News Flash(s)

New CCC Columnist: Sandra Haldane - Nurses Corner

Two New Perinatology Corner Modules

Twins: Antepartum assessment and Intrapartum management

**Double Trouble?**

**Antibody Screen Positive: Rh Disease and Other Atypical Antibodies**

**Kell kills, Duffy dies, and Lewis lives?**

![](media/image1.png){width="5.992361111111111in"
height="1.3020833333333333in"}

 

OB/GYN Chief Clinical Consultant's Corner

Volume 4, No. 3, March 2006

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

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

**Tired of hearing only bad news from the Women's Health Initiative
(WHI)?**

#### From your colleagues: page 7 {#from-your-colleagues-page-7 .Style-Heading-4-+-Arial-14-pt-Underline}

Carolyn Aoyama:

-Deadline Extended: Special AI/AN issue of the Maternal and Child Health
Journal

-Three Women\'s Health Awards

Burt Attico:

-Calcium Supplementation May Reduce the Severity of Pre-eclampsia

#### -Low-Dose Aspirin in the Primary Prevention of Cardiovascular Disease in Women {#low-dose-aspirin-in-the-primary-prevention-of-cardiovascular-disease-in-women .Style-Heading-4-+-Arial-14-pt-Underline}

Terry Cullen:

Indian Health Service Medical Provider Best Practice Conference

Costs Are Too High: Improving Perinatal Care -New Learning & Innovation
Community from IHI

Eve Espey

Sample templates for guidelines: IUDs, [Manual Vacuum Aspiration (MVA)
for SAB](http://www.ihs.gov/NonMedicalPrograms/NC4/nc4-clinguid.cfm#m),
etc...

Chuck North

Keams Canyon 1979: Have you ever noticed that some things never seem to
change?

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

#### Frances Placide {#frances-placide .Style-Heading-4-+-Arial-14-pt-Underline}

#### Please Welcome Frances Placide, new Chief Clinical Consultant for Physician Assistants {#please-welcome-frances-placide-new-chief-clinical-consultant-for-physician-assistants .Style-Heading-4-+-Arial-14-pt-Underline}

Jane Powers

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

Judy Thierry:

-What is the evidence on school health promotion in improving health?

-Meeting the needs of our native children in special education

Sara Thomas

#### Is a low fat diet not good idea? Comments on recent research? {#is-a-low-fat-diet-not-good-idea-comments-on-recent-research .Style-Heading-4-+-Arial-14-pt-Underline}

Roberta Ward

-New Information on Paxil and Congenital Malformations

#### -For Your Reading Pleasure . . . Asthma in Pregnancy {#for-your-reading-pleasure-.-.-.-asthma-in-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

Judy Whitecrane

-Needed: PHS Nurses with OB experience

#### -2006 Clinical Update on Substance Abuse and Dependency  {#clinical-update-on-substance-abuse-and-dependency .Style-Heading-4-+-Arial-14-pt-Underline}

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

##### Obstetrics: page 13

#### -GDM: Can we proceed directly to one step screening / diagnosis in AI / AN women?

-Link between GDM and Type 2 DM can be broken: Update

-Gestational Glucose Tolerance Risk of Type 2 Diabetes in Young Pima
Indian Offspring

-Is Influenza Vaccination Safe for Pregnant Women?

-Membrane sweeping at induction increases vaginal delivery rate and
patient satisfaction

and more...

**Gynecology: page 18**

-Diet and Exercise Reduce Incontinence in Women at Risk of Diabetes

-Hysterectomy increases resource use significantly, but increases
quality-of-life too

-Atypical glandular cells: High risk - several markers put patients at
more substantial risk

-Laparoscopic assistance not useful in performing vaginal hysterectomies
w/ BSO

-Psychosocial Stress May Raise Risk of Bacterial Vaginosis

and more...

**Child Health: page 19**

-Maternal cholestasis and neonatal respiratory distress syndrome

-FDA Warns Parents About Contaminated Teething Rings

#### -Incidence of a Type AB Infant Born to a Type O Mother  {#incidence-of-a-type-ab-infant-born-to-a-type-o-mother .Style-Heading-4-+-Arial-14-pt-Underline}

-CDC Releases Guidelines on Identifying and Referring Persons with FAS

-Prevalence of overweight among children entering school

and more...

**Chronic Illness and Disease: page 21**

-Colon cancer rates: Significantly increased in AI/AN women -- Colon
Cancer Month

-American Heart Association Updates Guidelines for Blood Pressure
Management

-Prenatal setting represents a missed opportunity for Tuberculosis
treatment completion

-Anyone snore in your house: Oral Appliances for Obstructive Sleep
Apnea?

-Statins and beta-blockers may reduce severity of first coronary event

and more...

#### Features: page 24 {#features-page-24 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician

Steroids Before Cesarean Delivery May Reduce RDS

American College of Obstetricians and Gynecologists

-LAY MIDWIFERY: Statement of Policy

-Tracking and Reminder Systems

**Agency for Healthcare Research and Quality**

Results raise doubts about the value of the bimanual pelvic exam in
routine screening

**Ask a Librarian**

I have a great resource for you: Diane Cooper, NIH

**Breastfeeding**

Breastfeeding as a Pain Reliever

**CCC Corner Digest**

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

\-[Results of a Well-Defined Protocol for a Trial of Labor After
Cesarean](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_AOM.cfm)

\-[Oral misoprostol for cervical priming in non-pregnant
women](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Coll.cfm)

\-[The term breech trial recommendations should be
re-evaluated](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_HT.cfm#ob)

\-[Superiority of Liquid-Based Cytology for Cervical Screening
Questioned](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_HT.cfm#gyn)

\-[Broad-spectrum antibiotics in labor linked to serious late-onset
neonatal
infections](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_HT.cfm#child)

\-[Dietary intervention alone of little benefit in preventing
disease](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_HT.cfm#chrIll)

\-[Vaginal Birth after Cesarean: Evidence Based
Recommendations](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#afp)

\-[Nearly half of urban AI/AN travel back to their reservation to visit
during the
year](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#ahrq)

\-[Birth News Highlights: Young mothers, VBACs down, Early Care? Low
birth
weight](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#AskLib)

\-[Maternal Child Health Website Gets a
Facelift](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#webSite)

\-[What is the latest on an OB/GYN solution for the PCC, PCC+ and EHR in
Indian
Health?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#it)

\-[Listen up any parents or grandparents: How NOT to give
Acetaminophen](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#mmtour)

\-[When Should We Clamp the Umbilical Cord? Preterm vs Term
Infants](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#MidWives)

\-[Liability in triage: management of EMTALA regulations and common
obstetric
risks](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#MidWives)

\-[Focus on preventable causes of stillbirth: 3
articles](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#periPicks)

\-[Efficacy and safety of azithromycin for treatment of C. trachomatis
in
pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#std)

\-[Women with pain, but w/o coronary artery disease: Coronary
microvascular
dysfunction](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#stillW)

\-[Vaginal Birth after Cesarean  - New Perinatology Corner
Module](http://www.ihs.gov/MedicalPrograms/MCH/M/VB01.cfm)

**Domestic Violence**

Survey queries women and men about their experiences as victims of rape

**Elder Care News**

-Not too Late: Funding Available for Palliative Care Training - April
3 - 5, 2006

-Screen for cognitive impairment with many non-English speaking elders 

**Family Planning**

#### -Fatal infection without fever: Sepsis and Medical Abortion - FDA Public Health Advisory -Pharmacists\' Knowledge, Attitudes, and Beliefs Toward Prescribing EC {#fatal-infection-without-fever-sepsis-and-medical-abortion---fda-public-health-advisory--pharmacists-knowledge-attitudes-and-beliefs-toward-prescribing-ec .Style-Heading-4-+-Arial-14-pt-Underline}

-Are continuous and extended-cycle combined contraceptives safe and
effective?

#### -Continuous OCPs with norethindrone: More bleeding-free days than levonorgestrel preps {#continuous-ocps-with-norethindrone-more-bleeding-free-days-than-levonorgestrel-preps .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

Two New Perinatology Corner Modules

-Twins: Antepartum assessment and Intrapartum management - Double
Trouble?

-Antibody Screen Positive: Rh Disease and Other Atypical Antibodies:

Kell kills, Duffy dies, and Lewis lives?

**Frequently asked questions**

-How do the EMTALA regulations effect the evaluation of patient with
false labor?

-Can we perform one step GDM screening in AI/AN?

-What is the best screening cut-off for gestational diabetes mellitus?

-What are some of the issues about viability in the range of 23-25 EGA
weeks?

**Indian Child Health Notes**

**Highlights for March 2006**

-Cardiovascular screening for high school athletes - a summary of the
appropriately named \"Sudden Death\" Committee of the American Heart
Association

-Medico legal Implications of Cardiovascular Screening of Athletes -
Yes, you can say \"No\"

-The new Rotavirus vaccine is on the way

-Doug Esposito: Race, genetics, social construct and political
correctness - read it if you dare

**Information Technology**

-UpToDate 14.1 is now available: Evidence based recommendations added
now

-IHS received an "effective" rating: buried in President Bush's fiscal
2007 budget

-Evaluation of IHI work within IHS

International Health

-Combating poverty and social exclusion

-Quinacrine sterilization (From Yolanda Meza)

-How to expand the reach of successful programs by replicating effective
ones

#### MCH Alert

Reducing substance uptake among younger adolescents

#### Medical Mystery Tour

As seen on TV- Desperate Housewives: Wandering spleen

#### Medscape

######### [Increasing Diversity in the Medical Workforce Is Way to Prevent Disparities in Healthcare](http://mp.medscape.com/cgi-bin1/DM/y/hyxu0G875W0Dzc0HJ760Gv)

**Menopause Management**

Hormone Therapy: Predictor of worsening insulin sensitivity in
postmenopausal women

**Midwives Corner**

-Should we continue to draw Rubella titers as part of the prenatal
panel?

-Do Birth Certificate Data Reflect the Number of CNM-Attended
Births**?**

**Navajo News**

VZIG No Longer Available: Protect non-immune women against Chickenpox
(pre-pregnancy)

**Nurses Corner**

#### -Nurse Education Loan Repayment Program: Deadline March 30 {#nurse-education-loan-repayment-program-deadline-march-30 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Idealized Design of Perinatal Care - Institute for Healthcare Improvement {#idealized-design-of-perinatal-care---institute-for-healthcare-improvement .Style-Heading-4-+-Arial-14-pt-Underline}

-Sign up for the 'Every Woman' quarterly magazine

-NNLC Award Announcement

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

-Global Tobacco Use in Young People: Future Chronic Disease Burden in
Adults

#### -National Women\'s Health Week, May 14-20, 2006 {#national-womens-health-week-may-14-20-2006 .Style-Heading-4-+-Arial-14-pt-Underline}

**Oklahoma Perspective**

Metformin and Polycystic Ovarian Syndrome

Osteoporosis

Nutritional Influences on Bone Health: Update on Research and Clinical
Implications

Patient Education

#### -Preterm Premature Rupture of Membranes: What it Means to You {#preterm-premature-rupture-of-membranes-what-it-means-to-you .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Behavior Problems in a Family Member with Dementia: What You Should Know {#behavior-problems-in-a-family-member-with-dementia-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Caring for Your New Baby {#caring-for-your-new-baby .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Move beyond 'integrated' screening to 'contingency' screening

-Misoprostol for postpartum hemorrhage

Primary Care Discussion Forum

Cardiology Topics for Primary Care Providers -- Ongoing, 'not too late
to join in

STD Corner

#### -Incorrect use of condoms not product failure may account for the lack of effectiveness {#incorrect-use-of-condoms-not-product-failure-may-account-for-the-lack-of-effectiveness .Style-Heading-4-+-Arial-14-pt-Underline}

-Expedited Partner Therapy in the Management of Sexually Transmitted
Diseases

-Chlamydia screening and management: Primary care providers in
California

-Raise Awareness of Impact of HIV /AIDS on Women and Girls

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

Statin Therapy for Type 2\'s Regardless of LDL Levels and CVD

###### Save the Dates: Upcoming events of interest page 51

#### What's new on the ITU MCH web pages page 52

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

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

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

**Tired of hearing only bad news from the WHI?**

**Reduction in diabetes incidence with combination hormone replacement**

AIMS/HYPOTHESIS: Studies examining the effect of postmenopausal hormone
therapy on concentrations of glucose, insulin and diabetes incidence
have been inconclusive, in part because many of the studies were too
small. We examined the effect of oestrogen plus progestin on diabetes
incidence and insulin resistance.

METHODS: The study was a randomised, double-blind trial comparing the
effect of daily 0.625 mg conjugated equine oestrogens (CEE) plus 2.5 mg
medroxyprogesterone acetate with that of placebo during 5.6 years of
follow-up. The participants were 15,641 postmenopausal women enrolled in
the Women\'s Health Initiative Hormone Trial. These women were aged 50
to 79 and all had an intact uterus. Diabetes incidence was ascertained
by self-report of treatment with insulin or oral hypoglycaemic
medication. Fasting glucose, insulin, and lipoproteins were measured in
a random sample at baseline and at 1 and 3 years.

RESULTS: The cumulative incidence of treated diabetes was 3.5% in the
hormone therapy group and 4.2% in the placebo group (hazard ratio 0.79,
95% CI 0.67-0.93, p=0.004). There was little change in the hazard ratio
after adjustment for changes in BMI and waist circumference. During the
first year of follow-up, changes in fasting glucose and insulin
indicated a significant fall in insulin resistance in actively treated
women compared to the control subjects (Year 1 to baseline between-group
difference -0.22+/-0.10, p=0.03).

INTERPRETATIONS/CONCLUSION: These data suggest that combined therapy
with oestrogen and progestin reduces the incidence of diabetes, possibly
mediated by a decrease in insulin resistance unrelated to body size.
Future studies of alternative postmenopausal hormone therapy regimens
and selective oestrogen agonists and/or antagonists should consider the
effects of these regimens on insulin resistance and diabetes.

[Margolis
KL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Margolis+KL"%5BAuthor%5D),
et al Effect of oestrogen plus progestin on the incidence of diabetes in
postmenopausal women: results from the Women\'s Health Initiative
Hormone Trial.
[Diabetologia.](javascript:AL_get(this, 'jour', 'Diabetologia.');) 2004
Jul;47(7):1175-87.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15252707>

**[Comment: Thomas Burke, Anchorage]{.underline}**\
**Does hormone replacement prevent Type II Diabetes?**

The question has been raised by several small observational studies with
conflicting results\*. Now we have 3 large studies that show a
significant decrease in diabetes incidence for women taking estrogen
with progesterone.

(\*A similar small study was published the February gray journal -- See
Menopause Management)

The Nurses Health Study (N=21,028) was prospective and observational.
HERS, the Heart and Estrogen / Progesterone Replacement Study (N=2029)
and WHI the Women's Health Initiative (N=15,641) were both large
prospective randomized studies.

All three showed a significant decrease in diabetes incidence of 20% or
more. The studies controlled for other risk factors like weight and the
WHI showed a decrease in insulin resistance as well. It is highly
unlikely that we will see additional studies of this size addressing
this issue. Hopefully the diabetes risk data from the estrogen only arm
of the WHI will be published soon.

While public attention his focused on other findings of these studies
the change in diabetes incidence may be of greater clinical
significance. As Type II DM is such a common disease in AI/AN we should
include this information in our counseling.

We do not recommend taking hormone replacement for the purpose of
disease prevention, even though we know that it is effective at least
for osteoporosis, hip fracture and colon cancer. We know that colon
cancer is increased to nearly double the prevalence in some AI/AN.
Currently it is reasonable to prescribe hormone replacement for the
treatment of menopausal symptoms after a discussion of the risks and
benefits.

The decreased incidence of Type II DM should now become a routine part
of that discussion.

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

Thanks to Dr. Burke for pointing out a possible bias which appears to
overlook the benefits of hormone therapy (HT), while emphasizing the
negative effects of HT. Another example is presented below. In the
estrogen alone trial, estrogen decreased coronary heart disease risk
among women 50 to 59 years of age at baseline.

Our goal should be to present balanced non-judgmental counseling to our
AI/AN patients.

**Lower coronary heart disease risk with CEE: Women 50 to 59 years of
age at baseline**

CONCLUSIONS: Conjugated equine estrogens provided no overall protection
against myocardial infarction or coronary death in generally healthy
postmenopausal women during a 7-year period of use. There was a
suggestion of lower coronary heart disease risk with CEE among women 50
to 59 years of age at baseline.

[Hsia
J](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Hsia+J"%5BAuthor%5D),
et all Conjugated Equine Estrogens and Coronary Heart Disease: The
Women\'s Health Initiative. [Arch Intern
Med.](javascript:AL_get(this, 'jour', 'Arch Intern Med.');) 2006 Feb
13;166(3):357-65.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16476878>

**Effects of conjugated equine estrogen in postmenopausal women with
hysterectomy**\
CONCLUSIONS: The use of CEE increases the risk of stroke, decreases the
risk of hip fracture, and does not affect CHD incidence in
postmenopausal women with prior hysterectomy over an average of 6.8
years. A possible reduction in breast cancer risk requires further
investigation. The burden of incident disease events was equivalent in
the CEE and placebo groups, indicating no overall benefit. Thus, CEE
should not be recommended for chronic disease prevention in
postmenopausal women.

[Anderson
GL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Anderson+GL"%5BAuthor%5D),
et al Effects of conjugated equine estrogen in postmenopausal women with
hysterectomy: the Women\'s Health Initiative randomized controlled
trial. [JAMA.](javascript:AL_get(this, 'jour', 'JAMA.');) 2004 Apr
14;291(14):1701-12.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15082697>

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

#### Carolyn Aoymana, HQE {#carolyn-aoymana-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**Deadline Extended: Special AI/AN issue of the Maternal and Child
Health Journal**

The submission date for a special American Indian and Alaska Native
(AI/AN) issue of the Maternal and Child Health Journal (MCHJ) has been
extended to June 1, 2006.

It has been clear from your enthusiastic response to this special AI/AN
MCHJ that there is a large unmet need to publish relevant research to
improve the health of AI/AN families! We hope that extension of the
submission date will allow more of you to send in manuscripts. Please
assist us once again by widely circulating this notice. Myra J. Tucker
<mjt2@cdc.gov>

**Three Women\'s Health Awards**

The following three awards will be presented at our special awards
luncheon at the Snowmass Institute\'s 22nd Annual Conference on
Achieving Success in Women\'s Health in Charlotte, NC, May 7-9, 2006

**Next Generation of Women\'s Health Leaders 2006\
**Awarded by Spirit of Women & The Snowmass Institute\
Recognizes a young woman who is a upcoming leader in women\'s health

**Lifetime Achievement Award in Women\'s Health 2006\
**Awarded by Bon Secours Richmond Health System & The Snowmass
Institute\
Recognizes a person who has been dedicated to women\'s health for 20+
years

**Innovation in Women\'s Health 2006\
**Awarded by The Snowmass Institute & Berry & Associates\
Recognizes a significant innovation achievement or project in women\'s
health

Please go to
[[www.snowinst.com/womens-health-conference.htm]{.underline}](http://www.snowinst.com/womens-health-conference.htm)
click on

AWARDS IN WOMEN\'S HEALTH for applications and information on each
award.

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

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

#### Calcium Supplementation May Reduce the Severity of Pre-eclampsia {#calcium-supplementation-may-reduce-the-severity-of-pre-eclampsia .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: A 1.5-g calcium/day supplement did not prevent preeclampsia but did reduce its severity, maternal morbidity, and neonatal mortality, albeit these were secondary outcomes. {#conclusion-a-1.5-g-calciumday-supplement-did-not-prevent-preeclampsia-but-did-reduce-its-severity-maternal-morbidity-and-neonatal-mortality-albeit-these-were-secondary-outcomes. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Villar J](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Villar+J"%5BAuthor%5D), et al World Health Organization randomized trial of calcium supplementation among low calcium intake pregnant women. [Am J Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006 Mar;194(3):639-49. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16522392**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16522392) {#villar-j-et-al-world-health-organization-randomized-trial-of-calcium-supplementation-among-low-calcium-intake-pregnant-women.-am-j-obstet-gynecol.-2006-mar1943639-49.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16522392 .Style-Heading-4-+-Arial-14-pt-Underline}

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

The Am J article, if replicated, could represent step back from what
Cochrane (below) has been reporting for quite a while. In the meantime,
calcium supplementation may reduce the risk of high blood pressure in
pregnancy in those AI/AN groups with low calcium intake.

Authors\' conclusions: Calcium supplementation appears to reduce the
risk of high blood pressure in pregnancy, particularly for women at high
risk of gestational hypertension and in communities with low-dietary
calcium intake. Optimum dosage and the effect on more substantive
outcomes requires further investigation.

Citation: Atallah AN, Hofmeyr GJ, Duley L. Calcium supplementation
during pregnancy for preventing hypertensive disorders and related
problems. The Cochrane Database of Systematic Reviews 2002, Issue 1.
Art. No.: CD001059. DOI: 10.1002/14651858.CD001059.

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

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

#### Low-Dose Aspirin in the Primary Prevention of Cardiovascular Disease in Women {#low-dose-aspirin-in-the-primary-prevention-of-cardiovascular-disease-in-women-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Dr. Attico shares this: {#dr.-attico-shares-this .Style-Heading-4-+-Arial-14-pt-Underline}

#### This report is interesting in that it shows that aspirin (low-dose) is helpful in preventing adverse cardiovascular events in women.  Previous studies had been done in males, and then simply \"abstracted\" to females, without substantial clinical proof that a similar effect occurred in women.  The Nurses\' Health Study has also been cited recently, but that study is in a younger group of women.  This report also contains an interview.  Since CV disease is the major cause of mortality in diabetes, and with the extremely high incidence of diabetes in AI/AN, this may prove to be a major preventive health factor in our patients.  I was particularly impressed by the statement that \"men and women may metabolize salicylates differently.\" {#this-report-is-interesting-in-that-it-shows-that-aspirin-low-dose-is-helpful-in-preventing-adverse-cardiovascular-events-in-women.-previous-studies-had-been-done-in-males-and-then-simply-abstracted-to-females-without-substantial-clinical-proof-that-a-similar-effect-occurred-in-women.-the-nurses-health-study-has-also-been-cited-recently-but-that-study-is-in-a-younger-group-of-women.-this-report-also-contains-an-interview.-since-cv-disease-is-the-major-cause-of-mortality-in-diabetes-and-with-the-extremely-high-incidence-of-diabetes-in-aian-this-may-prove-to-be-a-major-preventive-health-factor-in-our-patients.-i-was-particularly-impressed-by-the-statement-that-men-and-women-may-metabolize-salicylates-differently. .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: In this large, primary-prevention trial among women, aspirin lowered the risk of stroke without affecting the risk of myocardial infarction or death from cardiovascular causes, leading to a nonsignificant finding with respect to the primary end point. {#conclusions-in-this-large-primary-prevention-trial-among-women-aspirin-lowered-the-risk-of-stroke-without-affecting-the-risk-of-myocardial-infarction-or-death-from-cardiovascular-causes-leading-to-a-nonsignificant-finding-with-respect-to-the-primary-end-point. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Ridker PM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ridker+PM"%5BAuthor%5D) et al A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. [N Engl J Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2005 Mar 31;352(13):1293-304. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15753114**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15753114) {#ridker-pm-et-al-a-randomized-trial-of-low-dose-aspirin-in-the-primary-prevention-of-cardiovascular-disease-in-women.-n-engl-j-med.-2005-mar-31352131293-304.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15753114 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Indian Health Service Medical Provider Best Practice Conference**

Don't miss this opportunity!  The agenda for the Indian Health Service
Medical Provider Best Practice Conference, which will be held at the
Town and Country Resort & Conference Center, San Diego on April 4-5, is
available.  The conference theme is "How to Improve Patient Care through
GPRA tracking, best practices, and patient safety."  

This conference has been approved for 10 CEU credits for physicians and
physician assistants and 12 CEU credits for nurses.   This conference
will also be of interest to those who are involved with GPRA and
clinical quality.

# No registration fee is required to attend this conference, which is sponsored by the California Area Indian Health Service and is open to all IHS Areas.  However, we do ask that you complete and submit a registration form for our planning purposes.  You should make your hotel reservations directly with the Town and Country. 

<http://www.ihs.gov/FacilitiesServices/AreaOffices/California/Universal/PageMain.cfm?p=43#159>

# or

# Contact: [**Edna.Johnson@IHS.GOV**](mailto:Edna.Johnson@IHS.GOV)

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

#### Improving Perinatal Care A New Learning & Innovation Community from IHI

***Now available to all on a direct enrollment basis***

**The Costs Are Too High**\
The baby. The family. The care providers. The community. When adverse
events occur during labor and delivery, we all suffer heavy physical,
psychological and financial tolls. Additionally, increased premiums for
obstetricians have forced some practitioners to leave obstetrics,
thereby limiting access for expectant mothers.

**We Can Improve**\
By applying reliability concepts and best-known science, health care
organizations can significantly increase the safety and effectiveness of
perinatal care. To help participating organizations achieve outstanding
results in perinatal care, the Institute for Healthcare Improvement is
launching a new Learning & Innovation Community, "Improving Perinatal
Care." Meeting for the first time June 6-7, participants in this
Community will actively test changes aimed at achieving ambitious design
targets based on innovation work currently underway.

**Learn More & Enroll**\
Organizations have the option to participate in this Learning &
Innovation Community either through membership in IHI's IMPACT network
or through direct enrollment in the Community.

-   **IMPACT:** To learn more about the benefits of membership in
    IMPACT, IHI's association for change, please visit our website at:\
    <http://www.ihi.org/IHI/Programs/IMPACTNetwork/>

-   **Perinatal Care Community:** To learn more about this Community,
    including specific aims and areas of focus, please visit:\
    <http://www.ihi.org/IHI/Programs/CollaborativeLearning/IMPACTICImprovingPerinatalCare2006.htm>

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

#### Eve Espey, Albuquerque {#eve-espey-albuquerque .Style-Heading-4-+-Arial-14-pt-Underline}

**Sample templates for guidelines: IUDs, [Manual Vacuum Aspiration (MVA)
for SAB](http://www.ihs.gov/NonMedicalPrograms/NC4/nc4-clinguid.cfm#m),
etc...**

After two very interesting presentations on "[Manual Vacuum Aspiration
(MVA) for
SAB](http://www.ihs.gov/NonMedicalPrograms/NC4/nc4-clinguid.cfm#m)" and
"Extended indications for the IUD" at this year's 21st Annual Midwinter
Indian Health OB/PEDS Conference, Eve Espey M. D., Department of OB/GYN
at the University of New Mexico, has graciously shared some ideas for
possible guidelines at your facilities. These generic samples could be
used as templates for your facility after the content was modified to
your local specifications.

[**Manual Vacuum Aspiration for
SAB**](http://www.ihs.gov/NonMedicalPrograms/NC4/nc4-clinguid.cfm#m)

<http://www.ihs.gov/NonMedicalPrograms/NC4/Documents/MVA21206.doc>

**IUD guideline**

<http://www.ihs.gov/NonMedicalPrograms/NC4/Documents/IUDprotocol-WHC.doc>

**Medical management of missed abortion with misoprostol**

<http://www.ihs.gov/NonMedicalPrograms/NC4/Documents/Misoprostolformissedabprotocol.doc>

[**Depo Provera with more than 14 day
Interval**](http://www.ihs.gov/NonMedicalPrograms/NC4/Documents/DMPAinterval21206.doc)

<http://www.ihs.gov/NonMedicalPrograms/NC4/Documents/DMPAinterval21206.doc>

[**Depo Provera
guidelines**](http://www.ihs.gov/NonMedicalPrograms/NC4/Documents/DepoProveraprotocol-WHC4-21-05.doc)

<http://www.ihs.gov/NonMedicalPrograms/NC4/Documents/DepoProveraprotocol-WHC4-21-05.doc>

**Oral Contraceptive guidelines**

<http://www.ihs.gov/NonMedicalPrograms/NC4/Documents/OralContraceptiveProtocol-WHC.doc>

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

**Keams Canyon 1979: Have you ever noticed that some things never seem
to change?**

Tom Harris converted some old slides into Power Point for me about
Perinatal study at Keams Canyon in 1979. I thought you might be
interested in this data for historical comparisons. I presented it at a
COA meeting but never published the data. Here is the url on the MCH
site:

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

The findings were remarkably similar 20 years later from Zuni in 2
papers published by Larry and Rebecca Leeman in Journal of Family
Practice. The most interesting finding was the similarity in cesarean
rates of 7%.

Do all hospitals need cesarean delivery capability?

[Outcome based study: Zuni, New
Mexico](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=11978210&dopt=Abstract)

[J Fam Pract.](javascript:AL_get(this, 'jour', 'J Fam Pract.');) 2002
Feb;51(2):129-34

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=11978210&dopt=Abstract>

Native American Community with a 7% Cesarean Delivery Rate

[Leeman(s):](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=11978210&dopt=Abstract)
[What explains the low rate in
Zuni?](http://lyris.aafp.org/t/15218/6112154/159/0/)

[J Fam Pract.](javascript:AL_get(this, 'jour', 'J Fam Pract.');) 2002
Feb;51(2):129-34.

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=11978210&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=11978210&dopt=Abstract) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids11978210doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Frances Placide, Cherokee, North Carolina {#frances-placide-cherokee-north-carolina .Style-Heading-4-+-Arial-14-pt-Underline}

#### Please Welcome Frances Placide, new Chief Clinical Consultant for Physician Assistants {#please-welcome-frances-placide-new-chief-clinical-consultant-for-physician-assistants-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Frances Placide is the new Chief Clinical Consultant for Physician Assistants. Frances works at Cherokee Indian Hospital since 2001. Prior to joining PHS LCDR Placide spent 8 years in the Army as an Occupational Therapist (OT).  Upon joining PHS she worked in Federal Bureau of Prisons (BOP) as an OT and later as a PA.  In her current assignment as Senior PA at Cherokee Indian Hospital her clinical work includes providing medical services in the outpatient and urgent care clinic as well as medical management and coordination to this hospital's first program for chronic pain sufferers. For more information [**http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-pas.asp**](http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-pas.asp) {#frances-placide-is-the-new-chief-clinical-consultant-for-physician-assistants.-frances-works-at-cherokee-indian-hospital-since-2001.-prior-to-joining-phs-lcdr-placide-spent-8-years-in-the-army-as-an-occupational-therapist-ot.-upon-joining-phs-she-worked-in-federal-bureau-of-prisons-bop-as-an-ot-and-later-as-a-pa.-in-her-current-assignment-as-senior-pa-at-cherokee-indian-hospital-her-clinical-work-includes-providing-medical-services-in-the-outpatient-and-urgent-care-clinic-as-well-as-medical-management-and-coordination-to-this-hospitals-first-program-for-chronic-pain-sufferers.-for-more-information-httpwww.ihs.govnonmedicalprogramsnc4nc4-pas.asp .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Special thanks to Harry Taylor, the outgoing Physician Assistant CCC. Harry worked very hard to increase networking and continuing education among Indian Health Physician Assistants. {#special-thanks-to-harry-taylor-the-outgoing-physician-assistant-ccc.-harry-worked-very-hard-to-increase-networking-and-continuing-education-among-indian-health-physician-assistants. .Style-Heading-4-+-Arial-14-pt-Underline}

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

**From Jane Powers, Ft. Duchesne, UT**

**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]{.underline}](http://www.ovccap.ihs.gov/index.asp)

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

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

**What is the evidence on school health promotion in improving health?**

What is the evidence on school health promotion in improving health or
preventing disease and, specifically, what is the effectiveness of the
health promoting schools approach?  

Please see Findings and Policy Considerations

Health Evidence Network (HEN) coordinated by the WHO Regional Office for
Europe, March 2006
<http://www.euro.who.int/HEN/Syntheses/healthpromotion_schools/20060224_7>
or

<http://www.euro.who.int/Document/E88185.pdf>

**Meeting the needs of our native children in special education**

#### April 11-13, 2006 {#april-11-13-2006 .Style-Heading-4-+-Arial-14-pt-Underline}

#### San Diego, CA {#san-diego-ca .Style-Heading-4-+-Arial-14-pt-Underline}

#### Educating Every Child Institute {#educating-every-child-institute .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### Sara Thomas, Warm Springs {#sara-thomas-warm-springs .Style-Heading-4-+-Arial-14-pt-Underline}

#### Is a low fat diet not good idea? Comments on recent research {#is-a-low-fat-diet-not-good-idea-comments-on-recent-research-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**The Women\'s Health Initiative (WHI) Randomized Controlled Dietary
Modification Trial**

This study found no benefit of a low fat diet to decrease the risk of
breast cancer, colon cancer or cardiovascular disease (CVD) in women
50-79 years old.  That's the short version but the results were not
quite that simple, as you'll see below, and none of them suggested
having a fat "free for all" because of the results.

First this was a very well done study (n=48,835, 8 years follow-up),
however we have to consider the population studied, postmenopausal women
age 50 to 79 years, and not generalize to other age, sex, and population
groups. The other important thing to remember is that an equally well
done study (the Diabetes Prevention Program) proved that following a
low-fat diet DOES help decrease the risk of [diabetes]{.underline} by
58% when combined with exercise, **making the point that some diets
(just like some drugs) can help one problem but not another.** Also,
eight years really isn't all that long when considering cancer and heart
disease which can take 20-30 yrs to develop.

Another thing is that the diets they actually achieved in the WHI may
not have been different enough to pick up a benefit of the low fat diet
and some of the changes made confused the whole picture. Dietary goal
set: 20% fat or less, fruit&veg 5 servings/day or more, grains 6
servings/day or more (not specified to be whole grain or not).

**Actual Difference in intervention group vs. control group:**

§   8.2% less fat than control (vs. goal 13%), sat fat 2.9% less, 3
grams more fiber (18 vs 15, but 25g/day is the RDA)

§   1.1more servings fruits/veg a day (5.1 vs 3.9) 

§   0.5 more servings grains per day (but only 1.4 servings whole grain
vs. 1.1 servings whole grain in control group, whole grains are the type
of grains associated with decreased risk of heart disease and cancer and
3 servings of whole grain a day is the actual recommended amount.
Neither came close to this goal)

§   Nut intake lower, 0.5 vs. 1.3 servings a week so the intervention
group had lower levels than the controls. That confuses things because
nut intake has been associated with 30-50% decreased risk of CVD.

§   Fish intake same at about 2 servings a week

§   Soy intake same at about 0.2 servings a week

**Low-Fat Dietary Pattern and Risk of Invasive Breast Cancer** (in
postmenopausal women 50-79 y.o) no benefit found, however:

§   In the subset of women who made the biggest change in their fat
intake did have a 22% lower risk of breast cancer.

§   Fat may play more of a role in hormone sensitive breast cancers.
Secondary analysis of the WHI indicated that effect of fat in the diet
may vary by hormone receptor characteristics of the tumor, with fat
potentially (trend, p=0.09) playing a role in estrogen sensitive
cancers. This has been found in other research with Prentice et al
showing that dietary modification significantly reduced the risk of
breast cancer 36% for disease that was positive for the estrogen
receptor and negative for the progesterone receptor (hazard ratio, 0.64;
95% confidence interval, 0.49-0.84; *P* = .001).

**Low-Fat Dietary Pattern and Risk of Colorectal Cancer** (in
postmenopausal women 50-79 y.o) no benefit found, however:

§   Low fat diet did result in fewer colon polyps which suggests that
the low fat diet might decrease risk over a longer time frame than the 8
years studied.

§   Did not control for folic acid intake, which increased in both the
intervention and the control groups due to the introduction of folic
acid fortification in the US during the study time frame. Why is this
important? Previous large scale studies had found that the risk of colon
cancer is up to 75% lower in women who consume high levels of folic
acid. So folic acid intake could confound any effect of the modest
differences in fat intake between the groups.

§   In addition, this diet reduced all types of fat, not just saturated
fat (which actually has a documented biochemical link to colon cancer.)

**Low-Fat Dietary Pattern and Risk of Cardiovascular Disease**(in
postmenopausal women 50-79 y.o) no benefit found, however:

§   First the study was *not* designed as a CVD reducing diet
intervention, its focus was cancer with CVD as a *secondary* outcome
measure.

§   The study only focused on *total* fat when it is well known that the
*type* of fat is more important. The saturated fat intake was only 2.9%
less than control group. Sub-analysis actually did find that there were
trends to decreased CVD risk in women with the lowest saturated fat
(\<6.1%kcal), lowest trans (\<1.1%kcal) and highest fruit/veg (\>=6.5
svgs/day) yet once again there wasn't a focus on whole grains which have
a bigger effect on CVD risk than fruits & veggies do.

§   Also because of this focus on total fat rather than the type of fat
the intervention group actually decreased their nut intake. This is not
good because eating nuts regularly may reduce CVD risk by \~30-50%.

§   Folic acid intake may have been a confounding factor here as well.
The study did not control for folic acid intake, which increased in both
the intervention and the control groups due to the introduction of folic
acid fortification in the US during the study time frame. Why is this
important? Folic acid may reduce the risk of CVD by lowering
homocysteine levels.

**Bottom line:** This study found no benefit of a low fat diet to
decrease the risk of breast cancer, colon cancer or cardiovascular
disease (CVD) in women 50-79 years old.  That's not to suggest that one
should have a fat "free for all". In fact there are different types of
fat, hence the devil is in the details. The study was well done but it
has several limitations that we have to take into account.
<http://jama.ama-assn.org/current.dtl>

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

#### Roberta Ward, Anchorage {#roberta-ward-anchorage .Style-Heading-4-+-Arial-14-pt-Underline}

**New Information on Paxil and Congenital Malformations**

New warnings have been added to the labeling for Paxil and generic
paroxetine based on preliminary analyses of two recent unpublished
epidemiologic studies. Both studies showed a relatively small increased
risk for cardiac defects in infants born to women who received the drug
in early pregnancy, and one study also showed an increased risk of
congenital malformations overall.\
In both studies, the most common types of cardiac abnormalities in
children of women who took Paxil were atrial and ventricular septal
defects, with a wide range of severity. Neither of the studies addressed
the question of whether the risk might extend to use of the drug later
in pregnancy.\
FDA is recommending that Paxil generally not be started in women who are
planning to become pregnant, or are in the first trimester of pregnancy.
If a woman is already on Paxil, the physician should alert her about the
potential risk to the fetus. The physician should also consider
discontinuing the drug in these women, although in individual cases the
benefits of continuing Paxil may outweigh the potential risk to the
fetus. If Paxil is discontinued, it should be tapered off and not
stopped suddenly.
[[http://www.accessdata.fda.gov/psn/transcript.cfm?show=49#3]{.underline}](http://www.accessdata.fda.gov/psn/transcript.cfm?show=49#3)

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

#### For Your Reading Pleasure . . . Asthma in Pregnancy {#for-your-reading-pleasure-.-.-.-asthma-in-pregnancy-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Current guidelines for the management of asthma during pregnancy Studies have shown that pregnant asthmatic women have an increased risk of adverse perinatal outcomes, whereas controlled asthma is associated with reduced risks. Managing asthma during pregnancy is unique because the effect of the illness and the treatment on the developing fetus as well as the patient must be considered. The two main goals of asthma management during pregnancy are to optimize maternal and fetal health. This article summarizes specific studies and recently published guidelines regarding the optimal management of asthma during pregnancy. {#current-guidelines-for-the-management-of-asthma-during-pregnancy-studies-have-shown-that-pregnant-asthmatic-women-have-an-increased-risk-of-adverse-perinatal-outcomes-whereas-controlled-asthma-is-associated-with-reduced-risks.-managing-asthma-during-pregnancy-is-unique-because-the-effect-of-the-illness-and-the-treatment-on-the-developing-fetus-as-well-as-the-patient-must-be-considered.-the-two-main-goals-of-asthma-management-during-pregnancy-are-to-optimize-maternal-and-fetal-health.-this-article-summarizes-specific-studies-and-recently-published-guidelines-regarding-the-optimal-management-of-asthma-during-pregnancy. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [Namazy JA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Namazy+JA"%5BAuthor%5D), [Schatz M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Schatz+M"%5BAuthor%5D). Current guidelines for the management of asthma during pregnancy. [Immunol Allergy Clin North Am.](javascript:AL_get(this, 'jour', 'Immunol Allergy Clin North Am.');) 2006 Feb;26(1):93-102 {#namazy-ja-schatz-m.-current-guidelines-for-the-management-of-asthma-during-pregnancy.-immunol-allergy-clin-north-am.-2006-feb26193-102 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16443145**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16443145) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16443145 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Judy Whitecrane, Phoenix {#judy-whitecrane-phoenix .Style-Heading-4-+-Arial-14-pt-Underline}

**Needed: PHS Nurses with OB experience**

#### The Surgeon General has activated the Commissioned Corps to support the Yukon-Kuskokwim Health Center in Bethel, Alaska thru 4/29/06. The facility is experiencing an extreme staffing shortage among OB nurses (they are currently at 40% staffing). They are requesting 6 nurses with OB experience per rotation until the end of April. The facility states they will pay for travel, housing and per diem of deployed officers. If you are available for this activity, please go to the following website and indicate your availability: [[http://ccrf.hhs.gov/ccrf/missions/bethel.htm]{.underline}](http://ccrf.hhs.gov/ccrf/missions/bethel.htm) {#the-surgeon-general-has-activated-the-commissioned-corps-to-support-the-yukon-kuskokwim-health-center-in-bethel-alaska-thru-42906.-the-facility-is-experiencing-an-extreme-staffing-shortage-among-ob-nurses-they-are-currently-at-40-staffing.-they-are-requesting-6-nurses-with-ob-experience-per-rotation-until-the-end-of-april.-the-facility-states-they-will-pay-for-travel-housing-and-per-diem-of-deployed-officers.-if-you-are-available-for-this-activity-please-go-to-the-following-website-and-indicate-your-availability-httpccrf.hhs.govccrfmissionsbethel.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### 2006 Clinical Update on Substance Abuse and Dependency  {#clinical-update-on-substance-abuse-and-dependency-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### (formerly known as the Primary Care Provider Training on Chemical Dependency) {#formerly-known-as-the-primary-care-provider-training-on-chemical-dependency .Style-Heading-4-+-Arial-14-pt-Underline}

Phoenix, Arizona Bangor, Maine

May 9 - 11, 2006 June 20 - 22, 2006

(30 Training Slots) (30 Training Slots)

#### [[http://www.ihs.gov/MedicalPrograms/ClinicalSupportCenter/]{.underline}](http://www.ihs.gov/MedicalPrograms/ClinicalSupportCenter/) {#httpwww.ihs.govmedicalprogramsclinicalsupportcenter .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}

#### GDM: Can we proceed directly to one step screening / diagnosis in AI / AN women?

Some providers have noted that many AI/AN patients are lost to follow-up
between a positive glucose screen test result and the performance of the
definitive diagnostic test, the 3 hour oral glucose tolerance test.

Other providers noted that many AI/AN women live in remote areas with
limited access to care, yet have some of the highest rates of diabetes
in pregnancy in the U.S., and possibly the highest in the world.

ACOG and the Indian Health system convened an Expert Panel of 35 experts
on April 12, 1993\* to discuss these and other issues related to the
diagnosis of gestational diabetes mellitus in pregnancy. One of the main
areas of discussion was that eliminating the screening phase and
proceeding directly to a diagnostic test seemed warranted in certain
AI/AN populations.

There was general concurrence that these rates were so high that being
an AI/AN woman was sufficient to serve in itself as a positive screen,
and thus to indicate the need for a diagnostic level of testing
directly.

The Expert Panel suggested that upcoming Technical Bulletins
(subsequently modified to 'Practice Bulletins') reflect that other
loading doses are currently used in other populations.

Hence, the current [ACOG Practice Bulletin, No.
30](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11547793&dopt=Abstract)
now states...

".....there may be groups of individuals at such high risk for GDM that
it may be more convenient and cost-effective to proceed directly to the
diagnostic GTT without obtaining the laboratory screening test....."

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

After the above ACOG Consultation, the American Diabetes Association
issued the following statement in [Diagnosis and Classification of
Diabetes Mellitus *Diabetes Care* 29:S43-S48,
2006](http://care.diabetesjournals.org/cgi/content/full/29/suppl_1/s43)

**One-step approach: ADA**\
Perform a diagnostic OGTT without prior plasma or serum glucose
screening. The one-step approach may be cost-effective in high-risk
patients or populations (e.g., some Native-American groups). "

[Bottomline:]{.underline}

The ACOG Consultation was a high level document, e. g., no direct
recommendations came out of the ACOG Consultation -- it was ultimately
left up to the local facility.

Personally, a good rule of thumb is that if any AI/AN group exceeds 7 %,
then they would qualify for one step testing....hence within the context
of the ACOG / ADA verbiage above, I suggest...

....any AI/AN group that exceeds a 7% prevalence of diabetes in
pregnancy should consider one step universal diabetes screening. This
screening should occur at 24-28 weeks. If additional high risk factors
are present, then additional screening should also be performed at the
first prenatal visit.

High risk patients include those with the following factors:

a\. history of infant over 8 lb.14oz. (4000 grams) at birth;

b\. first degree family history of diabetes (parents or sibling);

c\. initial visit BMI \> 25     BMI = kg/m2  X 100  (see Appendix C)

d\. past hx:  stillbirth, habitual abortion, congenital anomaly

e\. current pregnancy:  unexplained polyhydraminos, persistent
glycosuria

f\. age \> 35 years

g\. prior history of gestational diabetes

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

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

**Frequently asked questions**

**Q. Can we perform one step GDM screening in AI/AN?**

A. Yes in some AI/AN. ACOG and IHS discussed it 1993 and it is endorsed
by the ADA

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/OneStep22306.doc>

**Q. What is the best screening cut-off for gestational diabetes
mellitus?**

**A**. A cut-off of 140 mg/dL has 10% less sensitivity than a threshold
of 130 mg/dL but fewer false-positive results; either threshold is
acceptable.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CutOff22506.doc>

[Gestational Diabetes. ACOG Practice Bulletin No.
30](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11547793&dopt=Abstract).
American College of Obstetricians and Gynecologists. Obstet Gynecol
2001;98:525--538

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11547793>

[Diagnosis and Classification of Diabetes Mellitus *Diabetes Care*
29:S43-S48,
2006](http://care.diabetesjournals.org/cgi/content/full/29/suppl_1/s43)

#### [**http://care.diabetesjournals.org/cgi/content/full/29/suppl_1/s43**](http://care.diabetesjournals.org/cgi/content/full/29/suppl_1/s43) {#httpcare.diabetesjournals.orgcgicontentfull29suppl_1s43 .Style-Heading-4-+-Arial-14-pt-Underline}

Above Risk factors from Indian Health National Guidelines web site

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

\* ACOG Consultation: Diagnosis of Gestational Diabetes Mellitus, April
12, 1993

Copies of the full 1993 Proceedings can be obtained from [Elaine
Locke](http://www.ihs.gov/MedicalPrograms/MCH/M/ELocke@acog.org),
<ELocke@acog.org>

or Neil Murphy, M.D., [nmurphy@scf.cc]{.underline}

Link between GDM and Type 2 DM can be broken: Update

The similarity of findings between the PIPOD and TRIPOD studies support
a class effect of thiazolidinedione drugs to enhance insulin
sensitivity, reduce insulin secretory demands, and preserve pancreatic
beta-cell function, all in association with a relatively low rate of
type 2 diabetes, in Hispanic women with prior gestational diabetes.

[Xiang
AH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Xiang+AH"%5BAuthor%5D),
et al Effect of pioglitazone on pancreatic beta-cell function and
diabetes risk in Hispanic women with prior gestational diabetes.
[Diabetes.](javascript:AL_get(this, 'jour', 'Diabetes.');) 2006
Feb;55(2):517-22.\
[**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16443789**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16443789)

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

The January 2006 the CCCC previously reported that treatment with
troglitazone delayed or prevented the onset of type 2 diabetes in
previous GDM patients (Buchanan et al). Unfortunately, troglitazone was
subsequently taken off the market. Xiang et al now report similar effect
which raises the question of a class effect in the thiazolidinedione
drugs. As many as 70% of GDM patients can progress onto Type II DM,
especially if they do not return to their ideal body weight. Combined
with the Diabetes Prevention Program that should the consistent moderate
exercise can also decrease the progression to DM, Xiang's finding give
us two strong tools in our armamentarium to prevent the future
complications of DM in our patients

Link between GDM and Type 2 DM can be broken (CCC Corner January 2006)

[**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_AOM.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_AOM.cfm)

Gestational Glucose Tolerance Risk of Type 2 Diabetes in Young Pima
Indian Offspring

In conclusion, maternal glycemia during pregnancy is associated with
increased birth weight and risk of diabetes in Pima Indian offspring,
even when mothers are normal glucose tolerant during pregnancy. Thus,
prevention of offspring type 2 diabetes may require strategies that
focus on improving gestational glucose tolerance even within the normal
range.

[Franks
PW](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Franks+PW"%5BAuthor%5D),
et al Gestational glucose tolerance and risk of type 2 diabetes in young
Pima Indian offspring.
[Diabetes.](javascript:AL_get(this, 'jour', 'Diabetes.');) 2006
Feb;55(2):460-5.\
[**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16443781**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16443781)

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

As with the above article, Franks et al reminds that our AI/AN patients
are at higher than expected risk for glucose intolerance and its
complications. The in utero environment is a powerful risk factor for
type 2 diabetes in offspring, but little is known about the risk
conveyed by nondiabetic gestational glucose levels. At the very least
Franks et al suggests that until we know more, we need to manage at
least our known GDM patients very closely and be sure to inform our
patients about their increased risk. For more information on the
diagnosis and management of diabetes in pregnancy, here are two
educational modules with excellent resources (and free CME/CEUs)

Diabetes in pregnancy: Screening and diagnosis, Part I

[**http://www.ihs.gov/MedicalPrograms/MCH/M/DP01.cfm#top**](http://www.ihs.gov/MedicalPrograms/MCH/M/DP01.cfm#top)

Diabetes in pregnancy: Management and Postpartum, Part II

[**http://www.ihs.gov/MedicalPrograms/MCH/M/DP21.cfm#top**](http://www.ihs.gov/MedicalPrograms/MCH/M/DP21.cfm#top)

Is Influenza Vaccination Safe for Pregnant Women?

Influenza has significant potential for morbidity and mortality in
pregnant women. Hospital admission rates for healthy pregnant women in
the third trimester with influenza-related diseases are similar to those
of persons with other high-risk conditions. The Advisory Committee of
Immunization Practices recommends that pregnant women receive trivalent
inactivated influenza vaccines during the influenza season. The
inactivated form is the only influenza vaccine approved for use at any
gestational age. Despite these recommendations, only about 12 percent of
pregnant women are vaccinated. This low rate may be attributed to safety
concerns regarding the vaccine, but studies have shown the influenza
vaccine to be safe for the mother and fetus.

Conclusion: Inactivated influenza vaccine provided during the second and
third trimesters is safe. They add that safety concerns do not justify
avoiding the use of the vaccine in pregnant women.

Munoz FM, et al. Safety of influenza vaccination during pregnancy. Am J
Obstet Gynecol April 2005;192:1098-106.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15846187>

**Membrane sweeping at induction increases vaginal delivery rate and
patient satisfaction**

CONCLUSION: Membrane sweeping at initiation of labor induction increased
the spontaneous vaginal delivery rate, reduced oxytocic drug use,
shortened induction to delivery interval, and improved patient
satisfaction. LEVEL OF EVIDENCE: I.

[Tan
PC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Tan+PC"%5BAuthor%5D),
[Jacob
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Jacob+R"%5BAuthor%5D),
[Omar
SZ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Omar+SZ"%5BAuthor%5D).
Membrane sweeping at initiation of formal labor induction: a randomized
controlled trial. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Mar;107(3):569-77.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16507926>

**What proportion of birth weight is attributable to maternal glucose?**

CONCLUSION: Maternal glycemia during third-trimester and prepregnancy
body mass index are independent predictors of birth weight in
pregnancies complicated by insulin-requiring gestational or type 2
diabetes.

[Sacks
DA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Sacks+DA"%5BAuthor%5D),
et al What proportion of birth weight is attributable to maternal
glucose among infants of diabetic women? [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Feb;194(2):501-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16458653>

**Bactericidal levels of ampicillin in cord blood within 30 minutes of
ampicillin**

CONCLUSION: The increase in the ratio of cord to maternal serum
ampicillin levels is directly related to time, suggesting a decrease in
the clearance of ampicillin in the newborns as compared to the mothers.
The cord blood ampicillin concentration exceeds the maternal
concentration and both continue to be above the minimal bactericidal
concentrations at 5.6 hours after administration. No relationship was
observed between the maternal body mass index and ratio of cord to
maternal serum concentrations of ampicillin. [Colombo
DF](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Colombo+DF"%5BAuthor%5D),
et al Optimal timing of ampicillin administration to pregnant women for
establishing bactericidal levels in the prophylaxis of Group B
Streptococcus. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Feb;194(2):466-70.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16458647>

**Use of oral decongestants late pregnancy: A favorable neonatal
outcome**

RESULTS: The risk ratio for any congenital malformation after the use of
oral decongestants was 0.96 (95% CI, 0.80-1.16). Women who were
prescribed decongestants after the first antenatal visit less often than
expected had infants who were born preterm (odds ratio, 0.68; 95% CI,
0.52-0.88), of low birth weight (odds ratio, 0.53; 95% CI, 0.37-0.77),
small-for-date (odds ratio, 0.71; 95% CI, 0.47-1.08), or perinatally
dead (odds ratio, 0.53; 95% CI, 0.22-12.5).

CONCLUSION: No teratogenic effect of oral decongestants was found. An
association found between the late pregnancy use of such drugs and a
favorable neonatal outcome can be explained hypothetically by the
postulated association between pregnancy rhinitis and placental
hormones. [Kallen
BA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Kallen+BA"%5BAuthor%5D),
[Olausson
PO](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Olausson+PO"%5BAuthor%5D).
Use of oral decongestants during pregnancy and delivery outcome. [Am J
Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Feb;194(2):480-5.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16458650>

**Iron supplementation may have benefits beyond the reduction of anemia
in low income**

[Results]{.underline} Mean birth weight was higher by 108 g (P = .03),
and the incidence of preterm delivery was lower (8% vs 14%; P = .05) in
the 30-mg group compared with the control group, respectively. Iron
supplementation did not affect the prevalence of small-for-gestational
age infants or third-trimester iron status.

[Conclusion]{.underline} Prophylactic iron supplementation that is begun
early in pregnancy among low income women in the United States may have
benefits beyond the reduction of iron deficiency anemia during
pregnancy.

[Siega-Riz
AM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Siega-Riz+AM"%5BAuthor%5D),
et al The effects of prophylactic iron given in prenatal supplements on
iron status and birth outcomes: a randomized controlled trial. [Am J
Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Feb;194(2):512-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16458655>

**Fluoxetine late in the 3rd trimester: Increased risk of persistent
pulmonary hypertension**

CONCLUSIONS: These data support an association between the maternal use
of SSRIs in late pregnancy and PPHN in the offspring; further study of
this association is warranted. These findings should be taken into
account in decisions as to whether to continue the use of SSRIs during
pregnancy.

[Chambers
CD](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Chambers+CD"%5BAuthor%5D)
et al Selective serotonin-reuptake inhibitors and risk of persistent
pulmonary hypertension of the newborn. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2006 Feb
9;354(6):579-87\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16467545&dopt=Abstract>

**Neonates with cerebral white matter injury: Increased nucleated red
blood cells**

CONCLUSION: Preterm neonates with cerebral white matter injury have
significant increases in nucleated red blood cell counts. Both acute and
chronic hypoxia-ischemia can increase these counts, which limits their
usefulness in timing injury. The predictive value of nucleated red blood
cell counts at birth in identifying injury is poor. LEVEL OF EVIDENCE:
II-2

[Silva
AM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Silva+AM"%5BAuthor%5D),
et al Neonatal Nucleated Red Blood Cells and the Prediction of Cerebral
White Matter Injury in Preterm Infants.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16507923>

**High rate of pelvic vein thrombosis after cesarean: Magnetic resonance
venography**

In the run-in phase of a thromboprophylactic trial in women at moderate
to high risk of deep vein thrombosis postcesarean section, we used
magnetic resonance venography and found a surprisingly high rate of
pelvic deep vein thrombosis (46% overall). Pelvic magnetic resonance
venography may be a useful surrogate outcome in obstetric
thromboprophylaxis studies but the clinical significance is not known.

[Rodger
MA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Rodger+MA"%5BAuthor%5D),
et al Pelvic magnetic resonance venography reveals high rate of pelvic
vein thrombosis after cesarean section. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Feb;194(2):436-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16458642>

**Low amniotic fluid volume not a contraindication in PPROM remote from
term**

CONCLUSION: Oligohydramnios should not be a consideration in determining
which women will be candidates for expectant management or antibiotic
treatment when it is identified at initial assessment of preterm PROM
remote from term

[Mercer
BM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Mercer+BM"%5BAuthor%5D),
et al. The NICHD-MFMU antibiotic treatment of preterm PROM study: Impact
of initial amniotic fluid volume on pregnancy outcome. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Feb;194(2):438-45.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16458643>

**Sulprostone reduces need for manual removal in patients with retained
placenta: RCT**

Sulprostone is a metabolism resistant synthetic analog of PGE2, a
selective agonist.

RESULTS: In the first phase of this sequential study, sulprostone was
compared with placebo. The null hypothesis of equal effectiveness of
both treatments was rejected after 50 patients. In patients with
retained placenta, the placenta was expelled after sulprostone in 13 of
24 cases (51.8%, bias adjusted), whereas expulsion after placebo was
achieved in only 4 of 26 cases (17.6%, bias adjusted). The difference
was significant (P = .034). In the second phase of the study, in which
the placebo arm was stopped, results were confirmed; in 25 of 53
patients (47%), the placenta was expelled. CONCLUSION: Sulprostone
reduces the need for the manual removal of the placenta by 49%. [van
Beekhuizen
HJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="van+Beekhuizen+HJ"%5BAuthor%5D),
et al Sulprostone reduces the need for the manual removal of the
placenta in patients with retained placenta: a randomized controlled
trial. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Feb;194(2):446-50.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16458644>

**Targeted HSV testing would miss a substantial proportion of neonatal
herpes**\
RESULTS: Ninety-one neonatal HSV cases were identified (8.4/100,000 live
births). Risk factors for infection included maternal age younger than
25 years (adjusted odds ratio \[aOR\] = 1.9, 95% CI 1.1-3.3) and
paternal age younger than 20 years or unknown (aOR = 1.7, 95% CI
0.7-3.7). Testing couples with either risk factor would require testing
36% of couples and could potentially prevent up to 60% of cases.
Maternal history of genital herpes, fever during labor, and premature
rupture of membranes were also associated with neonatal disease; using
all risk factors identifiable at delivery would require screening 60% of
pregnancies and identifying 84% of cases. CONCLUSION: Targeted HSV
testing would miss a substantial proportion of neonatal herpes.\
[Mark
KE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Mark+KE"%5BAuthor%5D),
et al Targeted prenatal herpes simplex virus testing: can we identify
women at risk of transmission to the neonate? [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Feb;194(2):408-14.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16458638>

**Preterm Premature Rupture of Membranes: Diagnosis and Management**

Preterm premature rupture of membranes is the rupture of membranes
during pregnancy before 37 weeks\' gestation. It occurs in 3 percent of
pregnancies and is the cause of approximately one third of preterm
deliveries. It can lead to significant perinatal morbidity, including
respiratory distress syndrome, neonatal sepsis, umbilical cord prolapse,
placental abruption, and fetal death. Appropriate evaluation and
management are important for improving neonatal outcomes. Speculum
examination to determine cervical dilation is preferred because digital
examination is associated with a decreased latent period and with the
potential for adverse sequelae. Treatment varies depending on
gestational age and includes consideration of delivery when rupture of
membranes occurs at or after 34 weeks\' gestation. Corticosteroids can
reduce many neonatal complications, particularly intraventricular
hemorrhage and respiratory distress syndrome, and antibiotics are
effective for increasing the latency period. Am Fam Physician
2006;73:659-64, 665-6 <http://www.aafp.org/afp/20060215/659.html> (Also
see Patient Education)

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

**Diet and Exercise Reduce Incontinence in Women at Risk of Diabetes**

CONCLUSIONS: Less-frequent urinary incontinence may be a powerful
motivator for women to choose lifestyle modification to prevent diabetes

[Brown
JS](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Brown+JS"%5BAuthor%5D),
et al Lifestyle intervention is associated with lower prevalence of
urinary incontinence: the Diabetes Prevention Program. [Diabetes
Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');) 2006
Feb;29(2):385-90.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16443892>

**Hysterectomy increases resource use significantly, but increases
quality-of-life too**

CONCLUSION: For women with abnormal uterine bleeding refractory to
cyclic medroxyprogesterone acetate, compared with expanded medical
treatment, hysterectomy increases resource use significantly and results
in better clinical and 6-month quality-of-life outcomes.

[Showstack
J](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Showstack+J"%5BAuthor%5D),
et al Randomized trial of medical treatment versus hysterectomy for
abnormal uterine bleeding: resource use in the Medicine or Surgery (Ms)
trial.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16458625>

**Atypical glandular cells: High risk - several markers put patients at
more substantial risk**

CONCLUSION: Histologic diagnosis showed that 29.0% of these Pap tests
had findings requiring follow-up or therapeutic intervention, including
a 5.2% rate of malignancy. Based on these findings, 99.6% of the
diagnoses are within the region of surveillance when AGUS Pap tests are
evaluated with colposcopy and directed biopsy, endocervical curettage,
an endometrial biopsy in patients with risk factors for endometrial
cancer, and pelvic examination.

[Schnatz
PF](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Schnatz+PF"%5BAuthor%5D),
et al Clinical significance of atypical glandular cells on cervical
cytology. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Mar;107(3):701-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16507944>

**Laparoscopic assistance not useful in performing vaginal
hysterectomies w/ BSO**

CONCLUSION: The overall complication rate was higher with LAVHO than
VHO. It thus appears that laparoscopic assistance is not useful in
performing vaginal hysterectomies with prophylactic bilateral
oophorectomies in patients without other related disorders
(endometriosis, adhesions, adnexal anomalies).\
[Agostini
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Agostini+A"%5BAuthor%5D),
et al Value of laparoscopic assistance for vaginal hysterectomy with
prophylactic bilateral oophorectomy. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Feb;194(2):351-4.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16458628>

**Psychosocial Stress May Raise Risk of Bacterial Vaginosis**

CONCLUSION: Increased psychosocial stress is associated with greater
bacterial vaginosis prevalence and incidence independent of other risk
factors.

[Nansel
TR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Nansel+TR"%5BAuthor%5D),
et al The association of psychosocial stress and bacterial vaginosis in
a longitudinal cohort. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Feb;194(2):381-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16458633>

**Carcinoma of the vulva: A Review**

Surgical modifications have lessened the morbidity associated with
radical surgery for vulvar cancer; patients with large primary tumors or
gross lymphadenopathy should be treated with chemoradiation.

The objective of this review is to summarize the published data about
squamous carcinoma of the vulva and to identify promising areas for
future investigation. Rather than the routine use of complete radical
vulvectomy, a radical wide excision of the vulvar lesion to achieve at
least a 1-cm gross margin appears sufficient to treat the primary
lesion....

[Stehman
FB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Stehman+FB"%5BAuthor%5D),
[Look
KY](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Look+KY"%5BAuthor%5D).
Carcinoma of the vulva. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Mar;107(3):719-33.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16507947>

**The Challenge of Pelvic Inflammatory Disease**

Pelvic inflammatory disease (PID) is an infection of the upper genital
tract in women that can include endometritis, parametritis, salpingitis,
oophoritis, tubo-ovarian abscess, and peritonitis. The spectrum of
disease ranges from subclinical, asymptomatic infection to severe,
life-threatening illness; sequelae include chronic pelvic pain, ectopic
pregnancy, and infertility. PID is diagnosed clinically, with laboratory
and imaging studies reserved for patients who have an uncertain
diagnosis, are severely ill, or do not respond to initial therapy. The
Centers for Disease Control and Prevention diagnostic criteria include
uterine, adnexal, or cervical motion tenderness with no other obvious
cause in women at risk of PID. Empiric treatment should be initiated
promptly and must cover *Chlamydia trachomatis* and *Neisseria
gonorrhoeae;* the possibility of fluoroquinolone-resistant *N.
gonorrhoeae* also should be considered. Hospitalization for initial
parenteral therapy is necessary for patients with tubo-ovarian abscess
and for those who are pregnant, severely ill, unable to follow a
prescribed treatment plan, or unable to tolerate oral antibiotics.
Patients also should be hospitalized if a surgical emergency cannot be
excluded or if no clinical improvement occurs after three days. Routine
screening for asymptomatic chlamydial infection can help prevent PID and
its sequelae. Am Fam Physician 2006;73:859-64.

<http://www.aafp.org/afp/20060301/859.html>

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

**Maternal cholestasis and neonatal respiratory distress syndrome**

The authors describe 3 cases of neonatal respiratory distress syndrome
(RDS) in near-term infants, born from mothers with severe intrahepatic
cholestasis of pregnancy. Common pictures of the cases were: good
indices of lung maturity in the amniotic fluid; severe RDS requiring
mechanical ventilation; high serum bile acid (BA) levels in the early
days of life; no meconium aspiration; negative cultures; and absence of
indirect laboratory signs of infection. After the first case, we

hypothesized that abnormally high BA levels could have reversed the
action of phospholipase A2 in the lungs, causing a degradation of
phosphatidylcholines to lysophosphatidylcholines and the consequent lack
of surfactant activity, leading to the severe respiratory distress.
Consequently, in cases 2 and 3, we gave intratracheal surfactant to the
infants, which, although administered around the first 24 hours of life,
showed to be helpful. Our experience suggests that a high level of
attention in the management of newborn infants (even near-term infants)
born from women with intrahepatic cholestasis of pregnancy is necessary
to detect as soon as possible signs and symptoms of this \"unexpected\"
RDS, which can assume a very severe clinical picture. In such instances,
we recommend that the diagnosis of BA pneumonia be kept in mind and that
exogenous surfactant be given as soon as possible, even in the presence
of indices of normal lung maturity in the amniotic fluid. Finding high
levels of BA and lysophosphatidylcholines in the bronchoalveolar lavage
of affected infants would aid in support of the diagnosis.

Zecca E, et al Bile acid pneumonia: a \"new\" form of neonatal
respiratory distress syndrome? Pediatrics. 2004 Jul;114(1):269-72

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15231944>

**Other cholestasis of pregnancy related articles:** **Available on
request**

**FDA Warns Parents About Contaminated Teething Rings**

The Food and Drug Administration urges parents to stop giving their
babies a liquid-filled plastic teething ring made by The First Years, a
unit of RC2 Corp., which may be contaminated with bacteria. Liquid in
the teething rings could infect infants if they swallow or absorb it
through a cut in the mouth, the FDA said. The risk of illness is
greatest for babies with immune systems weakened by cancer, malnutrition
or other health problems.
[http://www.thefirstyears.com](http://www.thefirstyears.com/)

#### Incidence of a Type AB Infant Born to a Type O Mother  {#incidence-of-a-type-ab-infant-born-to-a-type-o-mother-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Routine cord blood testing may include ABO, Rh, Direct Antigen Testing (DAT) and Indirect Coombs testing (IDC), among other testing, but varies widely from blood bank to blood bank. In this case, the routine testing revealed that an AB infant was born to an O mother. It is not routine to find an AB infant born to an O mother, as the mother carries an O,O type and would have to pass an O to the infant, leaving the possibilities of O,O; A,O; or B,O type for the infant, depending on the father\'s blood type. Because of the rarity of an AB infant being born to an O mother, several troubleshooting steps were taken prior to the release of test results. It is important to investigate whenever there is a discrepancy discovered during laboratory testing. An AB and O couple producing an AB child cannot be explained in terms of the usual inheritance patterns. One would not expect the cord blood result to be AB when the mother is type O, however, in very rare instances, such as the cis-AB blood type, it is possible. Extensive troubleshooting revealed the infant to have this very rare cis-AB blood type. {#routine-cord-blood-testing-may-include-abo-rh-direct-antigen-testing-dat-and-indirect-coombs-testing-idc-among-other-testing-but-varies-widely-from-blood-bank-to-blood-bank.-in-this-case-the-routine-testing-revealed-that-an-ab-infant-was-born-to-an-o-mother.-it-is-not-routine-to-find-an-ab-infant-born-to-an-o-mother-as-the-mother-carries-an-oo-type-and-would-have-to-pass-an-o-to-the-infant-leaving-the-possibilities-of-oo-ao-or-bo-type-for-the-infant-depending-on-the-fathers-blood-type.-because-of-the-rarity-of-an-ab-infant-being-born-to-an-o-mother-several-troubleshooting-steps-were-taken-prior-to-the-release-of-test-results.-it-is-important-to-investigate-whenever-there-is-a-discrepancy-discovered-during-laboratory-testing.-an-ab-and-o-couple-producing-an-ab-child-cannot-be-explained-in-terms-of-the-usual-inheritance-patterns.-one-would-not-expect-the-cord-blood-result-to-be-ab-when-the-mother-is-type-o-however-in-very-rare-instances-such-as-the-cis-ab-blood-type-it-is-possible.-extensive-troubleshooting-revealed-the-infant-to-have-this-very-rare-cis-ab-blood-type. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Nickel, CP. Incidence of a Type AB Infant Born to a Type O Mother. Lab Med  2006;37(1):28-35 {#nickel-cp.-incidence-of-a-type-ab-infant-born-to-a-type-o-mother.-lab-med-200637128-35 .Style-Heading-4-+-Arial-14-pt-Underline}

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

Description of this case report provides a good opportunity to remind
you that we have just unveiled a new educational module about Antibody
Screen Positive: Rh Disease and Other Atypical Antibodies. This module
could just be used for its many great resources, or for free CME/CEUs
from the Perinatology Corner, IHS.

**Antibody Screen Positive: Rh Disease and Other Atypical Antibodies,
PNC Module**

<http://www.ihs.gov/MedicalPrograms/MCH/M/AntBod01.cfm>

CDC Releases Guidelines on Identifying and Referring Persons with FAS

Prenatal exposure to alcohol can damage the developing fetus and is a
leading preventable cause of birth defects and developmental
disabilities. Despite the known adverse effects of prenatal exposure to
alcohol, children who experience these effects often do not receive a
correct diagnosis or referral for diagnostic evaluation because of the
absence of uniformly accepted diagnostic criteria and guidelines for
referral. The Centers for Disease Control and Prevention (CDC) has
issued consensus guidelines to help identify persons affected by
prenatal exposure to alcohol so that they and their families can receive
services that enable them to achieve healthy lives. The recommendations,
which were published in the October 28, 2005, issue of *Morbidity and
Mortality Weekly Report,* include guidelines to enhance identification
of and intervention for women at risk of alcohol-exposed pregnancies.

<http://www.cdc.gov/ncbddd/fas/documents/FAS_guidelines_accessible.pdf>

**Prevalence of overweight among children entering school**

Nearly one quarter of children entering school are already overweight. .
The article reports the findings of the CLOCC school survey and provides
the first estimates of measures of overweight (OW) prevalence in Chicago
children ages 3-5 entering school.

\*The overall prevalence of overweight was 24%, two to three times
higher than both the national prevalence of 10% for children ages 2-5
documented by the 1999-2002 National Health and Nutrition Examination
Survey (NHANES) and the 1998-1999 Early Childhood Longitudinal Study
prevalence estimate of 8% for children ages 5-7 in the Midwest region.

\*The prevalence of OW (24%) was higher than the prevalence of AROW
(16%).

\*The ratio of OW to AROW was more than 1.5 times higher than the
national ratio.

\*There were no significant differences in the percentage of OW by
sample source or gender.

This clearly establishes a need for local schools to develop protocols
and procedures to support the physical and mental health needs of
affected and at-risk children.

Mason M, Meleedy-Rey P, Christoffel KK, et al. 2006. Prevalence of
overweight and risk of overweight among 3- to 5-year-old Chicago
children, 2002-2003. Journal of School Health 76(3):104-110

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16475986>

**Discharge Procedures for Healthy Newborns (see also Patient
Education)**

Physicians should use a checklist to facilitate discussions with new
parents before discharging their healthy newborn from the hospital. The
checklist should include information on breastfeeding, warning signs of
illness, and ways to keep the child healthy and safe. Physicians can
encourage breastfeeding by giving parents written information on hunger
and feeding indicators, stool and urine patterns, and proper
breastfeeding techniques. Physicians also should emphasize that infants
should never be given honey or bottles of water before they are one year
of age. Parents should be advised of treatments for common infant
complaints such as constipation, be aware of signs and symptoms of more
serious illnesses such as jaundice and lethargy, and know how to
properly care for the umbilical cord and genital areas. Physicians
should provide guidance on how to keep the baby safe in the crib (e.g.,
placing the baby on his or her back) and in the car (e.g., using a car
seat that faces the rear of the car). It is also important to schedule a
follow-up appointment for the infant. Am Fam Physician 2006;73:849-52,
857-8.

<http://www.aafp.org/afp/20060301/849.html>

**Health and Well-Being of Children: A Portrait of States and the Nation
2005**

The National Survey of Children\'s Health, conducted for the first time
in 2003, addresses multiple aspects of child health­-including physical
and mental health, health care, and social well-being­-as well as aspects
of the family and the neighborhood that can affect children\'s health,
on both the National and State levels.  The survey was supported by the
U.S. Maternal and Child Health Bureau of the Health Resources and
Services Administration and conducted by the National Center for Health
Statistics of the Centers for Disease Control and Prevention. 

Chart Book:
[http://www.mchb.hrsa.gov/thechild/index.htm](http://www.magnetmail1.net/ls.cfm?r=12268528&sid=894411&m=156364&u=AHA_HFSF_1&s=http://www.mchb.hrsa.gov/thechild/index.htm)

**5th Annual Forum for Improving Children\'s Health Care**

March 16-18, 2006

Orlando, Florida

Enroll at
[www.nichq.org](../../../../../../../../C:%5CDocuments%20and%20Settings%5Camarchetti%5CApplication%20Data%5CMicrosoft%5CSignatures%5Cwww.nichq.org)

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

**Colon cancer rates: Significantly increased in AI/AN women -- Colon
Cancer Month**

Colorectal Cancer is Preventable, Treatable and Beatable!

March is National Colorectal Cancer Screening Awareness Month. The
Cancer Research and Prevention Foundation is delighted to offer you the
new [2006 NCRCAM Tool
Kit](http://www.preventcancer.org/colorectal/materials/toolkit.cfm) to
help you celebrate 2006 March National Colorectal Cancer Awareness
Month. We hope these ideas and resources will inspire you to develop
creative outreach and awareness programs in your community to help
spread the message: Colorectal Cancer is Preventable, Treatable and
Beatable! <http://www.preventcancer.org/colorectal/>

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

Colon cancer is a Women's Health cancer too, e.g., not just cervical,
ovarian, endometrial, and breast. Colon cancer rates are significantly
increased in AI/AN populations, especially in AI/AN women, so we should
pursue a vigorous colon cancer screening in women.

**American Heart Association Updates Guidelines for Blood Pressure
Management**

The American Heart Association (AHA) updated its position statement on
lifestyle modifications for the prevention and treatment of high blood
pressure (BP).

The guidelines emphasize increased intake of fruit and vegetables, and
limiting alcohol intake to moderate levels for patients who drink
alcohol. Clinicians should offer individualized lifestyle advice and
refer patients diagnosed as having hypertension to dietitians, health
educators, or behavioral modification programs. Other specific
recommendations include:

-   Maintaining normal weight or losing weight if overweight. Research
    suggests that weight loss lowers BP even before the ideal weight
    goal is reached. However, greater weight loss leads to greater BP
    reduction. In addition to diet, a high level of physical activity is
    vitally important to sustain weight loss.

-   Reducing sodium intake to about 1.5 g/day, because this measure
    lowers BP in people with and without hypertension, and it can
    ameliorate the age-associated rise in BP and lower the risk for
    atherosclerotic CVD events and congestive heart failure. Reducing
    salt intake is most effective in lowering BP in older people and in
    those with hypertension, diabetes, or chronic kidney disease. More
    than 75% of consumed salt in the US diet comes from processed foods,
    so the writing committee asked food manufacturers to reduce salts in
    food by 50% during the next 10 years.

-   Eating 8 to 10 servings of fruits and vegetables daily to increase
    potassium intake, which effectively reduces BP both in normotensive
    and in hypertensive individuals, especially in blacks. Although
    recommended potassium intake is 4.7 g/day, this amount should be
    reduced for patients with impaired renal function or severe
    congestive heart failure.

-   Moderating alcohol intake, because there is a dose-response
    relationship between alcohol and BP, especially in people drinking
    more than 2 drinks daily. Although a meta-analysis of 15 trials
    shows that consuming less alcohol reduces both systolic and
    diastolic BP, moderate alcohol intake may also be effective in
    lowering BP. Alcohol consumption should not exceed 2 drinks daily in
    most men or 1 drink daily in women and lighter-weight persons.

-   Following the DASH diet and emphasizing fruits, vegetables, and
    low-fat dairy products. The diet also includes whole grains,
    poultry, fish and nuts, and it restricts fats, red meat, sweets, and
    sugar-containing beverages. Research suggests that substituting some
    carbohydrates with protein, mostly from plant sources or with
    monounsaturated fat, further lowers BP. Because the DASH diet is
    relatively high in potassium, phosphorus, and protein, it is not
    recommended for those with renal failure.

[Appel
LJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Appel+LJ"%5BAuthor%5D),
et al Dietary approaches to prevent and treat hypertension: a scientific
statement from the American Heart Association.
[Hypertension.](javascript:AL_get(this, 'jour', 'Hypertension.');) 2006
Feb;47(2):296-308.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16434724>

**Prenatal setting represents a missed opportunity for Tuberculosis
treatment completion**

RESULTS: Among 678 women with known tuberculin skin test (TST) status,
341 (50.3%) had a TST-positive result, including 200 who were newly
diagnosed. Of 291 TST-positive women with no previous LTBI treatment or
history of TB, 27 (9.3%) completed \> or =6 months of INH. In a subset
with detailed follow-up, the most important reasons for not completing
treatment were nonreferral for evaluation of a TST-positive result
(30.9%), not keeping the appointment (17.9%), and nonadherence with
prescribed treatment (34.6%).

CONCLUSION: The prenatal setting represents a missed opportunity to link
TST-positive non-US-born women with LTBI treatment and support for
treatment completion.

[Sackoff
JE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Sackoff+JE"%5BAuthor%5D),
et al Tuberculosis prevention for non-US-born pregnant women. [Am J
Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Feb;194(2):451-6.

[**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16458645**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16458645)

Anyone snore in your house: Oral Appliances for Obstructive Sleep Apnea?

Cochrane for Clinicians: Putting Evidence into Practice

[Clinical Scenario]{.underline}

A 58-year-old man presents with excessive fatigue and daytime
sleepiness. After polysomnography, he is found to have severe
obstructive sleep apnea.

[Clinical Question]{.underline}

Should oral appliances be considered a first-line treatment for
obstructive sleep apnea?

[Evidence-Based Answer]{.underline}

Although oral appliances provide improved subjective sleepiness and
sleep-disordered breathing, continuous positive airway pressure (CPAP)
is more effective. Oral appliances should not be used as a first-line
treatment but rather should be reserved for patients who cannot tolerate
CPAP or who refuse to use it.

[Reviewers\' Conclusions]{.underline}. There is some evidence suggesting
that oral appliance use improves subjective sleepiness and
sleep-disordered breathing compared with a control. Nasal CPAP appears
to be more effective in improving sleep-disordered breathing than oral
appliances. Until there is more definitive evidence on the effectiveness
of oral appliances, it would appear to be appropriate to restrict oral
appliance therapy to patients with sleep apnea who are unwilling or
unable to comply with CPAP therapy.
<http://www.cochrane.org/cochrane/revabstr/AB004435.htm>

<http://www.aafp.org/afp/20060301/cochrane.html>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16458645>

**Statins and beta-blockers may reduce severity of first coronary
event**

CONCLUSION: Statin and beta-blocker use was associated with lower odds
of presenting with an acute myocardial infarction than with stable
angina. Additional studies are needed to confirm that these therapies
protect against unstable, higher-risk clinical presentations of coronary
disease.

[Go
AS](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Go+AS"%5BAuthor%5D),
et al Statin and beta-blocker therapy and the initial presentation of
coronary heart disease. [Ann Intern
Med.](javascript:AL_get(this, 'jour', 'Ann Intern Med.');) 2006 Feb
21;144(4):229-38.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16490908>

Guideline for Management of Dyspepsia

**Clinical Question:** What is the best approach to managing dyspepsia?

**Synopsis:** Patients with dyspepsia may have gastroesophageal reflux
disease (GERD), peptic ulcer, functional (nonulcer) dyspepsia, or,
rarely, malignancy. The authors reviewed the literature and based their
recommendations on the results of the best available evidence. Patients
with the onset of dyspepsia at 56 years or older, or those with alarm
symptoms (e.g., bleeding, anemia, early satiety, unexplained weight
loss, dysphagia or odynophagia, persistent vomiting, family history of
gastrointestinal malignancy, previous documented peptic ulcer, abdominal
mass, or lymphadenopathy) at any age should undergo immediate upper
endoscopy. Patients with reflux-predominant symptoms should be treated
as if they have GERD. If the prevalence of *Helicobacter pylori*
infection in the community is less than 10 percent, a trial of a proton
pump inhibitor is recommended. If that fails, a test for *H. pylori*
infection, followed by eradication if positive, should be pursued. When
*H. pylori* is more common, the test-and-treat strategy should be
pursued first, followed by a trial of a proton pump inhibitor. If these
strategies fail, upper endoscopy should be considered according to the
physician\'s judgment. However, the prevalence of ulcer or malignancy in
*H. pylori*-negative patients is low in this group.

**Bottom Line:** This evidence-based guideline summarizes the best
approach to the evaluation and treatment of patients with dyspepsia,
defined as chronic or recurrent pain in the upper abdomen. (Level of
Evidence: 1a)

<http://www.aafp.org/afp/20060301/tips/3.html>

Use of Acupuncture to Improve Symptoms of Osteoarthritis

The authors conclude that an eight-week course of acupuncture treatment
is associated with a reduction in symptoms and disability from
osteoarthritis, but that the benefits are no longer statistically
significant by 26 weeks.

Witt C, et al. Acupuncture in patients with osteoarthritis of the knee:
a randomised trial. Lancet July 9, 2005;366: 136-43.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16005336>

**Estrogen Status an Independent Marker of Cardiac Risk in Women**

In conclusion, ES appears to be an easily discernible independent marker
of risk that provides incremental prognostic information compared with
standard clinical variables in women with symptoms of suspected coronary
disease presenting for stress testing.

[Morise
AP](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Morise+AP"%5BAuthor%5D).
Assessment of estrogen status as a marker of prognosis in women with
symptoms of suspected coronary artery disease presenting for stress
testing. [Am J
Cardiol.](javascript:AL_get(this, 'jour', 'Am J Cardiol.');) 2006 Feb
1;97(3):367-71.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16442397>

Genetic Risk Assessment and BRCA Mutation Testing for Breast and Ovarian
Cancer

Summary of Recommendations: U.S. Preventive Services Task Force

The USPSTF recommends against routine referral for genetic counseling or
routine breast cancer susceptibility gene (BRCA) testing for women whose
family history is not associated with an increased risk for deleterious
mutations in breast cancer susceptibility gene 1 (BRCA1) or breast
cancer susceptibility gene 2 (BRCA2). **D recommendation**.

The USPSTF found fair evidence that women without certain specific
family history patterns, termed here \"increased-risk family history\"
(see Clinical Considerations for a definition), have a low risk for
developing breast or ovarian cancer associated with BRCA1 or BRCA2
mutations. Thus, any benefit of routine screening of these women for
BRCA1 or BRCA2 mutations, or routine referral for genetic counseling,
would be small or zero.

The USPSTF found fair evidence regarding important adverse ethical,
legal, and social consequences that could result from routine referral
and testing of these women. Interventions such as prophylactic surgery,
chemoprevention, or intensive screening have known harms. The USPSTF
estimated that the magnitude of these potential harms is small or
greater.

The USPSTF concluded that the potential harms of routine referral for
genetic counseling or BRCA testing in these women outweigh the benefits.

The USPSTF recommends that women whose family history is associated with
an increased risk for deleterious mutations in BRCA1 or BRCA2 genes be
referred for genetic counseling and evaluation for BRCA testing.\
**B recommendation**.

The USPSTF found fair evidence that women with certain specific family
history patterns (\"increased-risk family history\") have an increased
risk for developing breast or ovarian cancer associated with BRCA1 or
BRCA2 mutations. The USPSTF determined that these women would benefit
from genetic counseling that allows informed decision-making about
testing and further prophylactic treatment. This counseling should be
done by suitably trained health care professionals. There is
insufficient evidence to determine the benefits of chemoprevention or
intensive screening in improving health outcomes in these women if they
test positive for deleterious BRCA1 or BRCA2 mutations. However, there
is fair evidence that prophylactic surgery for these women significantly
decreases breast and ovarian cancer incidence. Thus, the potential
benefits of referral and discussion of testing and prophylactic
treatment for these women may be substantial.

The USPSTF also found insufficient evidence regarding important adverse
ethical, legal, and social consequences that could result from referral
and testing of high-risk women. Prophylactic surgery is associated with
known harms. The USPSTF estimated that the magnitude of these potential
harms is small.

The USPSTF concluded that the benefits of referring women with an
increased-risk family history to suitably trained health care
professionals outweigh the harms.

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

# 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)\*

Steroids Before Cesarean Delivery May Reduce RDS

**Clinical Question:** Can antenatal steroids reduce the risk of
respiratory distress syndrome (RDS) after an elective cesarean delivery
at term?

###### Bottom Line: Administration of antenatal steroids 48 hours before elective cesarean delivery at 37 weeks\' gestation reduced the risk of transient tachypnea of the newborn and respiratory distress requiring prolonged hospital care. The benefit of steroids persists until 39 weeks\' gestation. Further studies in other hospital settings with longer follow-up periods will be needed before this protocol becomes the standard of care. (Level of Evidence: 1b)

Stutchfield P, et al., for the Antenatal Steroids for Term Elective
Caesarean Section (ASTECS) Research Team. Antenatal betamethasone and
incidence of neonatal respiratory distress after elective caesarean
section: pragmatic randomised trial. BMJ September 24, 2005;331:662-4.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16115831>

**\*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.

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

**LAY MIDWIFERY: Statement of Policy**

The American College of Obstetricians and Gynecologists (ACOG) is the
representative organization of physicians who are qualified specialists
in providing health services to women. ACOG is committed to facilitating
access to women\'s health care that is both safe and high quality. One
method of attaining this goal is to assure that providers of care meet
educational and professional standards of a certification process. ACOG
recognizes the educational and professional standards currently used by
the American Midwifery Certification Board (AMCB)\* to evaluate and
certify midwives. While ACOG supports women having a choice in
determining their providers of care, ACOG does not support the provision
of care by lay midwives or other midwives who are not certified by the
AMCB.

\*The American Midwifery Certification Board (AMCB), formerly known as
the ACNM Certification Council (ACC), was incorporated in 1991. The AMCB
develops and administers the national certification examination for
Certified Nurse-Midwives (CNMs) and Certified Midwives (CMs). CNMs are
registered nurses who have graduated from a midwifery education program
accredited by the American College of Nurse Midwives Division of
Accreditation and have passed a national certification examination
administered by AMCB. Certified midwives have also graduated from a
midwifery education program accredited by the American College of Nurse
Midwives Division of Accreditation, have successfully completed the same
requirements, have passed the same AMCB national certification
examination as certified nurse-midwives and adhere to the same
professional standards as certified nurse-midwives.
<http://www.acog.org/departments/perinatalHIV/sop0602.cfm>

**Tracking and Reminder Systems**

ABSTRACT: An accurate and effective tracking or reminder system is
useful for the modern practice of obstetrics and gynecology. It is not
adequate to rely solely on the patient to complete all ordered studies
and to follow up on physician recommendations.
Obstetrician--gynecologists have an obligation to their patients to
encourage them to complete studies believed essential for patient care
within an acceptable time frame. Each office should establish a simple,
reliable tracking and reminder system to improve patient safety and
quality of care and to minimize missed diagnoses.

Tracking and reminder systems. ACOG Committee Opinion No. 329. American
College of Obstetricians and Gynecologists. Obstet Gynecol
2006;107:745-7

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

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

**Results raise doubts about the value of the bimanual pelvic exam in
routine screening**

Release of *Management of Adnexal Mass* Report

The evidence report on the management of adnexal masses -- enlargements
in the area of the ovaries and fallopian tubes that are sometimes a sign
of ovarian cancer has recently been released.

The report concludes that based on current evidence it is not possible
to estimate the effectiveness of different diagnostic strategies. In
particular, the common bimanual pelvic exam does not succeed very well
in detecting adnexal masses or distinguishing benign from malignant
masses. These results raise doubts about the value of the bimanual
pelvic exam in routine screening.

Evidence Report/Technology Assessment Number 130, *Management of Adnexal
Mass.*
<http://www.ahrq.gov/downloads/pub/evidence/pdf/adnexal/adnexal.pdf>

If you have any questions, please contact Dr. Mona Saraiya at (770)
488-4293.

#### 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}

![](media/image2.jpeg){width="4.041666666666667in"
height="1.6458333333333333in"}![](media/image3.png){width="2.7416666666666667in"
height="0.9083333333333333in"}

**Library Services for the Indian Health Service**

**[Your library contact:]{.underline}**

Diane Cooper, MSLS

Informationist for the Indian Health Service

National Institutes of Health (NIH) Library

<cooperd@mail.nih.gov>

301 594-2449

As your library contact, I am here to help you meet your information
needs. If you need to find information at either patient point-of-care
or to provide background for a specific project, I can help. I am here
to save you time and ensure you get the information you need.

As your direct link to HSRL, I can support you in the following ways:

-   Help with complex and difficult literature searches to support
    direct patient care and patient care activities

-   Participate and help with IHS projects and development team
    activities

-   Assist in manuscript preparation (verify references; editing)

-   Set up current awareness alerts in your field of interest

-   Create customized databases in bibliographic software programs to
    organize your information for easy retrieval when you need it

-   Provide instruction on how to search literature databases and other
    information resources

**[Other Services]{.underline}**

**[Website]{.underline}**: The library's website - located at
[http://hsrl.nihlibrary.nih.gov](http://hsrl.nihlibrary.nih.gov/),
provides access to electronic resources that are critical to the work of
HHS staff. These resources include:

-   **Online Journals** -- access to full-text articles

-   **Databases** -- MEDLINE, Web of Science, PsycINFO, and more

-   **Research Updates** -- Porpoise Alert Service developed at NIH

-   **Online Catalog** -- search for books and journals held by the HSRL

-   **Document Requests** -- journal articles delivered by email

**[Document Delivery]{.underline}**: The library provides document
delivery of journal articles and books. Items not available in the
library's collection are obtained from another library. You can submit a
request via the library's website.

##### 

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

**Breastfeeding as a Pain Reliever**

Most of us can manage the momentary discomfort from minor invasive
medical procedures. Just a little pinch for an injection, venopuncture
or finger stick is quickly forgotten as a small price for the knowledge
or benefit that the procedure provides. However, when the "little pinch"
is happening to newborns, parents and providers have a bigger struggle.
Neonates experience pain, possibly more profoundly than older
babies^1,\ 2^. Therefore, finding ways to reduce the level of pain that
a newborn experiences from necessary, minor, invasive medical procedure
is important to neonatal care.

Traditionally, there have been few options for newborn pain management.
Pharmaceutical tools have not been commonly used due to questionable
effectiveness and potential adverse effects. But with new tools such as
sweet solutions, pacifier use and breastfeeding being explored, there
are possibly new minor pain management options to use.

Expanding on work done by L. Gray et al at Boston University School of
Medicine ^3,4^ R. Carbajal et al ^5^ at Poissy-Saint Germain Hospital in
France explored the effectiveness of infant pain relief during a
routine, invasive, medical procedure. 180 term well infants were divided
into 4 groups of 45 infants each, to be monitored during a venopuncture.
The variable groups were breastfeeding, being held in their mother's
arms (not breastfeeding), receiving sterile water, and receiving 30%
glucose followed by a pacifier. During the venopuncture procedure,
infants were monitored for response to pain using videoed observations
of facial, eye and limb movements, and vocal response such crying and
clinical indicators of heart rate and oxygen saturation. The results
were consistent with L. Gray et al's research of slightly older infants
(5-7 wk). Breastfeeding was effective in reducing indicators of pain
response during a common invasive medical procedure.\*

It was noted that using glucose followed by a pacifier was equally as
effective as breastfeeding. The variables of holding an infant or
offering sterile water were not found to effectively reduce the pain
response.

Breastfeeding during a minor medical procedure could be easily achieved
in the clinic environment. It could also ease procedures, benefiting the
staff, patient, and family.

\* There was no variation in sucking reported by mothers who breastfed
during the venipuncture. This suggests that there was no negative
maternal impact, such as nipple chomping/biting, while the infant
experienced the venopuncture.

1\. Anand KJS. Clinical importance of pain and stress in preterm newborn
infants. *Biol Neonate 1998*; 73: 1- 9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9458936>

2\. Anand KJS, and the International Evidence-Based Group for Neonatal
Pain. Consensus statement for the prevention and management of pain in
the newborn. *Arch Pediart Adolesc Med* 2001; 155:173-80. (If you have
issues obtaining this, contact <cooperd@ors.od.nih.gov> )

<http://ezproxyhhs.nihlibrary.nih.gov:2429/cgi/content/abstract/155/2/173>

3\. Gray L, et al. Breastfeeding is analgesic in health newborns.
*Pediatrics* 2002; 109:590-3.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11927701>

4\. Gray L, et al. Skin-to-skin contact is analgesic in health newborns.
*Pediatrics* 2000; 105(1): E14.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10617751>

5\. Carbajal R et al, Analgesic effect of breast feeding in term
neonates: randomized controlled trial. *BMJ* 2003; 326 (4):13-18.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12511452>

####  {#section-19 .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}

#### February highlights include  {#february-highlights-include-1 .Style-Heading-4-+-Arial-14-pt-Underline}

\-[Results of a Well-Defined Protocol for a Trial of Labor After
Cesarean](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_AOM.cfm)

\-[Oral misoprostol for cervical priming in non-pregnant
women](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Coll.cfm)

\-[The term breech trial recommendations should be
re-evaluated](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_HT.cfm#ob)

\-[Superiority of Liquid-Based Cytology for Cervical Screening
Questioned](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_HT.cfm#gyn)

\-[Broad-spectrum antibiotics in labor linked to serious late-onset
neonatal
infections](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_HT.cfm#child)

\-[Dietary intervention alone of little benefit in preventing
disease](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_HT.cfm#chrIll)

\-[Vaginal Birth after Cesarean: Evidence Based
Recommendations](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#afp)

\-[Nearly half of urban AI/AN travel back to their reservation to visit
during the
year](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#ahrq)

\-[Birth News Highlights: Young mothers, VBACs down, Early Care? Low
birth
weight](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#AskLib)

\-[Maternal Child Health Website Gets a
Facelift](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#webSite)

\-[What is the latest on an OB/GYN solution for the PCC, PCC+ and EHR in
Indian
Health?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#it)

\-[Listen up any parents or grandparents: How NOT to give
Acetaminophen](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#mmtour)

\-[When Should We Clamp the Umbilical Cord? Preterm vs Term
Infants](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#MidWives)

\-[Liability in triage: management of EMTALA regulations and common
obstetric
risks](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#MidWives)

\-[Focus on preventable causes of stillbirth: 3
articles](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#periPicks)

\-[Efficacy and safety of azithromycin for treatment of C. trachomatis
in
pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#std)

\-[Women with pain, but w/o coronary artery disease: Coronary
microvascular
dysfunction](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#stillW)

\-[Vaginal Birth after Cesarean  - New Perinatology Corner
Module](http://www.ihs.gov/MedicalPrograms/MCH/M/VB01.cfm)

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

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

**Survey queries women and men about their experiences as victims of
rape**

Extent, Nature, and Consequences of Rape Victimization: Findings from
the National Violence Against Women Survey summarizes results from a
nationally representative telephone survey of 8,000 women and 8,000 men
about their experiences as rape victims. The survey, jointly sponsored
by the National Institute of Justice and the Centers for Disease Control
and Prevention, was conducted in 1995-96 to measure the extent of
violence against women. The report presents findings on the prevalence
of rape victimization by gender, age, and race and ethnicity;
characteristics of rape victims, rapists, and rape incidents; the
relationship between rape victimization as a minor and as an adult;
physical, social, and psychological consequences of rape victimization;
and satisfaction with the justice system. Questions for future research
are also discussed.
[[http://www.ncjrs.org/pdffiles1/nij/210346.pdf]{.underline}](http://www.ncjrs.org/pdffiles1/nij/210346.pdf)

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

**Not too Late: Funding Available for Palliative Care Training - April
3 - 5, 2006**

Funding remains in the ANTHC contract for Palliative Care Training to
cover the registration fees for IHS or Tribal clinical staff able to
attend the 2nd Annual Alaska Palliative Care Symposium to be held in
Anchorage, Alaska, April 3 - 5, 2006.  There is not funding for travel
expenses this year. Information about the symposium can be found at: 
<http://www.palliativeak.org/>

To receive the registration scholarship, complete the attached form and
email or fax to Brenda King at the Alaska Native Tribal Health

Consortium:  Fax: 907-729-1901   Email: <beking@anthc.org>

Scholarships will be awarded on a first come basis. If you have further
questions, please contact Brenda King at 907-729-1902

or Kay Branch at 907-729-4498
[[pkbranch@anmc.org]{.underline}](mailto:pkbranch@anmc.org)

To avoid duplicate charges please DO NOT register on the conference
website

My apologies for the late notice. We are also working with NCI to
develop a national training in the lower 48 for late summer, early
fall.  More information on this in the next month.

**Screen for cognitive impairment with many  non-English speaking
elders **

The Mini-Cog is a brief cognitive screen using the 3-item recall and
clock drawing test, designed for use in primary care with multilingual,
diverse elder populations.  This study involved 371 elderly community
residents in the Seattle area who were recruited specifically to be
evaluated for cognitive impairment or dementia.  The sample consisted of
22% African American, 17% Hispanic, 7% White non-Hispanic, 6% Native
Americans, and 6% other.  Elders underwent a full cognitive evaluation
and were classified according to standard diagnostic definitions for
cognitive impairment or dementia as well as type of dementia. Some form
of cognitive impairment was judged to be present in 62%.    The Mini-Cog
was comparable to the Mini-Mental Status Exam (MMSE) in classifying
individuals as "normal" or "cognitively impaired", with an overall
accuracy of 83%.  The Mini-Cog missed impairment in 12% of those with
impairment and the false positive rate was 17%; neither was
significantly different from the MMSE.  There was no effect of
educational level and limited interaction with literacy.

[Borson S, Scanlan JM, Watanabe J, Tu SP, Lessig
M.](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15877567&query_hl=1&itool=pubmed_docsum)
Simplifying detection of cognitive impairment: comparison of the
Mini-Cog and Mini-Mental State Examination in a multiethnic sample.  J
Am Geriatr Soc. 2005 May;53(5):871-4.

**Elder Care Directive Comment: Bruce Finke**

I have used the 3 item recall and clock drawing test in combination as a
screen for cognitive impairment with many  non-English speaking elders
for a number of years and found this approach to be comfortable,
acceptable to the elder and family, and easily integrated into busy
primary care practice. It is reassuring to see the data confirming that
this approach has acceptable accuracy.  

A copy of the Mini-Cog and instructions for use can be found in the
Geriatrics At Your Fingertips handbook, available at no cost on-line at:

<http://www.geriatricsatyourfingertips.org/ebook/gayf_36.asp>

There is also a discussion of the Mini-Cog in UpToDate in **Evaluation
of Cognitive Impairment** and Dementia:
<http://www.uptodateonline.com/utd/content/topic.do?topicKey=nuroegen/6698&type=A&selectedTitle=6~35>

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

#### Fatal infection without fever: Sepsis and Medical Abortion - FDA Public Health Advisory Update: All four cases of fatal infection tested positive for Clostridium sordellii.  In addition, FDA tested drug from manufacturing lots of mifepristone and misoprostol and found no contamination with Clostridium sordellii. {#fatal-infection-without-fever-sepsis-and-medical-abortion---fda-public-health-advisory-update-all-four-cases-of-fatal-infection-tested-positive-for-clostridium-sordellii.-in-addition-fda-tested-drug-from-manufacturing-lots-of-mifepristone-and-misoprostol-and-found-no-contamination-with-clostridium-sordellii. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The Food and Drug Administration (FDA) is aware of four cases of septic deaths in the United States, from September 2003 to June 2005 in women following medical abortion with mifepristone (Mifeprex) and misoprostol. The bacteria causing sepsis has been identified in two of the cases as Clostridium sordellii. The other two cases are under ongoing investigation by FDA along with the Centers for Disease Control and Prevention, State and local health departments, and the manufacturer of Mifeprex. All cases involve the off-label dosing regimen consisting of 200 mg of oral Mifeprex followed by 800 mcg of intra-vaginally placed misoprostol. The two confirmed cases of Clostridium sordellii did not have the usual signs and symptoms of an infection. Although these deaths are reported from California, all providers of medical abortion and their patients need to be aware of the risks of sepsis. As more information becomes available, FDA will alert the public. [**http://www.fda.gov/cder/drug/advisory/mifeprex.htm**](http://www.fda.gov/cder/drug/advisory/mifeprex.htm) {#the-food-and-drug-administration-fda-is-aware-of-four-cases-of-septic-deaths-in-the-united-states-from-september-2003-to-june-2005-in-women-following-medical-abortion-with-mifepristone-mifeprex-and-misoprostol.-the-bacteria-causing-sepsis-has-been-identified-in-two-of-the-cases-as-clostridium-sordellii.-the-other-two-cases-are-under-ongoing-investigation-by-fda-along-with-the-centers-for-disease-control-and-prevention-state-and-local-health-departments-and-the-manufacturer-of-mifeprex.-all-cases-involve-the-off-label-dosing-regimen-consisting-of-200-mg-of-oral-mifeprex-followed-by-800-mcg-of-intra-vaginally-placed-misoprostol.-the-two-confirmed-cases-of-clostridium-sordellii-did-not-have-the-usual-signs-and-symptoms-of-an-infection.-although-these-deaths-are-reported-from-california-all-providers-of-medical-abortion-and-their-patients-need-to-be-aware-of-the-risks-of-sepsis.-as-more-information-becomes-available-fda-will-alert-the-public.-httpwww.fda.govcderdrugadvisorymifeprex.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Though you may not be primarily prescribing medications for this purpose, Indian Health providers need to be aware of the complications our patients may return to your care with after receiving care outside our system. The side effects of misoprostol including vomiting, diarrhea, and abdominal cramping may be similar to the initial symptoms of toxic shock syndrome. {#though-you-may-not-be-primarily-prescribing-medications-for-this-purpose-indian-health-providers-need-to-be-aware-of-the-complications-our-patients-may-return-to-your-care-with-after-receiving-care-outside-our-system.-the-side-effects-of-misoprostol-including-vomiting-diarrhea-and-abdominal-cramping-may-be-similar-to-the-initial-symptoms-of-toxic-shock-syndrome. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### One needs to maintain a high index of suspicion as symptoms may not include fever, or other signs of infection. All four died 23 hours or less after presentation. Distinctive features include tachycardia, hypotension, edema, hemoconcentration, profound leukocytosis, and absence of fever. {#one-needs-to-maintain-a-high-index-of-suspicion-as-symptoms-may-not-include-fever-or-other-signs-of-infection.-all-four-died-23-hours-or-less-after-presentation.-distinctive-features-include-tachycardia-hypotension-edema-hemoconcentration-profound-leukocytosis-and-absence-of-fever. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### In its public health advisory the FDA recommends that all emergency care providers investigate the possibility of sepsis in patients undergoing medical abortion and presenting with nausea, vomiting, or diarrhea and weakness with or without abdominal pain and with or without fever or other signs of infection more than 24 hours after taking misoprostol. To help identify patients with hidden infection, strong consideration should be given to obtaining a complete blood count.  {#in-its-public-health-advisory-the-fda-recommends-that-all-emergency-care-providers-investigate-the-possibility-of-sepsis-in-patients-undergoing-medical-abortion-and-presenting-with-nausea-vomiting-or-diarrhea-and-weakness-with-or-without-abdominal-pain-and-with-or-without-fever-or-other-signs-of-infection-more-than-24-hours-after-taking-misoprostol.-to-help-identify-patients-with-hidden-infection-strong-consideration-should-be-given-to-obtaining-a-complete-blood-count. .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### [Greene MF](http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Greene+MF"%5BAuthor%5D). Fatal infections associated with mifepristone-induced abortion. [N Engl J Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2005 Dec 1;353(22):2317-8. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16319378**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16319378) {#greene-mf.-fatal-infections-associated-with-mifepristone-induced-abortion.-n-engl-j-med.-2005-dec-1353222317-8.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16319378 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [Centers for Disease Control and Prevention (CDC)](http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Centers+for+Disease+Control+and+Prevention+(CDC)"%5BCorporate+Author%5D). Clostridium sordellii toxic shock syndrome after medical abortion with mifepristone and intravaginal misoprostol\--United States and Canada, 2001-2005. [MMWR Morb Mortal Wkly Rep.](javascript:AL_get(this, 'jour', 'MMWR Morb Mortal Wkly Rep.');) 2005 Jul 29;54(29):724. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16049422**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16049422) {#centers-for-disease-control-and-prevention-cdc.-clostridium-sordellii-toxic-shock-syndrome-after-medical-abortion-with-mifepristone-and-intravaginal-misoprostol--united-states-and-canada-2001-2005.-mmwr-morb-mortal-wkly-rep.-2005-jul-295429724.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16049422 .Style-Heading-4-+-Arial-14-pt-Underline}

Medical management of abortion. ACOG Practice Bulletin No. 67. American
College of Obstetricians and Gynecologists. Obstet Gynecol
2005;106:871--82.

[**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16199653**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16199653)

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

#### Pharmacists\' Knowledge, Attitudes, and Beliefs Toward Prescribing EC {#pharmacists-knowledge-attitudes-and-beliefs-toward-prescribing-ec .Style-Heading-4-+-Arial-14-pt-Underline}

#### Conclusion: New Mexico pharmacists have positive attitudes/beliefs toward EC prescribing; however, their knowledge in this area is average. Although religious, moral, and political views influence pharmacists\' willingness to prescribe EC, factors such as education and practice environment must be addressed if more pharmacists are to accept this EC prescriptive authority. {#conclusion-new-mexico-pharmacists-have-positive-attitudesbeliefs-toward-ec-prescribing-however-their-knowledge-in-this-area-is-average.-although-religious-moral-and-political-views-influence-pharmacists-willingness-to-prescribe-ec-factors-such-as-education-and-practice-environment-must-be-addressed-if-more-pharmacists-are-to-accept-this-ec-prescriptive-authority. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Borrego ME, Short J, House N, Gupchup G, Naik GR, Cuellar D. New Mexico Pharmacists\' Knowledge, Attitudes, and Beliefs Toward Prescribing Oral Emergency ContraceptionJ Am Pharm Assoc.  2006;46(1):33-43 [**http://www.medscape.com/viewarticle/521829?src=mp**](http://www.medscape.com/viewarticle/521829?src=mp) {#borrego-me-short-j-house-n-gupchup-g-naik-gr-cuellar-d.-new-mexico-pharmacists-knowledge-attitudes-and-beliefs-toward-prescribing-oral-emergency-contraceptionj-am-pharm-assoc.-200646133-43-httpwww.medscape.comviewarticle521829srcmp .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Although Borrego et al report positive attitudes/beliefs toward EC prescribing, when Espey et al sent two research assistants posing as women needing EC their access to EC was not as positive. {#although-borrego-et-al-report-positive-attitudesbeliefs-toward-ec-prescribing-when-espey-et-al-sent-two-research-assistants-posing-as-women-needing-ec-their-access-to-ec-was-not-as-positive. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### METHODS: Two research assistants posed as women needing emergency contraception. They visited 89 pharmacies in Albuquerque, New Mexico, presenting a prescription for either Plan B or Preven. The assistants recorded the availability of the products in the pharmacies. When the product was not in stock, the research assistants asked pharmacy providers why the products were not carried. Fisher exact test was performed to compare categoric data.  {#methods-two-research-assistants-posed-as-women-needing-emergency-contraception.-they-visited-89-pharmacies-in-albuquerque-new-mexico-presenting-a-prescription-for-either-plan-b-or-preven.-the-assistants-recorded-the-availability-of-the-products-in-the-pharmacies.-when-the-product-was-not-in-stock-the-research-assistants-asked-pharmacy-providers-why-the-products-were-not-carried.-fisher-exact-test-was-performed-to-compare-categoric-data. .Style-Heading-4-+-Arial-14-pt-Underline}

#### RESULTS: Plan B and Preven were in stock at only 19 visits (11%). Of the pharmacies that did not stock the products, 53% reported they could obtain Plan B or Preven within 24 hours. The most common reason cited by pharmacy providers for not stocking Plan B or Preven was the lack of prescriptions received for them (65%).  {#results-plan-b-and-preven-were-in-stock-at-only-19-visits-11.-of-the-pharmacies-that-did-not-stock-the-products-53-reported-they-could-obtain-plan-b-or-preven-within-24-hours.-the-most-common-reason-cited-by-pharmacy-providers-for-not-stocking-plan-b-or-preven-was-the-lack-of-prescriptions-received-for-them-65. .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Plan B and Preven were not in stock at the majority of pharmacies in a moderately sized metropolitan area. Lack of availability at the pharmacy constitutes a major barrier to emergency contraception access. {#conclusion-plan-b-and-preven-were-not-in-stock-at-the-majority-of-pharmacies-in-a-moderately-sized-metropolitan-area.-lack-of-availability-at-the-pharmacy-constitutes-a-major-barrier-to-emergency-contraception-access. .Style-Heading-4-+-Arial-14-pt-Underline}

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

###### [Espey E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Espey+E"%5BAuthor%5D), [Ogburn T](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ogburn+T"%5BAuthor%5D), [Howard D](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Howard+D"%5BAuthor%5D), [Qualls C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Qualls+C"%5BAuthor%5D), [Ogburn J](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ogburn+J"%5BAuthor%5D). Emergency Contraception: Pharmacy Access in Albuquerque, New Mexico. [Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2003 Nov;102(5 Pt 1):918-21

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14672463**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14672463) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids14672463 .Style-Heading-4-+-Arial-14-pt-Underline}

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

A good web site for other Emergency Contraception resources,
Not-2-Late.com

<http://ec.princeton.edu/info/ecminip.html>

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

See MCH FAQs: Emergency Contraception

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

See August OB/GYN CCC Corner: Scroll down to Hot Topics

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/CCCCorner81703C.doc>

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

Are continuous and extended-cycle combined contraceptives safe and
effective?

Clinical Question: Cochrane for Clinicians

[Evidence-Based Answer]{.underline}

Evidence shows no difference in safety or effectiveness between cyclic
and continuous or extended-cycle combined contraceptives. There are
fewer menstrual symptoms with extended-cycle contraceptives. Patients\'
satisfaction and adherence is similar for all types.

Practice Pointers

American women in the 21st century experience earlier menarche, have
fewer babies, breastfeed for shorter periods, and live longer than women
in past centuries, and therefore they have many more episodes of
bleeding over their lifetimes. Bleeding with contraceptives is caused by
pill withdrawal rather than endometrial buildup. There is no biologic
reason why monthly cycles are necessary. Because many women prefer fewer
days of vaginal bleeding per year, continuous and extended-cycle oral
contraceptives have been developed.

To assess the safety and effectiveness of combined oral contraceptives
with longer cycle lengths, Edelman and colleagues reviewed the
literature for randomized controlled trials comparing 28-day cyclical
contraceptives (21 active pills, seven placebos) with continuous
combined contraceptives. They found six studies comparing 28-day cycles
of combined oral contraceptives with cycles ranging from 49 to 365 days.
There was no difference between the regular and extended cycles in
satisfaction, adherence, pregnancy rates, or safety. Patients taking
continuous oral contraceptives had four to 14 fewer days of bleeding per
trimester. In the two studies that included a sonogram or endometrial
biopsy, no evidence of endometrial hyperplasia was found after nine
cycles.

Although combined oral contraceptive pills also are used to treat
conditions such as acne and dysmenorrhea, there have been no studies on
the use of continuous combined oral contraceptives for purposes other
than the prevention of pregnancy. Limited data in this review suggest
that women taking continuous dosing have fewer headaches and less
genital irritation, fatigue, bloating, and menstrual pain.
<http://www.aafp.org/afp/20060301/cochrane.html>

<http://www.cochrane.org/cochrane/revabstr/AB004435.htm>

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

#### Continuous OCPs with norethindrone: More bleeding-free days than levonorgestrel preps {#continuous-ocps-with-norethindrone-more-bleeding-free-days-than-levonorgestrel-preps-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: The addition of 10 mug of ethinyl E2 to a 20 mug ethinyl E2 pill containing levonorgestrel or norethindrone acetate did not improve bleeding patterns. During continuous dosing, the use of oral contraceptives containing 1,000 mug norethindrone acetate resulted in more days of amenorrhea and fewer days of spotting than preparations containing 100 mug levonorgestrel. LEVEL OF EVIDENCE: I. {#conclusion-the-addition-of-10-mug-of-ethinyl-e2-to-a-20-mug-ethinyl-e2-pill-containing-levonorgestrel-or-norethindrone-acetate-did-not-improve-bleeding-patterns.-during-continuous-dosing-the-use-of-oral-contraceptives-containing-1000-mug-norethindrone-acetate-resulted-in-more-days-of-amenorrhea-and-fewer-days-of-spotting-than-preparations-containing-100-mug-levonorgestrel.-level-of-evidence-i. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Edelman AB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Edelman+AB"%5BAuthor%5D), et al Continuous oral contraceptives: are bleeding patterns dependent on the hormones given? [Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006 Mar;107(3):657-65. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16507938**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16507938) {#edelman-ab-et-al-continuous-oral-contraceptives-are-bleeding-patterns-dependent-on-the-hormones-given-obstet-gynecol.-2006-mar1073657-65.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids16507938 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

Two New Perinatology Corner Modules

Twins: Antepartum assessment and Intrapartum management

Double Trouble?

<http://www.ihs.gov/MedicalPrograms/MCH/M/Twin01.cfm>

**Antibody Screen Positive: Rh Disease and Other Atypical Antibodies**

**Kell kills, Duffy dies, and Lewis lives?**

<http://www.ihs.gov/MedicalPrograms/MCH/M/AntBod01.cfm>

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

**Q. How do the EMTALA regulations effect the evaluation of patient with
false labor?**

A. A physician has to officially certify 'false labor', but that can be
signed of later. See details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/EMTALA2806.doc>

**Q. Can we perform one step GDM screening in AI/AN?**

A. Yes, ACOG and IHS discussed it 1993 and it is endorsed by the ADA

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/OneStep22306.doc>

**Q. What is the best screening cut-off for gestational diabetes
mellitus?**

**A**. A cut-off of 140 mg/dL has 10% less sensitivity than a threshold
of 130 mg/dL but fewer false-positive results; either threshold is
acceptable.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/GDMScr21906.doc>

**Q. What are some of the issues about viability in the range of 23-25
EGA weeks?**

A. Try a collaborative approach that involves providers and the parents
in decisions. See details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Periviab22506.doc>

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

**Highlights for March 2006**

-Cardiovascular screening for high school athletes - a summary of the
appropriately named \"Sudden Death\" Committee of the American Heart
Association

-Medico legal Implications of Cardiovascular Screening of Athletes -
Yes, you can say \"No\"

-The new Rotavirus vaccine is on the way

-Doug Esposito takes on race, genetics, social construct and political
correctness - read it if you dare

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN306.doc>

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

**UpToDate 14.1 is now available: Evidence based recommendations added
now**

With this release, we have an important enhancement to announce -
evidence grading is now being added to recommendations for treatment and
screening. These grades will help users better understand the strength
of the recommendations being made, both in terms of importance and
quality of evidence. There are over one hundred graded topics in
UpToDate 14.1 and more will be added with each new release.
<http://www.uptodateonline.com/utd/index.do>

**IHS received an "effective" rating: buried in President Bush's fiscal
2007 budget**

Data automatically generated by the [Indian Health
Service](http://www.ihs.gov/)\'s Clinical Reporting System helped the
service\'s medical programs garner an \"effective\" performance rating
in President Bush\'s proposed fiscal year 2007 budget, *[Government
Health IT](http://www.govhealthit.com/article92243-02-08-06-Web)*
reports.\
\
The system collects data from the service\'s 182 clinics and other
programs in 12 regions and then compares the agency\'s quantitative
goals with program results, as required by the Government Performance
and Results Act.\
\
IHS in 2005 reported data on 20 clinical measures through the CRS
system - and only one measure, body-mass assessment, did not meet its
goal. \"What we\'re seeing as an agency is that our ability to track
performance and monitor it is leading to a change in what\'s discussed
on a regular basis,\" said Theresa Cullen, a senior medical informatics
specialist at the agency. She called the system \"a success story for
performance-based budgeting.\"\
\
IHS is the only one of three major federal agencies providing medical
services with an automated performance reporting system linked to an
electronic health records system, according to Cullen. The [Department
of Veterans Affairs](http://www.va.gov/) manually reviews charts and the
[Department of Defense](http://www.defenselink.mil/) uses billing data,
*Government Health IT* reports.\
\
[Healthcare Information and Management Systems
Society](http://www.himss.org/) this month at its conference will
present a major award to IHS for its reporting system (Ferris,
*Government Health IT*, 2/8). <http://www.himss.org/ASP/index.asp>

**Evaluation of IHI work within IHS**

We are trying to assess any current or former interactions with the
Institute for Healthcare Improvement as part of Dr. Grim's chronic care
initiative. Please take a few minutes to fill out this assessment by
going to the URL listed below. It should take less than 3 minutes. It
will be available until March 17^th^.  Thanks in advance for your help.

<http://www.surveymonkey.com/s.asp?u=556571843324>

For questions about the tool, or technical difficulties, please contact
<Michelle.Riedel@ihs.gov>

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

**Combating poverty and social exclusion**

Views from those fighting poverty and social exclusion on the future
development of the EU.

The book is aimed at making a contribution to the debate and policies
needed to eradicate poverty and social exclusion in the EU. Combating
poverty and social exclusion.

This publication has three parts:

1\. An overview of the reality of poverty and social exclusion in the EU
including the development

of EU policies

2\. Essays on key areas which need to be addresses if we are to reach
the type of EU where all

people have access to all their fundamental rights including their
economic, social and cultural

rights.

3\. Portraits of people who live in EU Member States and who face
poverty and social exclusion

Of note the word racism comes up 53 times in the text.  Section 8
addresses mothers and children.  It may address myths we commonly hold
here in the US on poverty in other affluent and developed countries.
European Anti poverty Network (EAPN) 2006

[http://eapn.horus.be/module/module_page/images/pdf/pdf_publication/EAPN%20Publications/book/Livre3-EN.pdf](http://eapn.horus.be/module/module_page/images/pdf/pdf_publication/EAPN Publications/book/Livre3-EN.pdf)

**Quinacrine sterilization (from Yolanda Meza, Anchorage)**

Quinacrine-induced tubal sclerosis is an alternative method of tubal
sterilization which does not require surgery. It has not been approved
for use in the United States. The method involves insertion of a
quinacrine pellet (252 mg) into the uterine cavity on two occasions one
month apart using a modified IUD insertion device. Histopathological
studies in prehysterectomy volunteers showed that tubal occlusion
occurred as a result of inflammation leading to fibrosis, which was
limited to the cornual area and the intramural portion of fallopian
tubes. Endometrial changes included atrophy, polypoid reactions, and
fine adhesions; however, long-term effects on the endometrium are not
known.

[Lippes
J](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Lippes+J"%5BAuthor%5D),
et al An FDA phase I clinical trial of quinacrine sterilization (QS).
[Int J Gynaecol
Obstet.](javascript:AL_get(this, 'jour', 'Int J Gynaecol Obstet.');)
2003 Oct;83 Suppl 2:S45-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14763185>

[el Sahwi
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="el+Sahwi+S"%5BAuthor%5D),
et al Hysteroscopic and hysterosalpingographic study after intrauterine
insertion of quinacrine pellets for non-surgical sterilization: results
in 180 women. [Int J Gynaecol
Obstet.](javascript:AL_get(this, 'jour', 'Int J Gynaecol Obstet.');)
2003 Oct;83 Suppl 2:S101-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14763194>

**How to expand the reach of successful programs by replicating
effective ones**

Copy That: Guidelines for Replicating Programs to Prevent Teen Pregnancy
presents an overview of the primary issues involved in copying and
putting into place evaluated adolescent pregnancy prevention programs
with positive results. The report, produced by the National Campaign to
Prevent Teen Pregnancy, draws on the experiences of three different
programs: (1) Plain Talk, (2) the Teen Outreach Program, and (3) the
Children\'s Aid Society-Carrera Adolescent Pregnancy Prevention Program.
The emphasis of the report is on which questions are most important to
answer before choosing and implementing a program \-- or offering up a
program to others to replicate \-- and why they are important.
Additional resources, contacts, endnotes, and related materials are also
included.
[[http://www.teenpregnancy.org/resources/reading/pdf/Copy_That.pdf]{.underline}](http://www.teenpregnancy.org/resources/reading/pdf/Copy_That.pdf)

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

**Reducing substance uptake among younger adolescents**

Appropriately designed in-school and community-based media efforts can
significantly reduce youth substance uptake, and that such efforts can
be used independently of, or in addition to, classroom prevention
curricula.

-Substance use uptake for students in treatment communities was half or
less than half of that of control communities.

-The media treatment effect on rate of change was significant for
marijuana use, marginally significant for alcohol use, and not
significant for cigarette use.

-Effects of the curriculum were statistically significant at Wave 4 for
each of the three substances.

-The effect of the curriculum was additive rather than synergistic.

A particularly encouraging dimension of this intervention is that it
appeared to influence several substance outcomes. Further research is
being conducted to identify paths of influence for the in-school and
community campaigns and to determine the relative contributions of the
in-school and the community campaign components.

Slater MD, Kelly KJ, Edwards RW, et al. 2600. Combining in-school and
community-based media efforts: Reducing marijuana and alcohol uptake
among younger adolescents. Health Education Research 21(1):157-167
[[http://her.oxfordjournals.org/cgi/content/abstract/21/1/157?etoc]{.underline}](http://her.oxfordjournals.org/cgi/content/abstract/21/1/157?etoc)

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

**Wandering spleen: As seen on Desperate Housewives**

If you, or any of your family members, happened to inadvertently
watching Desperate Housewives on 2/12/06, you might have wondered what a
'wandering spleen' really is.

If by chance you happen to have missed just this one particular episode,
one of the characters on the program had been recently been diagnosed
with a wandering spleen and was trying 'desperately' to get married
quickly so she could get health insurance.

Comments about our health insurance system and the increasing number of
uninsured Americans aside (see below), the character related that she
was told that her spleen could crash into her heart at any time. It has
been a month since that episode and I presume you have been on the edge
of your seat since then, so here finally is the rest of the story.

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

Congenital wandering spleen is a very rare, randomly distributed, birth
defect characterized by the absence or weakness of one or more of the
ligaments that hold the spleen in its normal position in the upper left
abdomen. The disorder is not genetic in origin. Instead of ligaments,
the spleen is attached by a stalk-like tissue supplied with blood
vessels (vascular pedicle). If the pedicle is twisted in the course of
the movement of the spleen, the blood supply may be interrupted or
blocked (ischemia) to the point of severe damage to the blood vessels
(infarction). Because there is little or nothing to hold it in place the
spleen \"wanders\" in the lower abdomen or pelvis where it may be
mistaken for an unidentified abdominal mass.\
\
Symptoms of wandering spleen are typically those associated with an
abnormally large size of the spleen (splenomegaly) or the unusual
position of the spleen in the abdomen. Enlargement is most often the
result of twisting (torsion) of the splenic arteries and veins or, in
some cases, the formation of a blood clot (infarct) in the spleen.\
\
\"Acquired\" wandering spleen may occur during adulthood due to injuries
or other underlying conditions that may weaken the ligaments that hold
the spleen in its normal position (e.g., connective tissue disease or
pregnancy). <http://www.webmd.com/hw/digestive_problems/nord1010.asp>

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

#### Yes, on the one hand, the character was correct that her spleen may be loosed tethered in its current location, but it would have 'crashed' into her mediastinum. On the other hand, another term for this phenomenon is 'pelvic spleen' so we should be aware of this as a possible cause of an unknown pelvic mass. Other terms for this phenomenon are: Displaced Spleen, Drifting Spleen, Floating Spleen, Splenic Ptosis, Splenoptosis, and Systopic Spleen. {#yes-on-the-one-hand-the-character-was-correct-that-her-spleen-may-be-loosed-tethered-in-its-current-location-but-it-would-have-crashed-into-her-mediastinum.-on-the-other-hand-another-term-for-this-phenomenon-is-pelvic-spleen-so-we-should-be-aware-of-this-as-a-possible-cause-of-an-unknown-pelvic-mass.-other-terms-for-this-phenomenon-are-displaced-spleen-drifting-spleen-floating-spleen-splenic-ptosis-splenoptosis-and-systopic-spleen. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The wandering spleen syndrome is also a rare cause of acute abdominal pain that is most typically seen in younger adolescents and children, although it can occur in adults. Patients typically present with acute left upper quadrant pain associated with an abdominal mass. CT imaging confirms the diagnosis. The treatment of choice is splenopexy; splenectomy may be required if the spleen is infarcted and there is torsion and absence of splenic blood flow. {#the-wandering-spleen-syndrome-is-also-a-rare-cause-of-acute-abdominal-pain-that-is-most-typically-seen-in-younger-adolescents-and-children-although-it-can-occur-in-adults.-patients-typically-present-with-acute-left-upper-quadrant-pain-associated-with-an-abdominal-mass.-ct-imaging-confirms-the-diagnosis.-the-treatment-of-choice-is-splenopexy-splenectomy-may-be-required-if-the-spleen-is-infarcted-and-there-is-torsion-and-absence-of-splenic-blood-flow. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Fun facts about wandering spleens aside, the real issue here is the extent to which this character, and many patients in the U.S., had to go to get adequate health care.  {#fun-facts-about-wandering-spleens-aside-the-real-issue-here-is-the-extent-to-which-this-character-and-many-patients-in-the-u.s.-had-to-go-to-get-adequate-health-care. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Unfortunately, due to economic factors there are increasingly more uninsured patients. While this may not directly effect our AI/AN patients it will affect their partners, if their partner is non-Native, and hence our greater tribal family systems. It also has downstream Indian Health funding effects on AI/ANs as the uninsured patients stress an already stressed Medicaid and Medicare system. As health professionals we should continue to educate our colleagues, the public, and our legislative representatives that health care is an important investment for a productive society. {#unfortunately-due-to-economic-factors-there-are-increasingly-more-uninsured-patients.-while-this-may-not-directly-effect-our-aian-patients-it-will-affect-their-partners-if-their-partner-is-non-native-and-hence-our-greater-tribal-family-systems.-it-also-has-downstream-indian-health-funding-effects-on-aians-as-the-uninsured-patients-stress-an-already-stressed-medicaid-and-medicare-system.-as-health-professionals-we-should-continue-to-educate-our-colleagues-the-public-and-our-legislative-representatives-that-health-care-is-an-important-investment-for-a-productive-society. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Here is an insightful statement from the [ACOG Committee on Health Care for Underserved Women](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="ACOG+Committee+on+Health+Care+for+Underserved+Women"%5BCorporate+Author%5D): {#here-is-an-insightful-statement-from-the-acog-committee-on-health-care-for-underserved-women .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-41 .Style-Heading-4-+-Arial-14-pt-Underline}

#### "The United States is one of the few industrialized nations in the world that does not guarantee access to health care for its population. Access to health care for all women is a paramount concern of obstetrician-gynecologists and the American College of Obstetricians and Gynecologists. Lack of health care coverage creates access issues that affect women, practitioners, and the health care system as a whole. The number of women in the United States without health care coverage grew 3 times faster than the number of men without such coverage during the late 1990s and early 2000s. A change in our currently fragmented health care system is warranted because the lack of coverage clearly matters to the millions of uninsured Americans. Pregnant women and infants are among the most vulnerable populations in the country and the American College of Obstetricians and Gynecologists believes that providing them with fill insurance coverage must be a primary step in the process of providing coverage for all Americans. However, it is only the first step; it is critical to expand coverage for all Americans. Health professionals can play a pivotal role in improving access to needed health care by helping society understand the importance of broadening health insurance coverage. " {#the-united-states-is-one-of-the-few-industrialized-nations-in-the-world-that-does-not-guarantee-access-to-health-care-for-its-population.-access-to-health-care-for-all-women-is-a-paramount-concern-of-obstetrician-gynecologists-and-the-american-college-of-obstetricians-and-gynecologists.-lack-of-health-care-coverage-creates-access-issues-that-affect-women-practitioners-and-the-health-care-system-as-a-whole.-the-number-of-women-in-the-united-states-without-health-care-coverage-grew-3-times-faster-than-the-number-of-men-without-such-coverage-during-the-late-1990s-and-early-2000s.-a-change-in-our-currently-fragmented-health-care-system-is-warranted-because-the-lack-of-coverage-clearly-matters-to-the-millions-of-uninsured-americans.-pregnant-women-and-infants-are-among-the-most-vulnerable-populations-in-the-country-and-the-american-college-of-obstetricians-and-gynecologists-believes-that-providing-them-with-fill-insurance-coverage-must-be-a-primary-step-in-the-process-of-providing-coverage-for-all-americans.-however-it-is-only-the-first-step-it-is-critical-to-expand-coverage-for-all-americans.-health-professionals-can-play-a-pivotal-role-in-improving-access-to-needed-health-care-by-helping-society-understand-the-importance-of-broadening-health-insurance-coverage. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Resources {#resources-1 .Style-Heading-4-+-Arial-14-pt-Underline}

The uninsured. ACOG Committee Opinion No. 308. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2004;104:1471--4.

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15572517**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15572517) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15572517 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Differential diagnosis of abdominal pain in adults, UpToDate {#differential-diagnosis-of-abdominal-pain-in-adults-uptodate .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.uptodateonline.com/utd/content/topic.do?topicKey=pri_gast/2173&type=A&selectedTitle=1\~1**](http://www.uptodateonline.com/utd/content/topic.do?topicKey=pri_gast/2173&type=A&selectedTitle=1~1) {#httpwww.uptodateonline.comutdcontenttopic.dotopickeypri_gast2173typeaselectedtitle11 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

######### [Increasing Diversity in the Medical Workforce Is Way to Prevent Disparities in Healthcare](http://mp.medscape.com/cgi-bin1/DM/y/hyxu0G875W0Dzc0HJ760Gv)

We need to make the physician workforce more diverse. Given our
nation\'s increasingly multiracial and multicultural makeup, medical
educators must address this issue if tomorrow\'s doctors are to be
optimally equipped to deal with our nation\'s healthcare needs. Racial
and ethnic disparities in healthcare are a major blight on our system
\-- and on our profession. A more diverse physician workforce is one
critical step toward eliminating those disparities.

But, unfortunately, too few minority students apply to US medical
schools. Those who do can be disadvantaged in the admissions process
because of lower GPAs and MCAT scores.

Why lower scores?

As a group, these students do not yet enjoy the same educational
advantages as students from other backgrounds. That is precisely why
affirmative action programs are critically important in medical school
admissions \-- to identify applicants who, despite lesser academic
credentials, are clearly destined to become excellent physicians.

Even with affirmative action, relying on the current applicant pool to
meet our diversity goal will not suffice. What else must we do? We can
all work harder to interest more minority students in a medical career.
But the long-term solution rests with our nation\'s K-12 schools.
Medicine must join forces with others to convince policy makers to
address the glaring disparities in our country\'s educational system.
Until students from all racial and ethnic backgrounds emerge from the
educational pipeline prepared to pursue advanced study, medicine\'s
diversity gap will remain. Only through a physician workforce that truly
reflects America will we finally find the right prescription for a more
equitable and effective healthcare system.

<http://www.medscape.com/viewarticle/514893?sssdmh=dm1.182986&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)

#########  {#section-45}

######### 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 (see also Abstract of the Month)**

**Hormone Therapy:** **Predictor of worsening insulin sensitivity in
postmenopausal women**

STUDY DESIGN: Seventy-one nonobese postmenopausal women were assigned
randomly to receive hormone replacement therapy (conjugated estrogens,
0.625 mg, plus medroxyprogesterone acetate, 2.5 mg) or placebo daily for
1 year (34 women received hormone replacement therapy, and 37 women
received placebo).

RESULTS: By univariate analysis, we found that significant predictors of
worsening insulin sensitivity were the use of hormone replacement
therapy, baseline insulin sensitivity, a younger age, and \<10 years
since menopause. By logistic regression, we determined that hormone
replacement therapy use and higher baseline insulin sensitivity were
independent predictors of worsening insulin sensitivity. CONCLUSION: The
use of hormone replacement therapy and baseline insulin sensitivity are
significant independent predictors of the development of worsening
insulin sensitivity in postmenopausal women.

[Goodrow
GJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Goodrow+GJ"%5BAuthor%5D),
et al Predictors of worsening insulin sensitivity in postmenopausal
women. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Feb;194(2):355-61.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16458629>

####  {#section-46 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Midwives Corner Rosemary Bolza, CNM and Marsha L. Tahquechi, CNM {#midwives-corner-rosemary-bolza-cnm-and-marsha-l.-tahquechi-cnm .Style-Heading-4-+-Arial-14-pt-Underline}

**Should we continue to draw Rubella titers as part of the prenatal
panel?**

I remember having rubella. It wasn't too bad. We had a trip planned so
my mother went ahead and took me on the Greyhound bus. I got to wear
dark glasses and thought I was pretty cool. However my children never
had this experience because of the development of vaccinations for
rubella and, measles (rubeola).

In my midwifery program in 1981, documenting immunity to rubella was
important for both the midwife and the prenatal patient even though
rubella was very rare at that time. The devastating consequence of
congenital rubella meant that health care providers needed to be sure
they were immune and that pregnant women who were not immune needed to
take precautions if there were an outbreak of rubella. However I believe
that today the rubella titer gives us a false sense of security and that
we would give better care by concentrating on documenting and updating
immunizations.

Several years ago the CDC put out new releases that rubella was not
present in the United States. The disease that is still sometimes seen
is the measles (rubeola). In the early 90s it became apparent that two
MMRs are needed to give good protection against the measles. I often see
providers who look only at the rubella immunity and do not take the time
to check if the patient has had two MMRs. Rubella immunity does not
assure immunity to rubeola. Even if a person is rubella nonimmune if
they have had two MMRs there is no recommendation to continue to give
more MMRs so the routine drawing of the rubella titer is not necessary.
The time and money spent on rubella titers for prenatal patients would
be better spent documenting and updating the all of the recommended
adult immunizations for the prenatal patient.

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

Special thanks to Rosemary Bolza for bringing up this subtle, but
important issue. Rosemary's point goes with a long line of obstetric
practices that consume energy, but have no 'value added', e.g., there is
no role for routine urine dipstick testing in return prenatal visits.

Here are some thoughts from Ros Singleton, CDC / ANMC, plus a link to
the CDC document that echo Rosemary's comments above.

**Should all pregnant women have serology screening for rubella and
varicella?***\
*No. Serologic testing for varicella should be considered only for women
who do not have evidence of immunity (reliable history of chickenpox or
documented vaccination). Rubella serologic testing is only necessary for
women who cannot provide written documentation of rubella vaccination.
Once a person has been found to be seropositive, it is not necessary to
test again in the future.

**If an employee has 2 documented MMRs but has negative titers for one
or more of these diseases, should I give an additional MMR dose?***\
*The Advisory Committee on Immunization Practices (ACIP) does not
routinely recommend more than two doses of MMR. A negative serology
after two documented doses of MMR probably represents a false negative
(i.e., antibody titer too low to detect with commercial tests). However,
it is theoretically possible to have true 2-dose vaccine failure. If a
person is found to have a negative serology after two documented doses
of MMR, it may be prudent to administer one additional dose of MMR. You
should also cease doing postvaccination serologic testing if an employee
has two documented doses of MMR, which is the ACIP definition of
\"immune.\"

See
[www.cdc.gov/mmwr/PDF/rr/rr4708.pdf](http://www.cdc.gov/mmwr/PDF/rr/rr4708.pdf)
for more information.

Acceptable documentation of immunity for rubella in childbearing women
include: documentation of 1 dose of MMR (or other rubella containing
vaccine) or lab evidence of immunity.  However, measles immunity
requires 2 doses of MMR.  I agree with you that it is important to
ensure immunity to both measles and rubella titers could prevent someone
from getting a second dose of MMR.  The 2nd MMR right now is only
required in school-aged children, some colleges, and in hospital care
workers - so it\'s not universal, but it\'s a good idea.

**Other resources**

The American College of Obstetricians and Gynecologists (ACOG)
recommends screening all pregnant women for rubella immunity and
offering postpartum immunization with combined measles, mumps, and
rubella (MMR) vaccine to susceptible mothers. However, only 21 percent
of U.S. hospitals surveyed follow the ACOG recommendations. In addition,
there are concerns that the ACOG strategy does not benefit women who
have immunity to rubella but are susceptible to mumps, measles, or both.
Haas and colleagues studied women obtaining prenatal care at a military
hospital to document susceptibility to one or more of these diseases and
estimate the

likely outcome of different screening and immunization strategies.

Yet Haas et al conclude that at least one third of pregnant women are
currently susceptible to one or more of the three viruses. History,
including recall of booster immunizations, is not a reliable indicator
of immune status. The authors argue that current ACOG guidelines are
poorly followed and provide a suboptimal strategy. They recommend that
strategies based on screening for antibody titers to all three viruses
be introduced to protect young women and their unborn children.

Haas DM, et al. Rubella, rubeola, and mumps in pregnant women. Obstet
Gynecol August 2005;106:295-300.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16055578>

**Do Birth Certificate Data Reflect the Number of CNM-Attended Births?**

The number of midwife attended births has been steadily increasing since
the 1970's. This growth has been primarily attributed to the growth in
the CNM population. In 2002 8.1% of all births were attended by a
midwife. Still, despite the increase there is evidence that midwife
attended births are under reported. This small study at a Michigan
practice from June to August of 1999 reviewed 899 births for accuracy in
reporting birth data.

Conclusions: There was an over reporting of CNM attended births at the
hospital level. However the state vital statistics records showed a
10.9% under reporting of CNM attended births. The under reporting of CNM
attended births while unclear in origin have been attributed to a
variety of possible errors. Recommendations were made to improve the
accuracy in the reporting of CNM attended births. CNM's are encouraged
to learn about the birth registration process at the local, state and
federal levels to ensure accuracy in reporting CNM attended births.

[Walker
DS](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Walker+DS"%5BAuthor%5D),
et al Do birth certificate data accurately reflect the number of
CNM-attended births? An exploratory study. [J Midwifery Womens
Health.](javascript:AL_get(this, 'jour', 'J Midwifery Womens Health.');)
2004 Sep-Oct;49(5):443-8\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15351335>

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

In a stroke of fortuitous coincidence the CDC released the following
QuikStat this month. So now that you looked at the above, do you think
the CDC is accurate?

In 2003, approximately 8.0% of births were attended by midwives, more
than double the 1990 rate of 3.9%. In six states (Alaska, Georgia, New
Hampshire, New Mexico, Oregon, and Vermont), rates were at least twice
as high as the national rate.

National Vital Statistics System, Natality File 2003.
<http://www.cdc.gov/nchs/births.htm>

![](media/image4.png){width="6.860416666666667in"
height="4.6409722222222225in"}

**Randomized Controlled Trial of Hands-and-Knees Positioning for
Occipitoposterior Position in Labor**

This is a small Canadian randomized controlled study of 147 laboring
women at greater than 37 week's gestation. Participants were randomized
to two groups. The intervention group, were given hands and knees
positioning for at lest 30 min. over a 1hour period during labor. The
control group had no hands and knees positioning. Ultrasound was used to
determine fetal position following the one hour study period.

Conclusions: Utilization of the maternal hands and knees positioning
with a fetus in the occipitoposterior position reduces persistent back
pain during the first stage of labor. Trends were noted toward improved
birth outcomes but did not reach statistical significance. There was a
9.2% increase in occipitoanterior positioning after use of hands and
knees positioning found in the study. However due to the small study
size no interpretation of the data could determine if this was real or
due to chance. Therefore no clear determination was made as to whether
hands and knees positioning in labor promotes fetal head rotation to
occipitoanterior and reduces operative delivery. No data were offered as
to fetal weight in relationship to fetal head rotation with hands and
knees positioning.

[Stremler
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Stremler+R"%5BAuthor%5D),
et al Randomized controlled trial of hands-and-knees positioning for
occipitoposterior position in labor.
[Birth.](javascript:AL_get(this, 'jour', 'Birth.');) 2005
Dec;32(4):243-51.\
<http://www.blackwell-synergy.com/doi/abs/10.1111/j.0730-7659.2005.00382.x>

**Q. How do the EMTALA regulations effect the evaluation of patient with
false labor?**

A. A physician has to officially certify 'false labor', but that can be
signed of later. See details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/EMTALA2806.doc>

**Navajo News Jean Howe, Chinle**

**VZIG No Longer Available**

**CDC suggests temporary unlicensed solution....yet another reason to
protect non-pregnant non-immune women against Chickenpox**

*Inevitably, at 5pm on Friday, the patient says, "I'm pregnant, my 4
year old has chicken pox, and my mother says that I never had it when I
was a child. Should I be worried?"*

Thankfully, with increasing use of varicella vaccine in children and
non-immune adults, this scenario is becoming much less common. But
varicella exposure of non-immune pregnant women still occurs and is now
more challenging to manage as the company that manufactured varicella
zoster immune globulin (VZIG) has recently discontinued production.

Varicella zoster virus is transmitted by respiratory droplets and close
contact and is highly contagious with 60-90% of susceptible people
becoming infected after contact. The period of infectivity is from 48
hours before the rash appears until the last vesicles crust over. The
incubation period is from 10 to 20 days (average 14 days). Infection
with varicella confers life-long immunity. Because of the high
prevalence of immunity in adults; varicella infection in pregnancy is
quite rare. Although the disease course is often mild in children,
affected adults may become gravely ill with complications including
pneumonia and encephalitis. If acquired in the first 20 weeks of
pregnancy, there is a small (\<2%) risk that the fetus will develop
congenital varicella syndrome. Infection around the time of delivery is
also especially risky for the neonate; if a mother develops chicken pox
from 5 days before until 2 days after giving birth, the neonate will
lack protective maternal antibodies and is especially at risk.

If a pregnant woman describes a recent possible exposure to varicella,
careful questioning will usually elicit a history of chickenpox
infection in the past. Of women who do not recall a history of
chickenpox, 70-90% will still have detectable antibodies. If antibody
testing is available in a timely manner, this will often confirm that no
further intervention is needed. If antibody testing is unavailable or
indicates that the patient is susceptible to varicella, then
administration of VZIG within 72 hours of exposure is recommended.

With VZIG now unavailable, the CDC has recommended consideration of the
use of VariZIG, which is only available under an "Investigational New
Drug Application Expanded Access Protocol" from a sole U.S. distributor.
VariZIG is a purified human immune globulin preparation prepared from
plasma with high levels of anti-varicella antibodies. It is very similar
to VZIG but is lyophilized. Because it is only available under IND
protocols, informed consent must be obtained prior to use. ACIP has
recommended that the following groups of non-immune exposed patients
receive VariZIG:

-Immunocompromised patients.

-Pregnant women.

-Neonates whose mothers have signs and symptoms of varicella infection
from 5 days before to 2 days after delivery.

-Premature infants born at [\>]{.underline}28 weeks gestation and
exposed in the neonatal period whose mothers are non-immune.

-Premature infants born at \<28 weeks (or \<1000g) and exposed in the
neonatal period regardless of maternal immune status.

Treatment should be given as soon as possible; efficacy more than 96
hours after exposure is unknown. If VariZIG cannot be obtained,
administration of intravenous immune globulin may be considered. If no
treatment is undertaken, close observation and early treatment with
acyclovir for any resulting infection is indicated. Post-exposure
prophylaxis for those not included in the above high risk groups can be
accomplished with prompt varicella vaccination.

ACOG recommends vaccination of nonpregnant women of childbearing age if
no history of previous chickenpox infection is elicited. The loss of
ready access to VZIG only increases the utility of this intervention.
Procuring VariZIG in a timely manner is likely to be difficult for even
large urban facilities; getting post-exposure prophylaxis to a woman
seeking care at a rural site such as those served by many Indian Health
Service facilities will be especially challenging.

CDC, A new product (VariZIG) for postexposure prophylaxis of varicella
available under an Investigational New Drug Application Expanded Access
Protocol, [MMWR]{.underline} Early Release February 24, 2006, Volume 55.
<http://www.cdc.gov/mmwr/PDF/wk/mm55e224.pdf>

American College of Obstetrics and Gynecology, Perinatal Viral and
Parasitic Infections, ACOG Practice Bulletin #20, September 2000. [Int J
Gynaecol
Obstet.](javascript:AL_get(this, 'jour', 'Int J Gynaecol Obstet.');)
2002 Jan;76(1):95-107.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11905409>

**ACOG Members**

<http://www.acog.org/publications/educational_bulletins/pb020.cfm>

American College of Obstetrics and Gynecology, Immunization During
Pregnancy, ACOG Committee Opinion #282. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2003
Jan;101(1):207-12.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12517674>

**ACOG Members**

<http://www.acog.org/publications/committee_opinions/co282.cfm>

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

#### Dr. Howe raises an excellent point when she says ....yet another reason to protect non-pregnant non-immune women of childbearing age against Chickenpox.  {#dr.-howe-raises-an-excellent-point-when-she-says-.yet-another-reason-to-protect-non-pregnant-non-immune-women-of-childbearing-age-against-chickenpox. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Here are a few other thoughts   {#here-are-a-few-other-thoughts .Style-Heading-4-+-Arial-14-pt-Underline}

-As Chickenpox is becoming relatively less frequent, one would have to
vaccinate a relatively larger number of women, to prevent one perinatal
case.

-Many women without a history of chickenpox will have antibodies from
non-clinical infection, so we should screen for varicella antibody titer
in all women without a history of chicken pox before immunizing them.

-As we don\'t want to vaccinate pregnant women, we should perform
antibody testing when possible

####  {#section-47 .Style-Heading-4-+-Arial-14-pt-Underline}

#### In addition to the CDC reference above, the IHS MCH website offer a Perinatology Corner module on this topic. The module can be used as a great resource, or free CME/CEU. {#in-addition-to-the-cdc-reference-above-the-ihs-mch-website-offer-a-perinatology-corner-module-on-this-topic.-the-module-can-be-used-as-a-great-resource-or-free-cmeceu. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-48 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Chickenpox (varicella) in pregnancy {#chickenpox-varicella-in-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/VC01.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/VC01.cfm) {#httpwww.ihs.govmedicalprogramsmchmvc01.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-49 .Style-Heading-4-+-Arial-14-pt-Underline}

**Nurses Corner Sandra Haldane, HQE**

#### Nurse Education Loan Repayment Program: Deadline March 30 {#nurse-education-loan-repayment-program-deadline-march-30-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Here is another opportunity for loan repayment in IHS. Graduate degrees
in nursing are included.

Please share with your colleagues.

FYI -- please share with staff... IHS qualifies as a full-time employer
for payback.

**Nurse Education Loan Repayment Program Applications
Available\--deadline March 30**\
The Fiscal Year 2006 application for the Nurse Education Loan Repayment
Program has been posted on the Health Resources and Services
Administration, U.S. Department of Health and Human Services (HRSA/HHS)
Web site. This program repays up to 85% of an RN\'s outstanding student
loans in return for full-time employment in a facility determined to
have a critical nursing shortage.
[www.nursingworld.org/news/ananews.htm#EduLoan](http://www.nursingworld.org/news/ananews.htm#EduLoan)

####  {#section-50 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Idealized Design of Perinatal Care - Institute for Healthcare Improvement {#idealized-design-of-perinatal-care---institute-for-healthcare-improvement-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Reviews of perinatal care have consistently pointed to failures of communication among the care team and documentation of care as common factors in adverse events that occur in labor and delivery. They are also prime factors leading to malpractice claims. {#reviews-of-perinatal-care-have-consistently-pointed-to-failures-of-communication-among-the-care-team-and-documentation-of-care-as-common-factors-in-adverse-events-that-occur-in-labor-and-delivery.-they-are-also-prime-factors-leading-to-malpractice-claims. .Style-Heading-4-+-Arial-14-pt-Underline}

The model described in this white paper, Idealized Design of Perinatal
Care, represents the Institute for Healthcare Improvement's best current
assessment of the components of the safest and most reliable system of
perinatal care. The four key components of the model are:

-The development of reliable clinical processes to manage labor and
delivery

-The use of principles that improve safety (i.e., preventing, detecting,
and mitigating errors)

-The establishment of prepared and activated care teams that communicate
effectively with each other and with mothers and families

-A focus on mother and family as the locus of control during labor and
delivery

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

####  {#section-51 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Sign up for the 'Every Woman' quarterly magazine {#sign-up-for-the-every-woman-quarterly-magazine .Style-Heading-4-+-Arial-14-pt-Underline}

#### AWHONN publishes a quarterly magazine: "Every Woman."  It is an excellent women's magazine geared at healthy living.  Please check out the article below via the second link and then you can go on line via the first link and order some for your clinics and hospitals or to give away to the women in your lives and practices.  {#awhonn-publishes-a-quarterly-magazine-every-woman.-it-is-an-excellent-womens-magazine-geared-at-healthy-living.-please-check-out-the-article-below-via-the-second-link-and-then-you-can-go-on-line-via-the-first-link-and-order-some-for-your-clinics-and-hospitals-or-to-give-away-to-the-women-in-your-lives-and-practices. .Style-Heading-4-+-Arial-14-pt-Underline}

The EW website to sign up is found at: 
<http://www.everywomanonline.com/signup.php>

The EW website to view articles is found at
[http://www.everywomanonline.com](http://www.everywomanonline.com/)

**NNLC Award Announcement**

The NNLC Awards committee announces the request for nominations for the
2006 National Nurse Leadership Council (NNLC) Awards. The NNLC awards
recognize individuals and groups for outstanding achievements in nursing
in Indian Health programs.

Submission Deadline is April 13th, 2006. Categories include:

Public Health Nurse

Clinical Nurse

Nurse Administrator

Advanced Practice Nurse (NP, CNM, CRNA)

Nursing Assistant; Licensed Practical Nurse

Special Friend of Nursing; Nursing Group

Awards will be presented at the awards ceremony on June 7th, 2006 during
the Annual National Council of Nurse Administrators (NCONA) Conference
being held in Kansas City, Missouri. Information about the conference
<http://www.ihs.gov/MedicalPrograms/ncona/ncona-conferences.asp>.

####  {#section-52 .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}

**Global Tobacco Use in Young People: Future Chronic Disease Burden in
Adults**

The difference in current cigarette smoking between boys and girls is
narrower than expected in many regions of the world. Use of tobacco
products other than cigarettes by students is as high as cigarette
smoking in many regions. Almost one in five never-smokers reported they
were susceptible to smoking in the next year. Student exposure to
secondhand smoke was high both at home (more than four in ten) and in
public places (more than five in ten). Never-smokers were significantly
less likely than current smokers to be exposed to secondhand smoke at
home and in public places.
<http://www.cdc.gov/cogh/publications/05art8184page.pdf>

####  {#section-53 .Style-Heading-4-+-Arial-14-pt-Underline}

#### National Women\'s Health Week, May 14-20, 2006 {#national-womens-health-week-may-14-20-2006-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Plan now to join the 2006 National Women\'s Health Week Celebration, May 14-20. Whether you are an individual, a health care provider, a business leader, a community organization, a governor, mayor, or tribal leader, there is something you can do to participate in National Women\'s Health Week. [**http://www.womenshealth.gov/whw/index.cfm**](http://www.womenshealth.gov/whw/index.cfm) {#plan-now-to-join-the-2006-national-womens-health-week-celebration-may-14-20.-whether-you-are-an-individual-a-health-care-provider-a-business-leader-a-community-organization-a-governor-mayor-or-tribal-leader-there-is-something-you-can-do-to-participate-in-national-womens-health-week.-httpwww.womenshealth.govwhwindex.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-54 .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}

**Metformin and Polycystic Ovarian Syndrome**

Polycystic ovarian syndrome is present in approximately 5-7% of women
and is defined as hyperandrogenism and chronic anovulation. Women with
PCOS have an 11 fold increased risk in the prevalence of metabolic
syndrome. Metformin combined with clomiphene citrate increases the
likelihood of successful ovulation and pregnancy rates. Metformin has
been shown to decrease insulin resistance and cause weight loss in obese
women.

[Metformin for the treatment of polycystic ovary syndrome]{.underline}
([Barbieri
RL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Barbieri+RL"%5BAuthor%5D).)

RESULTS: Three clinical trials reported that for the treatment of
anovulatory infertility caused by PCOS, metformin plus clomiphene is
more effective than clomiphene alone in inducing ovulation. For the
treatment of irregular menses caused by PCOS in women not attempting
conception, metformin therapy may restore ovulatory menses in the
majority of women. However, most women will require 4-6 months of
metformin therapy before they achieve ovulatory menses. In obese women,
metformin plus a low-calorie diet may be associated with more weight
loss than a low-calorie diet alone. CONCLUSION: Polycystic ovary
syndrome is a common gynecologic endocrine disorder.
Obstetrician-gynecologists should be familiar with the indications and
contraindications for the use of metformin in their practice.

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

Thanks to Dr. Woitte for reminding us about the high frequency of PCOS.
We should maintain a high index of suspicion, especially because PCOS is
highly amenable to medical therapy. Metformin has other beneficial uses
in the treatment of glucose intolerance and in the prevention of Type II
DM during the Diabetes Prevention Program. (Knowler et al, 2002)

**Another common question is....what is the role of metformin in
lactation?**

**The official notation is : "**Excretion in breast milk unknown/not
recommended", but please also review the following case series published
in the June 2005 CCC Corner by Briggs:

Metformin was excreted into breast milk, and neither hypoglycemia nor
other adverse effects were observed in 3 nursing infants.\
CONCLUSION: Metformin is excreted into breast milk, but the amounts seem
to be clinically insignificant. No adverse effects on the blood glucose
of the 3 nursing infants were measured. LEVEL OF EVIDENCE: III Briggs
GG, et al Excretion of metformin into breast milk and the effect on
nursing infants. Obstet Gynecol. 2005 Jun;105(6):1437-41.\
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15932841&dopt=Abstract]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15932841&dopt=Abstract)

**Resources:**

Polycystic ovary syndrome. ACOG Practice Bulletin No. 41. American
College of Obstetricians and Gynecologists. Obstet Gynecol 2002;
100:1389--402

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12468195>

ACOG Members

<http://www.acog.org/publications/educational_bulletins/pb041.cfm>

[Barbieri
RL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Barbieri+RL"%5BAuthor%5D).
Metformin for the treatment of polycystic ovary syndrome. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2003
Apr;101(4):785-93.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=12681887&dopt=Abstract>

[Knowler
WC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Knowler+WC"%5BAuthor%5D),
et al Reduction in the incidence of type 2 diabetes with lifestyle
intervention or metformin. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2002 Feb
7;346(6):393-403.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11832527>

**Metformin for treatment of the polycystic ovary syndrome, UpToDate**

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=r_endo_f/20044&type=A&selectedTitle=2~53>

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

**Nutritional Influences on Bone Health: Update on Research and Clinical
Implications**\
The dietary intake of calcium by children \-- most especially teenage
girls \-- in the United States is well below the recommended optimal
levels. Moreover, nutritional rickets in children due to vitamin D
insufficiency is making a comeback. Although adequate intake of calcium
and vitamin D is crucial for children, how important are these nutrients
for prevention of osteoporotic fracture in elderly adults? This CME/CE
program reviews current research with children, adolescents, midlife
women, and the elderly on the role of key nutritional factors in the
development of peak bone mass and prevention of osteoporosis. (See
Medscape instructions for access)

<http://www.medscape.com/viewprogram/5034?sssdmh=dm1.182082&src=nlpromo>

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

#### Preterm Premature Rupture of Membranes: What it Means to You {#preterm-premature-rupture-of-membranes-what-it-means-to-you-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060215/665ph.html**](http://www.aafp.org/afp/20060215/665ph.html) {#httpwww.aafp.orgafp20060215665ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-56 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Behavior Problems in a Family Member with Dementia: What You Should Know {#behavior-problems-in-a-family-member-with-dementia-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060215/653ph.html**](http://www.aafp.org/afp/20060215/653ph.html) {#httpwww.aafp.orgafp20060215653ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-57 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Caring for Your New Baby {#caring-for-your-new-baby-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060301/857ph.html**](http://www.aafp.org/afp/20060301/857ph.html)  {#httpwww.aafp.orgafp20060301857ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

#### Perinatology Picks George Gilson, MFM, ANMC {#perinatology-picks-george-gilson-mfm-anmc .Style-Heading-4-+-Arial-14-pt-Underline}

**Move beyond 'integrated' screening to 'contingency' screening**

There is a great deal of ongoing confusion about prenatal genetic
screening. First, here are just some common issues, plus some
misperceptions

-The nuchal translucency / PAPP-A testing can only offered to those
patients who have private insurance or who choose to pay for the testing
themselves (\$95-\$165).

-Advanced Maternal Age:

Are providers thinking about the Nuchal Translucency with the PAPP-A
testing?

It is not well documented in the charts, which I reviewed, that this
option was even discussed, i.e. benefit and risk. We can use the NT and
dating ultrasound for two purposes for the AMA woman.

 

-Who is available to do Genetic Amniocentesis? 

A 41 y. o. patient had to wait until 19 weeks for a genetic
amniocenteses because the perinatologist was out of town. She would have
acted on the result, if there was a genetic problem found.  Could we
have had another provider do the amniocentesis sooner?

-We don't have onsite chorionic villus sampling (CVS), so we shouldn't
offer 1^st^ trimester screening

**Let' s look at what methods are available?**

**Integrated test**

The combined 'integrated test' consists of ultrasound measurement of
nuchal translucency thickness at 10 to 11 weeks combined with serum
markers obtained in both the first (PAPP-A) and second (quadruple test)
trimesters (at 10 to 11 and 15 to 18 weeks).

**Serum only** --- The serum integrated test consists of serum markers
obtained in both the first (PAPP-A) and second (quadruple test)
trimesters (at 10 to 11 and 15 to 18 weeks), but no ultrasound markers.

**Sequential testing** --- Sequential screening refers to the repetition
of screening tests in the second trimester in women who have already had
first trimester screening.

**Contingent testing** --- Contingent screening has also been proposed.
This approach is defined in terms of three risk cut-offs: (1) women at
very high risk of having a fetus with Down syndrome after first
trimester testing would be offered immediate invasive prenatal
diagnosis, (2) women at very low risk would be provided with their risk
estimate and would require no additional testing, and (3) women at
intermediate risk would receive second trimester marker testing. The
risk of women in group (3) would be reevaluated in the second trimester
after integrating all first and second-trimester markers and comparing
the result with a third risk cut-off. This model provides an early
result in most pregnancies for only a small increase in the overall
false positive rate compared to the integrated test. It has the
advantage of avoiding the difficulty of nondisclosure of first-trimester
results, but has not been tested in clinical trials.

**Genetic sonogram** --- A genetic sonogram is a tool for the
sonographic risk assessment of Down syndrome in the second trimester.

**Now let's compare:**

**Integrated testing**

This combines markers measured in the first and second trimesters to
determine a single estimate of risk, is primarily used to detect trisomy
21, but, as described below can also detect trisomy 18, which is
associated with a different pattern of test results.

Current methods of first or second trimester screening yield a
relatively high level of detection (75 to 85 percent), but at a false
positive rate of 5 percent. Thus, 5 percent of women with unaffected
pregnancies are offered invasive testing, with its attendant risks.

The main downside is that the patient can not avail herself of 1^st^
trimester testing. Another related downside is the slightly troubling
ethics of withholding clinical information from the pt in the integrated
screening method\* that would have allowed her to get first trimester
diagnostic testing.

**Independent sequential testing**

Refers to an approach whereby results from first trimester screening are
divulged to the patient and CVS is offered to women whose results place
them at very high risk of an affected fetus, while those whose screen
does not place them at very high risk go on to have second trimester
screening. However, the second trimester risk is calculated without
considering the first trimester test results.

The downside is that it offers no opportunity to perform 1st trimester
testing. Hence, it raises questions about the ethics of withholding
information that denies 1st trimester options to patients.

The benefits and problems of independent sequential screening were
illustrated in a multicenter study of the first trimester combined test,
sponsored by the National Institute of Child Health and Human
Development.

The false positive rate for the second trimester test was 8.9 percent
for those who had been screen negative in the first trimester and 38.7
percent for those who had been screen positive in the first trimester
(10.2 percent false positive rate overall). An overall detection rate of
98 percent was achieved, but at a false positive rate for the first and
second trimester tests taken together of about 17 percent. This study
shows that independent first and second trimester sequential testing,
where the results of first trimester screening are not incorporated into
the total risk assessment, results in a very high overall detection
rate, but at an inappropriately high false positive rate.

**Step-wise sequential screening** --- The step-wise sequential
screening process involves performing the first trimester portion of the
integrated screen and then offering CVS to women whose results place
them at very high risk (possibly
![](media/image5.png){width="8.333333333333333e-2in"
height="9.236111111111112e-2in"}1 in 50) of an affected fetus, while
those whose screen does not place them at very high risk go on to
complete the second trimester portion of the test. The risk calculated
from the first trimester test and the effect of some of the first
trimester markers on some of the second trimester markers are taken into
account in determining the risk of Down syndrome from the second
trimester test. This is a complex calculation; issues related to this
type of step-wise sequential testing have been reviewed.

In the FASTER trial discussed above, step-wise sequential screening
detected 95 percent of Down syndrome fetuses at a FPR of 4.9 percent.
These rates approach those with fully integrated screening, but have the
benefit of availability of early results for the highest risk patients.

**Contingent screening** --- Contingent screening is a third type of
sequential screening. This approach is defined in terms of three risk
cut-offs: (1) women at very high risk (possibly \>1 in 10) of having a
fetus with Down syndrome after first trimester testing would be offered
immediate invasive prenatal diagnosis, (2) women at very low risk
(possibly \<1 in 2000) would be provided with their risk estimate and
would not undergo any additional testing, and (3) women at intermediate
risk (in this example, between 1 in 10 and 1 in 2000) would have a
second trimester blood draw.

The risk of Down syndrome in group (3) would be reevaluated by
incorporating all first and second-trimester markers into an integrated
risk assessment. This model provides an early result in most pregnancies
for only a small increase in the overall false positive rate compared to
the integrated test, and may also save costs, but requires further
analysis of appropriate risk cut-offs, as well as clinical testing. It
has the advantage of avoiding the difficulty of nondisclosure of
first-trimester results, but has not been tested in clinical trials.

In summary, in the contingent the patient receives both first and second
trimester screening. This method allows pt to get 1^st^ trimester
diagnostic testing. In addition pt receives a 1^st^ trimester score,
which obviates further testing in most (75-85%) patients who are
essentially finished if they have another way to screen for neural tube
defects (serum AFP or targeted US)

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

While 'integrated testing' is becoming the default choice in many
settings, other first trimester testing methods are actually preferable
to the integrated test for many logistical ways. There are also the
slightly troubling ethics of withholding clinical information from the
pt in the integrated screening method\* that would have allowed her to
get first trimester diagnostic testing.

Nationally, despite the high sensitivity of the 'Integrated screening',
the preferred method at this point is 'contingency testing'.

Unfortunately, many of our Indian Health settings do not have CVS
readily available. We are not alone, the U.S. in general is in a
transition in which there are too few providers skilled in CVS to keep
up with the advances in these combined analyte methods. If CVS is not
readily available, then a standardized referral pattern for CVS is
acceptable.

By the way, genetic amniocentesis can be performed by any provider who
has the documented training, experience, and current competence.

**Comment: George Gilson, MFM**

At ANMC we are offering 'contingency' screening\"' and it works quite
well. If the patient comes early enough for 1st trim screening they are
offered initial serum screening an genetic ultrasound. If their 1st
trimester screen is negative for Down syndrome, they really don\'t need
any further testing. (Also see NTD screening below\*) 

If her 1st trimester testing is positive, she is offered referral for
CVS or \"integrated\" screening with 2nd trim testing. If they present
after 13 wks, then they are offered the quad screen as per usual.  

  

To me the biggest advantage is not only the earlier answer, but the
lower false positive rate (FPR), with much less maternal anxiety and
invasive testing being generated. The FPR for women \<35 y/o is 3% with
1st trim screening. Since our sonographers have moved beyond nuchal
translucency (NT) and have become certified to also look at nasal bone
and ductus venosus, the detection rate is 91%, pretty reassuring for the
pt, and considerably better than the figures someone else quoted in
these email strings.

 

The cost \"problem\"

This has actually been less of an issue that one would expect. In many
states both Medicaid (which almost all our patients have) and private
insurances pay for 1st trim testing. Your administrative staff can
work on developing resources for those few who lack either. My
experience is our patients rarely had to / wished to pay out of pocket.

 

The logistics of CVS are challenging, but luckily very few of our
patients have requested CVS. For the 2 requests I\'ve had, one was able
to be scheduled in Seattle, the other was too late (13+ wks) to get
scheduled and so had a 15 wk amniocentesis.

CVS can be technically challenging and has a 2.6% post procedure loss
rate. Like anything else, if you don\'t do it regularly, you are not the
best to do it. Some providers perform \"early\" (12-14 wks)
amniocentesis, but the post-amniocentesis loss rate there is also high
(2.5% before 15 wks vs. 0.5% after 15 wks), so I don\'t feel that is an
acceptable alternative.

 

\*How about screening for neural tube defect (NTD) in patients who\'ve
had 1st trim screening?

While the AFP (which is only 65% sensitive for NTD) cannot be ordered
separately from the quad screen, the 18 wk anatomy scan is 90+%
sensitive for the detection of neural tube defect, so if they\'ve had
1st trim screening, they don\'t need a quad screen for the AFP if they
have an anatomic survey.

**Resources:**

**Prenatal Genetic Screening -- Serum and Ultrasound (use as a resource
or for CME/CEUs)**

<http://www.ihs.gov/MedicalPrograms/MCH/M/TM01.cfm>

[Berkowitz
RL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Berkowitz+RL"%5BAuthor%5D),
et al Aneuploidy screening: what test should I use? [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Mar;107(3):715-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16507946>

**Approach to prenatal screening for Down syndrome, UpToDate**

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=antenatl/16784&type=A&selectedTitle=2~118>

**First trimester screening for Down syndrome and trisomy 18, UpToDate**

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=antenatl/15225>

**Another Perinatology Picks Topic:**

**Misoprostol for postpartum hemorrhage**

Here is a Letter to the Editor that Dr. Gilson recently sent to
Contemporary OB/GYN

Re: Misoprostol for postpartum hemorrhage

To the Editor:

I would like to compliment Dr. Francois on her excellent review,
"Managing uterine atony and hemorrhagic shock" in the February 2006
Contemporary OB/GYN. I would however like to take issue with one
inclusion in Table 4, "Uterotonic Therapy", where rectal misoprostol is
recommended. Rectal misoprostol has pharmacokinetics very similar to
vaginal misoprostol (1, 2). Rectal misoprostol does not achieve
significant levels in plasma until approximately 60 minutes after
administration, and even at that time, only achieves levels
approximately 25% as high as those achieved with vaginal or oral
misoprostol (2). It cannot therefore be expected to be effective in the
urgent management of acute postpartum hemorrhage as the article implies.
"Evidence" for its efficacy is largely derived from anecdotal reports
and case series. Oxytocin, methylergonovine, and carboprost are all
rapid-acting and readily available agents. The clinician should not
waste precious time with the expectation that rectal misoprostol will
help in the expeditious resolution of the hemorrhage. Most women are
likewise not happy with this mode of administration. Thank you for your
consideration of these comments.

Zieman M, Fong SK, Benowitz NL, Banskter D, Darney PD. Absorption
kinetics of misoprostol with oral or vaginal administration. Obstet
Gynecol 1997; 90:88-92.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=9207820>

Khan RU, El-Refaey H, Sharma S, Sooranna D, Stafford M. Oral, rectal,
and vaginal pharmacokinetics of misoprostol. Obstet Gynecol 2004;
103:866-70.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15121558>

Respectfully,

George J. Gilson, MD

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

Dr. Gilson raises an important point:

Rectal misoprostol is a third line agent for the management of
postpartum hemorrhage (PPH) due to its slow uptake and low peak levels.
Rectal misoprostol has its greatest benefit in those low resource
settings without IV access, or in the management of PPH in developed
countries outside of the acute setting.

The management of PPH should be conducted in an organized approach as a
whole labor and delivery team. One excellent resource is the Advanced
Life Support in Obstetrics (ALSO). I suggest all Indian Health maternity
care providers attend and stay current with ALSO certification. Please
sign up early and often.

**Advanced Life Support in Obstetrics**

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

**Contemporary OB/GYN Home Page: February 2006 article**

<http://www.contemporaryobgyn.net/obgyn/>

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

**Cardiology Topics for Primary Care Providers -- Ongoing, 'not too late
to join in**

Moderator: Jim Galloway, MD

Director, Native American Cardiology Program

**Here are a few of the resources that have emerged:**

**-**[**BP and Lipids to Prevent CHD in
AI/AN**](http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#cardio)

**-[Cardiac Structure and Function:
STRONGHEART](http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#cardio)**

**-[Acute Coronary Syndrome Orders:
NNMC](http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#cardio)**

**-[AHA Conference March 2006 Lecture
Notes](http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#cardio)**

<http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#cardio>

**Here are some of the topics being discussed**

-Role of CRP in cardiac evaluation

-Should we all take statins? or get out of our chairs, work out, lose
weight, diet and get fitness religion?

-Lipid screening guidelines in non-smoking non-diabetic Native Americans

-Newer cardiac imaging techniques (MRI, CT angio) over traditional
catheterization procedures

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

Subscribe to the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51>

Unsubscribe from the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51>

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

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

#### Incorrect use of condoms not product failure may account for the lack of effectiveness {#incorrect-use-of-condoms-not-product-failure-may-account-for-the-lack-of-effectiveness-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Assessing the correct and consistent use of condoms is important in evaluating condom effectiveness. Incorrect use of condoms and not product failure may account for the lack of effectiveness when condoms are used to reduce the risk of contracting STDs.  {#assessing-the-correct-and-consistent-use-of-condoms-is-important-in-evaluating-condom-effectiveness.-incorrect-use-of-condoms-and-not-product-failure-may-account-for-the-lack-of-effectiveness-when-condoms-are-used-to-reduce-the-risk-of-contracting-stds. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Paz-Bailey G, et al. The effect of correct and consistent condom use on chlamydial and gonococcal infection among urban adolescents. Arch Pediatr Adolesc Med June 2005;159:536-42 [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15939852**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15939852) {#paz-bailey-g-et-al.-the-effect-of-correct-and-consistent-condom-use-on-chlamydial-and-gonococcal-infection-among-urban-adolescents.-arch-pediatr-adolesc-med-june-2005159536-42-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15939852 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-58 .Style-Heading-4-+-Arial-14-pt-Underline}

**Expedited Partner Therapy in the Management of Sexually Transmitted
Diseases**

This report summarizes the available literature on expedited partner
therapy (EPT) for the management of the partners of persons with STD and
interprets the results. It also incorporates perspectives gained from
two expert consultations, one that predominantly addressed the
scientific evidence related to EPT and a second that emphasized
operational issues that will affect implementation of EPT. The report
serves as background on EPT and provides the evidence in support of
anticipated guidelines for the selective use of EPT. It is intended as a
reference document for use by CDC and by public health agencies, other
organizations, interested individuals, and other partners in the public
and private sector. The document includes recommendations on EPT for
gonorrhea and chlamydial infection in women and men, and women with
trichomoniasis.
<http://www.cdc.gov/std/treatment/EPTFinalReport2006.pdf>

**Chlamydia screening and management: Primary care providers in
California**

CONCLUSIONS: The Chlamydia care practices of many California primary
care providers are inconsistent with current guidelines. Targeted
provider education and improved reimbursements are potential strategies
for improvement.

Guerry, SL et al Chlamydia screening and management practices of primary
care physicians and nurse practitioners in California. J Gen Intern Med.
2005 Dec;20(12):1102-7

<http://www.blackwell-synergy.com/doi/abs/10.1111/j.1525-1497.2005.00240.x>

####  {#section-59 .Style-Heading-4-+-Arial-14-pt-Underline}

**Raise Awareness of Impact of HIV /AIDS on Women and Girls**

In conjunction with the first annual National Women and Girls HIV/AIDS
Day (March 10, 2006) this Web site offers materials to contribute to
efforts to educate, motivate, and mobilize local communities in the
fight against HIV/AIDS.

#### The Web site, sponsored by the U.S. Department of Health and Human Services, contains downloadable materials and a toolkit to assist communities in planning and implementing observance activities at the local level. The toolkit includes public service announcements and videotapes, sample media and interview advisories, and suggestions for activities that can be undertaken in communities to acknowledge the observance (including post-event activities). Additional resources on the impact of HIV/AIDS, vaccine research, testing, and the Ryan White Care Act are also provided. [[http://www.omhrc.gov/hivaidsobservances/women/index.html]{.underline}](http://www.omhrc.gov/hivaidsobservances/women/index.html) {#the-web-site-sponsored-by-the-u.s.-department-of-health-and-human-services-contains-downloadable-materials-and-a-toolkit-to-assist-communities-in-planning-and-implementing-observance-activities-at-the-local-level.-the-toolkit-includes-public-service-announcements-and-videotapes-sample-media-and-interview-advisories-and-suggestions-for-activities-that-can-be-undertaken-in-communities-to-acknowledge-the-observance-including-post-event-activities.-additional-resources-on-the-impact-of-hivaids-vaccine-research-testing-and-the-ryan-white-care-act-are-also-provided.-httpwww.omhrc.govhivaidsobservanceswomenindex.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-60 .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}

**Statin Therapy for Type 2\'s Regardless of LDL Levels and CVD**

Based on the evidence, patients with type 2 diabetes may be candidates
for statin therapy regardless of LDL cholesterol level and in the
absence of a previous CV event.

The incidence of type 2 diabetes mellitus is expected to increase
dramatically over the next decade. Patients with type 2 diabetes are at
a much greater risk for cardiovascular disease (CVD) than are
nondiabetic individuals. Consequently, the treatment of CVD risk factors
is a healthcare priority in this patient population. Dyslipidemia is a
major cardiovascular (CV) risk factor in patients with type 2 diabetes,
and it is characterized by elevated triglyceride levels, low
high-density lipoprotein (HDL) cholesterol levels, and a preponderance
of small, dense low-density lipoprotein (LDL) particles.

These results suggest that low-dose statin therapy with atorvastatin
results in significant reduction of CV events in patients with type 2
diabetes without prior CVD or high LDL cholesterol levels. Based on this
evidence, patients with type 2 diabetes may be candidates for statin
therapy regardless of LDL cholesterol level and in the absence of a
previous CV event.

[Betteridge](javascript:void(0);) J. Benefits of lipid-lowering therapy
in patients with type 2 diabetes mellitus Am J Med. 2005 Dec;118 Suppl
12A:10-5.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16356802>

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

**Indian Health Service Medical Provider Best Practice Conference**

-   April 4-5, 2006

-   San Diego, CA

# [**Edna.Johnson@IHS.GOV**](mailto:Edna.Johnson@IHS.GOV)

<http://www.ihs.gov/FacilitiesServices/AreaOffices/California/Universal/PageMain.cfm?p=43#159>

# 18^th^ Annual IHS Research Conference

# April 24-26, 2006

# Albuquerque, NM

-   Discovering Pathways to Better Health for AI/AN

<http://www.ihs.gov/MedicalPrograms/ClinicalSupportCenter/index.cfm>

**Advances in Indian Health, 6^th^ Annual**

-   May 2-6, 2006

-   Albuquerque, NM

-   Save the dates brochure

> <http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#May06>

**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>

**ACOG 2006 Annual Clinical Meeting (ACM)**

-   May 6-10, 2006

-   Washington, DC

-   Save the dates brochure
    [http://www.acog.org/abstract%2Dsubmission/](http://www.acog.org/abstract-submission/)

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

-   September 17 -- 21, 2006

-   Denver, CO

-   Contact <YMalloy@acog.org> or call Yvonne Malloy at 202-863-2580

-   Neonatal Resuscitation Program available

-   Brochure

> <http://www.ihs.gov/MedicalPrograms/MCH/F/documents/ACOG_06brochR1_1.pdf>

**PUBLIC'S HEALTH & THE LAW IN THE 21^ST^ CENTURY**

-   June 12-14, 2006

-   Atlanta, Georgia

<http://www2a.cdc.gov/phlp/conference2006.asp>

# 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%)}

Two New Perinatology Corner Modules

Twins: Antepartum assessment and Intrapartum management

Double Trouble?

<http://www.ihs.gov/MedicalPrograms/MCH/M/Twin01.cfm>

**Antibody Screen Positive: Rh Disease and Other Atypical Antibodies**

**Kell kills, Duffy dies, and Lewis lives?**

<http://www.ihs.gov/MedicalPrograms/MCH/M/AntBod01.cfm>

There are several upcoming **Conferences**

<http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm>

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

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

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

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

# 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 February 2006 OB/GYN CCC Corner is available at: {#the-february-2006-obgyn-ccc-corner-is-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn0206.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

####  Abstract of the Month: page 5 {#abstract-of-the-month-page-5-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Results of a Well-Defined Protocol for a Trial of Labor After Cesarean

#### From your colleagues: page 7 {#from-your-colleagues-page-7-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Carolyn Aoyama**

-AHRQ expands women\'s health program to include gender-based research

-2nd Annual Summer Institute in Maternal-Fetal Pharmacology (Summer
Institute)

-Three Women\'s Health Awards

**Nancy Brannin**

Oral misoprostol for cervical priming in non-pregnant women

**Phil Smith**

18^th^ Annual IHS Research Conference

Judy Thierry

-Please Welcome Roy Hoffman: Roy is working on Children with Special
Health Care Needs

-Data to improve the health of mothers and infants: PRAMS

-Western Tobacco Prevention Project - NPAIHB Tribal Tobacco Policy
Workbook

-2005 NPAIHB Tobacco Policy on Pregnant Women

-WIC participant characteristics: Aggregate AIAN data

**Judy Whitecrane**

-13th Annual Mayo Clinic Nicotine Dependence Conference

-3rd Annual Spit Tobacco Summit, Mayo Clinic

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

##### Obstetrics: page 10

-Term breech trial: The original term breech trial recommendations
should be re-evaluated

-Late postpartum eclampsia: a preventable disease?

-Ensure that newborn infants are protected from hepatitis B virus (HBV)
infection, CDC

-Ginger is effective means for reducing postoperative nausea and
vomiting: Meta-analysis

-Obstetric Characteristics Predict Risk of Sudden Infant Death Syndrome

and more....

**Gynecology: page 14**

-Superiority of Liquid-Based Cytology for Cervical Screening Questioned

-LEEP: Treatment of Cervical Neoplasia Linked to Preterm Births

-Restricted activities after gynecologic surgery: No greater impact than
rising from a chair

-Continued frequent screening of women with normal pap: Costly and
benefits

-Protective Effect of Progesterone or Estrogen: Ovarian Cancer

and more....

**Child Health: page 17**

-Broad-spectrum antibiotics during labor linked to late-onset serious
infections in infants

-Over Bundling: Winter and SIDS

-Your female patient athletes: Treatment of stress fractures: the
fundamentals

-Screening and Counseling for Obesity in Children

-AAP Recommendations for Treating Children After a Disaster

**Chronic Illness and Disease: page 18**

-Dietary intervention alone of little benefit in preventing disease

-Cardiovascular Disease in American Indians and Alaska Natives

-Cold Sores: Famciclovir for the Treatment of Recurrent Genital and
Labial Herpes Lesions

-Percentage of Persons Aged [\>]{.underline}18 Years Reporting Severe
Headache or Migraine

-Substandard preventive care for diabetes more likely: Multiple low
priority visits

and more....

#### Features: page 23 {#features-page-23 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician

###### -Vaginal Birth after Cesarean (continued)

-No Difference Among New Antidepressants

-Are Alpha-glucosidase Inhibitors Effective for Control of Type 2
Diabetes?

-Gabapentin for Pain: Balancing Benefit and Harm

American College of Obstetricians and Gynecologists

Patient Safety in the Surgical Environment

**Agency for Healthcare Research and Quality**

## -Nearly half of urban AI/AN travel back to their reservation to visit during the year

## -Women with moderate PID: Similar reproductive outcomes - inpatient and outpatient care

-Misconceptions about cancer screening may be common among women

-Women who suffer from obesity less likely to undergo Pap testing

-Women who are at high risk of developing preeclampsia: Cytokine
genotypes may identify

**Ask a Librarian**

Birth News Highlights: Young mothers; VBACs down; Early Prenatal Care;
Low birth weight

**Breastfeeding**

-Dose-dependent association between duration of breastfeeding and risk
of overweight

-ACOG, AAP Develop First Collaborative Physician-Focused Breastfeeding
Handbook

-Quality of consumer related breastfeeding education: Web Site evaluates

-Health LITERACY: Breastfeeding is to be seen as normative

-GAO recommends removal of WIC logo from any formula marketing
                   

**CCC Corner Digest**

\-[Link between GDM and Type 2 DM can be
broken](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_AOM.cfm)

\-[Integrating prevention of mother-to-child HIV transmission into
routine antenatal
care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Coll.cfm)

\-[Bed Rest for pregnancy related hypertension: Not
recommended](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_HT.cfm#ob)

\-[Prior Function and Relationship, More Than Hormones, Affect Sexual
Function in
Midlife](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_HT.cfm#gyn)

\-[Oral Contraceptives and Dysmenorrhea in Adolescents:
RCT](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_HT.cfm#child)

**-**[Waking up to Sleep Deprivation: Countermeasures for Daytime
Sleepiness](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_HT.cfm#chrIll)

\-[New studies shows a 15% reduction for the risk of diabetes for every
year of
lactation](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#breast)

\-[Emergency Contraception Use Not Associated With Risky Sexual
Behavior](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#fp)

\-[Vaginal Birth after Cesarean  New Perinatology Corner Module -- 2
credits](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#webSite)

**-**[CC: I feel really cold and my side hurts, plus I am shaking all
over](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#mmtour)
 

\-[Shoulder Dystocia Prevention: plus the 'CCC Deliver Through
Maneuver](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#MidWives)'

\-[Depo-Provera available in a lower dose: limited data to assess 104mg
SQ vs. 150mg
IM](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#navajo)

\-[Should Pregnant Women Be Tested for Herpes
Susceptibility?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#periPicks)

\-[Cardiology Topics for Primary Care Providers -- February 15,
2006](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#pcf)

\-[Clinician-Delivered Intervention During Routine Care Reduces
Unprotected Sexual
Behavior](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#std)

\-[Antidepressants Are No Match for
Poverty](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#stillW)

**Domestic Violence**

Child Abuse Prevention for Nurses, Psychologists, Social Services, and
Community

**Elder Care News**

Euthanasia: The Dutch Experience

Over active bladder therapies on CNS functioning in elderly patients:
First-line therapies

**Family Planning**

-Progestin-Releasing IUDs for Women with Diabetes

#### -Emergency Contraception- Women with two children who need 30 years of family planning {#emergency-contraception--women-with-two-children-who-need-30-years-of-family-planning .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

-Maternal Child Health Website Gets a Facelift

-New Vaginal Birth After Cesarean Delivery CME/CEU module

**Frequently asked questions**

-Should a urine test be performed on every pregnant patient each
prenatal visit?

-Can we use medical therapy in the setting of spontaneous abortion
(SAB)?

-How do I manage patients with recurrent vulvovaginal candidiasis?

-Does IHS have any policy on distribution of the morning after pill?

-Does the IHS have a procedure for payment in pregnancy termination?

and more....

**Indian Child Health Notes**

\- To Bag or Not to Bag: Is a bag urine specimen ever reliable?

\- An updated immunization for Native Americans from Dr. Singleton

\- The latest literature reviews from Dr. Esposito

**Information Technology**

-What is the latest on an OB/GYN solution for the PCC, PCC+ and EHR?

#### -Patient Safety and Health IT - Exploring and Expanding the Intersections, AHRQ

-New PCC PATCH released

-National Release - BMC Referred Care Information System, Version 4.0

International Health

-Summer opportunity for undergraduate students

-Attitudes toward the use of quarantine in a public health emergency in
four countries

#### MCH Alert

-Cultural Competency into Medical Education and Training

-Potential Environmental Risks to Women

#### Medical Mystery Tour

#### How not to give Acetaminophen: Listen up any parents or grandparents {#how-not-to-give-acetaminophen-listen-up-any-parents-or-grandparents .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

**Menopause Management**

#### -American Heart Association Does Not Recommend Isoflavone Supplements -Black cohosh / St. John\'s wort combined: Decreases psychological climacteric complaints  {#american-heart-association-does-not-recommend-isoflavone-supplements--black-cohosh-st.-johns-wort-combined-decreases-psychological-climacteric-complaints .Style-Heading-4-+-Arial-14-pt-Underline}

-Nonhormonal Therapies for Hot Flashes in Menopause

**Midwives Corner**

-When Should We Clamp the Umbilical Cord? Preterm vs Term Infants

-Liability in triage: management of EMTALA regulations and common
obstetric risks

-Withholding coaching during maternal pushing is not harmful

-Injuries to the Brachial Plexus: Mechanisms and Management

-Centering Association National Conference

and more....

**Navajo News**

#### Who do you contact in Navajo Area for MCH issues?  {#who-do-you-contact-in-navajo-area-for-mch-issues .Style-Heading-4-+-Arial-14-pt-Underline}

**Nurses Corner**

-New Mexico Indian Nurses Association Annual Symposium 2006

-Drugs containing PHENYLPROPANOLAMINE are being recalled

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

-Trends in Spina Bifida and Anencephalus in the United States, 1991-2003

-Community Based Cancer Control: A Seminar for AI/AN Health Advocates

**Oklahoma Perspective**

Who do you contact in Oklahoma Area for MCH issues?

Osteoporosis

-Cost-effectiveness of Drug Treatment for Osteopenia

-Vitamin D Levels During Pregnancy Affect Childhood Bone Mass

Patient Education

#### -Non-hormonal Options for Hot Flashes {#non-hormonal-options-for-hot-flashes .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Vertigo: What You Should Know {#vertigo-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

-Keeping Your Heart Healthy Through Good Nutrition and Exercise

Perinatology Picks

-Focus on preventable causes of stillbirth: 3 articles

-'Integrated Screening' is the most efficient: Risk cutoff levels
determine strategies

-Emergency cervical cerclage improves perinatal outcome compared with
bed rest

-Cervical cerclage: Can the patient who could benefit from this
procedure be identified?

-Prophylactic cerclage of a short cervix according to interleukin-8 in
cervical mucus

Primary Care Discussion Forum

Cardiology Topics for Primary Care Providers -- February 15, 2006

STD Corner

-Efficacy and safety of azithromycin for treatment of C. trachomatis in
pregnancy

-Hormonal contraception use and risk of STIs: A systematic review

-New National Women and Girls HIV/AIDS Awareness Day: March 10, 2006

-2006 Price Fellowships for HIV Prevention Program

-A clinician's guide to condoms, spermicides, microbicides, and
lubricants

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

-The underlying pathology for heart disease in women

-Waist-to-Hip Ratio Is a Better Predictor for MI Than BMI

-Sulfonylureas Linked to Heart Deaths

-Getting Sufficient Sleep Helps Reduce Weight Gain

-Intensive Monitoring and Treatment Required for Gestational Diabetes

and more....

###### Save the Dates: Upcoming events of interest page 49

#### What's new on the ITU MCH web pages page 49

The past CCC Corners are archived at:

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

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

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

or 907 729 3154 (with voicemail)

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

<http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm>

3/17/06njm