10/25/03

OB/GYN Chief Clinical Consultant's Corner

Volume 1, No. 9, October 25, 2003

## 

## News flash.....Date change....

## The Obstetric, Neonatal, and Gynecologic Care: A.C.O.G./I.H.S. Postgraduate Course that is usually held in September each year has been moved to June 13-17, 2004. It will still be located at Radisson Hotel Denver SE. See the 'Save the Dates' section below for details. 

## Sign up soon, and / or spread this news, please.

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

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

Prophylactic Antibiotics in Labor and Delivery, ACOG Practice Bulletin

[From your colleagues:]{.underline}

From Hope Baluh: Wrong Site Surgery

#### From James Bresette: Possible Additional Resources for AI/AN Women\'s Health

From Tom Creelman: Information about intrathecal analgesia after reading
Leeman et al

From Terry Cullen: Domestic Violence Awareness Month, Health Promotion
and Disease Prevention, Asthma, Best Practices, VA Clinical Practice
Guidelines: Uncomplicated pregnancy guidelines and Home page

From Sandra Dodge: Cigarette Smoking Among Adults \-\-- United States,
2001, CDC

##### From James Galloway: [**Diabetic Dyslipidemia, ADA**](http://www.ihs.gov/NonMedicalPrograms/nc4/Documents/ADACardioReview_3.pdf)

From Ursula Knoki-Wilson: Two West Nile virus human cases confirmed in
the Navajo Nation

# From Larry Leeman: Effective repair of obstetric perineal lacerations requires a knowledge of perineal anatomy and surgical technique

From Elaine Locke: Tribal benefits counseling program: expanding health
care opportunities for tribal members.

From Kelly Moore: FAS on NBC television program Law & Order: Special
Victims Unit.

##### From Chuck North: Routine prenatal urine screening for preeclampsia?

From Judy Thierry: The Stop Chlamydia! Project Home Page

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

##### Obstetrics: Rapid HIV Test, Antenatal screening with fetal echocardiography: when and how, Legislation for Cord Blood Bank Network Reminiscent of Early Organ Transplant 

**Gynecology:** Colposcopy and Women's Value judgements: Funding is
available, Effectiveness of Strategies for Preventing Violence:
Firearms, Continuous combination oral contraceptive pills to eliminate
withdrawal bleeding: a randomized trial, Premenstrual dysphoric disorder
(PMDD)

**Child Health:** [**www.4girls.gov**](http://www.4girls.gov/), State
Policies in Brief: Sexuality Education presents information on sex
education policies, Prevention and Treatment of Type 2 Diabetes Mellitus
in Children With Special Emphasis on American Indian and Alaska Native
Children, Sudden Infant Death Syndrome, Infant Mortality Statistics from
the 2001 Period Linked Birth/Infant Death

**Chronic Illness and Disease:** October is Breast Cancer Awareness
Month, Prevalence of Diabetes and Impaired Fasting Glucose in
Adults-United States, Overweight or obese individuals in the US do not
believe that they are at serious risk of developing type 2 diabetes
mellitus

[Features:]{.underline}

##### AFP: Common skin conditions in women

## ACOG: Benefits and Risks of Sterilization, ACOG disagrees with WHI on osteoporosis prophylaxis

**AHRQ:** Lengthening postpartum hospital stays, Later admission in
labor and collaborative care increase spontaneous vaginal delivery

ACOG: Benefits and Risks of Sterilization

Breastfeeding: Educational programs were the most effective single
intervention

**Hormone Replacement Update**: ACOG disagrees with WHI on osteoporosis
prophylaxis, Red clover and soy both contain phytoestrogens

**Information Technology:** Comparison of telecolposcopy systems,

International Health: Outcomes, safety, and resource utilization in a
collaborative care birth center

# MCH Alert: Toolkit helps increase knowledge and awareness of emergency contraception, Effectiveness of early home visitation programs in preventing violence, Impact of health centers on reducing health disparities

**Office of Women's Health, CDC:** Preventing Male Perpetration of
Sexual Violence

Patient Education: Alternatives to Hysterectomy, Public health campaign
launched to promote appropriate use of antibiotics

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

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

# 

# [Abstract of the Month]{.underline}

#### Prophylactic Antibiotics in Labor and Delivery

ACOG Practice Bulletin NUMBER 47, OCTOBER 2003

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

-   All high-risk patients undergoing cesarean delivery should be given
    antibiotic prophylaxis.

-   For prophylaxis with cesarean delivery, narrow-spectrum antibiotics,
    such as a first-generation cephalosporin, should be used.

-   Antibiotic prophylaxis may be considered for patients with PROM,
    particularly in cases of extreme prematurity, to prolong the latency
    period between membrane rupture and delivery.

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

-   Evidence is insufficient to recommend perioperative antibiotic
    prophylaxis at the time of prophylactic or emergency cervical
    cerclage.

-   Prophylaxis for bacterial endocarditis is optional in patients with
    the following cardiac conditions who are undergoing uncomplicated
    obstetric delivery: prosthetic cardiac valves, prior bacterial
    endocarditis, complex cyanotic congenital cardiac malformations, and
    surgically constructed systemic pulmonary shunts or conduits.

-   Patients with the above cardiac conditions who are undergoing
    obstetric delivery complicated by intraamniotic infection should
    receive prophylaxis.

-   Although the evidence is inconclusive, for low-risk patients
    undergoing cesarean delivery, use of prophylactic antibiotics is
    recommended.

Prophylactic antibiotics in labor and delivery. ACOG Practice Bulletin
No. 47. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2003;102:875--82.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14551023&dopt=Abstract>

Full text for ACOG members, online

<http://www.acog.com/publications/educational_bulletins/pb047.cfm>

Table 1 for ACOG members

<http://www.acog.com/publications/educational_bulletins/pb047.cfm#table1>

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

Many of these recommendations represent a significant departure from the
past, because data has not continued to show clear efficacy for
antibiotic treatment in selected circumstances. In addition, it may be
difficult for the individual practitioner to recognize or acknowledge
the risks of inappropriate antibiotic use for his or her individual
patient, the impact of increasing use of antibiotics can be felt
clearly, even in the hospital setting.

I suggest that Indian Health facilities incorporate the recommendations
in Table 1 in this ACOG document into their facility's clinical
guidelines. njm

## From your colleagues:

#### [From Hope Baluh]{.underline} (Surgery CCC, IHS)

#### Dr. Baluh is developing an IHS-wide policy on Wrong Site Surgery. Here is one of the resources she is working with. 

<http://www.jcaho.org/general+public/patient+safety/preventing+wrong+site+surgery.htm>

Please contact Dr. Baluh with comments: <hope.baluh@mail.ihs.gov>

#### [From James Bresette]{.underline}

###### Possible Additional Resources for AI/AN Women\'s Health

Tommy Thompson Designates **Six National Centers of Excellence in
Women\'s Health** designated six new National Centers of Excellence in
Women\'s Health last week, which will provide a one-stop-shop for women
in communities, especially targeting rural communities. The new centers
announced today are at Virginia Commonwealth University, the University
of Mississippi Medical Center, Brown University, the University of
Minnesota, the University of Arizona and the Oregon Health and Science
University. The awards are funded through HHS\' Office on Women\'s
Health. [\<http://4woman.gov/\>]{.underline}.

##### From Tom Creelman and Paul Mobley

Tom Creelman and Paul Mobley asked for more information about
intrathecal analgesia after reading the Larry Leeman et al. articles
posted in last month's September OB/GYN CCC Corner

[**http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/CCCCorner92303.doc**](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/CCCCorner92303.doc)

Here is Larry Leeman's reply:

Thanks for comments on lack of info on intrathecal analgesia (IT). We
wanted to include information about intrathecals but were limited by
space. As it was AFP allowed us to publish a two-part article, editorial
and patient education handout so I can't complain much about space
limitations, Intrathecals were not mentioned in the article, as they
were neither covered in symposium nor readily available. I am in full
agreement that IT appears useful in rural hospitals without epidural
capacity. Per the Fontaine article IT appears to have a limited role if
epidurals are available (e.g. a multip at 7 cm who really wants regional
analgesia). Here are my comments that got edited out of the final
editorial:

"Although four family physicians were among the 130 conference
participants, several areas of particular interest to family practice
maternity care received minimal attention. Rural maternity care was
neglected other than for the mention of a decreased availability and
utilization of epidurals at smaller hospitals. A presentation on the use
of intrathecal analgesia as an option for rural maternity care would
have been beneficial."

Intrathecals were included in a workshop I presented at the annual
Family Centered Maternity Care conference. Below is info from the
handout for the workshop:

Intrathecal analgesia

1\) Subarachnoid injection of opioids

2\) Easy to administer

3\) No motor blockade

4\) Rapid onset

5\) Alternative to epidurals in rural areas without continual anesthesia
presence in labor and delivery

6\) Last up to 3 hours and may be repeated

7\) May combine morphine and fentanyl for long acting and rapid relief

8\) Pruritis is common and occurred in 95% of women in one study,
although it was mild or brief in 2/3 (Fontaine 2002)

9\) Not as effective as epidural for pain relief or maternal
satisfaction. There was a high degree of satisfaction for women
delivering within 3 hours of receiving intrathecal analgesia

10\) Unlikely to be popular alternative to epidural analgesia in larger
urban hospitals but has a role in rural and smaller

References

Fontaine P, Adam P, Svendsen KH. Should intrathecal narcotics be used as
a sole labor analgesic? A prospective comparison of spinal opioids and
epidural bupivacaine. J Fam Pract. 2002;51:630-635.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12160502&dopt=Abstract>

Stephens MB, Ford RE. Intrathecal Narcotics for Labor Analgesia.
American Family Physician 1997; 56:463-470

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9262527&dopt=Abstract>

The Nature and Management of Labor Pain: Part I. Nonpharmacologic Pain
Relief

<http://aafp.org/afp/20030915/1109.html>

The Nature and Management of Labor Pain: Part II. Pharmacologic Pain
Relief

<http://www.aafp.org/afp/20030915/1115.html>

Management of Labor Pain: Promoting Patient Choice

<http://www.aafp.org/afp/20030915/editorials.html>

Patient Information: Labor Pain: What to Expect and Ways to Relieve Pain

<http://www.aafp.org/afp/20030915/1121ph.html>

**[From Terry Cullen]{.underline}**

**Domestic Violence Awareness Month**

Health Cares About Domestic Violence Day

Rosebud Indian Health Service in South Dakota's screening program, and
the activities of the

other DV Pilot Project sites will be guided in part by materials from
the FVPF's National Health

Resource Center on Domestic Violence.  The Resource Center has developed
consensus

guidelines regarding screening and intervention applicable to a variety
of health care settings.  

To obtain these consensus guidelines and other educational materials you
can visit the Family

Violence Prevention Fund's web site at [www.endabuse.org\\health]() or
call the National Health

Resource Center on Domestic Violence at: 1-888-Rx-ABUSE, TTY:
1-800-595-4899.

Health Promotion and Disease Prevention, IHS.

<http://www.ihs.gov/NonMedicalPrograms/HPDP/>

This IHS HPDP web page is continually being updated. Please contact
Karen Moriah at

<Karen.moriah@mail.ihs.gov> with information on these resources.

Asthma, Best Practices, IHS

<http://www.ihs.gov/NonMedicalPrograms/HPDP/index.cfm?module=focus&option=asthma&newquery=1>

VA Clinical Practice Guidelines Home page

<http://www.oqp.med.va.gov/cpg/cpg.htm>

VA Clinical Practice Guidelines : Uncomplicated pregnancy guidelines

<http://www.oqp.med.va.gov/cpg/UCP/UP_base.htm>

###### [From Sandra Dodge]{.underline}

**Cigarette Smoking Among Adults \-\-- United States, 2001, CDC\
**<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5240a1.htm>

##### From James Galloway

######### A new addition to the IHS Clinical Guidelines page

[Diabetic Dyslipidemia,
ADA](http://www.ihs.gov/NonMedicalPrograms/nc4/Documents/ADACardioReview_3.pdf)
[(]{.underline}PDF 245k)

<http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-clinguid.cfm>

**[From Ursula Knoki-Wilson]{.underline}**

###### TWO WEST NILE VIRUS HUMAN CASES CONFIRMED ON THE NAVAJO NATION

Window Rock, Arizona \-\-- Two human cases of the West Nile Virus were
confirmed recently on the Navajo Nation, reported the Navajo Area Indian
Health Service as of Thursday, 9/18/03

Contact Jenny Notah at (928) 871-5821 or
[ursula.knoki-wilson@ihs.gov](mailto:ursula.knoki-wilson@his.gov)

# [From Larry Leeman]{.underline} 

# Effective repair of obstetric perineal lacerations requires a knowledge of perineal 

# anatomy and surgical technique. Sequelae of these lacerations include chronic perineal pain, dyspareunia, urinary incontinence, and fecal incontinence. CME available

<http://www.aafp.org/afp/20031015/1585.html>

**[From Elaine Locke]{.underline} (ACOG Committee on American Indian
Affairs)**

**Tribal benefits counseling program: expanding health care
opportunities for tribal** members. American Indian tribal clinics hired
benefits counselors to increase the number of patients with public and
private insurance coverage, expand the range of health care options
available to tribal members, and increase third-party revenues for
tribal clinics. Benefits counselors received intensive training,
technical assistance, and evaluation over a 2-year period. Six tribal
clinics participated in the full training program, including follow-up,
process evaluation, and outcomes reporting. Participating tribal sites
experienced a 78% increase in Medicaid enrollment among pregnant women
and children, compared with a 26% enrollment increase statewide during
the same period. Trained benefits counselors on-site at tribal clinics
can substantially increase third-party insurance coverage among
patients.

Friedsam D, Haug G, Rust M, Lake A.Tribal benefits counseling program:
expanding health care opportunities for tribal members. Am J Public
Health. 2003 Oct;93(10):1634-6.

# [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14534213&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14534213&dopt=Abstract)

# 

# [From Kelly Moore]{.underline}

**FAS on NBC television program Law & Order: Special Victims Unit.**

If you are watching TV anyway, try this.

On Tuesday evening, November 4th, we hope you\'ll tune in to watch the
NBC television program Law & Order: Special Victims Unit. When you do,
you\'ll see a storyline focusing on Fetal Alcohol Syndrome (FAS) and
featuring performances by two special young ladies with FAS: Karli
Schrider (pictured with Law & Order star Mariska Hargitay) of Olney,
Maryland, and Katherine Reynolds of Lake View, New York. The episode is
the result of collaboration among Law & Order Executive Producer Dr.
Neal Baer, who is a NOFAS Board member, Patrick Harbinson, Co-Executive
Producer, and NOFAS National Spokeswoman Kathy Mitchell.

In addition to Mariska Hargitay, who plays Detective Olivia Benson, and
the all-star cast, the episode features a guest appearance by Josie
Bissett, formerly of the television program Melrose Place, portraying
the mother of a FAS child.

NOFAS is grateful to Neal Baer for his ongoing efforts to spotlight
Fetal Alcohol Syndrome and educate the public about the risk of alcohol
and pregnancy.

<http://www.nofas.org/main/index2.htm>

##### From Chuck North

###### Routine urine screening for preeclampsia?

"Our nurses tend to get a non clean catch each visit regardless of risk,
which is time consuming, inconvenient and costly. I found only one good
article in the literature from the Medical Journal of Australia, 2002,
vol 177, pp 477-480 The Clinical Utility of Routine Urinalysis in
Pregnancy: A Prospective Study, Murray N, Homer CS, Davis GK, Curtis J,
Mangos G, Brown MA."

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12405888&dopt=Abstract>

The authors conclude that all low risk women should have just one
initial automated dipstick clean catch midstream urine. Abnormal results
or certain high risk conditions should be monitored accordingly."

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

Yes, routine urine dipstick screening for preeclampsia is highly
non-specific and insensitive. The practice of obtaining a urine sample
at each prenatal visit seems to have taken on a life of its own through
'traditional practice' and not based on the available evidence. The
practice came from an era when there was otherwise poor methods to
screen for preeclampsia and overt diabetes mellitus.

Routine urine dipstick testing is costly and slows down your prenatal
visit with very little value added. The benchmark for routine
preeclampsia screening is a casual sitting blood pressure determination.
(ACOG, AHRQ, USPSTF, see below) I suggest one take the funding and time
wasted on the practice on routine prenatal urine dipstick testing, and
hire a new Nurse's Aide to streamline the flow of your clinic.

**[Method of preeclampsia screening:]{.underline}**

To screen for preeclampsia, measure an upright sitting blood pressure
after a 10-minute rest.

The diastolic blood pressure is that pressure at which the sound
disappears (Korotkoff phase V)

To reduce inaccurate readings, an appropriate size cuff should be used
(length 1.5 times upper arm circumference or a cuff with a bladder that
encircles 80% or more of the arm). The blood pressure level should be
taken with the patient in an upright position, after a 10-minute or
longer rest period.

For patients in the hospital, the blood pressure can be taken with
either the patient sitting up or in the left lateral recumbent position
with the patient\'s arm at the level of the heart. The patient should
not use tobacco or caffeine for 30 minutes preceding the measurement.

Although validated electronic devices can be used, a mercury
sphygmomanometer is preferred because it is the most accurate device.

**On the other hand:**

\-**If** a patient presents with a BP \> 140/90, CNS / GI symptoms of
preeclampsia, or signs/symptoms of a urinary tract infection, **then** a
urine sample should be obtained for dipstick urine protein, 24 hour
urine Protein, Total Protein / Creat ratio, or urine culture, as
clinically appropriate.

-It is reasonable to obtain a **preconception** dipstick for protein and
glucose, followed by a urine culture at the **first prenatal visit**
**only**. That 1^st^ prenatal urine culture is indicated for testing of
asymptomatic bacteruria, not preeclampsia screening.

"Caring for our Future: The Content of Prenatal Care, A Report of the
Public Health Service Expert Panel on the Content of Prenatal Care, US
Public Health Service, 1989"

**[References]{.underline}**

Diagnosis and management of preeclampsia and eclampsia. ACOG Practice
Bulletin No. 33. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2002;99:159-167

[\<http://www.acog.com/publications/educational_bulletins/pb033.htm\>]{.underline}

Chronic Hypertension in Pregnancy. ACOG Practice Bulletin No. 29.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2001; 98:177-185

<http://www.acog.com/publications/educational_bulletins/pb029.htm>

Management of Chronic Hypertension During Pregnancy. Summary, Evidence
Report / Technology Assessment: Number 14. AHRQ Publication No. 00-E010,
August 2000. Agency for Healthcare Research and Quality, Rockville, MD.
[\<http://www.ahrq.gov/clinic/epcsums/pregsum.htm\>]{.underline}

Screening for Preeclampsia Guide to Clinical Preventive Services Second
Edition (1996) US Preventive Service Task Force.
<http://www.ahrq.gov/clinic/2ndcps/preeclam.pdf> njm

##### From Judy Thierry

###### The Stop Chlamydia! Project Home Page

From the Northwest Portland Area Indian Health Board. To address the
need for better Chlamydia surveillance, treatment, and prevention
efforts among AI/AN populations, we are collaborating with the Indian
Health Service, with support from the Centers for Disease Control (CDC)
to implement the *\"Stop Chlamydia - Use Azithromycin Program\"*.

<http://www.npaihb.org/epi/chlamydia/chlam.html>

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

# Obstetrics

Fundamentals of Testing and Prevention Counseling with the OraQuick
**Rapid HIV Test**\
Rapid HIV tests can play an important role in HIV prevention activities.
This page includes descriptions of the rapid HIV tests approved by the
Food and Drug Administration, how the tests can be implemented in
different settings, and research on the effectiveness and possible uses
of the tests. <http://www.cdc.gov/hiv/rapid_testing/>

###### Antenatal screening with fetal echocardiography: when and how 

Congenial Heart Disease (CHD) is a common cause of neonatal and infant
morbidity and mortality. Prenatal diagnosis remains an important goal.
Screening for familial, maternal, and fetal factors known to increase
the risk of CHD can help identify cases, but screening only at-risk
pregnancies will not identify the majority of cases of cardiac
malformations. Therefore, routine screening of the fetal heart\'s four
chambers and outflow tract in low-risk pregnancy remains important for
the detection of CHD.

Richard Benoit, Joshua Copel. U/S Clinics: Antenatal screening with
fetal echocardiography: when and how. *Contemporary Ob/Gyn* Sep. 1,
2003;48:59-70.

<http://www.contemporaryobgyn.net/be_core/MVC?mag=g&action=viewArticle&y=2003&m=09&d=01&article=/be_core/content/journals/g/data/2003/0901/gucbenoitcopel.html&title=U/S@Clinics:@Antenatal@screening@with@fetal@echocardiography:@when@and@how&template=past_issues_show_article.jsp&navtype=g>

###### Legislation for Cord Blood Bank Network Reminiscent of Early Organ Transplant 

Federal legislation introduced earlier this summer would expand even
further the federal government\'s role in regulating cord blood banks.
Medscape Ob/Gyn & Women\'s Health 8(2) 2003 (NB: you may need a password
for this, but it is free)

[http://mp.medscape.com/cgi-bin1/DM/y/hdkK0G875W0Dzc0Fhxy0AF]{.underline}

<http://www.medscape.com/viewarticle/461181?mpid=19187>

# Gynecology

**Colposcopy and Women's Value judgements: Funding is available**

Shared Decision Making is a tool that allows women to be educated about
a particular health care state (in this case, CIN 1), what it means,
where it comes from, and how it is managed\-- and the fact that there
are multiple options for follow up (3 in this case) that are all
medically equivalent. SDM provides information to help women elicit
their value judgements about each of the follow up methods to determine
what fits best with their personality, beliefs and preferences. And
finally SDM provides a mechanism for the woman to present her views and
preferences to her doctor so that together she and her doctor make the
management decision for her health state (CIN 1).

Diane M. Harper, MD, MPH, MS <Diane.M.Harper@Dartmouth.EDU>

Dartmouth Medical School, Norris Cotton Cancer Center, One Medical
Center Drive, Lebanon, NH 03756, 603-653-3693 office at Rubin,
603-653-9003 fax at NCCC

**Effectiveness of Strategies for Preventing Violence: Firearms** Laws
Findings from the Task Force on Community Preventive Services\
<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5214a2.htm>

**Continuous combination oral contraceptive pills to eliminate
withdrawal bleeding: a randomized trial (Level I)**

**OBJECTIVE:** To compare bleeding profiles of a traditional 28-day oral
contraceptive pill cycle with continuous administration.

**METHODS:** After a 28-day run-in cycle, women were randomized to
either 28-day cycles (21 active pills and a pill-free week) or
continuous use of the same 20 microg ethinyl estradiol/100 microg
levonorgestrel formulation for 12 study cycles (336 days). The number of
bleeding and spotting days were measured by daily diary. A subset
underwent cycle 1 (n = 16), and nine (n = 14) pelvic ultrasound and
endometrial histology sampling. Blood pressure, weight, hemoglobin, and
adverse events were measured at revisit. The sample size with 80% power
to detect a 67% reduction in bleeding days required 27 subjects in each
arm.

**RESULTS:** Of the 79 subjects randomized, 28 (70%) of the 28-day cycle
and 32 (82%) of the continuous-use subjects completed the entire study
(P =.6). With continuous use, 49%, 68%, and 88% of women reported no
bleeding during cycles 2, 6, and 12, respectively. Amenorrhea or
infrequent bleeding was present in 68% of continuous users during cycles
1-3 and increased to 88% during cycles 10-12. Spotting during cycle days
1-21 increased initially with continuous use but reduced over time, and
by 9 months was less than the spotting reported by cyclic users. Adverse
events, blood pressure, weight, and hemoglobin findings were similar
between groups. **CONCLUSION:** Extension of the 28-day oral
contraceptive cycle to continuous use with a low-estrogen dose
combination oral birth control pill resulted in significantly fewer
bleeding days.

Miller L, Hughes JP. Continuous combination oral contraceptive pills to
eliminate withdrawal bleeding: a randomized trial. Obstet Gynecol. 2003
Apr;101(4):653-61.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12681866&dopt=Abstract>

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

Use of continuous oral contraceptive pills (OCPs) results in fewer days
of bleeding, premenstrual discomfort, and increases quality of life. The
monthly menses is somewhat of modern contrivance that many AI/AN women
did not have traditionally, due to the repeated cycles of pregnancy and
lactation.

At this point we don't have an 84-pill pack available to us, but that
can be created with a 4 packs of OCPs, during which the patient skips
the placebo pills till the 4^th^ pack and a little patient education. It
is well worth the effort. njm

**Premenstrual dysphoric disorder (PMDD**) is considered a severe form
of premenstrual syndrome. Symptoms of PMDD occur during the last week of
the luteal phase of the menstrual cycle and usually abate at the onset
of menses. About 3-8% of all menstruating women experience PMDD, which
can lead to significant functional impairment. Several randomized,
controlled trials have assessed the efficacy of **selective serotonin
reuptake inhibitors (SSRIs)** in the treatment of PMDD. The SSRIs were
found to significantly improve symptoms, particularly psychological or
behavioral symptoms, during the luteal phase in women with PMDD. Also,
SSRIs were found to improve the quality of life in women with PMDD.
Headache, fatigue, insomnia, and anxiety were often reported as adverse
effects. A decrease in libido or sexual dysfunction also was reported.
In recent studies, intermittent SSRI therapy was found to be effective
treatment for PMDD and allows a woman to take the drug for only 14 days
each month. Intermittent SSRI therapy should be recommended before
continuous daily dosing of SSRIs in the treatment of PMDD.

Luisi AF, Pawasauskas JE.Treatment of premenstrual dysphoric disorder
with selective serotonin reuptake inhibitors. Pharmacotherapy. 2003
Sep;23(9):1131-40.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14524645&dopt=Abstract>

# Child Health

[**www.4girls.gov**](http://www.4girls.gov/)

Exciting new feature of the National Women's Health Information Center:
new website, [**www.4girls.gov**](http://www.4girls.gov/), is designed
especially for girls between the ages of 14 and 19, and provides
reliable, current health information that focuses on the many health
topics pertaining to adolescent girls' health concerns.  It will
motivate girls to choose healthy behaviors using positive, supportive,
and non-threatening messages. <http://www.4girls.gov/index2.htm>

Thanks to the National Women's Health Information Center
([www.4woman.gov](http://www.4woman.gov/)). 

**State Policies in Brief: Sexuality Education presents information on
sex education policies** in individual states. The brief was prepared by
the Alan Guttmacher Institute (AGI) and includes information on state
education requirements concerning human immunodeficiency syndrome (HIV),
sexually transmitted diseases (STDs), and sexuality education; content
requirements (if such education requirements are in place); and parental
involvement in students\' participation in HIV/STD and sexuality
education. The brief also presents a list of materials for more
information on the subject. The brief is intended for use by
policymakers, researchers, educators, and others interested in helping
adolescents make healthy and responsible decisions about sex. The brief
is available at
[www.guttmacher.org/pubs/spib_SE.pdf](http://www.guttmacher.org/pubs/spib_SE.pdf)

AGI has also made available Sex Education: Needs, Programs and Policies,
a PowerPoint slide and lecture presentation on sex education in the
United States and its effectiveness in preventing STDs and unintended
pregnancies among adolescents. The presentation includes PowerPoint
slides and speaking notes. References and detailed information on data
points are also included. The presentation is available at
[www.guttmacher.org/pubs/ed_slides.html](http://www.guttmacher.org/pubs/ed_slides.html).

The Prevention and Treatment of Type 2 Diabetes Mellitus in Children,
**With Special Emphasis on American Indian and Alaska Native Children**
statement has been released

### <http://pediatrics.aappublications.org/cgi/reprint/112/4/e328>

### **Sudden Infant Death Syndrome**

One in a series of chapters excerpted from Clinical Evidence Concise,
published by the BMJ Publishing Group

<http://www.aafp.org/afp/20031001/british.html>

**Infant Mortality Statistics from the 2001 Period Linked Birth/Infant
Death** Data Set\
A new report from CDC shows that the 2001 infant mortality rate in the
United States reached a record low of 6.8 per 1,000 live births.
Overall, about 27,500 infants died in the first year of life in 2001,
compared with 27,960 in 2000. The three leading causes of infant death
were congenital malformations, low birthweight, and sudden infant death
syndrome, which together accounted for 44 percent of all infant deaths.
Fact Sheet - <http://www.cdc.gov/nchs/releases/03facts/lowinfant.htm>\
PDF (1.3 MB) - <http://www.cdc.gov/nchs/data/nvsr/nvsr52/nvsr52_02.pdf>

**Chronic Illness and disease**

######### October is Breast Cancer Awareness Month

<http://www.acog.org/breastmonth/>

**Prevalence of Diabetes and Impaired Fasting Glucose in Adults-United
States**, 1999-2000\
This report presents data on prevalence of diagnosed and undiagnosed
diabetes and impaired fasting glucose from the National Health and
Nutrition Examination surveys (NHANES) 1999-2000 and NHANES III
(1988-1994). The findings indicate that diabetes and impaired fasting
glucose continue to affect a major proportion of the U.S. population. An
estimated 29 million (14.4%) persons aged [\>]{.underline}20 years had
either diagnosed diabetes, undiagnosed diabetes, or impaired fasting
glucose; 29% of diabetes cases were undiagnosed. Prevalence increased
slightly with age and was similar in men and women. Persons can reduce
their risk for diabetes through weight management and physical activity.

Text version - <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5235a1.htm>\
PDF version - <http://www.cdc.gov/mmwr/PDF/wk/mm5235.pdf>

**Overweight or obese individuals in the US do not believe that they are
at serious risk of developing type 2 diabetes mellitus**, according to a
survey conducted recently by the American Diabetes Association (ADA).
The survey comprised telephone interviews with 600 randomly selected
adults as part of \'Weight Loss Matters,\' the ADA\'s first educational
initiative to focus on the relationship between body weight and
diabetes. According to body mass index calculations, 52% of the
respondents were overweight or obese. However, despite the fact that
over half of these individuals reported knowing that being overweight or
obese was a leading risk factor for type 2 diabetes, 59% maintained that
they were not at personal risk for the disease.

[http://www.diabetes.org/]{.underline}

##### 

##### Features

## American Family Physician

###### Common SKIN CONDITIONS in women 

•Eczema

[\<http://lyris.aafp.org/t/40291/5913807/121942/0/\>]{.underline}

•Psoriasis

[\<http://lyris.aafp.org/t/40291/5913807/121943/0/\>]{.underline}

•Rosacea

[\<http://lyris.aafp.org/t/40291/5913807/121944/0/\>]{.underline}

•Seborrheic Dermatitis

[\<http://lyris.aafp.org/t/40291/5913807/121945/0/\>]{.underline}

**[AHRQ]{.underline}**

**Lengthening postpartum hospital stays** to meet minimum Federal
standards is cost effective

[http://www.ahrq.gov/research/aug03/0803RA12.htm#head2]{.underline}

**Later admission in labor and collaborative care increase spontaneous
vaginal delivery in** low-risk women
<http://www.ahrq.gov/research/aug03/0803RA13.htm#head3>

**[American College of Obstetricians and Gynecologists
(ACOG)]{.underline}**

#### Benefits and Risks of Sterilization

#### ACOG Practice Bulletin NUMBER 46, SEPTEMBER 2003 

**Summary of Recommendations**

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

-   Tubal sterilization may be recommended as a safe and effective
    method for women who desire permanent contraception. Women should be
    counseled that tubal ligation is not intended to be reversible;
    therefore, those who do not want permanent contraception should be
    counseled to consider other methods of contraception.

-   Patients should be advised that neither tubal sterilization nor
    vasectomy provides any protection against sexually transmitted
    diseases, including HIV infection.

-   Patients should be advised that the morbidity and mortality of tubal
    ligation, although low, is higher than that of vasectomy, and the
    efficacy rates of the 2 procedures are similar.

-   Patients should be counseled that tubal sterilization is more
    effective than short-term, user-dependent reversible methods.

-   Patients should be counseled that failure rates of tubal
    sterilization are comparable with those of IUDs.

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

-   If a patient has a positive pregnancy test result after a tubal
    ligation, ectopic pregnancy should be ruled out.

-   Indications for hysterectomy in women with previous tubal
    sterilization should be the same as for women who have not had tubal
    sterilization.

Benefits and risks of sterilization. ACOG Practice Bulletin No. 46.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2003;102:647--58.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12962966&dopt=Abstract>

Full text for ACOG members, online

<http://www.acog.com/publications/educational_bulletins/pb046.cfm>

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

Sterilization remains one of the most popular forms of contraception,
with 28% of women choosing nationally. Similar rates are seen in the
Indian Health System. Women sterilized before age 25 years were 18 times
more likely to request reversal over the course of follow-up than women
older than 30 years at the time of sterilization. Because young age at
the time of sterilization, regardless of parity or marital status, is
associated with significant levels of regret, individualized counseling
of younger women is critical.

-   Permanent nature of the procedure

-   Alternative methods available, including male sterilization

-   Reasons for choosing sterilization

-   Screening for risk indicators for regret

-   Details of the procedure, including risks and benefits of anesthesia

-   The possibility of failure, including ectopic pregnancy

-   The need to use condoms for protection against sexually transmitted
    diseases, including human immunodeficiency virus infection

-   Completion of informed consent process

-   Local regulations regarding interval from time of consent to
    procedure

Many questions arise about the details of the federal forms necessary
and the nature of the 30-day waiting period. These are my most
frequently asked questions, in fact.

Several sterilization case scenarios examples are explored here:

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHfaq.asp#B> njm

**[Breastfeeding]{.underline}**

**Educational programs were the most effective single intervention.**
One woman would breast-feed for up to 3 months for every 3 to 5 women
attending breastfeeding educational programs. Future research and policy
should focus on translating these findings into more widespread practice
in diverse primary care settings.

The Effectiveness of Primary Care-Based Interventions to Promote
Breastfeeding: Systematic Evidence Review and Meta-Analysis for the US
Preventive Services Task Force

Jeanne-Marie Guise, MD, MPH^1,2^, Valerie Palda, MD, MPH^3^, Carolyn
Westhoff, MD, MSc^4^, Benjamin K. S. Chan, MS^1^, Mark Helfand, MD,
MS^1^ and Tracy A. Lieu, MD, MPH^5^

*Annals of Family Medicine* 1:70-78 (2003)
<http://www.annfammed.org/cgi/content/abstract/1/2/70>

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

## ACOG disagrees with WHI on osteoporosis prophylaxis

"The WHI reports, however, calculate a global index to quantify overall
benefit versus risk of estrogen-progestin therapy. Because Cauley et al
calculated the global index HR to range from 1.23 to 1.03, depending on
a woman\'s risk of fracture, they concluded that there was no evidence
of a net benefit and recommended that treatment with estrogen plus
progestin not be used for prevention or treatment of osteoporosis in
women without vasomotor symptoms. We cannot agree with this global index
approach because we believe it to be biased."

\"The decision about use of hormone therapy requires evaluation of the
risks and benefits for each individual woman. For women currently using
hormone therapy, it is important to assess their reasons for use and to
evaluate potential risks, benefits and alternatives. ... For patients
with osteoporosis, other preventive therapies such as bisphosphonates
and selective estrogen receptor modulators are available. For women at
risk of osteoporosis who also have vasomotor menopausal symptoms,
hormone therapy can be of benefit. ... Periodic reassessment of the need
for hormone therapy is recommended at least at every annual visit or
more frequently if indicated.\"
<https://www.acog.com/from_home/publications/press_releases/nr10-07-03.cfm>

###### Natural Database eUPDATE and eCE

**Red clover and soy both contain phytoestrogens and are popular with
women as** alternatives to estrogen replacement. So, the question about
endometrial cancer always comes up. What is the risk of endometrial
cancer?

[http://www.naturaldatabase.com/monograph.asp?mono_id=308]{.underline}

<http://www.naturaldatabase.com/monograph.asp?mono_id=975>

# [Information Technology]{.underline}

**Comparison of telecolposcopy systems**\
The computer-based telecolposcopy system used in our study was, in all
fairness, more similar to cervicography. Each method involves evaluation
of 2 static images. Computer-based telecolposcopy provides 2 digitized
images, but of a low- and high-power magnification view of the cervix.
In comparison, cervicography produces dual low-power magnification
celluloid images (2 x 2 slides) of the cervix. The provision of a
high-power cervical image may explain the better sensitivity of
computer-based telecolposcopy. This one feature may be more valuable
than the better image resolution obtained from cervicography. However,
computer-based resolution appears to be sufficient to render diagnoses
at a level equivalent to or better than cervicography.\
-These 2 "static" systems differ in other aspects as well. First,
computer-based systems are nonproprietary. Several systems are
commercially available and other colposcopists have devised their own
unique systems using modifications of off-the-shelf technology. Although
not available at the initiation of our trial, computer-based systems now
have the capability of capturing short video streams. These video
segments should help improve the diagnostic ability of consulting
colposcopists as demonstrated by our study.\
-Second, computer-based telecolposcopy can provide instantaneous
consultation as opposed to cervicography, which generally takes a
minimum of several weeks to receive a report. Computer-based
telecolposcopy also allows interaction between the on-site provider and
remote expert.\
-Third, cervicography is a screening test adjunct. The computer-based
system was used as a colposcopy diagnostic adjunct. However, colposcopy
could easily be adapted to provide the function of cervicography. A
simple handheld miniature change-coupled device camera and light source
could potentially replace a more expensive colposcope and video camera,
or video colposcope. With an average laptop computer (with appropriate
software) and cellular phone, health care providers of potentially all
women in the world could have access to expert-level cervical evaluation
services.\
-Finally, computer-based telecolposcopy images and associated data
automatically become part of a modern electronic medical record. This
format is more conducive to the direction toward which contemporary
medicine is rapidly shifting. Consequently, computer-based
telecolposcopy may offer clinicians superior, modern diagnostic services
not previously available to women.

-Ferris DG, Litaker MS, Macfee MS, Miller JA. Remote diagnosis of
cervical neoplasia: 2 types of telecolposcopy compared with
cervicography. J Fam Pract. 2003 Apr;52(4):298-304.\
[\<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12681091&dopt=Abstract\>]{.underline}

# [International Health Update]{.underline}

**Outcomes, safety, and resource utilization in a collaborative care
birth center** program compared with traditional physician-based
perinatal care. For low-risk women, both scenarios result in safe
outcomes for mothers and babies. However, fewer operative deliveries and
medical resources were used in collaborative care.\
Jackson DJ, Lang JM, Swartz WH, Ganiats TG, Fullerton J, Ecker J, Nguyen
U. Outcomes, safety, and resource utilization in a collaborative care
birth center program compared with traditional physician-based perinatal
care. Am J Public Health. 2003 Jun;93(6):999-1006.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12773368&dopt=Abstract>

# [MCH Alert]{.underline}

# TOOLKIT HELPS INCREASE KNOWLEDGE AND AWARENESS OF EMERGENCY CONTRACEPTION

Developed by the Academy for Educational Development, this provides
basic information about emergency contraceptive pills, makes the case
that adolescents should know about EC, prepares adults to increase
access and awareness among adolescents (as well as among their own
peers), identifies resources for keeping current on the issues, and
suggests evaluation strategies. It is available at
<http://scs.aed.org/ECtoolkit3283.pdf>.

**REPORT PRESENTS FINDINGS ON EFFECTIVENESS OF EARLY CHILDHOOD HOME**
VISITATION PROGRAMS IN PREVENTING VIOLENCE

The Task Force recommends early childhood home visitation for prevention
of child abuse and neglect in families at risk for maltreatment.\".

Hahn RA, Bilukha OO, Crosby A, et al. 2003. First reports evaluating the
effectiveness of strategies for preventing violence: Early childhood
home visitation. Morbidity and Mortality Weekly Report 52(41):1-9.
Available at <http://www.cdc.gov/mmwr/PDF/RR/RR5214.pdf>.

###### IMPACT OF HEALTH CENTERS ON REDUCING HEALTH DISPARITIES

"The results of our analysis showed that greater levels of health center
penetration (i.e., proportion of low-income individuals served) were
associated with significant and positive reductions in minority health
disparities," state the authors of a report published by the Center for
Health Services Research and Policy at George Washington University.

<http://www.gwhealthpolicy.org/downloads/GWU_Disparities_Report.pdf>

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

###### Preventing Male Perpetration of Sexual Violence

CDC will host a live audio conference call and web seminar on October
27, 2003 from 1-3:00pm EST. This will be the fifth audio call in a
series of featured speakers focusing on Preventing Male Perpetration of
Sexual Violence.

Callers will need to RSVP by October 20 to email address:
<webseminar@cdc.gov>

Instructions to participate in the call and for accessing and viewing
the slides will be e-mailed to all who register.

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

**Alternatives to Hysterectomy, ACOG**

Women wanting more information on these subjects may request our patient
education pamphlets \"Uterine Fibroids\" (AP074) or \"Understanding
Hysterectomy\" (AP008) by emailing <resources@acog.org> or calling
202-863-2518.

PUBLIC HEALTH CAMPAIGN LAUNCHED TO PROMOTE APPROPRIATE USE OF
ANTIBIOTICS Get Smart: Know When Antibiotics Work is a national public
health campaign designed to reduce antimicrobial resistance through the
promotion of appropriate antibiotic use in the community. The campaign
was launched by the Centers for Disease Control and Prevention, the Food
and Drug Administration, and major national health organizations.
[**http://www.cdc.gov/drugresistance/community/files/Complete_ABR_VPK.pdf**](http://www.cdc.gov/drugresistance/community/files/Complete_ABR_VPK.pdf).

Additional information about the campaign, including educational tools,
technical information, and campaign partners, is available at
<http://www.cdc.gov/drugresistance/community/>

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

###### Domestic Violence Lethality Assessment

<http://www.ihs.gov/MedicalPrograms/MCH/W/Dv01.cfm#LethalityAssessment>

###### Domestic Violence Safety Assessment Tool

######### [**http://www.ihs.gov/MedicalPrograms/MCH/W/Dv01.cfm#SafetyAssessmentTool**](http://www.ihs.gov/MedicalPrograms/MCH/W/Dv01.cfm#SafetyAssessmentTool)

######### 

######### MCH Coordinators Teleconferences

This page has the materials and minutes used in these helpful networking
opportunities

<http://www.ihs.gov/NonMedicalPrograms/nc4/TelConf/TelConf.cfm>

There are several upcoming **Conferences**

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

and **Online CME/CEU resources**, etc....

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN13.cfm>

and the latest **Perinatology Corners** (free online CME from IHS) are
at

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

...or just take a look at the **What's New** page

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

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

#### Preventing Male Perpetration of Sexual Violence

October 27, 2003 from 1-3:00pm EST.

This will be the fifth audio call in a series of featured speakers. See
Office of Women's Health, above. Callers will need to RSVP by October 20
to email address: <webseminar@cdc.gov>

######## 

**Ninth Annual Maternal and Child Health Epidemiology Conference**\
December 10-12, 2003, Tempe, AZ

Accepting abstracts <http://www.cdc.gov/nccdphp/drh/index.htm>

**19^th^ Annual Midwinter Conference for providers caring for Native
women and children**

Jan 30 -- Feb 1, 2004.

2004 brochure = pending

See Conference Archives in February 2003 for information on last year's
conference

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

**3rd National Sexual Violence Prevention Conference, CDC **

May 25 - 28, 2004 

Los Angeles, California 

 <http://www.cdc.gov/ncipc/2004nsvpc.htm> 

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

-   June 13-17, 2004 **Please, note this date change!**

-   Denver, CO

-   Contact Barbara Fine at 301 443 1840

-   2003 brochure below. 2004 brochure will be available soon

<http://www.ihs.gov/MedicalPrograms/MCH/M/ConfDnlds/ACOGpostgradBroch-2002.doc>

**2004 Biennial OB/GYN meeting Please, note this date change!**

August 4-6, 2004

Albuquerque, New Mexico

Location and brochure to follow

Contact Neil Murphy for questions <nmurphy@anmc.org>

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

The **September 2003 OB/GYN CCC Corner** is available at:\
<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/CCCCorner92303.doc>

**[Contents:]{.underline} (September 2003 OB/GYN CCC Corner)**

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

Aspirin for Prevention of Preeclampsia in Women With Historical Risk
Factors: A Systematic Review. (Level I)

[From your colleagues:]{.underline}

From Melissa Boll: New Indian Health Breastfeeding page, thanks to
Melissa Boll, CNM.

From Ruth Lagerberg: New Indian Health Genetics page, thanks to Ruth
Lagerberg, CNM.

From Larry Leeman: The Nature and Management of Labor Pain

From Chuck North: Breast cancer and HRT in the Million Women Study.

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

##### Obstetrics: Rapid Point-of-Care Testing for HIV-1 During Labor and Delivery; Continuous support for women during childbirth; Exercise in Pregnancy; Seven ways to Control Postpartum Hemorrhage; 

**Gynecology:** Does HIV Status Make a Difference in the Experience of
Lifetime Abuse? Endometriosis and subfertility: is the relationship
resolved? Unique approach to understanding adolescents' sexual
relationships; Assisted Reproductive Technology Surveillance, 2000

###### Chronic Illness and Disease: Findings on relationship between obesity and food insecurity; Prevalence of Diabetes and Impaired Fasting Glucose in Adults; One-year outcome of a combination of weight loss therapies for subjects with type 2 diabetes 

Other: Consumption of dark chocolate \-- but not milk chocolate \--
could help protect against heart disease; Modest activity reduces risk
of breast cancer while women lose weight; MedScape OB/GYN Discussion
Boards;

[Features:]{.underline}

##### AAFP: Practice Guidelines: Epigastric Discomfort and Management of Dyspepsia and GERD

ACOG: Cervical cerclage for prevention of preterm delivery:
meta-analysis of randomized trials.

**AHRQ:** Researchers examine cost-effectiveness and quality of life
following surgery for early breast cancer; More assertive outreach
programs may be needed to link homeless women to case managers and a
broader range of services; Physicians have an important role in
identifying victims of domestic violence and referring them for
appropriate services; Parental misconceptions about respiratory
illnesses, not day care pressure, lead parents to pressure physicians
for antibiotics; Medical treatment of one child for an injury may signal
a period of increased injury risk for other children in the family;
School-based health centers reduce asthma-related hospitalization and
absenteeism among urban children

**Breastfeeding:** New Indian Health Breastfeeding web page; lactational
atrophic vaginitis.

**Hormone Replacement Update**: Phytoestrogen Intake and Endometrial
Cancer Risk; Ultralow-Dose Micronized 17-Estradiol and Bone Density and
Bone Metabolism in Older Women

International Health: The International Experience and Technical
Assistance Program

Patient Education: **Labor Pain: What to Expect and Ways to Relieve
Pain; Prenatal Care - What will happen during prenatal visits? Pregnancy
and Exercise; Respiratory Infections during Pregnancy**

The past CCC Corners are archived at:

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN01.cfm#top>

The CCC Corner is good way to inform ITU providers about recent updates,
while decreasing the number of e-mail messages.

Let me know if you want to add something to next month's CCC Corner at
<nmurphy@anmc.org>

or 907 729 3154 (with voicemail)