News flash: Not too late to sign up

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

-   June 13-17, 2004 **with separate NRP Course on first morning
    session, 6/13/04**

-   Denver, CO See Save the Dates, below

OB/GYN Chief Clinical Consultant's Corner

Volume 2, No. 5, May 2004

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

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

ACOG Recognizes Vermont and New Hampshire Ob-Gyns for Vaginal Birth
after Cesarean (VBAC) Project: What is the trend in VBAC?

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

**From Barbara Fine:** Impaired Fasting Glucose now starts a 100 mg/dL:
Millions More Have Pre-Diabetes; Native Women with Heart Disease; HRSA
Announces Perinatal Mental Wellness Grant; Scholarships for Native
Health leaders, practitioners, and other individuals committed to
promoting public health for Native American tribes.

**From Bill Green:** Aggressive Lipid Lowering With Statins Better Than
Moderate Lowering** **

From Steve Holve: May Child Health Notes, IHS, Steve Holve:
Bronchiolitis, etc...

From Elaine Locke: Free Job Postings for Indian Facilities Only on ACOG
Career Connection

From Barbara Orcutt: Post-Coital Contraception: Differing opinions and
options discussed

**From Jane Powers:** New Website from IHS / Office for Victims of
Crimes: Child Abuse Training

**From Laura Shelby:** Prevalence of chlamydial and gonococcal
infections among young adults

**From Barbara Stillwater:** Short Women Are At Greater Risk for
Gestational Diabetes; Diabetes doubled after gestational diabetes

**From Judy Thierry:** Breastfeeding and the Risk of Postneonatal Death
in the United States; Patient education for prenatals: I specifically
would like to know what.....; Please tell me how and if genetics clinics
are being run in your area?

**From Mary Wachacha:** Prenatal Patient Education Available in one
click

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

**Obstetrics: page 8**

Skin-to-Skin Contact Beneficial in Healthy Term Newborns: Kangaroo care;
Some treatments for cervical intraepithelial neoplasia increase risk of
PROM; Prenatal exposure to fluoxetine \[Sarafem, Prozac\] results in
poor neonatal adaptation; Maternal Physical Activity May Reduce
Gestational Diabetes Risk; Potential Risk Factors for Gestational
Hypertension Identified; Does Asthma Adversely Affect Pregnancy
Outcomes? Multigene Association Study With Pregnancy Hypertension;
Dental care use and self-reported dental problems in relation to
pregnancy; Maternal dental x-rays linked to increased risk of infant low
birth weight

**Gynecology:** **page 10**

Aromatase and Leiomyoma of the Uterus; Sacral nerve stimulation
effective for fecal incontinence; In vitro-fertilization outcomes
improving in U.S.; Emergency Contraception: Effectiveness of a telephone
prescription service; Metformin Helps Patients with Polycystic Ovary
Syndrome; Benefits and Risks of OCPs Beyond Contraception

###### Child Health: page 11

###### Adolescent Health Issues in Indian Health; Schools: Finding they can raise funds without undermining children\'s diets and health

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

Glucosamine Has a Disease-Modifying Effect on Osteoarthritis; ACS
Guidelines Updated for Detection of Cancer: Cervical, breast,
colorectal, endometrial; Reduce alcohol misuse by adults, including
pregnant women - USPSTF; Pain-free efficacy with sumatriptan in the mild
pain of menstrually associated migraine; Optimal Exercise Duration and
Intensity in Women; Aromatase inhibitors - Use of Letrozole After
Tamoxifen for Breast Cancer; Sibutramine Treatment for Binge-Eating
Disorder

[Features:]{.underline} page 13

**AFP:** Annual Proteinuria Screening Is Not Cost-Effective -- POEM;
Cochrane for Clinicians

Vaginal Estrogen Preparations for Relief of Atrophic Vaginitis; Abnormal
Uterine Bleeding; Impaired Glucose Tolerance and Impaired Fasting
Glucose; Diagnosis and Treatment of Acne;

**ACOG:** Failure of the FDA To Approve OTC Status for Plan B® :Question
of decision's motivation; ACOG Recognizes Vermont and New Hampshire
Ob-Gyns for VBAC Project; Ginger Supplement Helps Relieve
Pregnancy-Related Nausea and Vomiting

**AHRQ:** Do Me a Favor -- Web Morbidity and Mortality

**Breastfeeding:** Is Varicella Vaccination Safe During Lactation?

**Domestic Violence:** Domestic Violence Track at Indian Health
Conference on Women's Issues: August 4-6, 2004, Albuquerque; Intimate
partner violence (IPV) high: Female caregivers of children reported to
CPS

**Elder Care News:** Ultrasound bone assessment is a reliable predictor
of fracture risk

**Frequently asked questions:** What should I do about a pregnant
patient's varicella like rash?

**Hormone Replacement Update**: Estrogen Does Not Prevent Chronic
Disease in Postmenopausal Women With Hysterectomy -- Medscape CME

**Information Technology:** 2004 Technology Conference, Scottsdale, AZ

**International Health:** Guidelines Can Save Lives -- Royal College of
Obstetricians and Gynaecologists (RCOG); Confidential Enquiry into
Stillbirths and Deaths in Infancy (CESDI) and the Confidential Enquiry
into Maternal Deaths (CEMD); National Institute for Clinical Excellence

**MCH Alert:** Oral Health and Health in Women: A Two-Way Relationship

######### Medscape: Emergency Contraceptive Pills and Adolescents (Web Conference) CME

#### Office of Women's Health, CDC: Venous Thromboembolism after Air Travel: Thrombophilia and Oral Contraceptives

**Osteoporosis:** Higher Calcium Intake May Decrease Risk of Kidney
Stones in Younger Women; Vitamin D Use Reduces Risk of Falls in Elderly

**Patient Education:** What Every Pregnant Woman Needs to Know About
Cesarean Delivery; Vaginal Yeast Infections; Vaginal Discharge;
Bacterial Vaginosis

**Primary Care Discussion Forum**: Adolescent Risk Taking Behavior with
Donna Perry is the current discussion; Adult Asthma will begin on August
1, 2004 with Ty Reidhead

#### What's new on the ITU MCH web pages: page 20

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

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

# [Abstract of the Month]{.underline}

**What is the trend in offering vaginal birth after cesarean (VBAC)?**

**ACOG Recognizes Vermont and New Hampshire Ob-Gyns for VBAC Project**

***Philadelphia, PA*** \-- The American College of Obstetricians and
Gynecologists (ACOG) today awarded the annual Wyeth Pharmaceuticals
Section Award to its Vermont and New Hampshire Sections in recognition
of their leadership of the VBAC Project. Concerned with the decline in
the number of hospitals offering vaginal births after cesarean (VBAC),
ob-gyns from both states worked together to develop a project to improve
the safety and delivery of VBACs in their region.

The Vermont/New Hampshire VBAC Project led to the development of
guidelines for the management of VBAC. The guidelines are used to
re-institute VBACs in hospitals that no longer offer them. While VBAC
availability has declined in Vermont and New Hampshire, many patients
who have had previous cesarean sections prefer to attempt to deliver
their babies vaginally but have difficulty finding hospitals who perform
VBACs, says Peter H. Cherouny, MD, chair of the Vermont Section.
\"There's still clearly a demand for VBACs.\"

The project's risk profile of VBAC patients showed that VBACs could be
offered in a safe environment, Dr. Cherouny says. After identifying the
clinical characteristics of patients with low, medium, and high risk for
uterine rupture, a regional institutional classification was developed
that included specific recommendations for the care of VBAC patients at
the different risk levels. Dr. Cherouny points out that the group at low
risk showed fetal and maternal risks similar to what all hospitals deal
with every day with obstetric patients.

Three documents were developed and disseminated from the project: a
patient VBAC education form, a patient consent form for VBAC, and
regional guidelines for hospital management of VBAC. The support for the
project data and new documents is leading to the re-institution of VBAC
in some hospitals, while others are considering the option, according to
Dr. Cherouny.

More than 200 health care professionals and 35 of the 37 hospitals in
Vermont and New Hampshire were involved in the project. Input came from
ob-gyns, nurse managers, certified nurse midwives, anesthesia personnel,
administrators, and insurers throughout the region. Based on the
successful collaborative project, the hospitals have decided to create
the Northern New England Perinatal Quality Improvement Network, a
consortium that will develop other projects geared toward improving
perinatal care in the region. The network's first project will be to
collect patient outcome data on VBAC.

\"This award gives national recognition to the work of many people,
showing that you can start at a grassroots level and have a significant
impact on patient care,\" Dr. Cherouny says.

<http://www.acog.com/from_home/publications/press_releases/nr05-02-04.cfm>

######### Northern New England Perinatal Quality Improvement Network

<http://www.nneob.org/index.php?option=displaypage&itemid=50&op=pagemenu>=

######### VBAC Documents: Consents, Patient Education, Protocol

<http://www.nneob.org/index.php?option=displaypage&Itemid=52&op=page&SubMenu>=

**Emergency Cesarean Delivery: Simulations, Drills, Q/A**

<http://www.nneob.org/index.php?option=displaypage&Itemid=71&op=page&SubMenu>=

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

**What is the trend in offering VBAC?**

There has been a slight swing of the pendulum back to offering selected
VBAC in small and rural hospitals.

[Background]{.underline}: Since 1999 the overall trend had been away
from VBAC, especially since the July 1999 Practice Bulletin, No. 5 that
recommended that emergency delivery be 'immediately available' \*. In
the last few years that swing of the pendulum may be making small
iterative steps back toward VBAC for selected VBAC candidates.

This process involves recognizing different risk levels for VBAC
candidates. e.g., Low risk vs High risk, and triaging patients in small
rural hospitals accordingly. In fact the trend just reached national
prominence when ACOG recognized Vermont and New Hampshire Ob-Gyns for
VBAC Project.

The above approach to prenatal risking requires the entire facility to
change some basic paradigms. One approach to this is the use of
emergency delivery simulations and efforts on how to develop effective
teamwork. As symptomatic uterine rupture is an infrequent event, 0.7%,
one could argue that any facility providing any delivery, no matter how
low risk, should use a similar system-wide approach to careful risk
triage if they plan to offer vaginal delivery, much less cesarean
delivery.

As luck would have it the Indian Health System is on the forefront of
this issue and will have a Keynote Presentation from Michele Lauria --
Maternal Fetal Medicine, Dartmouth University at the upcoming Women's
Health and Maternity Care: Biennial IHS Tribal and Urban (ITU) Meeting
in August in Albuquerque.

It is not too late to sign up for that conference. See below njm

**Women's Health and Maternity Care: Biennial IHS Tribal and Urban (ITU)
Meeting**

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004>

**-Is There Such a Thing as a Low Risk Vaginal Birth after Cesarean
(VBAC)?**

Michele Lauria -- Maternal Fetal Medicine, Dartmouth University

**-Emergency Delivery Simulations: How to Develop Effective Teamwork**

Michele Lauria -- Maternal Fetal Medicine, Dartmouth University

The IHS MCH web site offers the Dartmouth Hitchcock VBAC consent as an
example in our Perinatology Corner VBAC module:
<http://www.ihs.gov/MedicalPrograms/MCH/M/VB01.cfm>

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

Because uterine rupture may be catastrophic, VBAC should be attempted in
institutions equipped to respond to emergencies with physicians
immediately available to provide emergency care

Vaginal Birth After Previous Cesarean Delivery NUMBER 5, JULY 1999
<http://www.acog.org/publications/educational_bulletins/pb005.cfm>

## 

## From your colleagues:

[From Barbara Fine]{.underline}

**Impaired Fasting Glucose now starts a 100 mg/dL: Millions More Have
Pre-Diabetes**

\"Pre-diabetes\" \-- a condition that raises a person\'s risk of
developing type 2 diabetes, heart disease, and stroke \-- is far more
common in America than previously believed About 40 percent of U.S.
adults ages 40 to 74 \-- or 41 million people \-- currently have the
condition, which is marked by blood glucose levels that are higher than
normal but not yet diabetic. Many people with pre-diabetes go on to
develop type 2 diabetes within 10 years.

The new estimate is based on a revised, more accurate definition of
pre-diabetes made by an international expert committee of the American
Diabetes Association (ADA) and published in Diabetes Care in November
2003.

Under previous criteria, it had been estimated that some 20.1 million in
this age group had pre-diabetes.

-   **IFG** is a condition in which the fasting blood sugar level is
    elevated **(100 to 125 mg/dL)** after an overnight fast but is not
    high enough to be classified as diabetes.

-   **IGT** is a condition in which the blood sugar level is elevated
    **(140 to 199 mg/dL)** after a 2-hour oral glucose tolerance test,
    but is not high enough to be classified as diabetes.

-   In a cross-section of U.S. adults aged 40-74 years who were tested
    from 1988 to 1994, 33.8% had IFG, 15.4% had IGT, and 40.1% had
    prediabetes (IGT or IFG or both). Were these percentages applied to
    the 2000 U.S. population, about 35 million adults aged 40-74 would
    have IFG, 16 million would have IGT, and 41 million would have
    prediabetes.

<http://www.cdc.gov/diabetes/pubs/factsheet.htm>

**Native Women with Heart Disease: All expenses paid**

National Conference at UCLA for women heart patients and their families
on July 15-19 and our Science and Leadership Symposium at Mayo Clinic on
October 9 --13. You may want to also circulate online links to these
brochures to your staff, colleagues and tribal health contacts to
promote the Conference and recruit women patient applicants for the
Symposium (please emphasize that Symposium applicants must have
diagnosed heart disease and that it is all-expenses-paid).

Here is the link for the UCLA conference registration brochure:

<http://www.womenheart.org/pdf/Womenheart_UCLA_Web.pdf>

Here is the link to the Mayo Clinic Symposium application brochure:

<http://www.womenheart.org/pdf/mayo_symposium_clinic_04.pdf>

**HRSA Announces Perinatal Mental Wellness Grant**\
This grant program will allow state maternal and child health programs
to launch an intensive multilingual, grassroots public health campaign
to promote mental wellness for mothers and their families, as well as a
better understanding of perinatal depression and its warning signs.
\$1,000,000 is available for 4-5 awards. Applications are due by **June
1**.

**Eligibility**: Any state maternal and child health department and, if
designated by the state Title V agency, any public/private entity.

For more information, contact Janice Berger at (301) 443-9992 or
<jberger@hrsa.gov> or visit
[www.hrsa.gov/grants/preview/mch.htm#hrsa04088](http://www.hrsa.gov/grants/preview/mch.htm#hrsa04088)

Scholarships for Native Health leaders, practitioners, and other
individuals committed to promoting public health for Native American
tribes.

The Center for American Indian Health at the Johns Hopkins Bloomberg
School of Public Health in Baltimore, Maryland is offering a one-week
training institute for Native American health leaders, practitioners,
and other individuals committed to promoting public health for Native
American tribes. The course description and specifics are presented
below. We hope you will share this information with colleagues and
encourage them to apply. Limited scholarships to cover tuition, travel,
and lodging are available.

DATES: 8:30-12, July 7, 8, 9, 12, 13, 2004 (lectures/presentations)

2-4 PM, July 7, 8, 9, 12, 2004 (computer labs)

LOCATION: Johns Hopkins Bloomberg School of Public Health, Baltimore, MD

SCHOLARSHIPS:

Please contact Felicia Frizzell, Training Program coordinator by email,
<ffrizzel@jhsph.edu>

or telephone, (410) 955-6931 to request a scholarship application.
Limited scholarships are available that will cover tuition, travel, and
lodging

REGISTRATION:

Please fill out attached form and fax to the "Attention of Felicia
Frizzell" at, (410) 955-2010 by June 7, 2004. If you have questions
regarding registration, please contact Felicia Frizzell.

[From Bill Green, Albuquerque]{.underline}

**Aggressive Lipid Lowering With Statins Better Than Moderate
Lowering **

[CONCLUSIONS:]{.underline} Among patients who have recently had an acute
coronary syndrome, an intensive lipid-lowering statin regimen provides
greater protection against death or major cardiovascular events than
does a standard regimen. These findings indicate that such patients
benefit from early and continued lowering of LDL cholesterol to levels
substantially below current target levels. Cannon CP, et al Intensive
versus moderate lipid lowering with statins after acute coronary
syndromes. N Engl J Med. 2004 Apr 8;350(15):1495-504

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15007110>

**[From Steve Holve, Pediatric Chief Clinical Consultant]{.underline}**

**May Child Health Notes, IHS,**

Bronchiolitis systematic review with Peds CCC Comments. Many other
updates.

[**http://www.ihs.gov/MedicalPrograms/MCH/C/CHdownloads/IHSPedsMay41504.doc**](http://www.ihs.gov/MedicalPrograms/MCH/C/CHdownloads/IHSPedsMay41504.doc)

[From Elaine Locke, ACOG]{.underline}

Free Job Postings for Indian Facilities Only on ACOG Career Connection

Post your ob-gyn physician jobs for FREE on ACOG's new online career
center. ACOG Career Connection is designed especially for women's health
care professionals and provides job opportunities that are updated
regularly and are targeted specifically to obstetrics and gynecology.
From the ob-gyn's point of view, job searches are free at the ACOG
Career Connection and offer more features and functionality than other
job banks.

Your job posting will be available 24 hours a day, seven days a week to
over 45,000 ACOG members. With ACOG Career Connection you can:

-   Post ob-gyn physician jobs for FREE

-   Target your search to women's healthcare professionals

-   Review résumé database

-   Receive candidate responses immediately online

-   Sign up for e-mailed "Résumé Alerts" when résumés meeting your
    criteria are posted

ACOG Career Connection is part of *HEALTH*e**CAREERS** Network, an
integrated Network of healthcare association job banks. You can post
jobs to over 200 disciplines within the Network. This provides a broad
reach for your position to the most qualified candidates -- association
members -- with volume discount pricing. Only ob-gyn physician positions
in AI/AN hospitals listed under the following disciplines will be posted
for free: General Obstetrics & Gynecology; Gynecological Oncology;
Maternal/Fetal Medicine; Reproductive Endocrinology. Post your jobs
today!

Take a look at the site:

[**http://www.healthecareers.com/site_templates/ACOG/index.asp?aff=ACOG&SPLD=ACOG**](http://www.healthecareers.com/site_templates/ACOG/index.asp?aff=ACOG&SPLD=ACOG)

but to post your ob-gyn physician position for free, or for more
information or, please contact Elaine Locke at 202-863-2596 or e-mail
her at [**Elocke@acog.org**](mailto:Elocke@acog.org)

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

This is an excellent opportunity for Indian Health facilities to
advertise for OB/GYNs. Traditionally the prior ACOG online recruiting
resource would produce dozens of candidates within a very short period
of time.

Due to ACOG continuing commitment to the health of Native American
Women, ACOG is offering this service free of charge to Indian Health
facilities if you contact Elaine Locke at 202-863-2596 or e-mail her at
[**Elocke@acog.org**](mailto:Elocke@acog.org) njm

[From Barbara Orcutt, Tuba City]{.underline}

Post-Coital Contraception: Differing opinions and options discussed

Powerpoint presentation (704k)

[**http://www.ihs.gov/MedicalPrograms/MCH/M/MCHfamPlng.asp#emergcon**](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHfamPlng.asp#emergcon)

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

**New Child Abuse Website from IHS and Office for Victims of Crimes:
Child Abuse Training**

The Project is a coordinated effort between two government agencies
(Office for Victims of Crime and Indian Health Service) to provide
equipment, training, and resources to medical providers within the
Indian Health Service and Tribal programs on the medical evaluation of
child abuse. It is an example of a successful partnership of two federal
agencies that evolved from a pilot project implemented on the Northern
Ute Indian Reservation in Utah in 1995.

The site offers training, course requirements, forms, policies and
procedures, and links of interest.

<http://www.ovccap.ihs.gov/index.asp>

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

**Prevalence of chlamydial and gonococcal infections among young
adults**

CONCLUSIONS: The prevalence of chlamydial infection is high among young
adults in the United States. Substantial racial/ethnic disparities are
present in the prevalence of both chlamydial and gonococcal infections.

Miller WC, Ford CA, Morris M, Handcock MS, Schmitz JL, Hobbs MM, Cohen
MS, Harris KM, Udry JR.Prevalence of chlamydial and gonococcal
infections among young adults in the United States. JAMA. 2004 May
12;291(18):2229-36.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15138245>

**[From Barbara Stillwater, Anchorage]{.underline}**

**Short Women Are At Greater Risk for Gestational Diabetes**

CONCLUSIONS: Women with GDM are shorter than glucose-tolerant women and
have a lower leg-to-height percentage. Consideration of short stature as
a risk factor for GDM is not valid without taking into account the
leg-to-height percentage.

Moses RG, Mackay MT. Gestational diabetes: Is there a relationship
between leg length and glucose tolerance? Diabetes Care. 2004
May;27(5):1033-5.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15111516>

**Diabetes doubled after gestational diabetes**

CONCLUSIONS: The incidence of diabetes among Danish women with previous
diet-treated GDM was very high and had more than doubled over a 10-year
period. This seems to be due to a substantial increase in BMI in women
with GDM.

Lauenborg J et al Increasing incidence of diabetes after gestational
diabetes: a long-term follow-up in a Danish population. Diabetes Care.
2004 May;27(5):1194-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15111544>

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

**Breastfeeding and the Risk of Postneonatal Death in the United
States**

Breastfed children have a lower risk of death between 1 and 12 months of
life, according to the study, \"Breastfeeding and the Risk of
Postneonatal Death in the United States.\" Using 1988 National Maternal
and Infant Health Survey (NMIHS) data representing nearly 9,000
postneonatal deaths in 48 states, the study revealed that breastfed
babies were 20% less likely to die in the postneonatal period (after 28
days). The longer the babies were breastfed, the lower the risk of
postneonatal death. The study suggests that if all US infants were
breastfed, approximately 720 postneonatal deaths could be prevented each
year at little cost or risk.

Breastfeeding and the Risk of Postneonatal Death in the United States,
Aimin Chen and Walter J. Rogan Pediatrics 2004;113 435-439

[[http://pediatrics.aappublications.org/cgi/content/abstract/113/5/e435?etoc]{.underline}](http://pediatrics.aappublications.org/cgi/content/abstract/113/5/e435?etoc)

**as per Alan Waxman, University of New Mexico**

"Given the consistently high postneonatal mortality rate in AI/AN
infants, this would seem to be a very important finding."

**Patient education for prenatals: I specifically would like to know
what.....**

-Manuals or curricula you are using, how you have arranged modules

-How you document patient education,

-Use of surveys, tools pre and post tests.

-Maternal outcomes as relates to whether they had pn educ or not.  If
you are evaluating this

-Risk education -- **modules specifically around alcohol** and tobacco,
DV

-Are you using    TWEAK    CAGE     IHS PRENATAL FORM 866 PN HEALTH
ASSESSMENT

FORM  OR  TACE  OR OTHER

-Special populations -- teen specific focus

Please contact Judy Thierry at: <Judith.Thierry@ihs.gov>

**Please tell me how and if genetics clinics are being run in your
area?**

-Who, what, where, when (how often), and how -- multidisciplinary with
or with out educational professionals.

-Treatment plans and followup if any?

-Linked with local providers or helicopter-in approach or referred out?

-Any info would be greatly appreciated.

Please contact Judy Thierry at: <Judith.Thierry@ihs.gov>

**[From Mary Wachacha, HQE]{.underline}**

**Prenatal Patient Education Available in one click**

I would like to bring to everyone's attention that the IHS has a
national committee that looks at the education (i.e., patient education)
that is provided within the I/T/Us -- and, of course, this includes all
prenatal education.  This national committee is responsible for *any and
all patient* education that is provided to our clients.  That education
is documented and coded via RPMS, Health Factors, etc. using the IHS
Patient Education Protocols and Codes (PEPC).  The PEPC's are the only
nationally recognized method of documentation and coding that is
recognized IHS-wide and as such, we certainly want to meet the needs of
prenatal education.  If you have not looked at the IHS Protocols and
Codes, you can do so by going to [www.ihs.gov](http://www.ihs.gov/) and
clicking on "Nation wide Programs and Initiative" and then looking in
the upper right hand corner and you will see "Patient Education
Protocols and Code Manual."

<http://www.ihs.gov/NonMedicalPrograms/HealthEd/Protocols/2003_bh.pdf#page=1>

or

[www.ihs.gov/NonMedicalPrograms/HealthEd/index.cfm?module=initiative&option=protocols&newquery=dsp_NatlPatientEd_Protocols.cfm](http://www.ihs.gov/NonMedicalPrograms/HealthEd/index.cfm?module=initiative&option=protocols&newquery=dsp_NatlPatientEd_Protocols.cfm)

This committee is holding their single, annual meeting the week of June
21-25, 2004 in Portland, OR.  We would certainly welcome any suggestions
on any changes needed for any new topics suggested for prenatal
education.  Please remember that this is a generic method of documenting
prenatal education.  I have met with group that is looking at improving
your prenatal education, we have approached this group to determine if
someone would like to attend our meetings.  In the past, we have not had
any representation from the prenatal group, but we would certainly
welcome your participation.  If you have suggestions/changes, we welcome
you to attend our meeting in Portland.  Please contact me, I may be able
to pay travel <Mary.Wachacha@ihs.gov>

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

**[Obstetrics]{.underline}**

**Skin-to-Skin Contact Beneficial in Healthy Term Newborns: Kangaroo
care**

[BACKGROUND:]{.underline} The method of skin-to-skin contact (kangaroo
care \[KC\]) has shown physiologic, cognitive, and emotional gains for
preterm infants; however, KC has not been studied adequately in term
newborns. AIMS: To evaluate the effect of KC, used shortly after
delivery, on the neurobehavioral responses of the healthy newborn.

[STUDY DESIGN:]{.underline} A randomized, controlled trial using a table
of random numbers. After consent, the mothers were assigned to 1 of 2
groups: KC shortly after delivery or a no-treatment standard care
(control group). SUBJECTS: Included were 47 healthy mother-infant pairs.
KC began at 15 to 20 minutes after delivery and lasted for 1 hour.
Control infants and KC infants were brought to the nursery 15 to 20 and
75 to 80 minutes after birth, respectively.

[RESULTS:]{.underline} During a 1-hour-long observation, starting at 4
hours postnatally, the KC infants slept longer, were mostly in a quiet
sleep state, exhibited more flexor movements and postures, and showed
less extensor movements.

[CONCLUSIONS]{.underline}: KC seems to influence state organization and
motor system modulation of the newborn infant shortly after delivery.
The significance of our findings for supportive transition from the womb
to the extrauterine environment is discussed. Medical and nursing staff
may be well advised to provide this kind of care shortly after birth.

Ferber SG, Makhoul IR The effect of skin-to-skin contact (kangaroo care)
shortly after birth on the neurobehavioral responses of the term
newborn: a randomized, controlled trial. Pediatrics. 2004
Apr;113(4):858-65.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15060238>

**Some treatments for cervical intraepithelial neoplasia increase risk
of PROM**

CONCLUSIONS: LEEP and laser cone treatments were associated with
significantly increased risk of pPROM. Careful consideration should be
given to treatment of CIN in women of reproductive age, especially when
treatment might reasonably be delayed or targeted to high-risk cases.
Sadler L, Saftlas A, Wang W, Exeter M, Whittaker J, McCowan L Treatment
for cervical intraepithelial neoplasia and risk of preterm delivery.
JAMA. 2004 May 5;291(17):2100-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15126438>

**Prenatal exposure to fluoxetine \[Sarafem, Prozac\] results in poor
neonatal adaptation**

\* Third trimester exposure to therapeutic doses of fluoxetine (20-80
mg/day orally) is associated with an increased incidence of poor
neonatal adaptation (e.g., jitteriness, hypoglycemia, hypothermia, poor
tone, respiratory distress, weak or absent cry, diminished pain
reactivity, or desaturation with feeding).

\* The evidence suggests that developmental toxicity can also occur in
the form of shortened gestational duration and reduced birthweight at
term.

\* There is sufficient evidence that fluoxetine can produce reproductive
toxicity in men and women as manifested by reversible, impaired sexual
function, specifically orgasm.

\* The mechanism by which fluoxetine can cause reproductive and
developmental toxicity is unknown.

\* There are insufficient data to draw conclusions about drug-induced
toxicity in infants exposed to fluoxetine through breast milk or about
children on fluoxetine therapy.

[[http://cerhr.niehs.nih.gov/news/fluoxetine/index.html]{.underline}](http://cerhr.niehs.nih.gov/news/fluoxetine/index.html).

**Maternal Physical Activity May Reduce Gestational Diabetes Risk**

Physical activity during pregnancy was also associated with reductions
in gestational diabetes mellitus risk. Women who engaged in physical
activity during both time periods experienced a 69% reduced risk (RR =
0.31, 95% CI: 0.12, 0.79). Findings suggest efforts to increase maternal
physical activity may contribute to substantial reductions in
gestational diabetes mellitus risk.

Dempsey JC et al Prospective study of gestational diabetes mellitus risk
in relation to maternal recreational physical activity before and during
pregnancy. Am J Epidemiol. 2004 Apr 1;159(7):663-70.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15033644>

**Potential Risk Factors for Gestational Hypertension Identified**

Women born before gestational week 37 had a 2-fold risk for gestational
hypertension in their first pregnancy. Women with gestational
hypertension and preeclampsia also had higher waist circumference,
waist/hip ratio, and body mass index, as well as increased serum insulin
levels and lower glucose/insulin ratio than women with previous
normotensive pregnancy. The associations remained after adjustment for
participant\'s own birth weight or gestational age.

Pouta A, Manifestations of metabolic syndrome after hypertensive
pregnancy. Hypertension. 2004 Apr;43(4):825-31.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14981067>

**Does Asthma Adversely Affect Pregnancy Outcomes?**

More severe forms of asthma are associated with intrauterine growth
restriction, possibly caused by fetal hypoxia. These findings validate
recommendations to treat pregnant asthmatic patients with beta agonists.
Conversely, preterm delivery appears to be related to treatment with
oral steroids or theophylline rather than to the severity of asthma. A
surprising finding was that one third of women without asthma in the
control group reported symptoms consistent with asthma. Bracken MB, et
al. Asthma symptoms, severity, and drug therapy: a prospective study of
effects on 2205 pregnancies. Obstet Gynecol October 2003;102:739-52.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14551004>

**Multigene Association Study With Pregnancy Hypertension**

This study addressed two main purposes: to validate previously published
associations related to preeclampsia and chronic essential hypertension
by examining ten different polymorphisms in nine genes, from nine
different studies; and to determine whether polymorphisms previously
found to be associated with preeclampsia are associated with essential
hypertension and vice versa.
<http://www.cdc.gov/genomics/hugenet/ejournal/AGT.htm>

**Dental care use and self-reported dental problems in relation to
pregnancy.**

**Objectives:** We examined the relationships between risk factors
amenable to intervention and the likelihood of dental care use during
pregnancy.\
**Methods:** We used data from the Washington State Department of
Health\'s Pregnancy Risk Assessment Monitoring System.\
**Results:** Of the women surveyed, 58% reported no dental care during
their pregnancy. Among women with no dental problems, those not
receiving dental care were at markedly increased risk of having received
no counseling on oral health care, being overweight, and using tobacco.
Among women who received dental care, those with dental problems were
more likely to have lower incomes and Medicaid coverage than those
without dental problems.\
**Conclusions:** There is a need for enhanced education and training of
maternity care providers concerning oral health in pregnancy.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15117698>

**Maternal dental x-rays linked to increased risk of infant low birth
weight**

CONCLUSION: Dental radiography during pregnancy is associated with low
birth weight, specifically with term low birth weight. DESIGN: A
population-based case-control study.

Hujoel PP, Bollen AM, Noonan CJ, del Aguila MA. Antepartum dental
radiography and infant low birth weight. JAMA. 2004 Apr
28;291(16):1987-93.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15113817>

**Assisted Reproductive Technology Surveillance \-\-- United States,
2001, CDC**

[[http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5301a1.htm]{.underline}](http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5301a1.htm)

**[Gynecology]{.underline}**

**Aromatase and Leiomyoma of the Uterus**

In leiomyoma of the uterus, both aromatase and 17beta-hydroxysteroid
dehydrogenase (17beta-HSD) type I are overexpressed compared with
myometrium. This suggests that leiomyoma cells convert circulating
androstenedione into estrone (via aromatase), then into the active form
of estrogen, estradiol (via 17beta-HSD type I). In vitro experiments and
several clinical findings support the notion that in situ estrogen plays
a role in leiomyoma growth under hypoestrogenemic conditions, such as
natural menopause and therapy with gonadotropin-releasing hormone (GnRH)
agonists. GnRH agonists abolish estrogen production both in situ in
leiomyoma and in the ovary, leading to quick and profound regression of
the leiomyoma. Aromatase inhibitors also inhibit estrogen synthesis in
both leiomyoma and the ovary and may be used therapeutically. Certain
doses of competitive aromatase inhibitors would completely inhibit
estrogen production in leiomyoma, whereas ovarian production of estrogen
would continue at reduced levels. This may lead to advantageous
therapeutic conditions in which leiomyoma regresses without adverse
symptoms related to estrogen depletion because levels of ovarian
estrogen would be insufficient to support leiomyoma growth but
sufficient to prevent symptoms associated with deficiency. This article
discusses the potential uses of aromatase inhibitors. Shozu M, Murakami
K, Inoue M.Aromatase and leiomyoma of the uterus. Semin Reprod Med. 2004
Feb;22(1):51-60.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15083381>

**Sacral nerve stimulation effective for fecal incontinence**

[INTERPRETATION:]{.underline} Sacral nerve stimulation greatly improves
continence and quality of life in selected patients with morphologically
intact or repaired sphincter complex offering a treatment for patients
in whom treatment options are limited.

Matzel KE et al Sacral spinal nerve stimulation for faecal incontinence:
multicentre study. Lancet. 2004 Apr 17;363(9417):1270-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15094271>

**In vitro-fertilization outcomes improving in U.S.**

[CONCLUSIONS:]{.underline} Since 1997 in the United States, there have
been consistent decreases in both the number of embryos transferred per
cycle and the percentage of pregnancies with three or more fetuses, as
well as a consistent increase in the percentage of live births per
cycle.

Jain T, Missmer SA, Hornstein MD. Trends in embryo-transfer practice and
in outcomes of the use of assisted reproductive technology in the United
States. N Engl J Med. 2004 Apr 15;350(16):1639-45.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15084696>

**Emergency Contraception: Effectiveness of a telephone prescription
service**

Between February 12, 2002, and June 30, 2003, DIAL EC provided 9,745
prescriptions to 7,774 callers. Most callers (84%) received only one
prescription over the entire duration of the project.

The number of prescriptions issued per month increased steadily over the
course of the project until January 2003, when an abrupt reduction
occurred concurrent with the start of charging for services.

Most calls resulting in prescriptions were prompted by either a broken
condom (43%), failure to use any contraception (42%), or missed oral
contraceptive pills (6%).

The most common source of information about the service was from Planned
Parenthood staff.

This data allay concerns that repeated or \'excessive\' use will be
common: over the 20 months of the project, only 16% of our callers
received more than one prescription, and only 5% received more than two.
Furthermore, callers who were young or poorly educated were not more
likely than older or more educated callers to use the service more than
once.

Raymond EG, Spruyt A, Bley K. 2004. The North Carolina DIAL EC project:
Increasing access to emergency contraceptive pills by telephone.
Contraception 69(5):367-372.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15105058>

**Metformin Helps Patients with Polycystic Ovary Syndrome**

DESIGN: Systematic review and meta-analysis. DATA SOURCES: Randomised
controlled trials that investigated the effect of metformin compared
with either placebo or no treatment, or compared with an ovulation
induction agent. CONCLUSIONS: Metformin is an effective treatment for
anovulation in women with polycystic ovary syndrome. Its choice as a
first line agent seems justified, and there is some evidence of benefit
on variables of the metabolic syndrome. No data are available regarding
the safety of metformin in long term use in young women and only limited
data on its safety in early pregnancy. It should be used as an adjuvant
to general lifestyle improvements and not as a replacement for increased
exercise and improved diet.

Lord JM, et al. Metformin in polycystic ovary syndrome: systematic
review and meta-analysis. BMJ October 25, 2003;327:951-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14576245>

**Benefits and Risks of OCPs Beyond Contraception**

Using a clinical vignette of a healthy, nonsmoking 35-year-old woman who
wants information about oral contraceptive pills (OCPs), Petitti reviews
the risks and benefits that figure into each decision about the use of
these agents. Petitti DB. Combination estrogen-progestin oral
contraceptives. N Engl J Med October 9, 2003;349:1443-50.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14534338>

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

## Adolescent Health Issues in Indian Health

School Based Health: Donna Perry, Susie John, and others

Adolescent Issues: Steve Holve and Donna Perry

...plus Sexually Transmitted Diseases, Contraception, and more....

All these and more can be found at the .....

**2004 Biennial Native Women's meeting: Prevention in Women's Health**

August 4-6, 2004

Albuquerque, New Mexico

Great CEU /CME, plus good networking for leaders of MCH

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

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004>

###### Schools: Finding they can raise funds without undermining children\'s diets and health

Everyone has assumed that schools can only raise funds in vending
machines and similar venues if they sell low-nutrition foods. However,
as schools are making improvements to their food and beverage offerings,
many are finding that they can raise funds without undermining
children\'s diets and health.\
We know of 14 schools around the country (in California, Kentucky,
Maine, Massachusetts, Minnesota, Mississippi, Montana, and Pennsylvania)
that have measured revenue before and after improving the nutritional
quality of their foods, and not one of them lost money. While this far
from a national study, it is a clear and encouraging pattern.

See <http://cspinet.org/new/pdf/school_vending_machine_case_studies.pdf>
for a list and description of what they have done.\
And in the long run, it certainly makes no sense to fund schools at the
expense of children\'s diets and health. As a society we are sure to
spend more money treating the resulting obesity, diabetes, and
osteoporosis than schools could ever hope to raise by selling junk food
to children.\
It\'s encouraging that schools are able to fund important programs in
ways that support both education and health.

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

Glucosamine Has a Disease-Modifying Effect on Osteoarthritis 

CONCLUSION: This analysis, focusing on a large cohort of postmenopausal
women, demonstrated for the first time that a pharmacological
intervention for OA has a disease-modifying effect in this particular
population, the most frequently affected by knee OA.

DESIGN: This study consisted of a preplanned combination of two
three-year, randomized, placebo-controlled, prospective, independent
studies evaluating the effect of glucosamine sulfate on symptoms and
structure

Bruyere O et al.Glucosamine sulfate reduces osteoarthritis progression
in postmenopausal women with knee osteoarthritis: evidence from two
3-year studies. Menopause. 2004 Mar-Apr;11(2):138-43.\
[**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15021442**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15021442)

ACS Guidelines Updated for Detection of Cancer: Cervical, breast,
colorectal, endometrial

The American Cancer Society (ACS) has released its annual
recommendations for the early detection of cancer. Cervical, breast,
colorectal, endometrial

<http://caonline.amcancersoc.org/cgi/content/full/54/1/41>.

**Reduce alcohol misuse by adults, including pregnant women**

USPSTF recommends screening and behavioral counseling in primary care
settings to reduce alcohol misuse by adults, including pregnant women.

#### Summary of Recommendations

-   The U.S. Preventive Services Task Force (USPSTF) recommends
    screening and behavioral counseling interventions to reduce alcohol
    misuse (go to [Clinical
    Considerations](http://www.ahrq.gov/clinic/3rduspstf/alcohol/alcomisrs.htm#clinical))
    by adults, including pregnant women, in primary care settings.

> **Rating: [B
> Recommendation](http://www.ahrq.gov/clinic/3rduspstf/ratings.htm#brec).**
>
> *Rationale*: The USPSTF found good evidence that screening in primary
> care settings can accurately identify patients whose levels or
> patterns of alcohol consumption do not meet criteria for alcohol
> dependence, but place them at risk for increased morbidity and
> mortality, and good evidence that brief behavioral counseling
> interventions with followup produce small to moderate reductions in
> alcohol consumption that are sustained over 6- to 12-month periods or
> longer. The USPSTF found some evidence that interventions lead to
> positive health outcomes 4 or more years post-intervention, but found
> limited evidence that screening and behavioral counseling reduce
> alcohol-related morbidity. The evidence on the effectiveness of
> counseling to reduce alcohol consumption during pregnancy is limited;
> however, studies in the general adult population show that behavioral
> counseling interventions are effective among women of childbearing
> age. The USPSTF concluded that the benefits of behavioral counseling
> interventions to reduce alcohol misuse by adults outweigh any
> potential harms.

-   The USPSTF concludes that the evidence is insufficient to recommend
    for or against screening and behavioral counseling interventions to
    prevent or reduce alcohol misuse by adolescents in primary care
    settings.

> **Rating: [I
> Recommendation](http://www.ahrq.gov/clinic/3rduspstf/ratings.htm#irec).**
>
> *Rationale*: The USPSTF found limited evidence evaluating the
> effectiveness of screening and behavioral counseling interventions in
> primary care settings to prevent or reduce alcohol misuse by
> adolescents. The USPSTF concluded that the evidence is insufficient to
> assess the potential benefits and harms of screening and behavioral
> counseling interventions in this population.

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

**Pain-free efficacy with sumatriptan in the mild pain of menstrually
associated migraine**

METHODS: A randomized, double-blind, placebo-controlled, single-attack
study was conducted

CONCLUSION: Sumatriptan 50-mg and 100-mg tablets are generally well
tolerated and effective in providing pain-free relief and relief of the
associated symptoms of menstrually associated migraine when administered
in the mild pain phase.

Nett R, et al. Pain-free efficacy after treatment with sumatriptan in
the mild pain phase of menstrually associated migraine. Obstet Gynecol
October 2003;102:835-42.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14551015>

**Optimal Exercise Duration and Intensity in Women**

CONCLUSIONS: Significant weight loss and improved cardiorespiratory
fitness were achieved through the combination of exercise and diet
during 12 months, although no differences were found based on different
exercise durations and intensities in this group of sedentary,
overweight women. Jakicic JM, et al. Effect of exercise duration and
intensity on weight loss in overweight, sedentary women. A randomized
trial. JAMA September 10, 2003;290:1323-30.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12966123>

**Aromatase inhibitors - Use of Letrozole After Tamoxifen for Breast
Cancer**

METHODS: We conducted a double-blind, placebo-controlled trial to test
the effectiveness of five years of letrozole therapy in postmenopausal
women with breast cancer who have completed five years of tamoxifen
therapy.

The estrogen-receptor blocker tamoxifen has been shown to approximately
halve the cancer recurrence rate when taken for five years after surgery
for early-stage breast cancer. However, increased rates of adverse
events occur if tamoxifen therapy continues beyond five years. Aromatase
inhibitors, which block the synthesis of estrogen, have been used for
treatment of metastatic breast cancer. Goss and colleagues present data
on the use of an aromatase inhibitor, letrozole, for prevention of
breast cancer recurrence in women who have completed five years of
tamoxifen therapy.

The authors conclude that the use of letrozole after five years of
tamoxifen therapy decreases the rates of ipsilateral breast cancer
recurrence and new contralateral breast cancer by almost one half after
a median of 2.4 years of treatment.

Goss PE, et al. A randomized trial of letrozole in postmenopausal women
after five years of tamoxifen therapy for early-stage breast cancer. N
Engl J Med November 6, 2003;349:1793-802.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14551341>

**Sibutramine Treatment for Binge-Eating Disorder**

CONCLUSIONS: Sibutramine is effective and well tolerated in the
treatment of obese patients with BED. Its effects address 3 main domains
of the BED syndrome, ie, binge eating, weight, and related depressive
symptoms.

Appolinario JC, et al. A randomized, double-blind, placebo-controlled
study of sibutramine in the treatment of binge-eating disorder. Arch Gen
Psychiatry November 2003;60:1109-16.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14609886>

##### Features

## American Family Physician\*\*

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

###### Annual Proteinuria Screening Is Not Cost-Effective

Is annual proteinuria screening in adults cost-effective? (i.e.,
diabetes and hypertension)

**Bottom Line:** Annual screening of adults to detect proteinuria and
prevent end-stage renal disease is not cost-effective unless directed
only at high-risk groups (i.e., patients with diabetes and
hypertension). Screening every 10 years beginning at 60 years of age,
however, is highly cost-effective. (Level of Evidence: 1b)
<http://www.aafp.org/afp/20040415/tips/3.html>

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

**Cochrane for Clinicians**

**Vaginal Estrogen Preparations for Relief of Atrophic Vaginitis**

A 60-year-old woman presents with vaginal dryness and dyspareunia. She
has declined systemic hormone therapy because of concerns about
potential complications.

Clinical Question

Should we prescribe a vaginal estrogen preparation for relief of
atrophic vaginitis?

Evidence-Based Answer

Vaginal estrogen preparations are safe and effective as short-term
treatment in patients with vaginal atrophy who are not candidates for
systemic hormone therapy. Compared with estradiol products, conjugated
equine estrogen creams may be associated with a higher incidence of
adverse effects. Women may prefer the estradiol-releasing vaginal ring
over other delivery systems.
<http://www.aafp.org/afp/20040501/cochrane.html>

**Abnormal Uterine Bleeding**

Medical management of anovulatory dysfunctional uterine bleeding may
include oral contraceptive pills or cyclic progestins. Menorrhagia is
managed most effectively with nonsteroidal anti-inflammatory drugs or
the levonorgestrel intrauterine contraceptive device. Surgical
management may include hysterectomy or less invasive, uterus-sparing
procedures.

<http://www.aafp.org/afp/20040415/1915.html>

**Patient Education: Abnormal Uterine Bleeding**

<http://www.aafp.org/afp/20040415/1931ph.html>

**Impaired Glucose Tolerance and Impaired Fasting Glucose**

When the diagnosis of impaired glucose tolerance or impaired fasting
glucose is made, physicians should counsel patients to lose 5 to 7
percent of their body weight and engage in moderate physical activity
for at least 150 minutes per week. Drug therapy with metformin or
acarbose has been shown to delay or prevent the onset of diabetes.
However, medications are not as effective as lifestyle changes, and it
is not known if treatment with these drugs is cost effective in the
management of impaired glucose tolerance

<http://www.aafp.org/afp/20040415/1961.html>

**Editorial: Metabolic Syndrome: Early Identification / Proactive
Approach Are Warranted**

<http://www.aafp.org/afp/20040415/editorials.html>

**Patient Education: Taking Steps to Prevent Type 2 Diabetes**

<http://www.aafp.org/afp/20040415/1971ph.html>

**Diagnosis and Treatment of Acne**

<http://www.aafp.org/afp/20040501/2123.html>

**Patient Education: Acne**

<http://www.aafp.org/afp/20040501/2135ph.html>

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

##### ACOG

**Failure of the FDA To Approve OTC Status for Plan B® : Question of
decision's motivation**

*Washington, DC* \-- The American College of Obstetricians and
Gynecologists (ACOG) finds the US Food and Drug Administration\'s
failure to approve over-the-counter status for Plan B®, despite the
nearly unanimous recommendation of its own advisory panels, morally
repugnant.

The Food and Drug Administration\'s (FDA\'s) action is a tragedy for
American women, and a dark stain on the reputation of an evidence-based
agency like the FDA.

This decision to ignore an advisory panel\'s assessment of the
scientific evidence is not only rare, but it gives credence to recent
criticisms that political interference is hampering scientific review
within federal agencies today.

In December 2003, two FDA expert advisory panels overwhelmingly
recommended approval of the drug by a 23-to-4 vote, after reviewing more
than 15,000 pages of clinical data from approximately 40 studies
submitted with the over-the-counter (OTC) application. The FDA typically
follows the recommendations of the scientific committees. These experts
made clear that EC is safe and that it does not increase promiscuity or
unprotected sex among teenaged women, nor does it cause women to abandon
their regular birth control methods.

There is a public health imperative in this country to increase access
to EC. Accidents and coercion happen, and post-coital contraception must
be made readily available to reduce unintended pregnancy and abortion
rates.

ACOG and other organizations have estimated that greater access to
emergency contraceptives could significantly reduce the US abortion
rate. Everyone should support measures that help decrease the number of
abortions in the US. The FDA, by failing to take action based on sound
scientific evidence, apparently does not.

Women\'s need for effective contraception will not go away, and neither
will Plan B®. Until such time as the FDA acts upon the sound scientific
evidence at its disposal, ACOG will step up its public education
campaign, \"Every Woman, Every Visit.\" We will continue to urge that
ob-gyns across the nation provide advance prescriptions for EC to all
reproductive age women at every office visit. Through the media, which
has been so effective in promoting awareness of EC, we will also remind
women to ask their doctor for advance prescriptions for EC.

ACOG\'s campaign, while it increases access to EC for many women,
represents only a fraction of what might have been accomplished had the
FDA approved widespread OTC status for Plan B®. We fervently hope that
this shameful episode in FDA history will pass and that respect for
scientific evidence will prevail once again at the FDA. By Vivian M.
Dickerson, MD, ACOG President

<http://www.acog.org/from_home/publications/press_releases/nr05-07-04.cfm>

**ACOG Recognizes Vermont and New Hampshire Ob-Gyns for VBAC Project**

Also see full text above in Abstract of the Month

[[http://www.acog.com/from_home/publications/press_releases/nr05-02-04.cfm]{.underline}](http://www.acog.com/from_home/publications/press_releases/nr05-02-04.cfm)

**Ginger Supplement Helps Relieve Pregnancy-Related Nausea and
Vomiting**

[[http://www.acog.com/from_home/publications/press_releases/nr03-29-04-2.cfm]{.underline}](http://www.acog.com/from_home/publications/press_releases/nr03-29-04-2.cfm)

##### AHRQ

**Do Me a Favor -- Web Morbidity and Mortality**

A 26-year-old gravida 4 para 1 woman reported that her last menstrual
period was 5 weeks prior, and she had a positive home pregnancy test.
With a history of one ectopic pregnancy, one normal vaginal delivery,
and one spontaneous abortion (miscarriage) at 6 weeks, she was concerned
about a repeat ectopic pregnancy. The patient was a nurse who worked at
the hospital and was friends with one of the obstetrics/gynecology
residents. She asked the resident to perform a transvaginal ultrasound
to check for an intrauterine pregnancy and rule out an ectopic
pregnancy.

The resident brought the patient into the antenatal testing room without
notifying the nursing staff or registering the patient. A transvaginal
ultrasound was done, which did find an intrauterine pregnancy; neither
the findings nor the patient\'s condition was documented in the medical
record. The vaginal probe was not cleaned appropriately after the
procedure.

The charge nurse on the floor noticed that the bed in the antenatal
testing room had been used. On inquiry, she could not find a patient who
had been admitted to that room. Ultimately, she asked the resident, who
revealed that he had scanned his friend.

For the rest of the story, go here:
<http://www.webmm.ahrq.gov/cases.aspx?ic=58>

##### Breastfeeding

**Is Varicella Vaccination Safe During Lactation?**

The authors conclude that no evidence was found of varicella virus
excretion in breast milk or of other transmission of virus to infants
when mothers were vaccinated postpartum. They encourage physicians to
identify susceptible women during pregnancy and ensure postpartum
vaccination.

Bohlke K, et al. Postpartum varicella vaccination: is the vaccine virus
excreted in breast milk? Obstet Gynecol November 2003;102:970-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14672472>

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

**Domestic Violence Track at Indian Health Conference on Women's Issues:
August 4-6, 2004, Albuquerque, NM (see below\*)**

Donald Clark and Rachel Locker will lead a series of sessions on
violence against Native

Women. In addition, Bonnie Duran, University of New Mexico, will also
present on Child maltreatment prevalence and mental disorders outcomes
among American Indian women in primary care.

Duran B, Malcoe LH, Sanders M, Waitzkin H, Skipper B, Yager J.Child
maltreatment prevalence and mental disorders outcomes among American
Indian women in primary care. Child Abuse Negl. 2004 Feb;28(2):131-45.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15003398>

**\*Women's Health and Maternity Care: Biennial IHS Tribal and Urban
(ITU) Meeting**

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004>

**Intimate partner violence (IPV) high: Female caregivers of children
reported to CPS**

High prevalence of IPV among the female caregivers in the present study
underscores the importance of . . .efforts \[to reform child protective
services in order to address issues arising from IPV\] and highlights
the need for effective screening and identification of IPV in families
referred to child protective services.

Hazen AL, Connelly CD, Kelleher K, et el. 2004. Intimate partner
violence among female caregivers of children reported for child
maltreatment. Child Abuse & Neglect 28(3):301-319.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15066348>

**2 New Provider Education resources available on IHS DV web site**

Documenting Intimate Partner Violence/ Domestic Violence: RPMS -- Denise
Grenier

<http://www.ihs.gov/MedicalPrograms/MCH/W/WHdownloads/CimtacIpvDvExamCodeApril132004.ppt>

Domestic violence: A Health Care Epidemic: Rachel Locker

<http://www.ihs.gov/MedicalPrograms/MCH/W/DV06.cfm>

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

**Ultrasound bone assessment is a reliable predictor of fracture risk**

A large (15,000) cohort of men and women recruited from primary care
practices as part of a cancer epidemiology study had heel ultrasound
measurements with a mean follow-up of 1.9 years. Fractures were
ascertained from admission data (missing less serious fractures and many
vertebral fractures). Men and women in the lowest 10% of the cohort (as
measured by broadband ultrasound attenuation -- BUA) had over 4 times
the risk of fracture over the study period as men and women in the
highest 30% (RR 4.44, 95% CI 2·24--8·89). The lowest 10% BUA was roughly
equivalent to 2.0 SD below the mean at age 45 in men and 1.5% below the
mean at age 45 in women. Ultrasound prediction of fracture risk was
independent of clinical risk factors and had the same power of
prediction in older and younger persons and in men and women. Bone
density as measured by heel ultrasound is a continuous variable. Every
1SD decrease in BUA (broadband ultrasound attenuation) was associated
with a doubling of the risk of fracture (RR 1.95, 95% CI 1·50--2·52).

This study adds to the evidence (Siris, et al) that ultrasound bone
assessment is a reliable predictor of fracture risk. Ultrasound is an
accessible modality for many Indian health facilities, but treatment
trials have all been based on the more expensive and less accessible
DEXA modality. It is also one of the few large studies to look
prospective bone health data and fracture risk in men. The authors point
out that a population-based approach to bone health (through ensuring
adequate calcium and vitamin D intake and regular physical activity) has
the potential to increase bone density (as measured by heel ultrasound
or DEXA) and thus reduce the rate of fracture.

Khaw K-T et al. Prediction of total and hip fracture risk in men and
women by quantitative ultrasound of the calcaneous: EPPIC-Norfolk
prospective population study. Lancet 2004 Jan17; 363:197-202.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14738792>

[Siris ES, et al. Identification and fracture outcomes of undiagnosed
low bone mineral density in postmenopausal women; results from the
National Osteoporosis Risk Assessment. JAMA 2001. 286(22):
2815-2822.](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11735756)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11735756>

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

**What should I do about a pregnant patient with a varicella like
rash?**

Rapid treatment may ameilorate maternal symptoms, but have little
benefit for the fetus.

<http://www.ihs.gov/MedicalPrograms/MCH/M//faqdnlds/Varicella41904.doc>

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

**Estrogen Does Not Prevent Chronic Disease in Postmenopausal Women With
Hysterectomy: Medscape CME\***

<http://www.medscape.com/viewarticle/473435?src=top10>

\*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.

# [Information Technology]{.underline}

**2004 Technology Conference**

DIR is planning to host the 2004 Technology Conference the week of
August 23^rd^, 2004 in Scottsdale, Az. Contact Terry Cullen for
questions <Theresa.Cullen@IHS.GOV>

# [International Health Update]{.underline}

**Guidelines Save Lives -- Royal College of Obstetricians and
Gynaecologists (RCOG)**

Recent review by the Confidential Enquiry into Stillbirths and Deaths in
Infancy (CESDI) and the Confidential Enquiry into Maternal Deaths (CEMD)
have shown that following the RCOG guidelines may reduce maternal death.
Two guidelines include: thromboembolic disease (RCOG) and cesarean
delivery (NICE)

**Royal College of Obstetricians and Gynaecologists Guidelines**

<http://www.rcog.org.uk/mainpages.asp?PageID=106>

**Thromboprophylaxis during Pregnancy, Labour and after Vaginal
Delivery**

<http://www.rcog.org.uk/guidelines.asp?PageID=106&GuidelineID=62>

**Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI)
and the**

**Confidential Enquiry into Maternal Deaths (CEMD)**

<http://www.cemach.org.uk/publications.htm>

**National Institute for Clinical Excellence (NICE)**

<http://www.nice.org.uk/catcg2.asp?c=20034>

**Cesarean Delivery -- NICE**

<http://www.nice.org.uk/Docref.asp?d=115077>

**Cesarean Delivery -- NICE: Quick Reference**

<http://www.nice.org.uk/pdf/CG013quickrefguide.pdf>

**Cesarean Delivery -- NICE: Evidence Tables**

<http://www.nice.org.uk/pdf/CG013evidencetables.pdf>

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

**Oral Health and Health in Women: A Two-Way Relationship**

National Maternal and Child Oral Health Resource Center (OHRC) has
released a new fact sheet in collaboration with health professionals,
program administrators, educators, and researchers in the fields of oral
health and women\'s health. The fact sheet provides general information
and national data on women's oral health. Topics include women's oral
health status, the relationship between oral health and general health
in women, oral health care, and strategies for improving women's oral
health. The fact sheet is available at
[[http://www.mchoralhealth.org/PDFs/WomensFactSheet.pdf]{.underline}](http://www.mchoralhealth.org/PDFs/WomensFactSheet.pdf).

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

######### Emergency Contraceptive Pills and Adolescents (Web Conference) CME

######### [**http://www.medscape.com/viewprogram/2904**](http://www.medscape.com/viewprogram/2904)

######### 

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

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

######### 

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

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

**Clinical Discussion Board Index, Medscape**

Hundreds of ongoing clinical discussions available

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

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

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

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

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

**Venous Thromboembolism after Air Travel: Thrombophilia and Oral
Contraceptives**

A case-control study was conducted to establish whether air travel is a
risk factor for venous thromboembolism (VTE), and to investigate the
interaction between air travel and thrombophilia. They also evaluated
the interaction between air travel and oral contraceptive use (a common
and independent risk factor for VTE). In general, the interaction
between air travel, thrombophilia, and oral contraceptive use in
determining VTE is significant. More research must be conducted to
assess interaction among thrombophilia, oral contraceptive use, and VTE.

<http://www.cdc.gov/genomics/hugenet/ejournal/VTE.htm>

**[Osteoporosis]{.underline}**

**Higher Calcium Intake May Decrease Risk of Kidney Stones in Younger
Women **

CONCLUSIONS: A higher intake of dietary calcium decreases the risk of
kidney stone formation in younger women, but supplemental calcium is not
associated with risk. This study also suggests that some dietary risk
factors may differ by age and sex. Finally, dietary phytate may be a
new, important, and safe addition to our options for stone prevention.

METHODS: We prospectively examined, during an 8-year period, the
association between dietary factors and the risk of incident symptomatic
kidney stones among 96 245 female participants in the Nurses\' Health
Study II

Curhan GC, Willett WC, Knight EL, Stampfer MJ. Dietary factors and the
risk of incident kidney stones in younger women: Nurses\' Health Study
II. Arch Intern Med. 2004 Apr 26;164(8):885-91.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15111375>

**Vitamin D Use Reduces Risk of Falls in Elderly**

[CONCLUSIONS:]{.underline} Vitamin D supplementation appears to reduce
the risk of falls among ambulatory or institutionalized older
individuals with stable health by more than 20%. Further studies
examining the effect of alternative types of vitamin D and their doses,
the role of calcium supplementation, and effects in men should be
considered.

[STUDY SELECTION:]{.underline} We included only double-blind randomized,
controlled trials (RCTs) of vitamin D in elderly populations (mean age,
60 years) that examined falls resulting from low trauma for which the
method of fall ascertainment and definition of falls were defined
explicitly

Bischoff-Ferrari HA, et al of Vitamin D on falls: a meta-analysis. JAMA.
2004 Apr 28;291(16):1999-2006.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15113819>

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

**What Every Pregnant Woman Needs to Know About Cesarean Delivery**

This booklet summarizes findings from current research on the risks and
benefits of cesarean birth compared with vaginal birth. The booklet was
developed by the Maternity Center Association with input from many other
national nonprofit organizations and from members of a wide variety of
groups, including childbirth educators, consumers, doctors, labor
support professionals, midwives, nurses, and researchers. The booklet is
intended to help pregnant women understand (1) the factors that can
affect whether they have a cesarean birth or a vaginal birth and what to
consider in making an informed decision; (2) what it means to give
informed consent and informed refusal; (3) situations that can lead to
cesarean birth; and (4) tips for avoiding unnecessary cesarean births,
assisted vaginal births, and pelvic floor injuries. The back page
includes a list of organizations that officially endorse the booklet,
along with their Web sites. The booklet, a description of the process
used to develop the information in the booklet, and a list and summary
of studies that were consulted are available at
[[http://www.maternitywise.org/mw/topics/cesarean/booklet.html]{.underline}](http://www.maternitywise.org/mw/topics/cesarean/booklet.html).

**Vaginal Yeast Infections: AFP\*\***

<http://www.aafp.org/afp/20040501/2189ph.html>

**Vaginal Discharge: AFP\*\***

<http://www.aafp.org/afp/20040501/2191ph.html>

**Bacterial Vaginosis: AFP\*\***

<http://www.aafp.org/afp/20040501/2193ph.html>

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

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

**Adolescent Risk Taking Behavior**

On May 1, 2004, Donna Perry in Chinle, began moderating a discussion of
Adolescent Risk Taking Behavior on the Primary Care Discussion Forum.
This will be a combined listserv Discussion with the Special Interest
Group -- Indian Health of the AAP.

The Discussion Forum provides an e-mail listserv based discussion
moderated by national leaders or experts in a particular field. The
discussion is captured and summarized online, here:
[[www.ihs.gov/MedicalPrograms/MCH/M/PCdiscForum.asp]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/PCdiscForum.asp)

To subscribe, go the site below and click the word 'subscribe' in the
first paragraph, or contact me

[[www.ihs.gov/MedicalPrograms/MCH/M/MCHdiscuss.asp]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdiscuss.asp)

**Adult Asthma**

On August 1, 2004, thanks to Charles (Ty) Reidhead, Whiteriver, we will
start an Adult Asthma Discussion. Ty is the IHS Internal Medicine CCC.

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

**New Midwives Main page: Multiple topics covered**

<http://www.ihs.gov/MedicalPrograms/MCH/M/mw00.cfm>

[**Emergency Contraception: WHO multicentre randomised
trial.**](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHfamPlng.asp#emergcon)

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

**Newest Perinatology Corner Module - Free CEU /CME available**

**Thyroid Disorders in Pregnancy:**

<http://www.ihs.gov/MedicalPrograms/MCH/M/THYR01.cfm>

There are several upcoming **Conferences**

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

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

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

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

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

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

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

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

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

May 25 - 28, 2004 

Los Angeles, California 

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

#### National IHS PA / APN Annual Meeting, June 7-11, 2004

Scottsdale, Arizona

[**http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#June2004**](http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#June2004)

Contact Judy Whitecrane for questions <judy.whitecrane@mail.ihs.gov>

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

-   June 13-17, 2004 **with separate NRP Course on first morning
    session, 6/13/04**

-   Denver, CO

-   Contact Teddra Penland at 301 443 1840

-   <http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#June2004>

-   2004 brochure
    <http://www.ihs.gov/MedicalPrograms/MCH/M/ConfDnlds/Brochure2004.doc>

-   June 13th at 8:00 am: Separate NEONATAL RESUSCITATION PROGRAM

-   NRP Class size limited. Sign up now

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

**2004 Biennial Native Women's meeting: Prevention in Women's Health**

August 4-6, 2004

Albuquerque, New Mexico

Great CEU /CME, plus good networking for leaders of Women's Health / MCH

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

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004>

**20th Annual Midwinter Conference**

-   For providers caring for Native women and children

-   January 28-30, 2005 (Tentative)

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

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

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

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

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/CCCCorner4104.doc>

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

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

## Singleton Vaginal Breech Delivery at Term: Still a Safe Option page 2

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

###### From Barbara Fine: 2004 National Women\'s Health Week celebration, May 9-15, 2004

**From Bruce Finke:** Evidence Based Elder Periodic Exam: Osteoporosis

**From George Gilson:** Thyroid Disorders in Pregnancy: New Perinatology
Corner Module

**From Bill Green:** Indian Health - Special Interest Group Discussion
Forum Now Available online\
**From Steve Holve:** IHS Child Health Notes: New service from Pediatric
CCC

From Ursula Knoki-Wilson: Keeping the sacred in childbirth practices

From Deborah Lessmeier: Patient at 4-6 weeks gestation with a varicella
like rash?

**From Janet Mehring:** Teenage pregnancy prevention: Any resources
available?

From Judy Thierry: School based care; Distance Learning Certificate in
MCH Epidemiology: Fellowships; Online Alcohol Screening; Funds for HIV
and Prevention Services Into Reproductive Health and Community Settings;
Do you live in a state with a primary seat belt law?

**From Judy Ungerleider:** Value of the total protein to creatinine
ratio in pre-eclampsia?

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

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

Visual dipstick urinalysis at the 1+ (30 mg/dL) threshold not reliable;
Safety of Vaginal Birth After Cesarean; Subdural hemorrhages not
uncommon in full-term infants; Mediolateral episiotomy: worse pelvic
floor function, incontinence, and prolapse; Vegetarian diet in pregnancy
raises risk of false-positive Down syndrome screen; Use of ginger in
early pregnancy will reduce their symptoms; Parental attitudes about a
pregnancy predict birth weight in a low-income population; Predictors of
Cesarean Delivery for the Second Twin in Vaginal Delivery of the First
Twin; Can Biophysical Profiles in Labor Predict C-Section? Normal
Control in Pregnant Women with Hypothyroidism; Benefits of Incomplete
Courses of Antenatal Corticosteroids; Effects of Automobile Crashes
Occurring During Pregnancy;

## Gynecology: page 9

## Single 1.5 mg levonorgestrel dose can substitute two 0.75 mg doses 12 h apart; Emergency Contraception Resources: Not-2-Late.com; Progestin only pills; Women often choose surgery after extended drug treatment of menorrhagia; 2 Randomized Trials on Menorrhagia Compare Medical Therapy With Hysterectomy; Managing Ovarian Cysts in Postmenopausal Women; High-Grade Squamous Intraepithelial Lesions: Abbreviating Post treatment Surveillance; 3 year screening is cost effective versus annual screening over 30 years; **Effect of Oral Contraceptives on Functional Ovarian Cysts; Metabolic Abnormalities in Bulimia Nervosa**; Can Women Self-Screen for Cervical Abnormalities? Diagnosing and Managing Endometriosis; Effects of Oral Contraceptive Use in Older Smokers; Extending the Interval between Pap Smears; Vaginal Delivery Affects Pelvic Organ Support

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

Ending an Anti-tobacco Youth Campaign on Adolescent Susceptibility to
Smoking

New Community Pediatrics Web Site Launched; FAS \"Better Safe than
Sorry; CATCH / Medical Home National Conference

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

Virtual colonoscopy sensitivity is low; Cigarette smoking, awareness of
diabetes, binge drinking, drinking / driving and others; Smoking ban
linked to drop in heart attacks; Type 2 diabetes linked to cognitive
decline in women; Long-Term Sequelae of Breast Cancer Treatment;
Exercise Testing as a Predictor of Mortality in Women; Asthma
Surveillance and Epidemiology; Abortions do not raise breast cancer risk

[Features:]{.underline} page 13

###### AFP: **COCHRANE FOR CLINICIANS:** What Is the Best Collection Device for Screening Cervical Smears? Shoulder Dystocia Chapter updated

ACOG: Nausea and Vomiting of Pregnancy; ACOG supports universal care:
Cover the Uninsured

**AHRQ:** Rural studies examine telecolposcopy for women with abnormal
Pap smears

**Breastfeeding:** Breastfeeding Track at Biennial OB/GYN meeting in
August 2004

**Domestic Violence:** Domestic Violence Track at Biennial OB/YN meeting
in August 2004; Take a Leadership Role in Combating Sexual Violence in
US: Funding available

**Elder Care News:** Prevention in Native Women: IHS Biennial meeting in
August 2004

**Frequently asked questions:** Can misoprostol be used in an outpatient
setting? Can we use Lispro in pregnancy? What is the clinical
significance of endometrial cells found on Pap smears? Am I eligible for
care at this Indian Health facility?

**Hormone Replacement Update**: Nonhormonal alternatives for the
treatment of hot flashes; Use of Ultra-Low-Dose Estrogen to Prevent Bone
Loss; Transdermal Estrogen and Venous Thromboembolism; Breast Cancer
Risk Related to Type of Hormone Therapy

**Information Technology:** 2004 Technology Conference

**International Health:** Suicides in young people in rural southern
India -- relevance to AI/AN youth

**MCH Alert:** Effectiveness of school-based suicide-prevention program
evaluated

**Medscape:** Bisphosphonates in Osteoporosis: Emerging Science
Endometriosis and Infertility Opioid Analgesia: Practical Treatment of
the Patient with Chronic Pain:

**Office of Women's Health, CDC:** First and only rapid HIV test
approved for use with oral fluid

**Osteoporosis**: Evidence Based Periodic Exam in the Elderly Native
Americans Osteoporosis in American Indian / Alaska Native Women, 2004
Early Discontinuation of Osteoporosis Treatment

**Patient Education:** Eating Disorders; Anorexia Nervosa; Sports and
Women Athletes: The Female Athlete Triad

**Primary Care Discussion Forum:** Adolescent Risk Behavior - 5/1/04;
Adult Asthma - 8/1/04

**What's new on the ITU MCH web pages: page 18**

New Perinatology Corner Module - Free CEU /CME available **-** Thyroid
Disorders 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@anmc.org>

or 907 729 3154 (with voicemail)

\*The opinions expressed in the OB/GYN CCC Corner are strictly those of
the authors, and not necessarily those of the Indian Health System, or
the coordinator of this newsletter 5/19/04