscape.com/viewarticle/575875)  {#httpcme.medscape.comviewarticle575875 .Style-Heading-4-+-Arial-14-pt-Underline}

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

############## Uncovering Rheumatoid Arthritis: A Diagnosis and Co-Management Case in Primary Care  {#uncovering-rheumatoid-arthritis-a-diagnosis-and-co-management-case-in-primary-care .unnumbered}

#### [**http://cme.medscape.com/viewprogram/12670**](http://cme.medscape.com/viewprogram/12670)  {#httpcme.medscape.comviewprogram12670 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Management of Herpes Simplex Infections Reviewed  {#management-of-herpes-simplex-infections-reviewed .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://cme.medscape.com/viewarticle/575879**](http://cme.medscape.com/viewarticle/575879)  {#httpcme.medscape.comviewarticle575879 .Style-Heading-4-+-Arial-14-pt-Underline}

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

############## Guidelines Issued on Pertussis, Tetanus, Diphtheria Prevention in Pregnant Women and Newborns   {#guidelines-issued-on-pertussis-tetanus-diphtheria-prevention-in-pregnant-women-and-newborns .unnumbered}

#### [**http://cme.medscape.com/viewarticle/574587**](http://cme.medscape.com/viewarticle/574587)  {#httpcme.medscape.comviewarticle574587 .Style-Heading-4-+-Arial-14-pt-Underline}

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

############## Adult Asthma: Individualizing and Optimizing Care  {#adult-asthma-individualizing-and-optimizing-care .unnumbered}

#### [**http://cme.medscape.com/viewprogram/14649**](http://cme.medscape.com/viewprogram/14649)  {#httpcme.medscape.comviewprogram14649 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### General Information about Medscape: {#general-information-about-medscape .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**

**Low-Dose Estradiol Spray to Treat Vasomotor Symptoms**

OBJECTIVE: To investigate the safety and efficacy of a transdermal
estradiol (E2) spray in women with postmenopausal vasomotor symptoms.

METHOD: A randomized, double-blind, placebo-controlled, multicenter,
parallel-group clinical trial was conducted. Postmenopausal women
(N=454) with at least eight moderate-to-severe hot flushes per day
applied daily, one, two, or three E2 (90 microliter spray contains 1.53
mg E2) or matching placebo sprays. The primary efficacy endpoints were
mean change from baseline in frequency and severity of
moderate-to-severe hot flushes at weeks 4 and 12.

RESULTS: All three E2 groups showed a significant decrease in hot
flushes at weeks 4 and 12 compared with their placebo groups (P\<.010).
The mean change in frequency at week 12 was eight fewer flushes per day
for women in the E2 groups and between four and six fewer flushes for
women in the placebo groups. Women in the three- and two-E2 spray groups
demonstrated significant (P\<.050) reductions in severity score at weeks
4 and 12; women in the one-spray group showed significant reductions at
week 5. At week 12, the majority (74-85%) of women on E2 showed at least
a 50% hot flush frequency reduction as compared with 46% in the placebo
group. The systemic E2 delivery rates at week 12 were approximately
0.021 mg/d, 0.029 mg/d, and 0.040 mg/d for the one-, two-, and
three-spray doses, respectively. Common adverse events were similar to
those previously reported with other transdermal products.
Treatment-related application site reaction rate was similar to placebo
(1.3% compared with 1.8%).

CONCLUSION: The three dose levels of E2 spray achieved efficacy at
0.021-0.040 mg/d delivery rates. The spray is a well-tolerated, new,
convenient method of delivering low-dose E2 transdermally.

## Buster JE, Koltun WD, Pascual ML, Day WW, Peterson C. Low-Dose Estradiol Spray to Treat Vasomotor Symptoms: A Randomized Controlled Trial. **Obstet Gynecol. 2008 Jun;111(6):1343-1351.<http://www.ncbi.nlm.nih.gov/pubmed/18515518>** 

**Midwives Corner** **Lisa Allee, CNM, 4 Corners Regional Health Center,
Red Mesa, AZ**

**ACNM Four Corners Chapter is sponsoring Centering Pregnancy Training**

**September 6 & 7, 2008 in Chinle!**

This event is being paid for by a grant from the March of Dimes to
support Centering Pregnancy on the Navajo Nation and, therefore, will be
***FREE*** to all who would like to provide Centering Pregnancy prenatal
care to women and families on the Navajo Nation.  Please try to assemble
a team of people from your site including midwives, nurses, nurses'
aides, physicians, other potential group co-facilitators, administrators
who can support a Centering program, support staff who will be involved
in promoting Centering and scheduling patients in groups, etc.  Think
big picture.  The training is limited to 30 participants, so please
register your team early! 

 

This training is fun and empowering for those who attend and then that
fun and empowerment ripples out to the women and families who are
blessed with the opportunity to participate in Centering groups.  Come
and join in this amazing, powerful form of care!

 

For more information, contact Lisa Allee, CNM at <lisa.allee@ihs.gov>.

**Navajo News Sandra Dodge, CNP, Chinle**

**Forty one (41) Indian Health Care Providers complete SANE/SAFE course
in Window Rock**

Chinle Service Unit recently sponsored a successful SANE/SAFE course at
the Navajo Nation Museum June 9-13, 2008. The course instructor was
Diana Faugno, RN, MSN, CNP, who provides this SANE/SAFE education across
the country. The course focused on forensic medical examination
techniques for adults and adolescent survivor of sexual assault. The
course also provided the licensed health care providers with the
didactic training and resources needed for the certification as sexual
assault nurse examiner or sexual assault forensic examiner.

There were 41 participates in Window Rock, Arizona with representatives
from the various service units from across the different Indian Health
Systems, Navajo, Phoenix, Aberdeen and Billings Area. There were
presentations from the Navajo Police Department and Dine Nation
Prosecutor's Office, U.S. Attorney's Office from Phoenix, Chinle's
Victim Advocate's Office and Crime Lab who provided protocols, policy
and procedures from their offices regarding sexual assault and how the
SANE/SAFE providers can best facilitate forensic evidences through the
examination.

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

**Nurses Corner Sandra Haldane, HQE**

**What Is Forensic Nursing?**

Forensic Nursing is the application of nursing science to public or
legal proceedings; the application of the forensic aspects of health
care combined with the bio-psycho-social education of the registered
nurse in the scientific investigation and treatment of trauma and/or
death of victims and perpetrators of abuse, violence, criminal activity
and traumatic accidents.

The forensic nurse provides direct services to individual clients,
consultation services to nursing, medical and law related agencies, and
expert court testimony in areas dealing with trauma and/or questioned
death investigative processes, adequacy of services delivery, and
specialized diagnoses of specific conditions as related to nursing.

The above is excerpted from the International Association of Forensic
Nurses web site.

For more information about how to become a Sexual Assault Nurse Examiner
(SANE) visit the IAFN web site at: <http://www.iafn.org/index.cfm>.

Need technical assistance? Visit the Sexual Assault Forensic Examiner
Technical Assistance web site at <http://www.safeta.org/>.

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

####  {#section-27 .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}

**Guiding Principles for Development of ACIP Recommendations for
Vaccination During Pregnancy and Breastfeeding**

This document provides guidance to help standardize procedures for
policy formulation and presentation of the rationale and recommendations
for vaccination of pregnant and breastfeeding women. Topics in *Guiding
Principles* include 1) guidance for structure of the background section,
2) guidance for structure and language of recommendations, 3)
clarification of the definitions of precautions and contraindications in
the context of pregnant and breastfeeding women, 4) suggestions for
approaches to policy decision-making in the absence of adequate data,
and 5) description of a consistent process to gather expert opinion.
These principles will be applied to future ACIP vaccine statements and
routine updates of existing statements in which vaccination of pregnant
and breastfeeding women is considered.

Text version -
[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5721a3.htm](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5721a3.htm)

PDF version (p. 580) -
[http://www.cdc.gov/mmwr/PDF/wk/mm5721.pdf](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.cdc.gov/mmwr/PDF/wk/mm5721.pdf) 

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

**Healthy Eating Index (HEI) Scores Among Adults, 60 Years of Age and
Over, by Sociodemographic and Health Characteristics: United States,
1999--2002**

Seventy-two percent of older adults met the guidelines for cholesterol
intake and 56% met the recommendation for diet variety, but less than
one-third met the recommendations for HEI's five food groups. Only 17%
of older adults consumed a ''good'' quality diet. Males had higher
scores for some components, but females had higher scores for others.
Females with a BMI of 30 or higher ate fewer servings of dairy products,
consumed a higher percentage of calories from total and saturated fat,
and had a lower quality diet than those whose BMI was less than 30.
[http://www.cdc.gov/nchs/data/ad/ad395.pdf](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.cdc.gov/nchs/data/ad/ad395.pdf) 

 

**HIV/AIDS Surveillance Slide Sets**

Slides focusing on HIV/AIDS in women (estimated number and proportion of
AIDS cases, AIDS rates and cases, those living with HIV infection and
AIDS, by transmission category, by race and ethnicity, age at diagnosis,
diagnosis rates, etc); general epidemiology; race and ethnicity, trends,
and adolescents and young adults.

Women -
[http://www.cdc.gov/hiv/topics/surveillance/resources/slides/women/index.htm](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.cdc.gov/hiv/topics/surveillance/resources/slides/women/index.htm) 

General Epidemiology -
[http://www.cdc.gov/hiv/topics/surveillance/resources/slides/epidemiology/index.htm](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.cdc.gov/hiv/topics/surveillance/resources/slides/epidemiology/index.htm)

Race and Ethnicity -
[http://www.cdc.gov/hiv/topics/surveillance/resources/slides/race-ethnicity/index.htm](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.cdc.gov/hiv/topics/surveillance/resources/slides/race-ethnicity/index.htm)

Trends -
[http://www.cdc.gov/hiv/topics/surveillance/resources/slides/trends/index.htm](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.cdc.gov/hiv/topics/surveillance/resources/slides/trends/index.htm)

Adolescents and Young Adults -
[http://www.cdc.gov/hiv/topics/surveillance/resources/slides/adolescents/index.htm](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.cdc.gov/hiv/topics/surveillance/resources/slides/adolescents/index.htm)

 

#### Visit the CDC Office of Women's Health website at [**www.cdc.gov/women**](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.cdc.gov/women) for information on these topics, including how to sign up for their monthly newsletter with links to women's health articles, conference and grant announcements and other useful information. {#visit-the-cdc-office-of-womens-health-website-at-www.cdc.govwomen-for-information-on-these-topics-including-how-to-sign-up-for-their-monthly-newsletter-with-links-to-womens-health-articles-conference-and-grant-announcements-and-other-useful-information. .Style-Heading-4-+-Arial-14-pt-Underline}

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

####  {#section-30 .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}

**ACOG Committee on Indian Affairs visits 3 Oklahoma Area Sites**

The ACOG Committee on Indian Affairs visited 3 sites in Oklahoma Area
(Claremore, Tahlequah, and Talihina) in early June. The ACOG Committee
has a longstanding relationship with Indian Health Service and performs
an annual site visit to a one region on a rotating basis to assess care
provided to Native Women, share best practices, and make suggestions for
improvement.

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

**New evidence that Calcium supplementation may work, at least while you
take them...**

BACKGROUND: The effect of supplementation with calcium alone on risk
fractures in a healthy population is not clear.

OBJECTIVE: The objective was to determine whether 4 y of calcium
supplementation would reduce the fracture risk during treatment and
subsequent follow-up in a randomized placebo-controlled trial.

DESIGN: The participants were aged \<80 y at study entry (mean age: 61
y), were generally healthy, and had a recent diagnosis of colorectal
adenoma. A total of 930 participants (72% men; mean age: 61 y) were
randomly assigned to receive 4 y of treatment with 3 g CaCO(3) (1200 mg
elemental Ca) daily or placebo and were followed for a mean of 10.8 y.
The primary outcomes of this analysis were all fractures and minimal
trauma fractures (caused by a fall from standing height or lower while
sitting, standing, or walking).

RESULTS: There were 46 fractures (15 from minimal trauma) in 464
participants in the calcium group and 54 (29 from minimal trauma) in 466
participants in the placebo group. The overall risk of fracture differed
significantly between groups during the treatment phase \[hazard ratio
(HR): 0.28; 95% CI: 0.09, 0.85\], but not during the subsequent
posttreatment follow-up (HR: 1.10; 95% CI: 0.71, 1.69). Minimal trauma
fractures were also less frequent in the calcium group during treatment
(HR: 0; 95% CI: 0, 0.50).

CONCLUSION: Calcium supplementation reduced the risk of all fractures
and of minimal trauma fractures among healthy individuals. The benefit
appeared to dissipate after treatment was stopped.

## Bischoff-Ferrari HA, Rees JR, Grau MV, Barry E, Gui J, Baron JA. Effect of calcium supplementation on fracture risk: a double-blind randomized controlled trial. **Am J Clin Nutr. 2008 Jun;87(6):1945-51.** [**http://www.ncbi.nlm.nih.gov/pubmed/18541589**](http://www.ncbi.nlm.nih.gov/pubmed/18541589) 

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

#### Food Allergies {#food-allergies .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20080615/1687ph.html**](http://www.aafp.org/afp/20080615/1687ph.html)  {#httpwww.aafp.orgafp200806151687ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Nutrition, Physical Activity, and Cancer: What You Should Know {#nutrition-physical-activity-and-cancer-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20080601/1579ph.html**](http://www.aafp.org/afp/20080601/1579ph.html)  {#httpwww.aafp.orgafp200806011579ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Vaccines for Your Child {#vaccines-for-your-child .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20080601/1571ph.html**](http://www.aafp.org/afp/20080601/1571ph.html)  {#httpwww.aafp.orgafp200806011571ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

####  {#section-34 .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}

**Longer PROM associated with more infections**

OBJECTIVE: This study was undertaken to define the time thresholds of
increased risk for infectious maternal morbidities with relationship to
length of ruptured membranes at term.

STUDY DESIGN: We designed a retrospective cohort study of all women with
premature rupture of membranes beyond 37 weeks\' gestation at a single
institution. Dichotomized time thresholds of length of ruptured
membranes before delivery were examined in 2-hour increments using
bivariate and multivariable analyses to assess the rates of
chorioamnionitis and endomyometritis. RESULTS: Among the 3841 women
meeting inclusion criteria, increased rates of chorioamnionitis and
endomyometritis were noted at time thresholds of 12 hours (adjusted odds
ratio 2.3 \[95% confidence interval, 1.2-4.4\]) and 16 hours (adjusted
odds ratio 2.5 \[95% confidence interval, 1.1-5.6\]), respectively.

CONCLUSION: We found that when length of time of ruptured membranes
before delivery is examined via dichotomized time thresholds, the risks
of chorioamnionitis and endomyometritis are significantly increased at
12 hours and 16 hours, respectively. These time thresholds derived from
dichotomized time analyses should be considered during risk-based
counseling and labor management in the setting of term premature rupture
of membranes.

## Tran SH, Cheng YW, Kaimal AJ. Caughey AB. Length of rupture of membranes in the setting of premature rupture of membranes at term and infectious maternal morbidity. **Am J Obstet Gynecol. 2008 Jun;198(6):700.e1-5.** [**http://www.ncbi.nlm.nih.gov/pubmed/18538159**](http://www.ncbi.nlm.nih.gov/pubmed/18538159) 

**Cesarean Delivery does not improve outcome in very low birthweight
vertex fetuses**

OBJECTIVE: This study was undertaken to compare neonatal outcome by
method of delivery in very low-birthweight less than 1500 g
vertex-presenting fetuses.

STUDY DESIGN: A retrospective cohort was conducted of 2466 very
low-birthweight singleton liveborn vertex-presenting fetuses in
Washington State (1994-2003). The exposure considered was cesarean
delivery vs vaginal delivery. The risk of neonatal demise was estimated
by logistic regression. Secondary outcomes included intraventricular
hemorrhage, respiratory distress, and neonatal sepsis. Analyses were
stratified by birthweight, gestational age, and growth restriction to
assess subgroup differences.

RESULTS: Cesarean delivery offered no survival advantage to very
low-birthweight infants when compared with vaginal delivery (adjusted
odds ratio \[95% confidence interval\]: 1.08 \[0.78-1.49\]). Survival
benefit was noted for growth-restricted infants (adjusted odds ratio
\[95% confidence interval\]: 0.09 \[0.02-0.47\]) although only 12% of
such infants delivered vaginally.

CONCLUSION: For very low-birthweight vertex-presenting fetuses at risk
of preterm delivery, cesarean delivery does not improve neonatal
survival. Further studies are warranted to assess the potential benefit
of cesarean delivery to growth-restricted very low-birthweight infants.

Wylie BJ, Davidson LL, Batra M, Reed SD. Method of delivery and neonatal
outcome in very low-birthweight vertex-presenting fetuses. Am J Obstet
Gynecol. 2008 Jun;198(6):640.e1-7; discussion e1-4. Epub 2008 Mar 7.
<http://www.ncbi.nlm.nih.gov/pubmed/18313634>

**Clostridium difficile-associated diarrhea: an emerging threat to
pregnant women**

OBJECTIVE: To estimate if Clostridium difficile-associated disease
(CDAD) is increasing in peripartum women.

STUDY DESIGN: Peripartum CDAD was assessed through 1) passive
surveillance collecting clinical and pathology data on severe cases and
2) survey among infectious disease consultants (ICDs) in the Emerging
Infections Network.

RESULTS: Ten severe cases were collected; most had associated antibiotic
use. Seven women were either admitted to the ICU or underwent colectomy.
Three infants were stillborn, and 3 women died. The epidemic Clostridium
difficile strain was found in 2 cases. Among 798 ICDs, 419 (52%)
participated in the survey. Thirty-seven respondents (9%) recalled 55
cases, mostly in the postpartum period with 21 complications, mainly due
to relapse.

CONCLUSION: Severe CDAD may be increasing in peripartum women.
Clinicians should have a low threshold for testing, be aware of the
potential for severe outcomes, and take steps to reduce both the risk of
disease and resultant complications.

Rouphael NG, O\'Donnell JA, Bhatnagar J, Lewis F, Polgreen PM, Beekmann
S, Guarner J, Killgore GE, Coffman B, Campbell J, Zaki SR, McDonald LC.
Clostridium difficile-associated diarrhea: an emerging threat to
pregnant women. Am J Obstet Gynecol. 2008 Jun;198(6):635.e1-6. Epub 2008
Apr 8. <http://www.ncbi.nlm.nih.gov/pubmed/18395693>

**Mycophenolate mofetil (MMF) may be linked to congenital anomalies**

FDA is aware of reports of infants born with serious congenital
anomalies, including microtia and cleft lip and palate, following
exposure to mycophenolate mofetil (MMF) during pregnancy. MMF, the
active drug substance in CellCept, is an ester of the active metabolite
mycophenolic acid (MPA), the active drug substance in Myfortic. In most
cases, the mothers were taking MMF following an organ transplant to
prevent organ rejection. However, some mothers taking MMF were being
treated for immune-mediated conditions such as systemic lupus
erythematosus (SLE) and erythema multiforme. Treatment began before
their pregnancies and continued into the first trimester or until the
pregnancy was detected. MMF and MPA increase the risk of spontaneous
abortion in the first trimester and can cause congenital malformations
in the offspring of women who are treated during pregnancy.\
\
FDA is continuing to work with the manufacturers of these drug products
to develop and implement means to mitigate the risks of fetal exposure.
See the FDA Healthcare Professional Information Sheet containing
considerations and recommendations for clinicians prior to prescribing
MMF or MPA to women of childbearing potential.

[http://www.fda.gov/medwatch/safety/2008/safety08.htm#MMF](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.fda.gov/medwatch/safety/2008/safety08.htm%23MMF)

#### Primary Care Discussion Forum Ann Bullock, Cherokee, NC {#primary-care-discussion-forum-ann-bullock-cherokee-nc .Style-Heading-4-+-Arial-14-pt-Underline}

### 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 <ANNBULL@nc-cherokee.com>

**STD Corner Lori de Ravello, National IHS STD Program**

## Chlamydia Positivity in American Indian/Alaska Native Women Screened in Family Planning Clinics, 1997-2004

BACKGROUND: Previous studies demonstrated high levels of Chlamydia
trachomatis (CT) infections within American Indian/Alaskan Native
(AI/AN) populations but there are few analyses of CT prevalence in these
populations over time.

METHODS: We analyzed data from 7374 visits at which diagnostic tests for
CT were collected in AI/AN women aged 15 to 24 years seen at family
planning clinics associated with the Region X Infertility Prevention
Project. Trends in population characteristics and test positivity were
examined and compared with non-AI/AN women tested in the same setting
and time period. Chlamydia positivity was adjusted for changes in
diagnostic test type. Multivariable logistic regression was used to
identify characteristics associated with infection.

RESULTS: Adjusted CT positivity in AI/AN women rose from 7.8% to 11.0%,
which was 1.5 to 2.2 times the non-AI/AN population levels over the
study period (absolute difference 2.8%-6.6%). Differences persisted
after correction for test type and age. Temporal changes in positivity
among AI/AN women were associated with a rise in reported risk behaviors
and decline in age of the population being tested. Risk factors
associated with positivity among AI/AN women were younger age, \>=1
behavioral risks, \>=1 clinical findings, partner with chlamydia,
chlamydia in past year, and pregnancy related visit.

CONCLUSIONS: AI/AN women had consistently higher levels of chlamydia
positivity than non-Native women, even after adjustment for age and
diagnostic test. Further investigation of risks for chlamydia, related
outcomes, access to screening, sexual networks, and enhanced
surveillance would be beneficial for improving health in this vulnerable
population.

Gorgos L, Fine D, Marrazzo J. Chlamydia Positivity in American
Indian/Alaska Native Women Screened in Family Planning Clinics,
1997-2004. [Sex Transm. Dis.]{.underline} 2008 Apr 29. \[Epub ahead of
print\] <http://www.ncbi.nlm.nih.gov/pubmed/18449068>

####  {#section-35 .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}

**Stretching exercises may reduce risk of pre-eclampsia during
pregnancy**

Stretching exercises may be more effective at reducing the risk of
pre-eclampsia than walking is for pregnant women who have already
experienced the condition and who do not follow a workout routine,
according to researchers at the University of North Carolina at Chapel
Hill School of Nursing.

OBJECTIVES: To compare a walking exercise to a stretching exercise
during pregnancy in high-risk women who were sedentary and had
previously experienced pre-eclampsia.

METHODS: A randomized clinical trial of the effects of the two types of
physical exercises was conducted between November 2001 and July 2006 in
Washtenaw County, Michigan. Both groups engaged in the assigned exercise
five times a week until the end of pregnancy.

RESULTS: Women were randomized to either the walking group (n = 41) or
the stretching group (n = 38). The walkers exercised an average of 36
(SD, 6) minutes at 18 weeks gestation, 34 (SD, 7) minutes at 28 weeks
gestation, and 31 (SD, 12) minutes at the last week of the intervention.
On average, they exercised within target heart rate ranges 35% (SD, 32%)
at 18 weeks gestation, 22% (SD, 25%) at 28 weeks gestation, and 17% (SD,
25%) at the last week of the intervention. The stretching group engaged
in stretching exercises following a 40-minutes videotape. On average,
the walking group exercised 4 (SD, 1) times a week at 18 weeks
gestation, 4 (SD, 1) time a week at 28 weeks gestation, and 3 (SD, 1)
times a week at the last week of the intervention. Equally on average,
the stretching group exercised 4 (SD, 2) times a week at 18 weeks
gestation, 5 (SD, 1) times a week at 28 weeks gestation, and 3 (SD, 1)
times a week at the last week of the intervention. No difference between
groups was observed, but both exercised significantly less frequently
over the time (p 0.0001). Together, participants reported average 7,040
(SD, 2,612) steps at the beginning and 5,711 (SD, 2,739) steps at the
end of the study. The walkers tracked an average 8,501 (SE, 778) steps a
day at 20 weeks gestation and 7,418 (SE, 788) steps at 34 weeks
gestation (n.s.). The stretchers tracked an average 6,189 (SE, 704)
steps at 20 weeks gestation and 4,848 (SE, 452) steps at 34 weeks
gestation (p 0.05). The incidence of pre-eclampsia was 14.6% (95% CI,
5.6 to 29.2) among the walkers and 2.6% (95% CI; 0.07 to 13.8) among the
stretchers. The incidence of gestational hypertension was 22 % (95%
C.I., 8.7 to 35.2) for the walkers and 40% (95% CI, 23.2 to 55.8) for
the stretchers. The mean transferrin level, an antioxidant marker, was
significantly higher in the stretching group mean (412 mg/dL, 95%CI, 389
to 435) than the walkers at the time of labor (mean = 368 mg/dL, 95%CI,
346 to 391) (p 0.05). No significant group differences were observed in
birth outcomes.

CONCLUSION: Regular stretching exercises may promote endogenous
antioxidants among women at risk for pre-eclampsia.

## Yeo S, Davidge S, Ronis DL, Antonakos CL, Hayashi R, O\'Leary S. A comparison of walking versus stretching exercises to reduce the incidence of preeclampsia: a randomized clinical trial. **Hypertens Pregnancy. 2008;27(2):113-30. <http://www.ncbi.nlm.nih.gov/pubmed/18504873>** 

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

#### Women's Health Headlines Carolyn Aoyama, HQE {#womens-health-headlines-carolyn-aoyama-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**Screening for Abuse May Be Key to Ending It**

This New York Times article reviews how screening for domestic violence
is different from other routine care, such as pap smears...but just as
important...

[http://www.nytimes.com/2008/05/20/health/20abus.html?ref=health](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.nytimes.com/2008/05/20/health/20abus.html?ref=health)

 

#### CDC Women's Health Resources for Health Professionals Video: Women's Health Resources from the CDC This three-minute video highlights resources that health professionals and others can use in their clinic, practice, organization, or community. [**www.cdc.gov/women/videopubs**](http://www.cdc.gov/women/videopubs)          Ways to Help Improve Women\'s Health What more can you do to help improve women\'s health? Prevention is key to keeping women healthy and safe.  [**www.cdc.gov/women/improve**](http://www.cdc.gov/women/improve)  Campaigns and Programs  {#cdc-womens-health-resources-for-health-professionals-video-womens-health-resources-from-the-cdc-this-three-minute-video-highlights-resources-that-health-professionals-and-others-can-use-in-their-clinic-practice-organization-or-community.-www.cdc.govwomenvideopubs-ways-to-help-improve-womens-health-what-more-can-you-do-to-help-improve-womens-health-prevention-is-key-to-keeping-women-healthy-and-safe.-www.cdc.govwomenimprove-campaigns-and-programs .Style-Heading-4-+-Arial-14-pt-Underline}

#### Learn more about selected CDC campaigns and programs that focus on women's or girls' health. [**www.cdc.gov/women/campaigns**](http://www.cdc.gov/women/campaigns)  Continuing Education  {#learn-more-about-selected-cdc-campaigns-and-programs-that-focus-on-womens-or-girls-health.-www.cdc.govwomencampaigns-continuing-education .Style-Heading-4-+-Arial-14-pt-Underline}

#### View a listing of selected CDC continuing education programs related to women's health and other topics. [**www.cdc.gov/women/ceu**](http://www.cdc.gov/women/ceu)   {#view-a-listing-of-selected-cdc-continuing-education-programs-related-to-womens-health-and-other-topics.-www.cdc.govwomenceu .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Sexual Assault Nurse Examiner/Forensic Examiner (SANE/SAFE) Training
Course**

-   July 21-25, 2008

-   Aberdeen, South Dakota

-   40 hour didactic portion of SANE/SAFE training

-   For additional information contact Lisa Palucci,
    <lisa.palucci@ihs.gov>, at the IHS Clinical Support Center

**Community Health Representative National Educational Meeting**

-   July 29-31, 2008

-   Las Vegas, Nevada

-   40^th^ Anniversary of the CHR Program

-   [www.nachr.net/conferences/2008/](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://nachr.cmail1.com/l/359077/l/www.nachr.net/conferences/2008/)

**Sexual Assault Nurse Examiner/Forensic Examiner (SANE/SAFE) Training
Course**

-   August 18-22, 2008

-   Oklahoma City, Oklahoma

-   40 hour didactic portion of SANE/SAFE training

-   For additional information contact Lisa Palucci,
    <lisa.palucci@ihs.gov>, at the IHS Clinical Support Center

**Postgraduate Course on Obstetric, Neonatal and Gynecologic Care**

-   September 14-18, 2008

-   Salt Lake City, Utah

-   Comprehensive Women's Health Update for Nurses, Advanced Practice
    Nurses, and Physicians

-   NRP offered as pre-conference session

-   Contact Yvonne Malloy, <ymalloy@acog.org>, for more information

>  

**International Indiginous Women's and Children's Health Meeting**

-   March 4-8, 209

-   Albuquerque, NM

-   Joint conference of Women's Health and Children's Health Providers
    from Canada and the United States

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

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/index.cfm>

# Did you miss something in the last Chief Clinical Consultant Corner? {#did-you-miss-something-in-the-last-chief-clinical-consultant-corner .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

**The June 2008 CCC Corner is available at:**
**<http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm#jun08>\
**

#### Abstract of the Month  {#abstract-of-the-month-2 .Style-Heading-4-+-Arial-14-pt-Underline}

Metformin vs. Insulin for the Treatment of Gestational Diabetes

#### From your colleagues  {#from-your-colleagues-2 .Style-Heading-4-+-Arial-14-pt-Underline}

Scott Giberson

National HIV Testing Mobilization Campaign

Elaine Locke

ACOG / IHS Denver Course Now in Salt Lake City, Utah

Charles North

Effects of optimizing blood pressure and cholesterol levels in diabetic
patients; the SANDS trial

**Ty Reidhead**

Chronic Care Initiative Readiness Curriculum

**Hot Topics**

**Obstetrics**

\-[HAPO Study
Group](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="HAPO Study Cooperative Research Group"%5BCorporate Author%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus):
Hyperglycemia and adverse pregnancy outcomes

-Prevention of Pertussis, Tetanus and Diphtheria among Pregnant and
Postpartum Women

-Prevalence of Self-Reported Postpartum Depressive Symptoms

-The Pfannenstiel incision as a source of chronic pain

#### -Increasing exposure to angiotensin-converting enzyme inhibitors in pregnancy {#increasing-exposure-to-angiotensin-converting-enzyme-inhibitors-in-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

**Gynecology**

-Management of Trichomonas vaginalis with Metronidazole hypersensitivity

-Levonorgestrel-releasing IUDs in patients with adenomyosis

-Treatment of vulvar intraepithelial neoplasia with topical imiquimod

**Child Health**

-Breastfeeding Promotion for Type 2 Diabetes Prevention in Native
American Communities

-Epidemiology of Invasive Group B Strep Disease

-Smoking Cessation in Adolescents

-Intensive Care for Extreme Prematurity

**Chronic Illness and Disease**

-Awareness of Stroke Warning Signs

-Mammography; alone or with ultrasound?

-Once Daily vs. Prandial Insulin

-Arthritis as a Potential Barrier to Physical Activity among Adults with
Diabetes

#### Features  {#features-2 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-Diagnosis and Management of Vulvar Skin Disorders

-Osteopenia and Fracture Risk

-Ovarian Tissue and Oocyte Cryopreservation

-Coping with the Stress of Medical Professional Liability Litigation

##### American Family Physician

-A Practical Approach to Neonatal Jaundice

-Physical Activity Counseling

-Oral Health during Pregnancy

**Agency for Healthcare Research and Quality**

-Outcomes of Maternal Weight Gain

-Helping Smokers Quit; A Guide for Clinicians

**Ask a Librarian**

Women's Health Resources

**Behavioral Health Insights**

Cutters-Understanding Intentional Self-Injury

**Breastfeeding**

Supporting Breastfeeding with money or a lot of time

**Domestic Violence**

"Keeping the Circle Strong"

**Elder Care News**

Landmark Study on Treatment of Hypertension in the Very Old

**Family Planning**

Fact Sheet on States' Efforts to Safeguard Adolescents' Confidentiality

**Featured Websites**

-Donald Coustan: Gestational Diabetes

-Donald Coustan: [Use of Oral Antidiabetic Agents in Obstetrics:
Workshop](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/Ws 42 - Coustan -- Albuquerque Workshop 2007 oral_1.ppt)

-Diabetes and Pregnancy Online Resources

**Frequently asked questions**

Who should be offered first trimester Down syndrome (DS) screening?

**Indian Child Health Notes**

Autism Articles of Interest

Child Health Infectious Disease Update

**Information Technology**

iCare Training

International Health

Fistulas and Ethics

#### MCH Alert

\- Brief Highlights Key Findings on Breastfeeding in the United States

\- New Edition of Overweight and Obesity Knowledge Path Available

\- Cultural and Linguistic Competence in the Diagnosis and Treatment of
Depression

#### MCH Headlines

\- New Lead Screening Requirements from CMS

\- Children and Youth Programs Newsletter

**Medical Mystery Tour**

A diabetic patient who is finally losing weight

#### Medscape

**Menopause Management**

Gabapentin for the treatment of menopausal hot flashes

**Midwives Corner**

Midwives Gathering

**Oklahoma Perspective**

Meet Dr. George Chiarchiaro, Oklahoma MCH Coordinator

**Navajo News**

SANE/SAFE Training

**Nurses corner**

No Relief from National Nursing Shortage

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

Availability of Cefixime Tablets

Osteoporosis

Screening for Osteoporosis in Men

Patient Education

Physical Activity

Perinatology Picks

-Who returns for postpartum glucose screening?

-BMI and weight gain prior to pregnancy; a risk for gestational
diabetes?

-Fetal outcome in motor-vehicle crashes

-VBAC; clinical risk factors for adverse outcome

Primary Care Discussion Forum

Conclusion of the adolescent behavioral health on-line discussion

STD Corner

-Predicting Adolescent Condom Use

-Missed Opportunities for Chlamydia Screening

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

Trends in DM/GDM

**Women's Health Headlines**

Funding for DV Programs

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

[2007 Native Women's Health and MCH
Conference](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Intro Slide and Eval Sli14.ppt)

The past CCC Corners are archived at:

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN02.cfm>

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
[jean.howe@ihs.gov](mailto:nmurphy@scf.cc)

or 928-674-7422 (with voicemail)

\*The opinions expressed in the 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>