New Features starting this month:

-Case Mangers Corner by Donna Brown, Anchorage

-Navajo News by Jean Howe, Chinle

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

OB/GYN Chief Clinical Consultant's Corner

Volume 3, No. 7, July, 2005

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

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

USPSTF recommends that clinicians screen all pregnant women for HIV

#### From your colleagues: page 6 {#from-your-colleagues-page-6 .Style-Heading-4-+-Arial-14-pt-Underline}

### **Katherine Palatianos:** Brachial plexus injury: Permanent in 1 of every 10,000 deliveries

**Terry Cullen:** Native Peoples of North America HIV/AIDS Conference

#### Kat Franklin: Simple Patient Education Handouts {#kat-franklin-simple-patient-education-handouts .Style-Heading-4-+-Arial-14-pt-Underline}

#### Sandy Haldane: Science and Leadership: Women With Heart Disease {#sandy-haldane-science-and-leadership-women-with-heart-disease .Style-Heading-4-+-Arial-14-pt-Underline}

**Steve Holve:** July 2005 Indian Child Health Notes

**Harvey Huddleston:** Interested in part-time or locums tenens

**Phil Smith:** Encouraging Onsite Mammography: New mammography
standards for HSP

**Roy Teramoto:** HPV and Cervical Cancer: An Update on Prevention
Strategies

**Judy Thierry:**

-Useful atlas for injury causes of AIAN morbidity and mortality when
citing stats

#### -Ribavirin pregnancy registry - seeking enrollment Hepatitis C {#ribavirin-pregnancy-registry---seeking-enrollment-hepatitis-c .Style-Heading-4-+-Arial-14-pt-Underline}

-Rural/Frontier Women\'s Health Coordinating Centers (RFCCs) RFP is Out

-RFP for SIDS Training and Outreach in the AI/AN Communities

#### -Mean length stay for delivery hospitalization among AI/AN {#mean-length-stay-for-delivery-hospitalization-among-aian .Style-Heading-4-+-Arial-14-pt-Underline}

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

##### Obstetrics: page 10

-Treatment of GDM reduces perinatal morbidity, may improve
health-related quality of life

-Elective Repeat Cesarean Delivery May Negatively Affect Neonatal
Outcomes

-Indomethacin tocolysis not associated with increased risk of adverse
neonatal outcomes

-Diabetic Retinopathy Occurs in Pre-Diabetes: Implications in GDM

-No benefit to hospitalization in women with arrested preterm labor and
intact membranes

...and more

**Gynecology: page 13**

-High Intake of Calcium, Vitamin D May Reduce the Risk of Premenstrual
Syndrome

-Pediatric Torsed Ovaries May Be More Salvageable Than Previously
Reported

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

-US exam of the perineum after childbirth improves diagnosis of anal
sphincter tears

-Short-term results of the TVT procedure encouraging, but long-term is
disappointing

...and more

**Child Health: page 14**

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

-How to get your child off the couch? Evidence based physical activity
for youth

-Children's adaptation to a fat reduced diet

-Adolescent Pregnancy: Current Trends and Issues: American Academy of
Pediatrics

-Suicide Prevention among AI/AN Adolescents Evaluated: Public Health
Approach

...and more

**Chronic Illness and Disease: page 15**

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

-Each Pound of Weight Lost May Reduce Knee Load per Step Fourfold

-Most parents want to quit smoking but they need assistance. Learn how
to help

-European study confirms red meat link with bowel cancer

-Self-Monitoring in Type 2 Diabetes Not on Insulin: A waste of money?

...and more

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

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

##### American Family Physician

-Three Days of Ciprofloxacin Better for Uncomplicated UTI

-Gonorrhea

-Low-Molecular-Weight Heparin for Initial Treatment of Venous
Thromboembolism

-Follow-up After Surgically Treated Breast Cancer

American College of Obstetricians and Gynecologists

-Hemoglobinopathies in Pregnancy

-Pregnancy and Depression: What Women Need to Know

**Agency for Healthcare Research and Quality**

-Breast cancer risk and the effects of tamoxifen prophylaxis among women
in primary care

-Acupuncture appears promising for the treatment of depression during
pregnancy

**Ask a Librarian**

A new quick and easy way to find best clinical articles: PubMed Clinical
Queries

**Breastfeeding**

-1st week of life critical window for ingestion of maternal \"diabetic\"
breast milk

-Medication Use During Pregnancy and Breastfeeding

-Breastfeeding may be associated with a reduced risk of atherosclerosis

**Case Manager's Corner**

What is an RN Case Manager?

**CCC Corner Digest**

-Have you had your 'morning after' antiretroviral cocktail yet?

-Why Prozac is okay during pregnancy and not for breastfeeding.... and
why Zoloft is

-Slight delay in umbilical cord clamping better for preterm infants

-Transdermal contraceptive promising for reducing bleeding and delaying
menses

-Risk of Autism: Parent, Pregnancy, and Birth Factors Found Possible
Associations

-Women with pregnancy induced HTN: Increased risk for metabolic syndrome
later

-Urinary Incontinence in Women: Practice Bulletin NUMBER 63, JUNE 2005

-AskUs Live! Available to all Indian Health Staff

-Being overweight may increase the risk of becoming pregnant while using
OCs

-Follow-up: Answer to the May Mystery Question

-Screening for Genital Herpes: USPSTF

-West Nile Virus in Women

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

-Screening for Gonorrhea: USPSTF Recommendation Statement

-Any new solutions to Nausea and Vomiting in Pregnancy?\
-New Perinatology Corner Free CEU / CME Module

**Domestic Violence**

#### Women who declined survey regarding DV at risk for adverse pregnancy outcome {#women-who-declined-survey-regarding-dv-at-risk-for-adverse-pregnancy-outcome .Style-Heading-4-+-Arial-14-pt-Underline}

#### Juvenile Justice Issues - Coordinating Council - Key Programs Advancing Youth {#juvenile-justice-issues---coordinating-council---key-programs-advancing-youth .Style-Heading-4-+-Arial-14-pt-Underline}

**Elder Care News**

-2nd Annual Alzheimer\'s Disease and Dementia Update Conference 

-Secondary Prevention of Coronary Heart Disease in Elderly Patients

-Nursing Guide to Prevention / Management of Falls in Patients in
Long-term Care Settings

-2005 ASCP Foundation Interdisciplinary GeroPsych/Behavioral Disorders
Traineeship

-Prevention of Falls in Older Patients

**Family Planning**

Low-dose oral contraceptives increase cardiovascular disease risk

**Frequently asked questions**

-Do you know of any good links to simple patient education?

-What are some good paper based women's resources for Advanced Practice
Nurses?

**Information Technology**

Computer-assisted cognitive therapy effectively treats depression: RCT

International Health

#### Medical Investigations of Homicides of Prisoners of War in Iraq and Afghanistan

Association between subsidized housing and children's nutritional status

#### MCH Alert

Health Care Insurance (SCHIP) Improves racial / ethnic health
disparities

#### Medical Mystery Tour

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

#### Medscape

######### Mammography: Is Early Detection Really the Best Form of Prevention?

**Menopause Management**

-Benefits of low-fat dairy products on weight loss

-Testosterone Patch Helps Surgically Menopausal With Hypoactive Sexual
Desire: RCT

-SSRIs Ineffective for the Management of Hot Flashes

-Hormone replacement therapy plummeted after findings from the WHI trial
(AHRQ)

**Midwives Corner**

-USPSTF Issues Revised Guidelines for Routing Gonorrhea Screening

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

-The Nursing Mothers Herbal

-Current Resources for Evidence-Based Practice

-National Indian Health Board Conference - Oct. 16-19, 2005, Phoenix

**Navajo News**

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

-Annual Navajo Area Women's Health Provider Meeting

-Upcoming ALSO Course in Shiprock

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

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

**Oklahoma Perspective**

Patient should be capable of talking or singing during exercise during
pregnancy

Osteoporosis

-Here is a good web based calcium screening tool

-Benefits and limitations of quantitative heel ultrasound in screening
for osteoporosis

Patient Education

-Simple Patient Education Handouts

-Endometriosis, from WebMD Health

-Guide to Endometriosis- [**More Printable Patient
FAQ\'s**](http://www.medscape.com/pages/editorial/public/index/faq)

Primary Care Discussion Forum

August 1, 2005 Appropriate use of narcotics for chronic non-malignant
(non-cancer) pain

STD Corner

-Can chlamydia be stopped?

**-Chlamydia trachomatis infection in a colposcopy unit**

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

Waist Circumference Can Exclude Insulin Resistance and Identify Those At
Greatest Risk

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

#### What's new on the ITU MCH web pages page 32

-Simple Patient Education Handouts

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

-Atlas of Heart Disease and Stroke in AI/AN

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

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

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

**USPSTF recommends that clinicians screen all pregnant women for HIV**

**Rating: [A
Recommendation](http://www.ahrq.gov/clinic/3rduspstf/ratings.htm#arec).**

*Rationale*: The USPSTF found good evidence that both standard and
FDA-approved rapid screening tests accurately detect HIV infection in
pregnant women and fair evidence that introduction of universal prenatal
counseling and voluntary testing increases the proportion of
HIV-infected women who are diagnosed and are treated before delivery.
There is good evidence that recommended regimens of HAART are acceptable
to pregnant women and lead to significantly reduced rates of
mother-to-child transmission. Early detection of maternal HIV infection
also allows for discussion of elective cesarean section and avoidance of
breastfeeding, both of which are associated with lower HIV transmission
rates. There is no evidence of an increase in fetal anomalies or other
fetal harm associated with currently recommended antiretroviral regimens
(with the exception of efavirenz). Serious or fatal maternal events are
rare using currently recommended combination therapies. The USPSTF
concluded that the benefits of screening all pregnant women
substantially outweigh potential harms.

**The U.S. Preventive Services Task Force (USPSTF) strongly recommends
that clinicians screen for human immunodeficiency virus (HIV) all
adolescents and adults at increased risk for HIV infection (go to
[Clinical
Considerations](http://www.ahrq.gov/clinic/uspstf05/hiv/hivrs.htm#clinical)\*
for discussion of risk factors).**

**Rating: [A
Recommendation](http://www.ahrq.gov/clinic/3rduspstf/ratings.htm#arec).**

*Rationale*: The USPSTF found good evidence that both standard and U.S.
Food and Drug Administration (FDA)-approved rapid screening tests
accurately detect HIV infection. The USPSTF also found good evidence
that appropriately timed interventions, particularly highly active
antiretroviral therapy (HAART), lead to improved health outcomes for
many of those screened, including reduced risk for clinical progression
and reduced mortality. Since false-positive test results are rare, harms
associated with HIV screening are minimal. Potential harms of
true-positive test results include increased anxiety, labeling, and
effects on close relationships. Most adverse events associated with
HAART, including metabolic disturbances associated with an increased
risk for cardiovascular events, may be ameliorated by changes in regimen
or appropriate treatment. The USPSTF concluded that the benefits of
screening individuals at increased risk substantially outweigh potential
harms.

**The USPSTF makes no recommendation for or against routinely screening
for HIV adolescents and adults who are not at increased risk for HIV
infection (go to [Clinical
Considerations](http://www.ahrq.gov/clinic/uspstf05/hiv/hivrs.htm#clinical)\*
for discussion of risk factors).**

**Rating: [C
Recommendation](http://www.ahrq.gov/clinic/3rduspstf/ratings.htm#crec).**

*Rationale*: The USPSTF found fair evidence that screening adolescents
and adults not known to be at increased risk for HIV can detect
additional individuals with HIV, and good evidence that appropriately
timed interventions, especially HAART, lead to improved health outcomes
for some of these individuals. However, the yield of screening persons
without risk factors would be low, and potential harms associated with
screening have been noted (above). The USPSTF concluded that the benefit
of screening adolescents and adults without risk factors for HIV is too
small relative to potential harms to justify a general recommendation.

<http://www.ahrq.gov/clinic/uspstf/uspshivi.htm>

**\*Clinical Recommendations, USPSTF**

<http://www.ahrq.gov/clinic/uspstf05/hiv/hivrs.htm#clinical>

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

#1 This decision by the USPSTF reinforces several recent CCC Corner
Indian Health items on this topic.

The U.S. Preventive Services Task Force issued a new recommendation
calling for all pregnant women, to be screened for HIV. This
recommendation is based on evidence that currently available tests
accurately identify pregnant women who are HIV infected and that
recommended treatment strategies can dramatically reduce the chances
that an infected mother will transmit HIV to her infant.

The Task Force also reaffirmed its 1996 recommendation that all
adolescents and adults at increased risk for HIV infection be screened
and has broadened its definition of high risk.  In addition to patients
who report high-risk behaviors, all patients receiving care in high-risk
settings such as homeless shelters or clinics dedicated to the treatment
of sexually transmitted diseases should be tested. 

The Task Force found at least fair evidence that screening adolescents
and adults who are not at increased risk can improve health outcomes,
but concluded that the balance of benefits and harms is too close to
justify a general recommendation.

Other recent Indian Health HIV screening items

**Use 'Opt out' HIV screening methods during pregnancy in Indian
Country**

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0305_AOM.cfm>

**Have you had your 'morning after' antiretroviral cocktail yet?**

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0605_AOM.cfm>

#2

In addition, HIV testing and education are Indian Health GPRA
Indicators, so there are significant clinical and administrative reasons
to improve HIV screening in pregnancy and its documentation. As you see
the GPRA system gives you credit for HIV counseling and education as
well as testing (as well as refusals).

**GPRA \# 33**

[**HIV Screening:**]{.underline} Support screening for HIV infections in
appropriate population groups. \[outcome\]

**[Prenatal HIV Screening:]{.underline}**\
In FY 2005, establish the baseline number of women screened for HIV in
pregnancy.

**[Prenatal HIV Screening:]{.underline}**\
In FY 2006, increase the proportion of pregnant female patients screened
for HIV.

In FY 2006, assure that the proportion of pregnant female patients
screened for HIV does not decrease more than 1% from the FY 2006 level.

Contact: Jim Cheek, DPHS/Epi, 505-248-4226

**Background**

**Q. What is the Indian Health procedure for HIV screening in
pregnancy?**

<http://www.ihs.gov/misc/links_gateway/download.cfm?doc_id=9808&app_dir_id=4&doc_file=HIV_Consent_Procedures-revised.pdf>

**Q. Does it have to be a separate specific consent in writing during
pregnancy?**

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/HIVscreen52005.doc>

**PRENATAL HIV TESTING AND EDUCATION**

**Changes for Version 5.1, as noted below.**

**Denominator: GPRA:** All pregnant patients with no documented
*miscarriage or abortion* *during the past 20 months* and NO recorded
HIV diagnosis ever*.*

**Numerators:** 1) Patients who received counseling and/or patient
education about HIV and testing during the past 20 months.

2\) **GPRA:** Patients who received HIV test during the past 20 months,
including refusals.

2A) Number of documented refusals.

**Definitions:** 1) **Pregnancy:** At least 2 visits with POV:
V22.0-V23.9, 640.\*-648.\*, 651.\*-676.\* during the past 20 months,
with one diagnosis occurring during the reporting period.

2\) Miscarriage: Occurring after the second pregnancy POV and during the
past 20 months.  POV: 630, 631, 632, 633\*, 634\*, CPT: 59812, 59820,
59821, 59830

3\) Abortion: Occurring after the second pregnancy POV and during the
past 20 months. POV: 635\*, 636\*, 637\*, CPT: 59840, 59841, 59850,
59851, 59852, 59855, 59856, 59857

4\) **HIV:** V POV or Problem List: 042.0-044.9, V08, 795.71

5\) **HIV Counseling/Patient Education:** POV: V65.44, Patient Education
codes containing "HIV-" ***or \"-HIV\"*** or HIV diagnosis 042.0-044.9,
V08, 795.71

6\) **HIV Test:** CPT: 86689, 86701-86703, 87390, 87391; LOINC taxonomy;
site-defined taxonomy BGP GPRA HIV TESTS

7\) **Refusal of HIV Test:** Lab Test HIV

**GPRA Description: ** In FY 2005, establish baseline screening rates
for HIV in pregnancy.

**Patient List:** Patients not screened.

<http://www.ihs.gov/cio/crs/>

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

### **Katherine Palatianos HRSA (former HQE)**

### **Brachial plexus injury: Permanent in 1 of every 10,000 deliveries**

### [Conclusion]{.underline} A case of brachial plexus injury occurs 1 time in every 1000 births, is permanent in 1 of every 10,000 deliveries, and is litigated 1 time for every 45,000 deliveries. The infrequent nature of injury may preclude prevention. 

Chauhan SP et al Brachial plexus injury: A 23-year experience from a
tertiary center American Journal of Obstetrics and Gynecology, Volume
192, Issue 6, June 2005, Pages 1800-1802

#### [**http://www.sciencedirect.com/science?\_ob=ArticleURL&\_udi=B6W9P-4GDS7T6-D&\_user=10&\_coverDate=06%2F30%2F2005&\_rdoc=1&\_fmt=summary&\_orig=browse&\_cdi=6688&\_sort=d&\_docanchor=&view=c&\_acct=C000050221&\_version=1&\_urlVersion=0&\_userid=10&md5=33e0c0aa19e3e7f502b06e9c98b9623c**](http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6W9P-4GDS7T6-D&_user=10&_coverDate=06%2F30%2F2005&_rdoc=1&_fmt=summary&_orig=browse&_cdi=6688&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=33e0c0aa19e3e7f502b06e9c98b9623c) {#httpwww.sciencedirect.comscience_obarticleurl_udib6w9p-4gds7t6-d_user10_coverdate062f302f2005_rdoc1_fmtsummary_origbrowse_cdi6688_sortd_docanchorviewc_acctc000050221_version1_urlversion0_userid10md533e0c0aa19e3e7f502b06e9c98b9623c .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

-   May 3--6, 2006

-   Anchorage, Alaska

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

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

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

#### Kat Franklin, Sante Fe {#kat-franklin-sante-fe .Style-Heading-4-+-Arial-14-pt-Underline}

#### Simple Patient Education Handouts {#simple-patient-education-handouts .Style-Heading-4-+-Arial-14-pt-Underline}

#### I have attached the following list I have spent about 12 hours researching so far. It is still not done. The list is for OB/GYN specific issues and not found in many other websites. {#i-have-attached-the-following-list-i-have-spent-about-12-hours-researching-so-far.-it-is-still-not-done.-the-list-is-for-obgyn-specific-issues-and-not-found-in-many-other-websites. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Simple Patient Education Handouts online {#simple-patient-education-handouts-online .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### Here is a helpful site for simple patient education handouts from the National Library of Medicine {#here-is-a-helpful-site-for-simple-patient-education-handouts-from-the-national-library-of-medicine .Style-Heading-4-+-Arial-14-pt-Underline}

#### [[http://www.nlm.nih.gov/medlineplus/easytoread/all_easytoread.html]{.underline}](http://www.nlm.nih.gov/medlineplus/easytoread/all_easytoread.html) {#httpwww.nlm.nih.govmedlinepluseasytoreadall_easytoread.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Sandy Haldane, HQE {#sandy-haldane-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

#### Science and Leadership: Women With Heart Disease - October 8 -12, 2005 {#science-and-leadership-women-with-heart-disease---october-8--12-2005 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Mayo Clinic, asking for our assistance in identifying several AI/AN women with cardiac disease who might be interested and appropriate to become community leaders in talking to other women about cardiac disease prevention, etc. Last year, with the assistance of Barbara Fine, 3-4 of our women attended.  I asked if there were a limit on the number of women from our communities they would accept and there is not.  It is based on space available but there is a big focus on diversity. If you know of anyone who fits this bill, call 202 728 7199 or [**joann@womenheart.org**](mailto:joann@womenheart.org) {#mayo-clinic-asking-for-our-assistance-in-identifying-several-aian-women-with-cardiac-disease-who-might-be-interested-and-appropriate-to-become-community-leaders-in-talking-to-other-women-about-cardiac-disease-prevention-etc.-last-year-with-the-assistance-of-barbara-fine-3-4-of-our-women-attended.-i-asked-if-there-were-a-limit-on-the-number-of-women-from-our-communities-they-would-accept-and-there-is-not.-it-is-based-on-space-available-but-there-is-a-big-focus-on-diversity.-if-you-know-of-anyone-who-fits-this-bill-call-202-728-7199-or-joannwomenheart.org .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**July 2005 Indian Child Health Notes**

Summary of Clincal Standards for treatment of Overweight Children

A Modestly Successful Trial of Orlistat in Overweight Adolescents

[Recent Literature:]{.underline}

The continued excess burden of lower respiratory infections in American

Indian Alaskan Native infants and children

<http://www.ihs.gov/MedicalPrograms/MCH/C/documents/Ichn62705.doc>

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

**Harvey Huddleston, Mayo Clinic**

**Interested in part-time or locums tenens**

Primarily, I would be interested in staying with the surgical side of my
training and limiting Obstetrics to that of consulting on Operative
Obstetrics with Family Practitioners.  At present, I am a Visiting
Clinician at Mayo Rochester\'s Gyn Surgery Section.

My first job with L.S.U. was as a Consultant to the Family Practice
Residency Training Program at their East Campus, E.A. Conway Memorial
Hospital in Monroe, La.  I worked in that capacity for one year and was
advanced to the Director of Ob/Gyn for the following year.  The third
year I was promoted to the \"big house\", L.S.U. Health Science Center-
Shreveport, the following year.  

After serving as Director of Gynecology and Head of Section of Pelvic
Reconstructive Surgery/Urogynecology for nearly ten years, I \"retired\"
from L.S.U. in late 2001.   After 6 months I accepted a contract job for
Community Health Services, at one of their hospitals (Big Bend Regional
Medical Center) in Alpine, Texas, as the only Ob/Gyn Surgeon to ever be
in the three-county area of the Rio Grande border of Southwest
Texas (Brewster, Davis & Presidio).  

A second consideration would be the Southwestern Section of the U.S., as
I almost became bilingual in Spanish while working the last three and
one-half years in S.W. Texas.  To live in an area with Spanish language
exposure would be a plus.

Harvey T. Huddleston, M.D, FACS, FICS, FRS <harveyhuddleston@mac.com>

#### Phil Smith, HQE {#phil-smith-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**Encouraging Onsite Mammography: New mammography standards for HSP**

Driver:  women [\>]{.underline} 40 X 70%

Volume threshold:  800 exams per year

[What this means]{.underline} is that we are assuming 1 exam per year
for 70% of all women age 40 or greater.  This is different from the old
standard which projected 1 exam every 2 years for all women between 40
-- 50 and years for all [\>]{.underline} 50  and assumes 100%
compliance.  The old threshold was 1600 exams per year.  The new formula
requires a smaller user pop to justify mammography on-site; if one
assumes that about 13% of the population are women [\>]{.underline} 40,
then to reach the 800 exams per year threshold, the projected user pop
would be 8,800.

#### [**Phillip.Smith@ihs.gov**](mailto:Phillip.Smith@ihs.gov) {#phillip.smithihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Healthy Vision Community Awards Program**

To Support Healthy People 2010 Vision Objectives. The National Eye
Institute (NEI) is pleased to announce the 2006 round of the Healthy
Vision Community Awards Program. The focus of the 2006 awards is on
diabetic retinopathy, glaucoma, occupational eye injury, personal
protective eyewear, and vision rehabilitation. Each award is worth up to
\$10,000 per year. Postmark by Wednesday, August 31, 2005.
[[www.healthyvision2010.org/news]{.underline}](../www.healthyvision2010.org/news)

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

#### Roy Teramoto, Phoenix {#roy-teramoto-phoenix .Style-Heading-4-+-Arial-14-pt-Underline}

**HPV and Cervical Cancer: An Update on Prevention Strategies**

August 9, 2005 - 1:00 PM -- 2:00 PM ET

A National Center for HIV, STD, and TB Prevention and Public Health
Training Network Webcast

<http://www.phppo.cdc.gov/PHTN/HPV-05>

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

**Useful atlas for injury causes of AIAN morbidity and mortality when
citing stats**

Unintentional injury is the 4^th^ leading cause of death among AI/AN
infants, following congenital anomalies, SIDS, and PTD.  Suffocation,
choking and strangulation are the #1 type of infant injury death.
 Homicide is #2.  (Deaths to infants accounted for 58% of all AI/AN
suffocation deaths and for 13% of AI/AN homicides.)    The Division of
Unintentional Injury Prevention just published an AI/AN child injury
atlas
<http://www.cdc.gov/ncipc/pub-res/American_Indian_Injury_Atlas/default.htm>

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

#### Ribavirin pregnancy registry - seeking enrollment Hepatitis C {#ribavirin-pregnancy-registry---seeking-enrollment-hepatitis-c-1 .Style-Heading-4-+-Arial-14-pt-Underline}

The Ribavirin Pregnancy Registry is an FDA program to monitor pregnancy
exposures to ribavirin. The Registry was implemented in January 2004.
Ribavirin is a nucleotide analog used in combination with interferon or
pegylated interferon for treatment of chronic hepatitis C (HCV).

**What is the Registry?**

The Ribavirin Pregnancy Registry is a voluntary, prospective Registry
designed to collect observational data on pregnancies and the outcomes
following a pregnancy exposure to ribavirin. Ribavirin exposures may be
direct, through the pregnant female or indirect, through her male sexual
partner. For more info:
[www.ribavirinpregnancyregistry.com](http://www.ribavirinpregnancyregistry.com/)

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

**Rural/Frontier Women\'s Health Coordinating Centers (RFCCs) RFP is
Out**

This would fit nicely with existing or new DV projects, other existing
WH activities - Montazume Creek in Utah is already one site - I have
sent a separate email out on their project. Let me know if you will
apply and I can write a letter of endorsement. <Judith.Thierry@ihs.gov>
Proposals are due by 1:00 p.m. (EDT) on Friday, July 22
<http://www2.eps.gov/spg/HHS/PSC/DAM/05T050034/Attachments.html> 

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

**RFP for SIDS Training and Outreach in the AI/AN Communities**

The National Institute on Child Health and Human Development(NICHD)
under the National Institutes of Health intends to solicit proposals
under a 100% small business set-aside (NAICS code 541519 with a size
standard of \$21M**)** to develop materials and outreach strategies for
increasing Sudden Infant Death Syndrome awareness and risk reduction in
American Indian and Alaska Native communities*.* Proposals are due by
July 27, 2005.

<http://www.eps.gov/spg/HHS/NIH/NICHD/RFP-NICHD-2005-01/listing.html>

Dan Ricketts at ASIP headquarters (703) 902-1260 or
<dricketts@sidsprojectimpact.com>.

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

#### Mean length stay for delivery hospitalization among AI/AN {#mean-length-stay-for-delivery-hospitalization-among-aian-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### National Patient Information Reporting System, 2002-2004  {#national-patient-information-reporting-system-2002-2004 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### ![](media/image2.wmf){width="5.729166666666667in" height="4.46875in"} {#section-15 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Determined in 5 IHS sites with surgical obstetric delivery capacity: 1.9 for non c-section non complicated births  {#determined-in-5-ihs-sites-with-surgical-obstetric-delivery-capacity-1.9-for-non-c-section-non-complicated-births .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Average Length of Hospital\* Stay, by Diagnostic Category \-\-- United States {#average-length-of-hospital-stay-by-diagnostic-category-----united-states .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.cdc.gov/nchs/data/ad/ad359.pdf**](http://www.cdc.gov/nchs/data/ad/ad359.pdf) {#httpwww.cdc.govnchsdataadad359.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### MCH Leadership Award {#mch-leadership-award .Style-Heading-4-+-Arial-14-pt-Underline}

This year the Association of Maternal and Child Health Programs (AMCHP)
gave their prestigious Vince Hutchins Leadership Award to Marian Wright
Edelman, MPA, Founder and President of the Children\'s Defense Fund at
their national conference. To read her acceptance speech, go to
[[http://www.cademedia.com/archives/mchb/amchp2005/transcripts/l1a.htm]{.underline}](http://www.cademedia.com/archives/mchb/amchp2005/transcripts/l1a.htm)

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

#### Developing an operational definition of a local governmental public health agency {#developing-an-operational-definition-of-a-local-governmental-public-health-agency .Style-Heading-4-+-Arial-14-pt-Underline}

#### The National Association of County and City Health Officers (NACCHO) is in the process of developing an operational definition of a local governmental public health agency.  The overarching goal of this project is to develop a shared understanding of what people in any community, regardless of size, can expect from their local governmental public health agency. To read or comment on their current draft. [**http://www.naccho.org/topics/infrastructure/operational_definition.cfm**](http://www.naccho.org/topics/infrastructure/operational_definition.cfm) {#the-national-association-of-county-and-city-health-officers-naccho-is-in-the-process-of-developing-an-operational-definition-of-a-local-governmental-public-health-agency.-the-overarching-goal-of-this-project-is-to-develop-a-shared-understanding-of-what-people-in-any-community-regardless-of-size-can-expect-from-their-local-governmental-public-health-agency.-to-read-or-comment-on-their-current-draft.-httpwww.naccho.orgtopicsinfrastructureoperational_definition.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Grant Opportunities: Rural and Frontier Women's Health Coordinating
Centers**

-One exists at Montezuma Creek
[[http://www.4woman.gov/owh/RFCC/]{.underline}](http://www.4woman.gov/owh/RFCC/)

-Establish Rural / Frontier Women's Health Coordinating Centers
Amendment 04

#### [[http://www.fbo.gov/spg/HHS/PSC/DAM/05T050034/listing.html]{.underline}](http://www.fbo.gov/spg/HHS/PSC/DAM/05T050034/listing.html) {#httpwww.fbo.govspghhspscdam05t050034listing.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

**Treatment of GDM reduces perinatal morbidity, may improve
health-related quality of life**

CONCLUSIONS: Treatment of gestational diabetes reduces serious perinatal
morbidity and may also improve the woman\'s health-related quality of
life.

Crowther CA, et al Effect of treatment of gestational diabetes mellitus
on pregnancy outcomes. N Engl J Med. 2005 Jun 16;352(24):2477-86.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15951574&dopt=Abstract>

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

This RCT confirms the observational studies and blinded controlled
studies reported in last month's CCC Corner\*. In combination these data
should put a final nail in the coffin for the erroneous statement that
"Gestational diabetes is a diagnosis still looking for a disease".

The authors randomly assigned women between 24 and 34 weeks\' gestation
who had gestational diabetes to receive dietary advice, blood glucose
monitoring, and insulin therapy as needed (the intervention group) or
routine care. Primary outcomes included serious perinatal complications
(defined as death, shoulder dystocia, bone fracture, and nerve palsy),
admission to the neonatal nursery, jaundice requiring phototherapy,
induction of labor, cesarean birth, and maternal anxiety, depression,
and health status.

This Level I randomized trial found the rate of serious perinatal
complications was significantly lower among the infants of the 490 women
in the intervention group than among the infants of the 510 women in the
routine-care group (1 percent vs. 4 percent; relative risk adjusted for
maternal age, race or ethnic group, and parity, 0.33; 95 percent
confidence interval, 0.14 to 0.75; P=0.01). However, more infants of
women in the intervention group were admitted to the neonatal nursery
and other measures of morbidity.

\* Scroll down to comments from George Gilson

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0605_Coll.cfm>

\*Langer O, Yogev Y, Most O, Xenakis EM. Gestational diabetes: the
consequences of not treating. Am J Obstet Gynecol. 2005
Apr;192(4):989-97.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15846171&query_hl=1>

**See also NEJM Editorial**

Gestational diabetes mellitus \-- time to treat.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15951575>

**Elective Repeat Cesarean Delivery May Negatively Affect Neonatal
Outcomes**

RESULTS: Neonates born by elective repeat cesarean are more frequently
admitted to advanced care nurseries than infants born to mothers
intending to deliver vaginally (risk ratio 3.58, 95% confidence interval
3.35-3.58). CONCLUSION: The decision to undergo scheduled cesarean
delivery appears to negatively impact immediate neonatal outcomes.

Fogelson NS, et al Neonatal impact of elective repeat cesarean delivery
at term: a comment on patient choice cesarean delivery. Am J Obstet
Gynecol. 2005 May;192(5):1433-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15902129&query_hl=12>

**Indomethacin tocolysis does not appear to be associated with increased
risk of adverse neonatal outcomes**

Conclusion: Although our pooled results did not identify significantly
increased risks of adverse effects, the limited statistical power of
published randomized trials does not allow us to exclude the possibility
that indomethacin tocolysis increases the risk of adverse neonatal
outcomes

[Loe
SM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Loe+SM"%5BAuthor%5D),
et al Assessing the neonatal safety of indomethacin tocolysis: a
systematic review with meta-analysis. Obstet Gynecol. 2005
Jul;106(1):173-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15994634&dopt=Abstract>

**Diabetic Retinopathy Occurs in Pre-Diabetes**: **Implications in GDM**

Diabetic retinopathy has been found in nearly 8 percent of pre-diabetic
participants in the Diabetes Prevention Program (DPP). Diabetic
retinopathy, which can lead to vision loss, was also seen in 12 percent
of participants with type 2 diabetes who developed diabetes during the
DPP. No other long-term study has evaluated retinopathy in a population
so carefully examined for the presence or development of type 2
diabetes. These findings reinforce the recommendation that patients with
newly diagnosed type 2 diabetes should be screened for retinopathy.

<http://www.nih.gov/news/pr/jun2005/niddk-12.htm>

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

#### These findings have immediate implications in gestational diabetes patients who are newly diagnosed in the first trimester, and hence represent pre-existing glucose intolerance that was not previously diagnosed. These patients should receive appropriate ophthalmologic follow-up which may include a thorough dilated examination. {#these-findings-have-immediate-implications-in-gestational-diabetes-patients-who-are-newly-diagnosed-in-the-first-trimester-and-hence-represent-pre-existing-glucose-intolerance-that-was-not-previously-diagnosed.-these-patients-should-receive-appropriate-ophthalmologic-follow-up-which-may-include-a-thorough-dilated-examination. .Style-Heading-4-+-Arial-14-pt-Underline}

#### These findings also have implications in the GDM patients are discovered to have impaired glucose intolerance or impaired fasting glucose (pre-diabetes) on their GDM follow-up visits. Those visits should occur at 6 weeks postpartum and every 3 years thereafter. {#these-findings-also-have-implications-in-the-gdm-patients-are-discovered-to-have-impaired-glucose-intolerance-or-impaired-fasting-glucose-pre-diabetes-on-their-gdm-follow-up-visits.-those-visits-should-occur-at-6-weeks-postpartum-and-every-3-years-thereafter. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Here is a helpful set of Diabetes in Pregnancy Guidelines with postpartum recommendations {#here-is-a-helpful-set-of-diabetes-in-pregnancy-guidelines-with-postpartum-recommendations .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/w/Documents/DMPreg102504_000.doc**](http://www.ihs.gov/MedicalPrograms/MCH/w/Documents/DMPreg102504_000.doc) {#httpwww.ihs.govmedicalprogramsmchwdocumentsdmpreg102504_000.doc .Style-Heading-4-+-Arial-14-pt-Underline}

**Screening for Gestational Diabetes Mellitus: At what cost?**

We conducted a cost-effectiveness analysis to compare four screening
strategies for universal screening of GDM, including the sequential
strategy, the 75- and 100-g GTT, and a no-screening strategy. We
assessed the relative cost and effectiveness (quality-adjusted
life-years \[QALYs\]) of each strategy relative to the sequential
strategy using a decision model.

[Conclusion:]{.underline} Conventional use of sequential strategy is the
preferred strategy followed by a 100g OGTT. The 75g OGTT and the no
screening strategy are not currently viable screening methods

Nicholson WK  et al Screening for Gestational Diabetes Mellitus: A
decision and cost-effectiveness analysis of four screening strategies.
Diabetes Care. 2005 Jun;28(6):1482-4.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15920072&dopt=Abstract>

**No benefit to hospitalization in women with arrested preterm labor and
intact membranes**

[Conclusion:]{.underline} Compared with hospitalization, outpatient
management of women with arrested preterm labor and intact membranes had
no effect on the rate of preterm birth.

Level of Evidence: I. [Yost
NP](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Yost+NP"%5BAuthor%5D),
et al Hospitalization for women with arrested preterm labor: a
randomized trial. Obstet Gynecol. 2005 Jul;106(1):14-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15994611&dopt=Abstract>

**External Abdominal Ice to Complete External Cephalic Version in Term
Breech Pregnancy**

A 36-year-old multiparous woman with fetus in the breech position
applied ice to the fundus of the uterus and achieved successful cephalic
version. No other reports of using ice to induce cephalic version are
found with MEDLINE search; however, it has been used as a folk remedy.
Further research to evaluate the efficacy and safety of ice is needed to
determine whether it increases cephalic vaginal birth.

Crawford, Maj Paul F. Use of External Abdominal Ice to Complete External
Cephalic Version in Term Breech Pregnancy J Am Board Fam Pract 2005 18:
312-313

[[http://www.jabfp.org/cgi/content/abstract/18/4/312]{.underline}](http://www.jabfp.org/cgi/content/abstract/18/4/312)

**Maternal Obesity Raises Risk of Infant Orofacial Clefts**

Conclusions: In this large sample, a positive association appears
between maternal obesity in early pregnancy and orofacial clefts in the
offspring. The explanation for this association is not known, but a
relationship with undetected type 2 diabetes is one possibility.

[Cedergren
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Cedergren+M"%5BAuthor%5D),
[Kallen
B](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Kallen+B"%5BAuthor%5D).
Maternal obesity and the risk for orofacial clefts in the offspring.
Cleft Palate Craniofac J. 2005 Jul;42(4):367-71.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16001917&query_hl=15>

**Maternal Postpartum Health Care Utilization: Minnesota Early Discharge
Legislation**

[Conclusions:]{.underline} Implementation of Minnesota's early discharge
legislation corresponded with significantly increased lengths of stay
and an increase in the percentage of mothers who received early
follow-up visits. However the majority of mothers with short stays
continued to lack early follow-up.

Madlon-Kay, Diane J., DeFor, Terese A. Maternal Postpartum Health Care
Utilization and the Effect of Minnesota Early Discharge Legislation J Am
Board Fam Pract 2005 18: 307-311

[[http://www.jabfp.org/cgi/content/abstract/18/4/307]{.underline}](http://www.jabfp.org/cgi/content/abstract/18/4/307)

**Sustiva (Efavirenz) Use During Pregnancy May Cause Fetal Harm**

The U.S. Food and Drug Administration (FDA) and Bristol-Myers Squibb
have warned healthcare professionals via letter against the use of
efavirenz (Sustiva), a retroviral, during pregnancy due to the potential
risk of fetal harm, especially during the first trimester, according to
an alert sent last Friday from MedWatch, the FDA\'s safety information
and adverse event reporting system.

The change in pregnancy category from C to D was based on four
retrospective reports of neural tube defects in infants born to women
with first trimester exposure to efavirenz, including three cases of
meningomyelocele and one of Dandy Walker Syndrome. Efavirex is an
antiretroviral Agent, Reverse Transcriptase Inhibitor (Non-nucleoside)
<http://www.fda.gov/medwatch>

**Pregnancy-Related Mortality in the United States**

Deaths from pregnancy complications remain an important public health
concern. CDC reports maternal mortality through the National Vital
Statistics System (NVSS) and the Pregnancy Mortality Surveillance System
(PMSS) conducts epidemiological surveillance of pregnancy-related
deaths. The numbers of deaths reported by these two systems have
differed over the past two decades. From the 1471 unduplicated deaths
classified as maternal or pregnancy-related from either reporting
system, we estimated a combined pregnancy-related mortality ratio of
12.6/100 000 live births for 1995-97, compared with 11.9 for PMSS only
and 7.5 for NVSS only.
<http://www.blackwell-synergy.com/links/doi/10.1111/j.1365-3016.2005.00653.x/full/?cookieSet=1>

**Home Birth as Safe as Hospital Delivery for Low-Risk Pregnancies**

CONCLUSIONS: Planned home birth for low risk women in North America
using certified professional midwives was associated with lower rates of
medical intervention but similar intrapartum and neonatal mortality to
that of low risk hospital births in the United States.

[Johnson
KC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Johnson+KC"%5BAuthor%5D),
[Daviss
BA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Daviss+BA"%5BAuthor%5D).
Outcomes of planned home births with certified professional midwives:
large prospective study in North America. BMJ. 2005 Jun
18;330(7505):1416.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15961814&query_hl=6>

**Genetic testing and the family: Two family stories**

The family experience of genetic testing is explored in this article.
Two family stories are presented to illustrate how families define and
manage the ethical and social issues that emerge during 2 types of
genetic testing: mutation analysis for Huntington\'s disease and genetic
testing for breast and ovarian cancer susceptibility. These 2 families
were purposefully selected because their stories exemplify the
complexity of the genetic testing experience. In addition, the story of
the family living with Huntington\'s disease shows how negative
consequences can occur for the individual tested, other family members,
the marital relationship, and the family system, even when the test
results indicate that the individual does not carry a deleterious gene
mutation. Both of the families presented in this article participated in
an ongoing study, Family Experience of Genetic Testing: Ethical
Dimensions , in which 118 family members from 67 families have
participated. The guiding framework for this research was the family
management style framework developed and refined by Knafl and
colleagues. [Van Riper
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Van+Riper+M"%5BAuthor%5D)
Genetic testing and the family. Midwifery Womens Health. 2005
May-Jun;50(3):227-33.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15895001&query_hl=2>

**Meta-analysis reveals that cerclage significantly reduces preterm
birth in singleton gestations with short cervical length and a prior
preterm birth**

Conclusion: Cerclage does not prevent preterm birth in all women with
short cervical length on transvaginal ultrasonography. In the subgroup
analysis of singleton gestations with short cervical length, especially
those with a prior preterm birth, cerclage may reduce preterm birth, and
a well-powered trial should be carried out in this group of patients. In
contrast, in twins, cerclage was associated with a significantly higher
incidence of preterm birth.

[Berghella
V](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Berghella+V"%5BAuthor%5D),
et al Cerclage for Short Cervix on Ultrasonography: Meta-Analysis of
Trials Using Individual Patient-Level Data. Obstet Gynecol. 2005
Jul;106(1):181-189.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15994635&dopt=Abstract>

**Enhanced OB track for a family practice residency program: results
from the first 6 years**

CONCLUSIONS: A 4-year enhanced obstetrics track is an effective means of
improving the training of family medicine residents in obstetric
procedures while maintaining the other fundamental training and
residency review committee requirements for family medicine residents.

[Eidson-Ton
WS](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Eidson-Ton+WS"%5BAuthor%5D),
et al An enhanced obstetrics track for a family practice residency
program: results from the first 6 years. J Am Board Fam Pract. 2005
May-Jun;18(3):223-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15879571&query_hl=19>

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

**High Intake of Calcium, Vitamin D May Reduce the Risk of Premenstrual
Syndrome**

CONCLUSIONS: A high intake of calcium and vitamin D may reduce the risk
of PMS. Large-scale clinical trials addressing this issue are warranted.
Given that calcium and vitamin D may also reduce the risk of
osteoporosis and some cancers, clinicians may consider recommending
these nutrients even for younger women.

Bertone-Johnson ER, et al Calcium and vitamin D intake and risk of
incident premenstrual syndrome. Arch Intern Med. 2005 Jun
13;165(11):1246-52.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15956003&query_hl=10>

**Pediatric Torsed Ovaries May Be More Salvageable Than Previously
Reported**

CONCLUSIONS: These data suggest pediatric ovarian torsion is a more
salvageable condition than previously reported. Prolonged time of
symptoms prior to initial examination does not preclude ovarian salvage.
Ovarian tumor accounts for less than half of cases. Urgent imaging and
surgical management may lead to improved outcomes.\
Anders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian
torsion in pediatric patients. Arch Pediatr Adolesc Med. 2005
Jun;159(6):532-5.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15939851&query_hl=15>

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

Conclusion: Topical benzocaine spray does not appear to offer effective
pain control in patients undergoing an endometrial biopsy. Level of
Evidence: I.

[Einarsson
JI](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Einarsson+JI"%5BAuthor%5D),
et al Topical analgesia for endometrial biopsy: a randomized controlled
trial. Obstet Gynecol. 2005 Jul;106(1):128-30.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15994627&dopt=Abstract>

**US exam of the perineum after childbirth improves diagnosis of anal
sphincter tears**

Conclusion: Ultrasound examination of the perineum after childbirth
improves the diagnosis of anal sphincter tears, and their immediate
repair decreases the risk of severe fecal incontinence. Level of
Evidence: I. [Faltin
DL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Faltin+DL"%5BAuthor%5D),
et al Diagnosis of anal sphincter tears to prevent fecal incontinence: a
randomized controlled trial. Obstet Gynecol. 2005 Jul;106(1):6-13.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15994610&dopt=Abstract>

**Short-term results of the TVT procedure in mixed urinary incontinence
are encouraging, but long-term outcome is disappointing.**

Conclusion: The results of this study indicate that initial good cure
rates of TVT for mixed incontinence do not persist after 4 years. Level
of Evidence: III.

[Holmgren
C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Holmgren+C"%5BAuthor%5D),
Long-Term Results With Tension-Free Vaginal Tape on Mixed and Stress
Urinary Incontinence. Obstet Gynecol. 2005 Jul;106(1):38-43.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15994615&dopt=Abstract>

**The Benefits of Vaginal Drug Administration \-- Communicating
Effectively With Patients**

<http://www.medscape.com/viewprogram/4087?src=mp>

(see Medscape section for free access issues)

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

**Oral contraceptives are more effective than placebo treatment for
relieving dysmenorrhea pain in adolescents**

Conclusions: Among adolescents, a low-dose oral contraceptive relieved
dysmenorrhea-associated pain more effectively than placebo. Level of
Evidence: I.

[Davis
AR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Davis+AR"%5BAuthor%5D),
et al Oral contraceptives for dysmenorrhea in adolescent girls: a
randomized trial. Obstet Gynecol. 2005 Jul;106(1):97-104.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15994623&dopt=Abstract>

**How to get your child off the couch? Evidence based physical activity
for youth**

Increasing levels of habitual moderate- to vigorous-intensity physical
activity in youth is a health promotion and disease-prevention strategy.
Recommendations are as follows:

\* School-age children and adolescents should participate every day in
60 minutes or more of moderate to vigorous physical activity that is
enjoyable and developmentally appropriate.

\* As general movement skills become established in the preschool and
early school stages, health, fitness, and behavioral components of
physical activity increase in importance.

\* Health-related activities include those that emphasize cardiovascular
and muscular endurance and muscular strength and those that involve
weight bearing.

\* The setting of physical activity is especially important in achieving
positive behavioral outcomes.

\* Although there is less emphasis on the development of motor skills
during adolescence, refinement of those skills is important, and new
movement skills can be learned and can contribute to a physically active
lifestyle.

Strong WB, Malina RM, Blimkie CJ, et al. 2005. Evidence based physical
activity for school-age youth. The Journal of Pediatrics 146(6):732-737.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15973308&query_hl=1>

**Children's adaptation to a fat reduced diet**

Practical implications for health care providers to predict problems
with long-term adherence \[to a fat-reduced diet\] and to identify foods
or food groups that may require special intervention approaches to
achieve nutrient adequacy while reducing saturated fat, total fat, and
cholesterol.

Future interventions should target greater use of fruits as snacks and
as part of the meal. Greater access to lower-fat, whole-grain, and or
vegetarian-style pizza in this age group could also improve overall
dietary quality and help reduce total dietary fat, saturated fat, and
cholesterol intake while increasing dietary fiber as well.

Van Horn L, Obarzanek E, Friedman LA, et al. 2005. Children\'s
adaptation to a fat-reduced diet: The Dietary Intervention Study in
Children (DISC). Pediatrics 115(6):1723-1733.
[[http://pediatrics.aappublications.org/cgi/content/abstract/115/6/1723?etoc]{.underline}](http://pediatrics.aappublications.org/cgi/content/abstract/115/6/1723?etoc)

**Adolescent Pregnancy: Current Trends and Issues: American Academy of
Pediatrics**

This clinical report is intended to provide pediatricians with recent
data on adolescent sexuality, contraceptive use and child bearing, as
well as information about preventing adolescent pregnancy in their
communities. The report highlights new information on the topic of
adolescent pregnancy:

Most successful prevention programs include multiple and varied
approaches to the problem, including both abstinence promotion and
contraception information and availability, sexuality education,
school-completion strategies and job training.

Current research indicates that encouraging abstinence and urging better
use of contraception are compatible goals. Evidence shows that sexuality
education that discusses contraception does not increase sexual
activity, and programs that emphasize abstinence as the safest and best
approach, while also teaching about contraceptives for sexually active
youth, do not increase sexual activity and improve teens\' knowledge
about access to reproductive health.

The report urges pediatricians to encourage adolescents to postpone
early sexual activity and encourage parents to educate their children
and adolescents about sexual development, responsible sexuality,
decision-making and values.
[[http://pediatrics.aappublications.org/cgi/content/full/116/1/281]{.underline}](http://pediatrics.aappublications.org/cgi/content/full/116/1/281)

**Suicide Prevention among AI/AN Adolescents Evaluated: Public Health
Approach**

The consistency and timing of reduction in suicidal behavior correlated
with the development and delivery of prevention program interventions in
this small AIAN \[American Indian/Alaska Native\] community, indicating
that prevention efforts were likely successful in reducing suicidal
behavior.

....success is owed to the program\'s public health approach, which
included mental health services integrated into a comprehensive
continuum of services that target other behavioral health topics at all
levels of prevention.

May PA, Serna P, Hurt L, et al. 2005. Outcome evaluation of a public
health approach to suicide prevention in an American Indian Tribal
Nation. American Journal of Public Health 95(7):1238-1244
[[http://www.ajph.org/cgi/content/abstract/AJPH.2004.040410v1]{.underline}](http://www.ajph.org/cgi/content/abstract/AJPH.2004.040410v1)

**Native Fish Oils - Developmental Coordination Disorder**

Fatty Acid Supplementation May Be Helpful in Developmental Coordination
Disorder

CONCLUSIONS: Fatty acid supplementation may offer a safe efficacious
treatment option for educational and behavioral problems among children
with DCD. Additional work is needed to investigate whether our inability
to detect any improvement in motor skills reflects the measures used and
to assess the durability of treatment effects on behavior and academic
progress.

Richardson AJ, Montgomery P. The Oxford-Durham study: a randomized,
controlled trial of dietary supplementation with fatty acids in children
with developmental coordination disorder. Pediatrics. 2005
May;115(5):1360-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15867048&query_hl=3>

**Safe Sleep Policies: Samples available?**

#### I am interested in finding out what types of hospital policies exist regarding safe sleep policies in NICUs and/or Well Baby Units.   If you have any sample hospital policies that you would be willing to share, please mail or email them to me.  Or, if you know of a hospital that has such policies, let me know the name and I will contact them. [**Judith.Thierry@ihs.gov**](mailto:Judith.Thierry@ihs.gov) {#i-am-interested-in-finding-out-what-types-of-hospital-policies-exist-regarding-safe-sleep-policies-in-nicus-andor-well-baby-units.-if-you-have-any-sample-hospital-policies-that-you-would-be-willing-to-share-please-mail-or-email-them-to-me.-or-if-you-know-of-a-hospital-that-has-such-policies-let-me-know-the-name-and-i-will-contact-them.-judith.thierryihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

**AHRQ** **Data on Antibiotic Use in Children with Otitis Media**

<http://www.meps.ahrq.gov/printproducts/printprod_detail.asp?id=683>

**National Bullying Prevention Conference, October 27 - 28, 2005**

Atlanta, GA 2nd Annual [www.sapaofga.org](http://www.sapaofga.org/)

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

**Death rates for CVD are higher among AI/AN than other U.S. groups
(AHRQ)**

National vital event data published by the Indian Health Service (IHS)
prior to the early 1990s suggest that cardiovascular disease (CVD)
mortality rates (for example, for heart attack and stroke) are lower for
American Indians and Alaska Natives (AIAN). This finding is somewhat
puzzling, given that American Indians have for years had some of the
Nation\'s highest rates of major CVD risk factors, such as smoking,
diabetes, and obesity.

In a recent study, Dorothy A. Rhoades, M.D., M.P.H., of the University
of Colorado Health Sciences Center, adjusted for racial
misclassification in the IHS data (something that was not done by the
IHS until the early 1990s) and concluded quite the opposite. She found
that AIAN have higher CVD mortality rates than the rest of the U.S.
population, and these rates may have been higher for more than a decade.

Furthermore, CVD mortality is increasing among AIAN but decreasing in
the general population widening a previously unrecognized disparity,
notes Dr. Rhoades. She used IHS vital event data to compare trends in
CVD mortality from 1989-1991 to 1996-1998 among three U.S. population
groups: AIAN, all races, and whites.

After adjusting for age and racial misclassification, by 1996-1998, the
number of CVD deaths per 100,000 among AIAN was 195.9 compared with
166.1 and 159.1 for all races and whites, respectively. The annual
percent change in CVD mortality for AIAN was 0.5, a slight increase,
compared with -1.8, a decline, in the other groups. The most striking
and widening disparities were found for middle-aged AIAN, but CVD
mortality among elderly AIAN was lower than in the other groups. Efforts
to reduce CVD mortality in AIAN must begin before the onset of middle
age, concludes Dr. Rhoades. Her work was supported in part by the Agency
for Healthcare Research and Quality (HS10854).
<http://www.ahrq.gov/research/may05/0505RA19.htm#head19>

Rhoades DA. Racial misclassification and disparities in cardiovascular
disease among American Indians and Alaska Natives. Circulation. 2005 Mar
15;111(10):1250-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15769765&query_hl=1>

**Each Pound of Weight Lost May Reduce Knee Load per Step Fourfold**

CONCLUSION: Our results indicate that each pound of weight lost will
result in a 4-fold reduction in the load exerted on the knee per step
during daily activities. Accumulated over thousands of steps per day, a
reduction of this magnitude would appear to be clinically meaningful.

[Messier
SP](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Messier+SP"%5BAuthor%5D)
et al Weight loss reduces knee-joint loads in overweight and obese older
adults with knee osteoarthritis. Arthritis Rheum. 2005
Jul;52(7):2026-32.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15986358&query_hl=17>

**Most parents want to quit smoking but they need assistance. Learn how
to help**

It is estimated that 20%-50% of adult smokers reside with children, and
the majority of these smokers (70%) continue to smoke inside their homes
despite the adverse health effects of second hand smoke (SHS) for their
children. Smoking is more prevalent among parents with lower incomes and
less education. Young persons, ages 20-40 in the family child-rearing
stage, are more likely to be smokers. However, they usually have less
time and financial resources for quitting smoking. To prevent the
adverse health effects of SHS for children, pediatric nurses must
provide parents with accurate information on affordable smoking
cessation education resources. Evidenced-based smoking cessation
guidelines, the cost and efficacy of prescription and over-the-counter
(OTC) pharmacological aids, and essential counseling tips for parents
are reviewed.

[Sheahan
SL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Sheahan+SL"%5BAuthor%5D),
[Free
TA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Free+TA"%5BAuthor%5D).
Counseling parents to quit smoking. Pediatr Nurs. 2005
Mar-Apr;31(2):98-102, 105-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15934562&query_hl=21>

**European study confirms red meat link with bowel cancer**

CONCLUSIONS: Our data confirm that colorectal cancer risk is positively
associated with high consumption of red and processed meat and support
an inverse association with fish intake.

Norat T, et al Meat, fish, and colorectal cancer risk: the European
Prospective Investigation into cancer and nutrition. J Natl Cancer Inst.
2005 Jun 15;97(12):906-16.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15956652&query_hl=7>

**Self-Monitoring of Glucose in Patients With Type 2 Diabetes Who Are
Not Using Insulin**

Welschen LM  et al Self-Monitoring of Blood Glucose in Patients With
Type 2 Diabetes Who Are Not Using Insulin: A systematic review. Diabetes
Care. 2005 Jun;28(6):1510-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15920083&dopt=Abstract>

**vs**

**A waste of money?**

[Davidson
MB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Davidson+MB"%5BAuthor%5D)
Counterpoint: Self-monitoring of blood glucose in type 2 diabetic
patients not receiving insulin: a waste of money. Diabetes Care. 2005
Jun;28(6):1531-3.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15920088&dopt=Abstract>

**Primary Care Interventions to Prevent Low Back Pain in Adults:
Recommendation**

The USPSTF concludes that the evidence is insufficient to recommend for
or against the routine use of interventions to prevent low back pain in
adults in primary care settings.

**I recommendation** <http://www.aafp.org/afp/20050615/us.html>

**Preventing Acute Mountain Sickness** (See Medscape below for free
access)

<http://www.medscape.com/viewarticle/407640?src=nlpromo>

**Updated** **ACG Guidelines for Diagnosis and Treatment of GERD**

<http://www.aafp.org/afp/20050615/practice.html>

**Health Effects of Garlic**

<http://www.aafp.org/afp/20050701/103.html>

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

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

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

Three Days of Ciprofloxacin Better for Uncomplicated UTI

[Clinical Question:]{.underline} Are amoxicillin-clavulanate and
ciprofloxacin equivalent as a three-day treatment for uncomplicated
cystitis in women?

[Bottom Line:]{.underline} Three days of ciprofloxacin is superior to
three days of amoxicillin-clav­ulanate in the treatment of uncomplicated
cystitis in women. In areas where resistance is not yet a significant
problem, physicians should use less expensive
trimethoprim-sulfamethoxazole as a first-line agent. (Level of Evidence:
1b-) <http://www.aafp.org/afp/20050615/tips/7.html>

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

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

Gonorrhea Clinical Evidence Concise, A Publication of BMJ

What are the effects of treatments for uncomplicated infections in men
and nonpregnant women?

beneficial

**Single-dose Antibiotic Regimens (Based on Comparisons of Results
Across Arms of Different Trials).** One systematic review found limited
evidence that single-dose regimens (e.g., ceftriaxone, ciprofloxacin,
gatifloxacin, spectinomycin, azithromycin, ofloxacin, and cefixime)
achieve cure rates of 95 percent or higher in urogenital or rectal
infection. Cure rates were lower (about 80 percent) for pharyngeal
infection. Resistance to penicillins, tetracyclines, and sulfonamides is
now widespread, and resistance to fluoroquinolones has become common in
some geographic areas.

What are the effects of treatments for uncomplicated infections in
pregnant women?

beneficial

**Single-dose Antibiotic Regimens.** One systematic review found that
antibiotic treatment (e.g., amoxicillin plus probenecid, spectinomycin,
ceftriaxone, and cefixime) was effective for curing gonorrhea in
pregnant women. We found no reports of serious adverse effects.

What are the effects of treatments for disseminated gonococcal
infection?

likely to be beneficial

**Multidose Antibiotic Regimens (Based on Nonrandomized Controlled
Trials Evidence and Consensus).** We found no randomized controlled
trials (RCTs) assessing treatments for disseminated gonococcal
infection, but there is consensus that multidose regimens using
injectable cephalosporins or quinolones (except where
quinolone-resistant *Neisseria gonorrhoeae* have been reported) are the
most effective treatments. We found no reports of treatment failures
with these regimens.

What are the effects of dual treatment for gonorrhea and chlamydia
infection?

unknown effectiveness

**Dual Antibiotic Treatment.** Dual treatment with an antimicrobial
effective against gonorrhea and chlamydia infections is based on theory
and expert opinion rather than on evidence from RCTs. The balance
between benefits and harms will vary with the prevalence of coinfection
in each population. <http://www.aafp.org/afp/20050701/bmj.html>

Clinical Evidence Concise, A Publication of BMJ Publishing Group

<http://www.clinicalevidence.com/ceweb/conditions/seh/1604/1604.jsp>

Low-Molecular-Weight Heparin for Initial Treatment of Venous
Thromboembolism

Clinical Scenario Cochrane for Clinicians

A 72-year-old woman presents with swelling and pain in her calf that has
lasted two days. Evaluation reveals that she has an acute
thromboembolism of the deep femoral vein.

Clinical Question

Should venous thromboembolism initially be treated with unfractionated
heparin or a low-molecular-weight heparin (LMWH)?

**Reviewers\' Conclusions.** LMWH is more effective than unfractionated
heparin for the initial treatment of venous thromboembolism. LMWH
significantly reduces the occurrence of major hemorrhage during initial
treatment and overall mortality at follow-up.

Evidence-Based Answer

LMWH is safer and more effective than unfractionated heparin for initial
treatment of venous thromboembolism.

The practice recommendations in this activity are available online at
<http://www.cochrane.org/cochrane/revabstr/AB001100.htm>

**Follow-up After Surgically Treated Breast Cancer Cochrane for
Clinicians**

**Clinical Question**

What follow-up should women have after surgical treatment of breast
cancer?

**Evidence-Based Answer**

The best available evidence supports clinical breast examinations every
three to six months for five years and annual mammography for
asymptomatic breast cancer survivors. More intensive follow-up and
subspecialist visits do not improve survival.

**Practice Pointers**

Rojas and colleagues identified four studies that compared different
approaches to follow-up in 3,055 women who were surgically treated for
Stage I, II, or III breast cancer. Two studies (2,563 women) compared a
minimal follow-up strategy (i.e., clinical breast examination every
three to six months and annual mammography) with more intensive
follow-up that included laboratory and imaging tests such as chest
radiograph and bone scan in addition to regular examinations. After five
to 10 years, the studies found no difference in overall mortality
(relative risk \[RR\], 0.98; 95 percent confidence interval \[CI\], 0.84
to 1.15) or quality of life between groups. One study found a benefit in
disease-free survival in the intensive follow-up group (bone scan and
chest radiograph every six months), though the other did not. The pooled
RR for disease-free survival for both studies was 0.84 (*P* = .05; 95
percent CI, 0.71 to 1.00).

One study with 296 women compared hospital-based subspecialist follow-up
with follow-up by the patient\'s family physician. There was no
significant difference in the likelihood of recurrence (7 percent with
family physicians versus 11 percent with subspecialists) and patients
reported more satisfaction with care from their family physician. A
limitation of these studies is their age, but recent evidence-based
guidelines are consistent with their findings. The Institute for
Clinical Systems Improvement^1^ and the National Comprehensive Cancer
Network^2^ also recommend clinical breast examinations every four to six
months for five years, then annually, with annual mammograms for
asymptomatic breast cancer survivors. They do not recommend routine
laboratory or imaging studies for asymptomatic women who are not
expected to have a recurrence.
<http://www.aafp.org/afp/20050701/cochrane.html>

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

**Hemoglobinopathies in Pregnancy**

**Summary of Recommendations and Conclusions**

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

-   Individuals of African, Southeast Asian, and Mediterranean descent
    are at increased risk for being carriers of hemoglobinopathies and
    should be offered carrier screening and, if both parents are
    determined to be carriers, genetic counseling.

-   A complete blood count and hemoglobin electrophoresis are the
    appropriate laboratory tests for screening for hemoglobinopathies.
    Solubility tests alone are inadequate for screening because they
    fail to identify important transmissible hemoglobin gene
    abnormalities affecting fetal outcome.

-   Couples at risk for having a child with sickle cell disease or
    thalassemia should be offered genetic counseling to review prenatal
    testing and reproduction options. Prenatal diagnosis of
    hemoglobin-opathies is best accomplished by DNA analysis of cultured
    amniocytes or chorionic villi.

Hemoglobinopathies in pregnancy. ACOG Practice Bulletin No. 64. American
College of Obstetricians and Gynecologists. Obstet Gynecol
2005;106:203--11.

**ACOG Members**

<http://www.acog.org/publications/educational_bulletins/pb064.cfm>

**Pregnancy and Depression: What Women Need to Know**

In response to recent celebrity statements about postpartum depression,
The American College of Obstetricians and Gynecologists (ACOG), the
nation\'s leading organization of physicians specializing in women\'s
health care, provides the following excerpt, \"Riding the Emotional
Roller Coaster,\" from ACOG\'s *Plum*^TM^ magazine, as a resource for
women and their families. *Plum*^TM^ is the first-ever pregnancy
magazine to target American women age 35 and older and is distributed
free of charge by obstetrician-gynecologists to their patients.

This article addresses the many physiological issues related to
pregnancy and the postpartum period. It also explores the role of
hormones, the safety of antidepressants during pregnancy, and symptoms
of depression. It is written to dispel myths and misunderstandings about
perinatal and postpartum depression-both are real and can be treated.
ACOG advises women to talk with their ob-gyns about their own feelings
and concerns and about available treatments and resources.

<https://www.acog.com/from_home/publications/press_releases/nr07-07-05.cfm>

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

**Breast cancer risk and the effects of tamoxifen prophylaxis among
women in primary care**

<http://www.ahrq.gov/research/may05/0505RA14.htm#head14>

**Acupuncture appears promising for the treatment of depression during
pregnancy**

<http://www.ahrq.gov/research/may05/0505RA16.htm#head16>

#### 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}

##### A new quick and easy way to find best clinical articles: PubMed Clinical Queries

If you want to know the answers to these questions or if you just want
to spend less time looking for just the right article...

What is 'Search by Clinical Study Category'?

What is 'Find Systematic Reviews'?

How to find and use PubMed Clinical Queries?

...then go to...IHS Primary Care Provider, March 2005 Volume 30, No. 3,
page 73

##### [**http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV0305.pdf**](http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV0305.pdf)

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

**1st week of life critical window for ingestion of maternal
\"diabetic\" breast milk**

CONCLUSIONS: Neither late neonatal DBM intake nor the duration of
breast-feeding has an independent influence on childhood risk of
overweight or IGT in ODM. Therefore, the 1st week of life appears to be
the critical window for nutritional programming in ODM by ingestion of
maternal \"diabetic\" breast milk. Rodekamp E, et al Long-Term Impact of
Breast-Feeding on Body Weight and Glucose Tolerance in Children of
Diabetic Mothers: Role of the late neonatal period and early infancy.
Diabetes Care. 2005 Jun;28(6):1457-62.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15920068&dopt=Abstract>

**Medication Use During Pregnancy and Breastfeeding**

Many pregnant women or mothers who are breastfeeding worry about whether
to take medications - including prescription and over-the-counter drugs,
vitamins, and dietary or herbal supplements. This page includes sections
on frequently asked questions, fast facts about medication use during
pregnancy and while breastfeeding, CDC activities, and more.

<http://www.cdc.gov/ncbddd/meds/default.htm>

**Breastfeeding may be associated with a reduced risk of
atherosclerosis**

#### Based on a cohort study based on a 65-year follow-up of the Carnegie (Boyd Orr) survey of diet and health in prewar Britain. Having been breastfed was inversely associated with common carotid intima-media thickness (IMT; difference -0.03 mm; 95% CI, -0.07 to 0.01), bifurcation IMT (difference -0.19 mm; 95% CI, -0.37 to -0.01), carotid plaque (odds ratio \[OR\], 0.52; 95% CI, 0.29 to 0.92), and femoral plaque (OR, 0.54; 95% CI, 0.26 to 1.12), compared with having been bottle fed. Martin RM et al (2005). Breastfeeding and Atherosclerosis: Intima-Media Thickness and Plaques at 65-Year Follow-Up of the Boyd Orr Cohort. *Arteriosclerosis, Thrombosis, and Vascular Biolog* 25:1482. [[http://atvb.ahajournals.org/cgi/content/abstract/25/7/1482?ct]{.underline}](http://atvb.ahajournals.org/cgi/content/abstract/25/7/1482?ct) {#based-on-a-cohort-study-based-on-a-65-year-follow-up-of-the-carnegie-boyd-orr-survey-of-diet-and-health-in-prewar-britain.-having-been-breastfed-was-inversely-associated-with-common-carotid-intima-media-thickness-imt-difference--0.03-mm-95-ci--0.07-to-0.01-bifurcation-imt-difference--0.19-mm-95-ci--0.37-to--0.01-carotid-plaque-odds-ratio-or-0.52-95-ci-0.29-to-0.92-and-femoral-plaque-or-0.54-95-ci-0.26-to-1.12-compared-with-having-been-bottle-fed.-martin-rm-et-al-2005.-breastfeeding-and-atherosclerosis-intima-media-thickness-and-plaques-at-65-year-follow-up-of-the-boyd-orr-cohort.-arteriosclerosis-thrombosis-and-vascular-biolog-251482.-httpatvb.ahajournals.orgcgicontentabstract2571482ct .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Case Managers Corner, Donna Brown, Anchorage {#case-managers-corner-donna-brown-anchorage .Style-Heading-4-+-Arial-14-pt-Underline}

**What is an RN Case Manager?**

I was asked by my newest provider when we were introduced almost a year
ago....

"What do you do? Are you a Social Worker?"

At Southcentral Foundation Women's Health Services (WHS), Case Managers
are first and foremost, Registered Nurses. There are currently nine
full-time positions. The turnover rate in WHS is the lowest I have ever
experienced in 25 years of nursing. The background of education and
experience of the case managers is very diverse. Some of the case
managers were just emerging from the security of nursing school, while
others are counting down the years until retirement.

Each case manager has physician and mid-level providers with whom we
work very closely as a team for a positive patient outcome. We work with
our providers within the clinic to provide pre-op teaching and post-op
care. The case managers each have a region within the state of Alaska to
coordinate continuity of patient care. We schedule patients for surgical
procedures and transfer high risk prenatal patients for antenatal care
and delivery in Anchorage.

We also have a telephone triage nurse available from 8am to 4pm Monday
through Friday.

We utilize the ACOG recommendation, Telephone Triage book for Obstetrics
and Gynecology, Vickie E. Long, MSN, CNM and Patricia C McMullen, JD,
MS, CNS, CRNP, Lippincott, 2003.

We are interested in hearing how other case managers are utilized in
providing services for American Indians and Alaska Natives. Please feel
free to contact me <dnbrown@anmc.org>

Here are some helpful links:
[www.RNCaseManager.com](http://www.rncasemanager.com/)
<http://www.rncasemanager.com/case_manager_training.htm>

By Donna N. Brown, BSN, RNC, CMC, Southcentral Foundation

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

#### The inclusion of RN Case Managers to the ANMC Women's Health Service has revolutionized clinical care and remarkably increased patient satisfaction. Many kudos to all the Indian Health Case Managers !  {#the-inclusion-of-rn-case-managers-to-the-anmc-womens-health-service-has-revolutionized-clinical-care-and-remarkably-increased-patient-satisfaction.-many-kudos-to-all-the-indian-health-case-managers .Style-Heading-4-+-Arial-14-pt-Underline}

#### The CCCC welcomes this new posting from Donna Brown and we look forward to future entries for a RN Case Managers Corner. If other RN Case Managers have ideas they would like to share, please feel free to contact Donna Brown at [**dnbrown@anmc.org**](mailto:dnbrown@anmc.org)  {#the-cccc-welcomes-this-new-posting-from-donna-brown-and-we-look-forward-to-future-entries-for-a-rn-case-managers-corner.-if-other-rn-case-managers-have-ideas-they-would-like-to-share-please-feel-free-to-contact-donna-brown-at-dnbrownanmc.org .Style-Heading-4-+-Arial-14-pt-Underline}

#### In the meantime here are some other possible resources {#in-the-meantime-here-are-some-other-possible-resources .Style-Heading-4-+-Arial-14-pt-Underline}

University of Wisconsin Nursing

<http://www.son.wisc.edu/academics/msclinicalspecialties.htm>

(scroll down to bottom of page)

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

#### Nursing Spectrum: Student's Corner {#nursing-spectrum-students-corner .Style-Heading-4-+-Arial-14-pt-Underline}

<http://www.nursingspectrum.com/StudentsCorner/CareersInNursing/Specialties/CM.htm>

and

Case Management Society of America

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

CASE MANAGEMENT ALONG THE CONTINUUM

September 11-14, 2005, Washington, DC

20.4 contact hours, Contemporary Forums
<http://cforums.com/m687/bene.asp>

Pre-conferences: A - 8.5 contact hours or B - 9 contact hours

Contemporary Forums Home page

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

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

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

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

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

-Have you had your 'morning after' antiretroviral cocktail yet?

-Why Prozac is okay during pregnancy and not for breastfeeding.... and
why Zoloft is

-Slight delay in umbilical cord clamping better for preterm infants

-Transdermal contraceptive promising for reducing bleeding and delaying
menses

-Risk of Autism: Parent, Pregnancy, and Birth Factors Found Possible
Associations

-Women with pregnancy induced HTN: Increased risk for metabolic syndrome
later

-Urinary Incontinence in Women: Practice Bulletin NUMBER 63, JUNE 2005

-AskUs Live! Available to all Indian Health Staff

-Being overweight may increase the risk of becoming pregnant while using
OCs

-Follow-up: Answer to the May Mystery Question

-Screening for Genital Herpes: USPSTF

-West Nile Virus in Women

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

-Screening for Gonorrhea: USPSTF Recommendation Statement

-Any new solutions to Nausea and Vomiting in Pregnancy?\
-New Perinatology Corner Free CEU / CME Module

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05jun_OL.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05jun_OL.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocuments05jun_ol.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-24 .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-25 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Women who declined to be surveyed regarding domestic violence were at increased risk for adverse pregnancy outcome {#women-who-declined-to-be-surveyed-regarding-domestic-violence-were-at-increased-risk-for-adverse-pregnancy-outcome .Style-Heading-4-+-Arial-14-pt-Underline}

#### Conclusion: Women who declined to be surveyed regarding domestic violence were at increased risk for adverse pregnancy outcome. Level of Evidence: II-2n [**Yost NP**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Yost+NP"%5BAuthor%5D), et al A prospective observational study of domestic violence during pregnancy. Obstet Gynecol. 2005 Jul;106(1): {#conclusion-women-who-declined-to-be-surveyed-regarding-domestic-violence-were-at-increased-risk-for-adverse-pregnancy-outcome.-level-of-evidence-ii-2n-yost-np-et-al-a-prospective-observational-study-of-domestic-violence-during-pregnancy.-obstet-gynecol.-2005-jul1061 .Style-Heading-4-+-Arial-14-pt-Underline}

#### 61-5. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15994618&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15994618&dopt=Abstract) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids15994618doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Juvenile Justice Issues - Coordinating Council - Key Programs Advancing Youth {#juvenile-justice-issues---coordinating-council---key-programs-advancing-youth-1 .Style-Heading-4-+-Arial-14-pt-Underline}

The Coordinating Council on Juvenile Justice and Delinquency Prevention
is an independent advisory committee within the executive branch. One of
its main functions is to assist in implementing the recommendations of
the White House Task Force for Disadvantaged Youth.

#### The Council meeting highlighted the many opportunities for collaboration among federal and non-profit organizations. The presenters discussed the ability of youth serving organizations to offer excellent youth development programs to young people in low resource environments across the U.S. [**www.juvenilecouncil.gov**](http://www.juvenilecouncil.gov/) {#the-council-meeting-highlighted-the-many-opportunities-for-collaboration-among-federal-and-non-profit-organizations.-the-presenters-discussed-the-ability-of-youth-serving-organizations-to-offer-excellent-youth-development-programs-to-young-people-in-low-resource-environments-across-the-u.s.-www.juvenilecouncil.gov .Style-Heading-4-+-Arial-14-pt-Underline}

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

**2nd Annual Alzheimer\'s Disease and Dementia Update Conference **

**Challenges in the Care of American Indian Elders**

**August 19, 2005 Flagstaff, AZ**

This is a conference designed specifically for Indian Country, targeting
a broad audience including health care professionals, caregivers and
program staff working with elders with dementia. Sun Health Research
Institute.
[http://www.shri.org/conference/index.cfm](https://hqwebmail.ihs.gov/exchweb/bin/redir.asp?URL=http://www.shri.org/conference/index.cfm)

**Secondary Prevention of Coronary Heart Disease in Elderly Patients**

<http://www.aafp.org/afp/20050615/2289.html>

**A Nursing Guide to the Prevention and Management of Falls in Geriatric
Patients in Long-term Care Settings**
<http://www.medscape.com/viewprogram/4086?src=mp>

(see Medscape section for free access issues)

**2005 ASCP Foundation Interdisciplinary GeroPsych/Behavioral Disorders
Traineeship**

This would be a good opportunity for sites looking to develop an
interdisciplinary approach to dementia and geriatric depression and
anxiety.  Appropriate for physicians, NPs, PAs, plus pharmacist. 
Lodging and tuition are covered, per diem and travel are not.  I would
be glad to look with you for additional funding if your site commits to
sponsoring a team. 

<http://www.ascpfoundation.org/traineeships/train_interdisciplinary.htm>

I will also support applications with letters of recommendation.
<Bruce.Finke@ihs.gov>

**Prevention of Falls in Older Patients**

<http://www.aafp.org/afp/20050701/81.html>

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

**Low-dose oral contraceptives increase cardiovascular disease risk**

Conclusions: In conclusion, a rigorous meta-analysis of the literature
suggests that current use of low-dose OCs significantly increases the
risk of both cardiac and vascular arterial events, including a
significant risk of vascular arterial complications with third
generation OCs.

[Baillargeon
JP](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Baillargeon+JP"%5BAuthor%5D),
et al Association between the Current Use of Low-Dose Oral
Contraceptives and Cardiovascular Arterial Disease: A Meta-Analysis. J
Clin Endocrinol Metab. 2005 Jul;90(7):3863-70.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15814774&query_hl=13>

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

**Q. Do you know of any good links to simple patient education?**

A. Kat Franklin CNM compiled these [Simple Patient Education
Handouts](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/PtEDHANDOUTS.doc)

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

**Q. What are some good paper based women's resources for Advanced
Practice Nurses?**

A. Here are some good paper based and web based resources for Advanced
Practice Nurses

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/APNreferWomen62305.doc>

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

**Computer-assisted cognitive therapy effectively treats depression:
RCT**

CONCLUSIONS: A multimedia, computer-assisted form of cognitive therapy
with reduced therapist contact was as efficacious as standard cognitive
therapy. Computer-assisted therapy could decrease costs and improve
access to cognitive therapy for depression.

[Wright
JH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Wright+JH"%5BAuthor%5D),
et al Computer-assisted cognitive therapy for depression: maintaining
efficacy while reducing therapist time. Am J Psychiatry. 2005
Jun;162(6):1158-64.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15930065&query_hl=2>

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

**Medical Investigations of Homicides of Prisoners of War in Iraq and
Afghanistan**

This article reviews another human rights issue \-- the medical
evaluation of cases of which prisoners potentially died of because of
mistreatment or under suspicious circumstances.

<http://www.medscape.com/viewarticle/507284?src=mp> (See Medscape below
for free access)

**Association between subsidized housing and children's nutritional
status**

Receiving public housing subsidies is associated with anthropometric
evidence of improved nutritional status in young children among
low-income renter families in the urban populations studied in this
sentinel surveillance program. Few studies have examined the possible
effects of housing assistance on the health and nutritional status of
young children from families with low incomes who are most directly
affected by these policies.

[Conclusion:]{.underline} Decreases in housing subsidies may further
compromise the nutritional status of low-income children.\"

\* Twenty-four percent of households without a housing subsidy were food
insecure.

\* Children from families with food insecurity who were not receiving
housing subsidies had lower weight-for-age than children from families
with food insecurity who were receiving housing subsidies.

\* Children from families with food insecurity who were not receiving
housing subsidies were more than twice as likely to have weight-for-age
2 standard deviations below the mean than children from families with
food insecurity who were receiving housing subsidies.

\* Housing subsidy status was not associated with children\'s risk for
fair or poor health or history of hospitalization. There was also no
association between housing subsidy status and childhood overweight.

Meyers A, Cutts D, Frank DA, et al. 2005. Subsidized housing and
children\'s nutritional status: Data from a mulitisite surveillance
study. Archives of Pediatrics and Adolescent Medicine 159(6):551-556
<http://archpedi.ama-assn.org/cgi/content/abstract/159/6/551>

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

**Health Care Insurance (SCHIP) Improves racial / ethnic health
disparities**

The simple provision of health insurance to uninsured low-income
children may enhance efforts to reduce preexisting racial/ethnic
disparities in care; in this case, disparities in access to care, unmet
need, and continuity of care were virtually eliminated. Future
expansions of SCHIP or of other health insurance programs for children
and additional research on mechanisms of disparities may both improve
care and reduce disparities among these vulnerable children.

Shone LP, Dick AW, Klein JD, et al. 2005. Reduction in racial and ethnic
disparities after enrollment in the State Children\'s Health Insurance
Program. Pediatrics Electronic Pages 115(6):e697-e705
[[http://pediatrics.aappublications.org/cgi/content/abstract/115/6/e697]{.underline}](http://pediatrics.aappublications.org/cgi/content/abstract/115/6/e697)

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

#### 2 positive blood cultures found in a postpartum patient with a fever {#positive-blood-cultures-found-in-a-postpartum-patient-with-a-fever .Style-Heading-4-+-Arial-14-pt-Underline}

#### -This 22 year old G1 P0 presented in active labor at 40 weeks gestation after a benign prenatal course that was significant only for a positive perineum and rectal culture for beta streptococcus group B screen at 36 weeks and a weight gain of over 50 pounds with a normal glucose challenge test. {#this-22-year-old-g1-p0-presented-in-active-labor-at-40-weeks-gestation-after-a-benign-prenatal-course-that-was-significant-only-for-a-positive-perineum-and-rectal-culture-for-beta-streptococcus-group-b-screen-at-36-weeks-and-a-weight-gain-of-over-50-pounds-with-a-normal-glucose-challenge-test. .Style-Heading-4-+-Arial-14-pt-Underline}

#### -The patient had a Stage I of 17:40 and a Stage II of 00:23 with delivery of a viable male infant weighing 4407 g with Apgars of 8/9 over a large 4^th^ degree laceration. There was also an extensive left perineal laceration with avulsion. Stage III lasted 00:05 with delivery of an intact placenta. The patient had a standard repair of the 4^th^ degree laceration and a right vulvar skin flap closure of the left perineal laceration in the delivery room. What followed was an unremarkable post partum course. The patient was discharged locally on the 3^rd^ post partum day. The patient remained afebrile throughout with an intact perineal repair and had a normal bowel movement prior to discharge. {#the-patient-had-a-stage-i-of-1740-and-a-stage-ii-of-0023-with-delivery-of-a-viable-male-infant-weighing-4407-g-with-apgars-of-89-over-a-large-4th-degree-laceration.-there-was-also-an-extensive-left-perineal-laceration-with-avulsion.-stage-iii-lasted-0005-with-delivery-of-an-intact-placenta.-the-patient-had-a-standard-repair-of-the-4th-degree-laceration-and-a-right-vulvar-skin-flap-closure-of-the-left-perineal-laceration-in-the-delivery-room.-what-followed-was-an-unremarkable-post-partum-course.-the-patient-was-discharged-locally-on-the-3rd-post-partum-day.-the-patient-remained-afebrile-throughout-with-an-intact-perineal-repair-and-had-a-normal-bowel-movement-prior-to-discharge. .Style-Heading-4-+-Arial-14-pt-Underline}

#### -The patient returned on postpartum day #5 with a temperature of 101.9 degrees F, a tender uterus with an intact perineum, and a WBC of 13.3K. The patient was re-hospitalized for endometritis and treated with metronidazole and ampicillin / sulbactam. The patient defervesced and was discharged home again on post partum day #8. The patient was called back into the hospital within hours of leaving when it was noted that 2 of her blood cultures had become positive.  {#the-patient-returned-on-postpartum-day-5-with-a-temperature-of-101.9-degrees-f-a-tender-uterus-with-an-intact-perineum-and-a-wbc-of-13.3k.-the-patient-was-re-hospitalized-for-endometritis-and-treated-with-metronidazole-and-ampicillin-sulbactam.-the-patient-defervesced-and-was-discharged-home-again-on-post-partum-day-8.-the-patient-was-called-back-into-the-hospital-within-hours-of-leaving-when-it-was-noted-that-2-of-her-blood-cultures-had-become-positive. .Style-Heading-4-+-Arial-14-pt-Underline}

#### The blood cultures positive with what organism? What was the source? {#the-blood-cultures-positive-with-what-organism-what-was-the-source .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### If you have the answer, or other questions please contact me at [**nmurphy@scf.cc**](mailto:nmurphy@scf.cc) {#if-you-have-the-answer-or-other-questions-please-contact-me-at-nmurphyscf.cc .Style-Heading-4-+-Arial-14-pt-Underline}

#### Otherwise we will discuss the 'rest of the story' in the August Medical Mystery Tour. {#otherwise-we-will-discuss-the-rest-of-the-story-in-the-august-medical-mystery-tour. .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

######### Mammography: Is Early Detection Really the Best Form of Prevention?

<http://www.medscape.com/viewarticle/499386?src=nlpromo>

######### 

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

**Benefits of low-fat dairy products on weight loss**

Obesity is increasing in the United States in epidemic proportions.
Epidemiologic data suggest that people with high calcium intake have a
lower prevalence of overweight, obesity, and insulin resistance
syndrome. Studies in transgenic mice have demonstrated that calcium
influences adipocyte metabolism. High calcium intake depresses levels of
parathyroid hormone and 1,25-hydroxy vitamin D. These decreased hormone
levels cause decreases in intracellular calcium, thereby inhibiting
lipogenesis and stimulating lipolysis. High dietary calcium intakes also
increases excretion of fecal fat and may increase core body temperature.
Calcium from dairy products seems to have more of an impact than calcium
from dietary supplements. Primary care providers should include
recommendations about adequate calcium intake in standard dietary
counseling about weight management.

[Schrager
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Schrager+S"%5BAuthor%5D).
Dietary calcium intake and obesity. J Am Board Fam Pract. 2005
May-Jun;18(3):205-10.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15879568&query_hl=4>

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

If the above recommendation work well for your patient's individually,
that is great, otherwise please note that on the order 50 million people
in the US are lactose intolerant as is the majority of our patients and
those worldwide. [Beware]{.underline} the recommendation made by the
authors \"All patients should be encouraged to consume 3 to 4 servings
of low-fat dairy".

**Testosterone Patch Helps Surgically Menopausal With Hypoactive Sexual
Desire: RCT**

CONCLUSION: In surgically menopausal women with hypoactive sexual desire
disorder, a 300 mug/d testosterone patch significantly increased
satisfying sexual activity and sexual desire, while decreasing personal
distress, and was well tolerated through up to 24 weeks of use.

[Buster
JE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Buster+JE"%5BAuthor%5D)
Testosterone patch for low sexual desire in surgically menopausal women:
a randomized trial. Obstet Gynecol. 2005 May;105(5 Pt 1):944-52.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15863529&query_hl=4>

**SSRIs Ineffective for the Management of Hot Flashes**

**Clinical Question:** Are citalopram and fluoxetine effective therapies
for vasomotor symptoms in menopausal women?

**Bottom Line:** Neither citalopram nor fluoxetine improved the
vasomotor symptoms (i.e., hot flashes) of menopausal women more than
placebo. As in other well-designed clinical trials of treatments for hot
flashes, there was a marked placebo effect and improvement in all groups
over time. (Level of Evidence: 1b)
<http://www.aafp.org/afp/20050615/tips/8.html>

**Hormone replacement therapy plummeted after findings from the WHI
trial (AHRQ)**

In the mid-1990s, an estimated 38 percent of postmenopausal women in the
United States used estrogen plus progestin hormone therapy (EPT) or
estrogen therapy alone (ET). On May 31, 2002, the Women\'s Health
Initiative (WHI) study of hormone therapy (HT) in women with an intact
uterus was stopped after an average of 5 years because the risks
associated with the use of HT (breast cancer, coronary heart disease,
and stroke) were found to outweigh the benefits.

By December 31, 2002, 5 months after the trial results were published
(July 9, 2002), 46 percent fewer women were taking EPT compared with the
average proportion of women using EPT 2 years before the results were
published (a decline from 14.6 percent to 7.9 percent). ET use declined
by 28 percent during the same period (from 12.6 percent to 9.1 percent).

These findings are from a study by the HMO Research Network Center for
Education and Research on Therapeutics (CERT) and the HMO Cancer
Research Network. The study was supported in part by the Agency for
Healthcare Research and Quality through funding from its patient safety
program to the CERTs initiative (HS11843). A multicenter research team
used automated pharmacy data to identify all oral and transdermal
estrogen and progestin dispensed to 169,586 women aged 40 to 80 years
who were enrolled in five U.S. health maintenance organizations. The
researchers examined EPT and ET use between September 1, 1999 and June
31, 2002 (baseline) and December 31, 2002 (followup).

Along with the decline in EPT use following published trial results,
there was an immediate decrease in the proportion of women beginning EPT
and ET, from 0.4 percent and 0.3 percent at baseline, respectively, to
0.2 percent for both groups at followup. A striking finding was the high
discontinuation rates among ET users despite the fact that the ET
portion of the WHI trial (for women who had undergone hysterectomies)
was ongoing during the study period. The ET portion of the trial was
stopped on March 4, 2004, due to increased stroke risk. It is unclear
whether the discontinuation of ET reflected women\'s and providers\'
misunderstanding of the HT trial results or a generalization of the HT
findings to ET, note the researchers.

<http://www.ahrq.gov/research/may05/0505RA15.htm#head15>

Buist DS, et al Hormone therapy prescribing patterns in the United
States. Obstet Gynecol. 2004 Nov;104(5 Pt 1):1042-50.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15516400&query_hl=4>

Another AHRQ-supported study on a related topic found that the
prevalence of hormone replacement therapy among Medicaid-insured women
aged 50 and older in all racial groups also decreased significantly
following release of the WHI study findings.

Hillman JJ, Zuckerman IH, Lee E.. The impact of the Women\'s Health
Initiative on hormone replacement therapy in a Medicaid program J Womens
Health (Larchmt). 2004 Nov;13(9):986-92.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15665655&query_hl=6>

#### Midwives Corner: Marsha Tahquechi, CNM, GIMC {#midwives-corner-marsha-tahquechi-cnm-gimc .Style-Heading-4-+-Arial-14-pt-Underline}

**USPSTF Issues Revised Guidelines for Routing Gonorrhea Screening**

The U.S. Preventative Services Task Force (USPSTF) has issued revised
guidelines for routine gonorrhea screening. The new recommendation is in
favor of screening high risk women and against the screening of low risk
women and men. Risk/benefit analysis supports the use of risk assessment
screening rather than routine screening as a cost effective method for
targeting those most likely to have disease.
<http://www.annfammed.org/cgi/content/full/3/3/263>

This publication is available for **CME\***
<http://www.medscape.com/viewarticle/505770?src=hp16.cmecallout>

(See Medscape above for free access)

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

This is an interesting review article on the criteria utilized in
determining a medication's eligibility for over the counter status. It
also provides an historical account of the emergency contraceptive Plan
B. <http://www.medscape.com/viewarticle/505440?src=hp16.lead> \*

(see Medscape section above for tips on how to obtain free access)

**From Jenny Glifort, CNM, ANMC - More CNM News**

**BOOKS: The Nursing Mothers Herbal**

By Jan Weingrad Smith

<http://www.mosby.com/scripts/om.dll/serve?article=as1526952305001339>

**Resources: Evidence-based Practice**

Current Resources for Evidence-Based Practice, July/August 2005

By Carol Sakala

<http://www.mosby.com/scripts/om.dll/serve?article=as1526952305001789>

**National Indian Health Board Conference - Oct. 16-19, 2005 in
Phoenix**

The NIHB Conference info is up on their web site: it\'s Oct. 16-19, 2005
in Phoenix you plan to attend. It\'s not too late to submit an
application to present a workshop. The topic is \"Youth and Tradition -
Our Greatest Resources,\" ...so presentations about birth and
breastfeeding seem particularly appropriate.
<http://www.nihb.org/staticpages/index.php?page=200403301344379533>

**Navajo News, Jean Howe, Chinle**

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

OBJECTIVE: This study\'s objective was to judge whether active
management of the third stage of labor is as effective in reducing
maternal blood loss among rural American Indian women as in randomized
trials.

METHODS: We collected retrospective data on a cohort of largely
multiparous American Indian women having singleton vaginal births at a
rural hospital in 2000-2001, comparing measures of blood loss among
women receiving active (n=62) versus routine (n=113) management of the
third stage of labor. Outcomes included both objective (postpartum
hemoglobin decline) and subjective (estimated blood loss) measures of
maternal blood loss.

RESULTS: Active management was associated with reduced maternal blood
loss on several measures when compared to routine management, including
incidence of a 3 g/dl or greater postpartum hemoglobin decline (5%
versus 27%), mean postpartum hemoglobin decline (1.7 versus 2.2 g/dl),
and mean estimated blood loss (355 versus 430 ml). Compared to women who
received routine management, women who received active management had
87% reduced odds of a 3 g/dl or greater postpartum hemoglobin decline
after adjusting for preeclampsia, manual placental extraction,
laceration repair, and maternal age.

CONCLUSIONS: Our findings suggest that active management of the third
stage is as effective in reducing maternal blood loss among rural
American Indian women as in randomized trials in maternity hospitals.

Fenton JJ, Baumeister LM, Fogarty J Active management of the third stage
of labor among american Indian women. Fam Med. 2005 Jun;37(6):410-4.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15933913&query_hl=1>

**Comment from George Gilson, MFM, Anchorage**

**"Get Active"**

World-wide, postpartum hemorrhage, a readily preventable event, is the
leading cause of maternal death. In the U.S., PPH is likewise an
important cause of maternal morbidity and mortality. There is a
significant body of evidence, now added to by an investigation in an
Indian Health setting, which should urge all of us to implement some
form of \"active management of the third stage of labor\" into our own
practices. It is simple, cost-effective, and can be life-saving.

Active management of the 3^rd^ stage of labor consists of:

-administration of a uterotonic medication after delivery of the
infant\'s shoulders

-early clamping and cutting of the umbilical cord

-application of controlled traction to the cord (Brandt-Anders maneuver)

Active management of the 3^rd^ stage of labor is used to hasten
placental expulsion. It\'s simple, evidence-based, and non-intrusive.
It\'s particularly appropriate in all Indian Health practice settings
that attend births, but do not have access to a large blood bank or
readily available surgical facilities. Hope you will follow the links
above to review the evidence and then \"get active\"!

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

All Indian Health facilities which provide maternity care / labor and
delivery should incorporate the active management of the 3^rd^ stage of
labor into their routine practice guidelines.

The studies reviewed used oxytocin, ergometrine, or a mixture of those
drugs administered intravenously or intramuscularly immediately after
delivery of the infant. A subsequent review found that the combination
of oxytocin and ergometrine resulted in greater reductions in postpartum
blood loss (but not in need for transfusion) compared with oxytocin
alone. However, more adverse effects (e.g., nausea, vomiting,
hypertension) were observed with use of the combined medications. Based
on these reviews, oxytocin appears to be the agent of choice for
third-stage management in low-risk women, because of the incidence of
side effects associated with ergometrine. Hence, one common method is to
administer Oxytocin 10 units intramuscularly.

Trial findings did not substantiate the concerns regarding retained
placenta. Trials using oxytocin alone showed reduced rates of manual
removal of the placenta, whereas those using ergot preparations
demonstrated increased rates. The slight trend of increased manual
removal mentioned in the Cochrane meta-analysis above was entirely due
to the results of the single trial that used intravenous ergot.

Educating obstetric providers about early cord clamping and controlled
cord traction will be necessary in maternity units where active
management is not standard. Other agents, including prostaglandins such
as misoprostol, are currently under investigation for use in the
management of the third stage of labor.

This abstract was forwarded to the CCCC by Larry Leeman, formerly at
Zuni, now at the University of New Mexico. This article was coauthored
by John Fogarty, one of the affiliated FP faculty at Crownpoint IHS.

**[Other links of Interest]{.underline}**

**Cochrane for Clinicians: Putting Evidence into Practice**

<http://www.aafp.org/afp/20030515/cochrane.html>

**eMedicine**

<http://www.emedicine.com/med/topic3569.htm>

**The Cochrane Library**

<http://www.update-software.com/cochrane/abstract.htm>

**Annual Navajo Area Women's Health Provider Meeting**

and

**Upcoming ALSO Course in Shiprock**

The Navajo Area Annual Meeting will be held Friday, September 23^rd^,
from 11am to 3pm in Chinle. It will be preceded by a 9am meeting of the
Four Corners Midwifery Chapter.

Please let me know of any topics that you would like to discuss.

The ALSO course will be held September 24^th^ and 25^th^ in Shiprock.
Registration forms will be available soon from Mary Porvaznik at
Shiprock. [mary.porvaznik@ihs.gov](mailto:Mary.porvaznik@ihs.gov)

For those of you working at federal facilities, please don't forget to
file those travel orders soon, before the fiscal year close out...
Please share this information with any new Women's Health providers that
have joined your teams. Hope to see you there!!

####  {#section-31 .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}

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

On the basis of data for 1995-2002 combined, the target of 4.5 infant
deaths per 1,000 live births had been achieved by few racial/ethnic
populations. During 1995-2002, IMRs declined for all racial/ethnic
populations; however, the decrease for infants of American Indian/Alaska
Native mothers was not statistically significant.

Mathews TJ, Keppel KG. 2005. Racial/ethnic disparities in infant
mortality United States, 1995-2002. Morbidity and Mortality Weekly
Report 54(22):553-556.
[[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5422a1.htm]{.underline}](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5422a1.htm)

####  {#section-32 .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}

**Patient should be capable of talking or singing during exercise during
pregnancy**

Exercise has been recommended as adjunct for diabetic management as well
as weight loss. The current guidelines for exercise, according to the
American College of Sports Medicine, is at least 30 minutes of physical
exertion over the course of a day on most days of the week. As we are a
country that is growing larger and larger (around the waistline), we as
providers are seeing the need for exercise in our patients. If your
patient population is similar to mine, there is a large number of
patients with diabetes and are obese.

**But what about our pregnant patients?**

It is widely accepted that exercise during pregnancy is safe, however;
there are a few guidelines that should be observed. Activities that
increase the risk of falling should prompt counseling the patient about
the risk of abdominal trauma with a fall. Scuba diving is an absolute
contraindication due to the possibility of decompression sickness in the
fetus.

Patients should be evaluated prior to starting an exercise program to
ensure that no preexisting condition exists. ACOG has put out a
Committee opinion that lists absolute and relative contraindications to
aerobic exercise during pregnancy as well as warning signs to terminate
exercising. Patients who are healthy and pregnant should be encouraged
to engage in regular exercise before, during and after a pregnancy.

Exercise during pregnancy and the postpartum period. ACOG Committee
Opinion No. 267. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2002;99:171--173

**Non-ACOG Members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11777528&query_hl=1>

**ACOG members:**

<http://www.acog.org/publications/committee_opinions/co267.cfm>

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

I welcome Dr. Woitte's comments as they echo those of ACOG and emphasize
those of the Indian Health system. Moderate exercise in pregnancy is
recommended in general, and highly recommended in diabetes in pregnancy.
The latter recommendation includes both new onset gestational diabetes
and pre-existing diabetes.

Here is Appendix F from the Diabetes in Pregnancy Guidelines posted on
the Indian Health Clinical Guidelines web site, page 18, for more
details

# [Exercise guidelines to improve glucose control]{.underline}

Type of activities:

Aerobic activities such as walking, stationary cycling, or swimming

Frequency:

At least 3 days per week

Duration:

20-45 minutes per session

Intensity:

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

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

exertion (RPE) exertion level should feel "fairly light" to "somewhat
hard".

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

have snacks nearby if needed.

Initial exercise consult:

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

Supervised exercise:

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

<http://www.ihs.gov/MedicalPrograms/MCH/w/Documents/DMPreg102504_000.doc>

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

**Here is a good web based calcium screening tool**

From Stephen Rudd, Warm Springs, OR

<http://www.eatsmart.org/external/default.asp?URL=/games/c_calculator/>

**Benefits and limitations of quantitative heel ultrasound in screening
for osteoporosis**

The National Osteoporosis Foundation has an excellent, brief review of
the benefits and limitations of quantitative heel ultrasound in
screening for osteoporosis at
<http://www.nof.org/cmeexam/Issue1QUS/QUSOnlineCME.pdf>

 The review complements and supports the approach suggested by Brown and
Finke in the [October
2004](http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV1004.pdf)
issue of the [IHS Primary Care Provider]{.underline} that heel
ultrasound can be used to increase access to osteoporosis screening and
treatment where central DEXA is not available.  However the NOF article
suggests a lower threshold for DEXA following heel ultrasound (DEXA if
less than -1 or between 1 and -1 if there are risk factors) than is
suggested in the algorithm accompanying the article by Brown and Finke.

Osteoporosis screening and management is a rapidly evolving area and one
in which evidence-based strategies must be reviewed frequently and
adjusted to reflect new information. 

Brown SR and Finke B. Osteoporosis and Fracture Prevention in the Indian
Health System: Toward a Public Health Approach.  The IHS Primary Care 
Provider, October 2004;29(10):229-234
<http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV1004.pdf>

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

**Simple Patient Education Handouts**

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

**Endometriosis, from WebMD Health** (\*See Medscape above for free
access)

<http://www.medscape.com/viewarticle/504171?src=sr>

**Guide to Endometriosis**- **[More Printable Patient
FAQ\'s](http://www.medscape.com/pages/editorial/public/index/faq) \***

<http://www.medscape.com/viewarticle/504157?src=sr>

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

**August 1, 2005 Appropriate use of narcotics for chronic non-malignant
(non-cancer) pain**

Moderator: Chuck North\
-Are you comfortable using narcotics to treat chronic pain?\
-Is there abuse of prescription controlled medications in your
community?\
-What controls should health professionals have in place to regulate the
use of controlled substances? \
-Do you use pain contracts?  Are they useful?\
-What services are available to serve your chronic pain patients in
addition to primary care? \
-Are you successful in obtaining mental health services for your
patients?

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

Subscribe to the Primary Care listserv

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

Unsubscribe from the Primary Care listserv

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

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

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

**Can chlamydia be stopped?**

Chlamydia is a rampant sexually transmitted disease, the world\'s
leading cause of preventable blindness and a possible contributor to
heart disease. Recent discoveries are suggesting new ways to curtail its
spread.

David M. Ojcius, Toni Darville and Patrik M. Bavoil Can chlamydia be
stopped? Sci Am. 2005 May;292(5):72-9.

<http://www.sciam.com/article.cfm?articleID=000C5367-144D-1264-944D83414B7F0000>

**Chlamydia trachomatis infection in a colposcopy unit**

An audit of a fast track referral system for infected patients to a
genitourinary medicine department and a survey of patients\' demography,
clinical findings and partner details.

We had previously shown that screening and treating patients for
Chlamydia trachomatis prior to termination of pregnancy significantly
reduces postoperative morbidity. Our success led us to consider
screening women attending our colposcopy unit and this was introduced in
1998. However, it became apparent that a formal protocol was needed for
managing women who had positive results to ensure that all patients and
their partners were adequately treated. An interdepartmental protocol
was devised for fast track referral of infected patients to the
Genitourinary Medicine (GUM) clinic Health Advisor who arranged
immediate treatment and partner notification. A re-audit, presented
here, has shown that the introduction of the protocol has resulted in
all infected patients receiving adequate treatment and partner
notification with minimal use of doctor time or disruption of routine
GUM services. We suggest that our system is effective and could be
extended to other clinics where chlamydia screening is carried out

Blackwell A.1; Linton D.2; Emery S.3; Calvert J.3 [International Journal
of STD & AIDS](http://www.ingentaconnect.com/content/rsm/std), 1 October
2003, vol. 14, no. 10, pp. 661-664(4)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14596768&query_hl=7>

####  {#section-33 .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}

**Waist Circumference Can Exclude Insulin Resistance and Identify Those
At Greatest Risk\
**A waist circumference of less than 39.4in. (100 cm) excludes
individuals of both sexes from being at risk of being insulin resistant.
Although insulin resistance is an important pathogenic factor in common
metabolic disorders, no easy clinical test exists for predicting the
insulin resistance of an individual. Waist circumference is a simple
tool to exclude insulin resistance and to identify those at greatest
risk, therefore those who would benefit most from lifestyle adjustments.

Hans Wahrenberg et al Use of waist circumference to predict insulin
resistance: retrospective study. BMJ 2005;330:1363-1364. 11 June 2005

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15833749&query_hl=1**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15833749&query_hl=1) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15833749query_hl1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Comprehensive Colposcopy course, ASCCP**

-   August 4-7, 2005

-   San Francisco

-   [29 credits](http://www.asccp.org/meetings/comprehensive.shtml),
    American Society for Colposcopy and Cervical Pathology

> <http://www.asccp.org/meetings/comprehensive.shtml>

**Primary Care Provider Training in Addictions**

-   August 8 - 12, 2005

-   Tacoma, WA

-   Alcoholism and Substance Abuse Program Branch (ASAPB), IHS\
    Clinical Training in American Indian/Alaska Native Alcohol and Other
    Drug Abuse\
    Contact Teresa Sappier, Behavioral Health HQE
    <Teresa.Sappier@ihs.gov>

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

#### Treatment and Management of HIV Infection in the United States {#treatment-and-management-of-hiv-infection-in-the-united-states .Style-Heading-4-+-Arial-14-pt-Underline}

#### September 15-18, 2005 {#september-15-18-2005 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Atlanta, Georgia {#atlanta-georgia .Style-Heading-4-+-Arial-14-pt-Underline}

#### 16.5 Credits, Univ. of California @ San Francisco / VA Administration {#credits-univ.-of-california-san-francisco-va-administration .Style-Heading-4-+-Arial-14-pt-Underline}

#### First domestic conference of its kind. Mark your calendar {#first-domestic-conference-of-its-kind.-mark-your-calendar .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

-   October 16-19, 2005

-   Phoenix, AZ

-   Distinguished presenters and informative workshops

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

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

-   May 3--6, 2006

-   Anchorage, Alaska

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

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

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

**Simple Patient Education Handouts**

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

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

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

**Atlas of Heart Disease and Stroke in AI/AN**

<http://www.ihs.gov/MedicalPrograms/MCH/W/WHcvd.asp#atlas>

There are several upcoming **Conferences**

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

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

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

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

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

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

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

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

The **June 2005 OB/GYN CCC Corner** is available at:\
<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0605.cfm>

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

#### Abstract of the Month: page 4 {#abstract-of-the-month-page-4-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Have you had your 'morning after' antiretroviral cocktail yet?

#### From your colleagues: page 6 {#from-your-colleagues-page-6-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Burt Attico: Only Half of Women Requesting Postpartum Sterilization
Undergo the Procedure

#### Carol Ballew: **Community-Based Child Abuse Programs for Tribes and Migrant Workers,** NCAST- AVENUW Institute 2005 - Fri/Sat August 5 & 6, 2005, Seattle, WA  {#carol-ballew-community-based-child-abuse-programs-for-tribes-and-migrant-workers-ncast--avenuw-institute-2005---frisat-august-5-6-2005-seattle-wa .Style-Heading-4-+-Arial-14-pt-Underline}

**Tammy Brown:** Seeking Recipes Using Traditional Foods

**Zelda Collett-Paule:** Prozac is OK in pregnancy, but not for
breastfeeding while Zoloft is

#### Terry Cullen: How to sign up for an Indian Health listserv? Share this with a colleague {#terry-cullen-how-to-sign-up-for-an-indian-health-listserv-share-this-with-a-colleague .Style-Heading-4-+-Arial-14-pt-Underline}

#### George Gilson: Is Gestational Diabetes Mellitus Just a Diagnosis Waiting for a Disease? {#george-gilson-is-gestational-diabetes-mellitus-just-a-diagnosis-waiting-for-a-disease .Style-Heading-4-+-Arial-14-pt-Underline}

**Steve Holve:** Funds for small projects - Community Access To Child
Health (CATCH) Program, June 2005 Highlights: Indian Child Health

#### Chuck North: Perinatal study at Keams 1979: Not previously published {#chuck-north-perinatal-study-at-keams-1979-not-previously-published .Style-Heading-4-+-Arial-14-pt-Underline}

**Phil Smith:** Access to CDC\'s Guide to Community Preventive Services

**Judy Thierry:** Leading Causes of Death Charts / ICD codes:
Enhancement to WISQARS; Ideal for a network supporting women\'s health

**Alan Waxman:** Covering Kids Act of 2005 - Bipartisan legislation

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

##### Obstetrics: page 10

-Slight delay in umbilical cord clamping better for preterm infants

-Public versus Private Umbilical Cord Blood Banking: Editorial Green
Journal

-Pregnancy-Related Changes in Physical Activity, Fitness, and Strength

-Women with hypoglycemia during OGTT have lower incidence of GDM and
neonatal BW

-Does the presence of a funnel increase the risk in a patient with a
short cervix?

-And more...

**Gynecology: page 12**

-More effective than povidone iodine in vaginal hysterectomy:
Chlorhexidine gluconate

-Transdermal contraceptive promising for reducing bleeding and delaying
menses

-Collagen Injections May Be a Reasonable Option for Treating Female
Stress Incontinence

-Menorrhagia and Screening for von Willebrand Disease

-Sexual functioning / quality-of-life outcomes similar in RCT of
supracervical hysterectomy

-And more...

**Child Health: page 13**

-Risk of Autism: Parent, Pregnancy, and Birth Factors Found Possible
Associations

-Screening for Idiopathic Scoliosis in Adolescents: Recommendation
Statement, USPSTF

**Chronic Illness and Disease: page 13**

-Women with pregnancy-induced hypertension: Increased risk of metabolic
syndrome later

-Improving Adherence to Treatment for Hypertension

-American Cancer Society Guidelines for Early Detection of Cancer
Recommendations

-Cognitive Therapy May Be Effective for Moderate to Severe Major
Depression

-Untreated Depression Common in Minority Women With Cancer

#### Features: page 15 {#features-page-15 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician

Pregnant Patients with Lupus Have High Rates of Fetal Loss

American College of Obstetricians and Gynecologists

-Urinary Incontinence in Women: Practice Bulletin

-Ob-Gyns Address Health Needs of Underserved Women With New Publication

-Latest ACOG News on Genetic Disorders, Prenatal Tests, DOs and DON\'Ts,
and Exercise

**Agency for Healthcare Research and Quality**

-Web M+M - Pregnant with Danger

-Most OB/GYNs reluctant to perform first-time cesarean without medical
indications

-Caregiver characteristics influence the hospitalization / discharge of
elderly women

-Sociodemographic factors affect receipt of preventive care services
among women \> 65

**Ask a Librarian**

AskUs Live! Now Available to all Indian Health Staff

**Breastfeeding**

#### -Metformin: neither hypoglycemia nor other adverse effects were observed in 3 infants {#metformin-neither-hypoglycemia-nor-other-adverse-effects-were-observed-in-3-infants .Style-Heading-4-+-Arial-14-pt-Underline}

#### **-Exclusive breastfeeding may reduce postnatal HIV transmission** {#exclusive-breastfeeding-may-reduce-postnatal-hiv-transmission .Style-Heading-4-+-Arial-14-pt-Underline}

**CCC Corner Digest**

-Should we counsel pregnant patients on storage of umbilical cord stem
cells?     

-Medical Mystery Tour - Mystery Question Asked During Post partum
Hemorrhage

-To VBAC, or not to VBAC, that is the question...

-Using the quad screen? (New CME Module) Prenatal Genetic Screening --
Serum and US

-Pelvic Floor Muscle Function and Urinary Incontinence: Role for
Physical Therapy

-Good Screening Tools for Substance Use: 5 P's or 4 P's

-Negative LEEP Is Not Reassuring

-To eat fruit and vegetables or not? Factors in consumers' decisions

-What are the best ways to quit smoking?

-Intrapartum fetal heart rate monitoring, ACOG Practice Bulletin

-Vitamin C reduced premature rupture of the membranes (PROM)

-Antibiotic Tx for Bacterial Vaginosis Does Not Prevent Preterm Birth

-Young age at first sexual intercourse and STIs in adolescents

-There are 1440 minutes in a day. Make 30 of them active

**Domestic Violence**

-McCain introduces safety to Indian Women Act

-PREVENT WORKSHOP: Moving Towards Violence Prevention

**Elder Care News**

-Is your patient with chronic somatic symptoms just depressed**?**

**Family Planning**

-Being overweight may increase the risk of becoming pregnant while using
OCs

**Frequently asked questions**

-Is it standard of care to obtain a 2nd ultrasound on low risk patients
for a fetal survey?

-What is the Indian Health procedure for HIV screening in pregnancy?

-If a pregnant woman is dependent on opiates, can I treat her addiction?

**Hormone Replacement Update**

-Use of Soy Not effective for Menopausal Symptoms

-Management of postmenopausal hot flushes with venlafaxine
hydrochloride: a RCT

-USPSTF Makes Recommendation Against Routine Use of Estrogen

**Information Technology**

-Tribal access to NIH library services

International Health

-Considerable evidence to support reinstatement of symphysiotomy, for
obstructed labour

-International Electives: Maximizing the Opportunity to Learn and
Contribute

#### MCH Alert

-Summer Fun: Surgeon General issues healthy dozen tips for toddlers

-Follow-up testing among children with elevated screening blood lead
levels

-Effectiveness of school based programs to reduce drinking and driving

#### Medical Mystery Tour

-Follow-up: The Case of the Mystery Question

#### Medscape

-The Prevention and Treatment of Osteoporosis: A Review

**Midwives Corner**

-Primary Care for Midwives: Two Resources

#### -Screening for Genital Herpes: USPSTF

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

-Atlas of Heart Disease and Stroke Among American Indians and Alaska
Natives 2005

-WISEWOMAN Works, Vol 2: Success Stories on Empowering Women to Stop
Smoking

**Oklahoma Perspective**

-West Nile Virus in Women

Osteoporosis

-Limitations of Bone Mineral Density Measurements in the Management of
Osteoporosis

-What are the effects of treatments to prevent fractures in
postmenopausal women?

Patient Education

-Post-term Pregnancy: What You Should Know

-Wild is better: Farmed Atlantic and wild Pacific salmon contaminated
with dioxins

Primary Care Discussion Forum

-August 1, 2005: Appropriate use of narcotics for chronic non-cancer
pain

-Fall 2005: Web based Indian Health M + M

STD Corner

-The National STD-related Infertility Prevention Program

-Ectopic Pregnancy / Reproductive Capacity After Chlamydia Positive and
Negative Results

-Chlamydia Screening: Characteristics of Top-Performing Primary Care
Offices

\-[Screening for Gonorrhea: USPSTF Recommendation
Statement](http://lyris.aafp.org/t/177903/6112154/314254/0/)

#### Barbara Stillwater {#barbara-stillwater .Style-Heading-4-+-Arial-14-pt-Underline}

-Study Links Daily Steps to Specific Health Gains, Costs Saved

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

#### What's new on the ITU MCH web pages page 30

-Any new solutions to Nausea and Vomiting in Pregnancy?

New Perinatology Corner Module: Nausea and Vomiting in 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@scf.cc>

or 907 729 3154 (with voicemail)

\*The opinions expressed in the OB/GYN CCC Corner are strictly those of
the authors, and not necessarily those of the Indian Health System, or
the author of this newsletter. If you have any comments, please share
them by joining the Primary Care Discussion Forum where this topic was
recently discussed. To join the Primary Care Listserv, click on
'Subscribe' here
<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdiscuss.asp>

7/16/05