**News Flash(s)**

**ACOG / IHS Course Total Women's Health and Neonatal Course:      June
19-23, 2005**

**  Sign up before it is too late Late fees = waived**

**New Perinatology Corner Module - Should you be using the quad
screen?**

**Prenatal Genetic Screening -- Serum and Ultrasound**

** **

**New Features:**

**Medical Mystery Tour: Can you guess what the correct question is?**

#### Oklahoma Perspective by Greggory Woitte -- Hastings Indian Medical Center {#oklahoma-perspective-by-greggory-woitte-hastings-indian-medical-center .Style-Heading-4-+-Arial-14-pt-Underline}

**CCC Corner Digest - Print friendly Digest of the CCC Corner can be
mailed to you, or **

**your colleagues. Just send your address to**
[[nmurphy@scf.cc]{.underline}](mailto:nmurphy@scf.cc)

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

OB/GYN Chief Clinical Consultant's Corner

Volume 3, No. 5, May, 2005

# 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}

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

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

**Terry Cullen:** What is GPRA?

#### James Galloway: School junk food ban law in Arizona - How about our IHS facilities next? {#james-galloway-school-junk-food-ban-law-in-arizona---how-about-our-ihs-facilities-next .Style-Heading-4-+-Arial-14-pt-Underline}

#### George Gilson: AI/AN Premature Delivery Rate Higher than the National Average {#george-gilson-aian-premature-delivery-rate-higher-than-the-national-average .Style-Heading-4-+-Arial-14-pt-Underline}

Sandy Haldane: ACOG / IHS Course - DISREGARD \$50.00 fee for late
registration

**Steve Holve:** May 2005 Indian Child Health Notes; Methamphetamine in
Indian Country

#### Ted Mala: American Indian/Alaska Native Health Policy Monograph {#ted-mala-american-indianalaska-native-health-policy-monograph .Style-Heading-4-+-Arial-14-pt-Underline}

## Chuck North: Loss of bone mass reversed: Significant gains post DMPA discontinuation

**Robert Pittman:** Use lindane products as second-line only

**Phil Smith:** Quality Through Collaboration: The Future of Rural
Health Care

Judy Thierry:

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

-Post GDM care at your site: Anything interesting? What more could be
done?

-Feature Highlight: 2005 Prematurity Profile -- March of Dimes

-CDC web site with Repro health and SIDS and SUID

-Infant mortality (SIDS/SUIDI) in AIAN and structure of IHS health care

-Federal Registry HP/DP Grant Announcement

-Child abuse prevention Funding

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

##### Obstetrics: page 11

-Should we help patients decide on storage of umbilical cord stem cells?
Yes

-Brief interventions for prenatal alcohol use reduce subsequent
consumption the most

-Time has come to take on the professional responsibility of reducing
episiotomy use

-Subcutaneous drain is ineffective in preventing wound complications in
obese women

-Cesarean and Vaginal Birth After Previous Cesarean Delivery

-Epidural Analgesia During Labor Increases Risk of Abnormal Fetal Head
Position

-Evidence-Based Prenatal Care: Part II. 3^rd^ Trimester Care, Infectious
Disease Screening

-Perinatal Depression: Prevalence, Screening Accuracy, and Screening
Outcomes: AHRQ

**Gynecology: page 13**

-Testosterone patch effective in hypoactive sexual desire in surgically
menopausal

-Negative LEEP Is Not Reassuring

-Human Papillomavirus Quadrivalent Vaccine May Be Effective

-Oophorectomy and Hysterectomy No Curb on Sexuality

-Randomised comparison of microwave endometrial ablation with
transcervical resection

-The physiologic effects of pneumoperitoneum in the morbidly obese

-Hypertension Boosts Uterine Fibroid Risk

-Failure to simply get a Pap test often to blame for cervical cancer
diagnosis

**Child Health: page 14**

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

-School nutrition resources

**Chronic Illness and Disease: page 14**

-What are the best ways to quit smoking?

-Screening for Asymptomatic Bacteriuria: Recommendation Statement:
USPSTF

-The Living to 100 Life Expectancy Calculator

-Improving the Quality of Care for Adults with Type 2 Diabetes Mellitus

-Acupuncture: a clinical review

-Benefits of Omega-3 Fatty Acids

-One size doesn\'t fit all

-Evidence-Based Guidelines for Cardiovascular Disease Prevention in
Women

-Evaluation of Palpable Breast Masses

-AHRQ Recent Findings: Cardiovascular Disease

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

##### American Family Physician page 16

-Does Lipid Lowering Decrease Stroke Risk?

-Hyperbaric Oxygen Therapy in Patients with Chronic Wounds

-Mammography Screening Intervals Questioned

-Estrogen Increases the Risk of Gallbladder Disease

-Fibroids (Uterine Myomatosis, Leiomyomas) BMJ Clinical Evidence Concise

-Anticonvulsant Medications for Migraine Prevention: Cochrane for
Clinicians

American College of Obstetricians and Gynecologists

Intrapartum fetal heart rate monitoring. ACOG Practice Bulletin

**Agency for Healthcare Research and Quality**

-Recent findings

-AHRQ Patient Safety Network (PSNet), the new \"one-stop\" patient
safety portal

**Ask a Librarian**

[Vitamin C reduced premature rupture of the membranes
(PROM)](../../../../../../../../C:%5CDocuments%20and%20Settings%5Ccooperd%5CMy%20Documents%5Cvitamin%20c.pdf)

**Breastfeeding**

-Making Every Mother and Child Count - Through Breastfeeding, One Baby
at a Time

#### -Breast-feeding initiation in low-income women {#breast-feeding-initiation-in-low-income-women .Style-Heading-4-+-Arial-14-pt-Underline}

-Interested in the US Breastfeeding Committee Task Force and Coalition
Conference?

-AAP Releases Updated Breastfeeding Recommendations

#### -Exclusive Breast-feeding May Reduce Risk of Postnatal HIV Transmission {#exclusive-breast-feeding-may-reduce-risk-of-postnatal-hiv-transmission .Style-Heading-4-+-Arial-14-pt-Underline}

**CCC Corner Digest - Highlights include:**

-Human Papillomavirus ACOG Practice Bulletin

-Burt Attico, Phoenix: DMPA / BMD, and Teens: Recent and Reassuring Data

-Tx for BV or T. vaginalis does not reduce Preterm birth or adverse
outcome

-Antibiotics for Recurrent Urinary Tract Infections: Cochrane for
Clinicians

-FASlink: The approach is directed at maternal drinking behavior and
dose

-Can Patients with Cancer Postpone Death for Important Events?

##### -Access to the NIH Library web resources being explored - Indian Health Tribal staff

-'The patch': Trouble getting it on your formulary?

-Midwifery care of poor and vulnerable women, 1925-2003

-Natural mentoring relationships and adolescent health: evidence from a
national study

-A Decline in Life Expectancy in the US

-Should you be using the quad screen?

-Prenatal Genetic Screening -- Serum and Ultrasound - New Perinatology
Corner Module

**Domestic Violence**

-Upcoming Child Abuse Project

-Intimate Partner Violence using PRAMS data - group studied age 20+

-AHRQ Recent Findings: Violence Against Women

-McCain introduces safety to Indian Women Act

-PREVENT WORKSHOP: Moving Towards Violence Prevention

\-[Preventing Sexual and Intimate Partner Violence Within Racial/Ethnic
Minorities](http://fedgrants.gov/Applicants/HHS/CDC/PGO/CDC-RFA-05043/listing.html)

-Injury Prevention Fact Sheet Focuses on Child Maltreatment

-Hidden Problem of Child Abuse

**Elder Care News**

#### -Funding available to engage elders in service and mentor youth {#funding-available-to-engage-elders-in-service-and-mentor-youth .Style-Heading-4-+-Arial-14-pt-Underline}

**Family Planning**

Oral Contraceptives: Their Mode of Action and Dermatologic Applications

**Frequently asked questions**

-What types of drug testing are indicated in pregnancy?

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

-What kind of availability is necessary for vaginal birth after
cesarean? and

-Does there have to be Pediatrician at all emergency deliveries?

-Does the active management of the third stage of labor really work?

-What is the significance of ultrasound (US) 'soft markers' for Down
Syndrome?

-What are the main risks for expectant mothers in day care settings?

-Do you need help documenting Patient Education or GPRA items?

**Hormone Replacement Update**

-Estrogen plus progestin: WHI showed relief of menopausal symptoms but
adverse effects

-Exercise: Alternative to estrogen for endothelial dysfunction in
postmenopausal women

-Black cohosh extract is more effective than placebo in treating
climacteric symptoms

-Does Beginning HT Earlier Decrease Mortality?

-The Impact of Comorbidities on Hormone Use

**Information Technology**

IHS Office of Information Technology (OIT) latest edition of the IT
News:

International Health

#### -10.6 million children die before age five, and half a million women die in childbirth

-Neonatal survival: a call for action

-Make Every Mother and Child Count: The World Health Report 2005

-Some countries will not achieve millennium development goals for health
by 2015

-Children having children: The state of the World's mothers 2004

-Improving Aboriginal Health: First Ministers' and Aboriginal Leaders'
Meeting

#### MCH Alert

-Randomized controlled trial: Risk of Adolescent Suicide Screening
Programs

-Reduce the Risk of SIDS: New Tools from American Academy of Pediatrics

-Interventions to improve cultural competence among health professionals

#### Medical Mystery Tour

-The Case of the Mystery Question

-Who prescribed that really potent clomiphene in 1978? March Medical
Mystery follow-up

#### Medscape

**Midwives Corner**

-Antibiotic Treatment for Bacterial Vaginosis Does Not Prevent Preterm
Birth

-Elective Cesarean Section; How informed is informed?

-Share These With Women -- ACNM Patient/ client hand- outs

-New low and high -- Tech calendar methods of family planning

-Herbs and the childbearing woman: Guidelines for midwives

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

Health Characteristics of the American Indian and Alaska Native Adult
Population

Oklahoma Perspective

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

Osteoporosis

-Statins and osteoporosis: a clinical review

-Guidelines Unclear on Screening for Osteoporosis

-AHRQ Recent Findings: Osteoporosis

Patient Education

-Infections During Pregnancy: What You Should Know?

-A Guide to Perimenopause: Patient FAQs -- Cleveland Clinic

Primary Care Discussion Forum

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

STD Corner

-After the promise: The STD consequences of adolescent virginity
promises

-2005 4-Corners STD/HIV Summit June 22 -- 24, 2005, Farmington, NM

-Oral versus vaginal sex among adolescents: Perceptions, attitudes, and
behavior

-Young age at first sexual intercourse and sexually transmitted
infections in adolescents

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

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

-Waistline of one meter or more are at serious risk of insulin
resistance

-Rosiglitazone Crosses Placenta in First Trimester

-Happy People Are Healthier - Song \"Don\'t Worry, Be Happy,\" - Sound
medical advice

-Depressed diabetics die sooner than depressed non-diabetics

-Be surprised: Portion size, calories, amount of activity needed to
expend those calories

-Step Counting Increases Exercise More Than Timed Walking

-Carrying weight around waist increases risk of metabolic syndrome even
if BMI is normal

-Diabetes Increases Risk of Urinary Infection in Postmenopausal Women

-National Employee Health & Fitness Day: Wednesday, May 18, 2005

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

#### What's new on the ITU MCH web pages page 34

-New Perinatology Corner Module Should you be using the quad screen?

Prenatal Genetic Screening -- Serum and Ultrasound

-US OB/GYNs helping to create residency program in Kabul

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

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

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

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

Lois Goode, MS, PT, ATC is the Chief Clinical Consultant for Physical
Therapy

White River Indian Health Hospital

The pelvic floor muscles are comprised of two layers of muscles. The
deep layer of the pelvic floor is known as the levator ani muscle group.
The superficial layer is known as the urogenital diaphragm muscles
(consisting not only of the deep transverse and superficial transverse
perineal muscles but also the bulbocavernosus and ischiocavernous
muscles, and the anal sphincter muscle).
(<http://incontinet.com/kegelpix.htm>) The functions of the pelvic floor
muscles are to squeeze around the pelvic openings and to provide and
inward lift.^1,\ 2^ When these two muscle group layers are not
contracting simultaneously, or if the contraction is preceded by an
increase in abdominal pressure, stress urinary incontinence can occur.
^1,3^

Stress Incontinence is defined by the International Continence Society
as the complaint of any involuntary leakage of urine.^4^ Stress
incontinence, the most common type of urinary incontinence in women, is
defined as the involuntary leakage of urine on effort or exertion, such
as sneezing or coughing.^1,\ 4^

There is good evidence to support the use of pelvic floor muscle
training to treat stress urinary incontinence^.1^ Pelvic floor muscle
training can improve the muscle control, timing of superficial and deep
layer contractions, and the pelvic floor strength. Further,
strengthening the pelvic floor muscles improves quality of life by
improving incontinence, increasing support of pelvic viscera and sexual
functioning.

Without proper instruction, many women are unable to volitionally
contract these muscle groups on demand as the pelvic floor muscles are
located at the floor of the pelvis and seldom used consciously. One
common error is the substitutions of gluteal, hip adductor and/or
abdominal muscles rather than contraction the pelvic floor muscles.

Assessment of pelvic floor muscle strength can be done through clinical
observation (although visual observation alone is often inadequate),
vaginal palpation, ultrasound and MRI, or electromyography. Two main
reasons for physical therapist to conduct high-quality assessment of
pelvic floor muscle function and strength are: 1) to ensure proper
pelvic floor muscle contraction technique prior to performing a strength
exercise program, 2) to measure and assess program outcomes and adjust
the training parameters (intensity, frequency, or duration)
appropriately as indicated.^1^

For more information on current physical therapy programs for urinary
incontinence within American Indian and Alaska Native populations
<http://www.ihs.gov/medicalprograms/MCH/W/WHmature.asp#PT>

1\. Bo, K, et al. Evaluation of Female Pelvic-Floor Muscle Function and
Strength, Physical Therapy. 2005;85:3; 269-281

2\. Kegel AH. Progressive resistance exercise in the functional
restoration of the perineal muscles. Am J Obstet Gynecol.
1948;56:238-249

3\. Constantinou CE, et al, Contribution and Timing of Transmitted and
Generated Pressure Components in the Female Urethra: Female
Incontinence. New York, NY; Allan R Liss, Inc; 1981:113-120

4\. Hey-Smith E, et al. Pelvic Floor Muscle Training for Urinary
Incontinence in Women. Oxford, United Kingdom: The Cochrane Library, The
Cochrane Collaboration; 2001:3

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

I would like you to welcome Lois Goode, the new Chief Clinical
Consultant for Physical Therapy. Lois points out several good points
about the role of physical therapy in Women's Health.

Here are the Cochrane Library postings on urinary incontinence:

**Authors\' conclusions:** Pelvic floor muscle training appeared to be
an effective treatment for adult women with stress or mixed
incontinence. Pelvic floor muscle training was better than no treatment
or placebo treatments. The limitations of the evidence available mean
that is difficult to judge if pelvic floor muscle training was better or
worse than other treatments. Most trials to date have studied the effect
of treatment in younger, pre-menopausal women. The role of pelvic floor
muscle training for women with urge incontinence alone remains unclear.
Many of the trials were small with poor reporting of allocation
concealment and masking of outcome assessors. In addition there was a
lack of consistency in the choice and reporting of outcome measures that
made data difficult to combine. Methodological problems limit the
confidence that can be placed in the findings of the review. Further,
large, high quality trials are necessary.

Hay-Smith EJC et al. Pelvic floor muscle training for urinary
incontinence in women. The Cochrane Database of Systematic Reviews 2001,
Issue 1.

**Authors\' conclusions:** The limited evidence available suggests that
bladder training may be helpful for the treatment of urinary
incontinence, but this conclusion can only be tentative as the trials
were of variable quality and of small size with wide confidence
intervals around the point estimates of effect. There was also not
enough evidence to determine whether bladder training was useful as a
supplement to another therapy. Definitive research has yet to be
conducted: more research is required.

Wallace SA, et al Bladder training for urinary incontinence in adults.
The Cochrane Database of Systematic Reviews 2004, Issue 1.

There are also other Cochrane postings available on the role of female
physical therapy, e.g., fecal incontinence:
<http://www.update-software.com/cochrane/abstract.htm>

Please contact Lois for any question you have at <Lois.Goode@ihs.gov>

Lois's own CCC web page is
<http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-pt.asp>

In addition, the IHS Women's Health: 'Mature Women' web site has a
wealth of other information.

<http://www.ihs.gov/medicalprograms/MCH/W/WHmature.asp#PT>

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

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

**WHAT IS GPRA?**

Contrary to popular belief, "GPRA" is [not]{.underline} something the
Indian Health Service (IHS) invented to "**G**et **P**eople **R**eally
**A**ngry"! Well, what exactly is GPRA and how does it affect you, as a
patient of IHS?

-   GPRA = Government Performance and Results Act

-   Is a federal law.

-   Shows Congress how the Indian Health Service is performing based on
    a set of clinical measures.

-   Information that is reported to Congress must be supported by
    [data]{.underline} that can be [verified and validated]{.underline}.

-   IHS is subject to having its GPRA report audited.

-   An annual GPRA Report is required every year.

-   IHS (federal) operated facilities are required to report for GPRA.
    Tribal and urban operated facilities are not required but are highly
    encouraged to report on GPRA measures.

-   GPRA reporting is linked to the annual budget request for IHS.

-   The goal of GPRA is to improve effectiveness by promoting a strong
    focus on results, service quality, and customer satisfaction.

-   You, as a patient of IHS, can ask your clinic/facility to see how it
    is doing on providing quality clinical care to its patients and to
    you.

#### For the complete patient oriented fact sheet: {#for-the-complete-patient-oriented-fact-sheet .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/misc/links_gateway/download.cfm?doc_id=9643&app_dir_id=4&doc_file=Article_on_GPRA-patient-rev_May_9,05.pdf**](http://www.ihs.gov/misc/links_gateway/download.cfm?doc_id=9643&app_dir_id=4&doc_file=Article_on_GPRA-patient-rev_May_9,05.pdf) {#httpwww.ihs.govmisclinks_gatewaydownload.cfmdoc_id9643app_dir_id4doc_filearticle_on_gpra-patient-rev_may_905.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Jim Galloway, Tucson Director, Native American Cardiology Program {#jim-galloway-tucson-director-native-american-cardiology-program .Style-Heading-4-+-Arial-14-pt-Underline}

#### School junk food ban signed into law in Arizona - How about our IHS facilities next? {#school-junk-food-ban-signed-into-law-in-arizona---how-about-our-ihs-facilities-next .Style-Heading-4-+-Arial-14-pt-Underline}

#### "Take a long last look at those bottles of soda, bags of potato chips and boxes of Milk Duds. They\'re going to get very scarce \-- at least in elementary, middle and junior high schools \-- under the terms of new legislation signed into law by (Arizona) Gov. Janet Napolitano. The restrictions, which actually kick in when students return to class after the summer of 2006, make it illegal to sell items classified by the federal government as having \"minimal nutritional value.\" Also gone from vending machines and snack bars would be anything else the state Department of Education determines to be unacceptable." By HOWARD FISCHER *Capitol Media Services* 04/27/2005 PHOENIX {#take-a-long-last-look-at-those-bottles-of-soda-bags-of-potato-chips-and-boxes-of-milk-duds.-theyre-going-to-get-very-scarce----at-least-in-elementary-middle-and-junior-high-schools----under-the-terms-of-new-legislation-signed-into-law-by-arizona-gov.-janet-napolitano.-the-restrictions-which-actually-kick-in-when-students-return-to-class-after-the-summer-of-2006-make-it-illegal-to-sell-items-classified-by-the-federal-government-as-having-minimal-nutritional-value.-also-gone-from-vending-machines-and-snack-bars-would-be-anything-else-the-state-department-of-education-determines-to-be-unacceptable.-by-howard-fischer-capitol-media-services-04272005-phoenix .Style-Heading-4-+-Arial-14-pt-Underline}

#### After long efforts here in Arizona by many of us involved, we were able to affect a change in Arizona to ban junk food and serve healthier school lunches, at least in elementary and junior high schools\..... Now it is time for us to work together and move on to the BIA facilities (and our IHS clinical facilities)\.... I invite anyone interested to join in the effort to move this forward. {#after-long-efforts-here-in-arizona-by-many-of-us-involved-we-were-able-to-affect-a-change-in-arizona-to-ban-junk-food-and-serve-healthier-school-lunches-at-least-in-elementary-and-junior-high-schools.....-now-it-is-time-for-us-to-work-together-and-move-on-to-the-bia-facilities-and-our-ihs-clinical-facilities....-i-invite-anyone-interested-to-join-in-the-effort-to-move-this-forward. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**jgalloway@umcaz.edu**](mailto:jgalloway@umcaz.edu) {#jgallowayumcaz.edu .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### George Gilson, Anchorage {#george-gilson-anchorage .Style-Heading-4-+-Arial-14-pt-Underline}

#### AI/AN Premature Delivery Rate Higher than the National Average {#aian-premature-delivery-rate-higher-than-the-national-average .Style-Heading-4-+-Arial-14-pt-Underline}

#### The AI/AN premature delivery rate exceeds the White rate by 15% (13.0 vs 11.0 - percent live births) The March of Dimes just released a new Prematurity Fact Sheet, 3/3/0/05, with helpful tables and figures for presentations [**http://www.smfm.org/attachedfiles/PrematurityFact.pdf**](http://www.smfm.org/attachedfiles/PrematurityFact.pdf) Or [**gjgilson@anmc.org**](mailto:gjgilson@anmc.org)  {#the-aian-premature-delivery-rate-exceeds-the-white-rate-by-15-13.0-vs-11.0---percent-live-births-the-march-of-dimes-just-released-a-new-prematurity-fact-sheet-33005-with-helpful-tables-and-figures-for-presentations-httpwww.smfm.orgattachedfilesprematurityfact.pdf-or-gjgilsonanmc.org .Style-Heading-4-+-Arial-14-pt-Underline}

#### March of Dimes Prematurity Campaign: [**http://www.marchofdimes.com/prematurity/5196_5786.asp**](http://www.marchofdimes.com/prematurity/5196_5786.asp) {#march-of-dimes-prematurity-campaign-httpwww.marchofdimes.comprematurity5196_5786.asp .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### ACOG / IHS Course - DISREGARD the notice of a \$50.00 fee for late registration {#acog-ihs-course---disregard-the-notice-of-a-50.00-fee-for-late-registration .Style-Heading-4-+-Arial-14-pt-Underline}

#### DISREGARD the notice of a \$50.00 fee for late registration (after May 2nd) to the 2005 ACOG Post Graduate Course being held in Denver in June. The late registration fee (\$50.00) has been waived. [**[Sandra.Haldane@ihs.gov]{.underline}**](mailto:Sandra.Haldane@ihs.gov) {#disregard-the-notice-of-a-50.00-fee-for-late-registration-after-may-2nd-to-the-2005-acog-post-graduate-course-being-held-in-denver-in-june.-the-late-registration-fee-50.00-has-been-waived.-sandra.haldaneihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**May 2005 Indian Child Health Notes: Highlights**

-Microscopic Hematuria - Don\'t Ask, Don\'t tell, Don\'t Pursue

-Etiology of Pneumonia in School Aged Children - It\'s not about
Amoxacillin

-Infant Mortality in AI/AN 2002 - Overall good news except for SIDS

<http://www.ihs.gov/MedicalPrograms/MCH/C/documents/ICHN5405.doc>

**Methamphetamine Use in Indian Country**

Dr. Holve moderated an excellent discussion about Methamphetamine Use in
Indian Country.

There was agreement that methamphetamine use is a major problem in
most communities and only likely to worsen.

The most difficult questions revolved around how to best screen prenatal
patients (universal versus selected patients), the need for consent to
test (informed individually or as a blanket policy) and the how to
balance need for treatment against a judicial system that focuses on
punishment.

The discussion was lively and well worth reading in its entirety which
is available here:

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

(scroll down page to Methamphetamine in Indian Country)

Also please see the many excellent resources below that were shared
during the discussion

**Whole Discussion**

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/MethDisc42605.doc>

**Background Material**

**Arizona Guidelines for Identifying Substance Exposed Newborns, 2005**

<http://www.governor.state.az.us/cps/documents/SenGuidelines.pdf>

**Methamphetamine, Word document by Thomas Drouhard, MD**

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/listservmethdocument.rtf>

**Methamphetamine Abuse: Fact or Fiction? PPT by Diana Hu**

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ListservMethPowerpoint.ppt>

**DRAFT Substance Abuse Screening**

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

[**UNM Maternal / Neonatal Drug
Monitoring**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/UNMScr.doc)

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

**Summary of Discussion**

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/SumMeth5705.doc>

#### Ted Mala, Anchorage {#ted-mala-anchorage .Style-Heading-4-+-Arial-14-pt-Underline}

#### American Indian/Alaska Native Health Policy Monograph {#american-indianalaska-native-health-policy-monograph .Style-Heading-4-+-Arial-14-pt-Underline}

This month\'s issue of the American Journal of Public Health is devoted
to AI/AN Health Policy.

#### [**http://www.ajph.org/content/vol95/issue5/?etoc**](http://www.ajph.org/content/vol95/issue5/?etoc) {#httpwww.ajph.orgcontentvol95issue5etoc .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

## Loss of bone mass is apparently reversed: Significant gains post DMPA discontinuation

## Conclusion: Use of DMPA contraception in adolescents was associated with significant continuous losses of bone mineral density at the hop and spine.  However, significant gains post-discontinuation provide evidence that the loss of bone mass is apparently reversed. 

## Scholes D, et al Change in Bone Mineral Density Among Adolescent Women Using and Discontinuing DMPA Contraception. Archives of Pediatrics and Adolescent Medicine 2005;159:139-144

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15699307>

## Robert Pittman, Principal Pharmacy Consultant

**Use lindane products as second-line only**

Most IHS sites have already switched to non-lindane containing products
as first line treatment of scabies and lice and only use lindane
products as second-line therapy.** ** There are several different of
medications that can be used for the treatment of scabies and lice. 
Which medications are available at particular Indian Health Service or
Tribal sites is a decision made by the local hospital or clinic Pharmacy
and Therapeutics Committee.  Health care providers and pharmacists are
well aware of the risks and benefits of topical lotions and shampoos
containing Lindane and the need to properly education patients and
caregivers about the appropriate use of these products.

**American Hospital Formulary 2005**

**[Scabicides\*]{.underline}**

Benzyl Benzoate 28% Lotion

Crotamiton 10% Cream or lotion (Eurax)

Lindane 1% lotion

Permithrin 1% Cream Rinse (Nix)

**[Pediculicides (Lice)]{.underline}**

Lindane 1% Shampoo

Malathion 0.5% lotion (Ovide)

Permithrin 5% cream (Acricin or Elimite)

Pyrethrins 0.3% with Piperonyl Butoxide 3% or 4% (RID Mousse, Tisit Blue
Gel, Tisit Shampoo, A-200 Lice Killing Shampoo, etc)

If your site has not yet reviewed this issue and made changes to your
local formulary, then go here for information.
<http://www.fda.gov/cder/drug/infopage/lindane/default.htm>

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

**Quality Through Collaboration: The Future of Rural Health Care**

#### From the Committee on The Future of Rural Health Care*,* the Future of Rural Health offers a strategy to address the quality challenges in rural communities [**http://www.nap.edu/catalog/11140.html**](http://www.nap.edu/catalog/11140.html) {#from-the-committee-on-the-future-of-rural-health-care-the-future-of-rural-health-offers-a-strategy-to-address-the-quality-challenges-in-rural-communities-httpwww.nap.educatalog11140.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

These instruments actually are very similar to each other. Both start
with the premise that women relate more through their relationships with
others and therefore the screen should address some

of who else may influence their drinking behavior. This is quite
different from traditional screens for men which usually look at things
like tolerance, number of drinks to get drunk, black-outs, etc, i. e.,
the focus is also on identifying mostly heavy users in other screens

**5 P\'s**

1\. Do either of your parents have a problem with using alcohol or
drugs?

**Yes, No, or No answer**

2\. Do any of your friends (peers) have a problem with drugs or alcohol?

**Yes, No, or No answer**

3\. Does your partner have a problem with drug or alcohol use?

**Yes, No, or No answer**

4\. Before you knew you were pregnant (past) how often did you drink
beer,

wine, wine coolers, or liquor?

**Not at all, rarely, sometimes, frequently**

5\. In the past month (present) how often did you drink beer, wine, wine

coolers or liquor?

**Not at all, rarely, sometimes, frequently**

Kennedy C, Finkelstein N, Hutchins E, Mahoney Improving screening for
alcohol use during pregnancy: the Massachusetts ASAP program. Matern
Child Health J. 2004 Sep;8(3):137-47.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15503394>

**4 P\'s**

1\. Did either of your parents ever have a problem with drinking or
using drugs?

**Answers = Yes or No**

2\. Does your partner have any problem with drinking or using drugs?

**Answers = Yes or No**

3\. Have you ever drunk alcohol?

**Answers = Yes or No**

4\. In the month before you knew you were pregnant, how many beers did
you drink?

**Answer = Quantity**

5\. In the month before you knew you were pregnant, how many cigarettes
did you smoke?

**Answer = Quantity**

Developed by Ira Chasnoff, MD. An article will be published in the next
few months on use of this screen with pregnant women in publicly funded
clinics and some of the findings, to be published in the Journal of
Perinatology. Lead author: Ira Chasnoff, MD

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/DgSc41205.doc>

**Post GDM care at your site: Anything interesting? What more could be
done?**

From your individual perspectives, professional activities, and clinical
practice populations can you give me some further information for when I
go to the National Diabetes Educators Program meeting to represent IHS
and gestational DM in our populations? The NDEP is still developing this
initiative so nothing is set yet, but the focus will be preventing Type
II diabetes [in women after pregnancy]{.underline} when they had a
diagnosis of GDM. <Judith.Thierry@ihs.gov>

**References:**

Benjamin E, Winters D, Mayfield J, Gohdes D. Diabetes in pregnancy in
Zuni Indian women. Prevalence and subsequent development of clinical
diabetes after gestational diabetes. Diabetes Care. 1993
Sep;16(9):1231-5

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8404425>

Pettitt DJ, Narayan KM, Hanson RL, Knowler WC Incidence of diabetes
mellitus in women following impaired glucose tolerance in pregnancy is
lower than following impaired glucose tolerance in the non-pregnant
state. Diabetologia. 1996 Nov;39(11):1334-7

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8933001>

Steinhart JR, Sugarman JR, Connell FA. Gestational diabetes is a herald
of NIDDM in Navajo women. High rate of abnormal glucose tolerance after
GDM. Diabetes Care. 1997 Jun;20(6):943-7
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9167104>

**Feature Highlight: 2005 Prematurity Profile -- March of Dimes**\
New prematurity profiles are available for the United States and every
state. These documents provide a brief summary of prematurity-related
statistics and describe some of the most commonly reported risk factors
for preterm labor and birth. Click on your state for access

<http://www.marchofdimes.com/peristats/newsletter/April2005.html>

**CDC web site with Repro health and SIDS and SUID**

Please mark the new CDC Division of Reproductive Health website.  Please
note that the MCH EPI Program website is also updated giving you access
to many links including the MCH EPI Conference, MCH EPI Grand Rounds,
and more.  The MCH EPI Website reached by clicking on MCH EPI the far
right column.
[[http://www.cdc.gov/reproductivehealth/SIDS/index.htm]{.underline}](http://www.cdc.gov/reproductivehealth/SIDS/index.htm)

**Infant mortality (SIDS/SUIDI) in AIAN and structure of IHS health
care**

In August 2004 Ernie Weyand (FBI), Betty Hastings (EMS-C) and I
presented a breakout session on Infant mortality (SIDS/SUIDI) in AIAN
and structure of IHS health care system at the National Summit on Child
Death Review held in St. Louis. Contact for Ernie's Powerpoint or the
Protocol

<Judith.Thierry@ihs.gov>

**Federal Registry HP/DP Grant Announcement**

The announcement will be available at the HP/DP website at
[[http://www.ihs.gov/hpdp/]{.underline}](http://www.ihs.gov/hpdp/)

Application deadline is June 1, 2005
[[http://www.grants.gov]{.underline}](http://www.grants.gov/)

#### [**http://www.fedgrants.gov/Applicants/HHS/IHS/DAGM/HHS-2005-IHS-HPDP-0001/listing.html**](http://www.fedgrants.gov/Applicants/HHS/IHS/DAGM/HHS-2005-IHS-HPDP-0001/listing.html) {#httpwww.fedgrants.govapplicantshhsihsdagmhhs-2005-ihs-hpdp-0001listing.html .Style-Heading-4-+-Arial-14-pt-Underline}

**Child abuse prevention Funding**

The goal of the programs and activities supported by these funds is to
prevent the occurrence or recurrence of abuse or neglect within the
tribal and migrant populations. Application Deadline: July 5, 2005
Grants to Tribes, Tribal Organizations, and Migrant Programs for
Community-Based Child Abuse Prevention Programs 
<http://www.acf.hhs.gov/grants/grants_cb.html>

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

#### APN/PA Meeting: June 6-10, 2005  {#apnpa-meeting-june-6-10-2005 .Style-Heading-4-+-Arial-14-pt-Underline}

'Thought I\'d send again.  In case you\'re on the fence\...please
consider coming.

2005 PA/APN Indian Health Continuing Education Seminar

-   June 6-10, 2005

-   Scottsdale, Arizona

-   [CEU/CME credit from IHS Clinical Support
    Center](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05flyer.doc)

[**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05flyer.doc**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05flyer.doc)

Primary Care Provider Training in Addictions

August 8 -- 12, 2005 Tacoma, WA

Since 1988, the Indian Health Service (IHS) Alcoholism and Substance
Abuse Program Branch (ASAPB), utilizing the [IHS Primary Care Provider
Curriculum: Clinical Training in American Indian/Alaska Native Alcohol
and Other Drug Abuse,]{.underline} has offered four day intensive
workshops which include both didactic and experiential training. Teresa
Sappier in Behavioral Health HQE <Teresa.Sappier@ihs.gov>

**Do you want to learn more about VRE, MRSA, and Influenza? Other
topics?**

The Topics Based listserv is a new feature developed by the N-PAC
Communications Committee to provide readers with current information and
resources on topics related to public health issues (See the attachment
for directions on how to subscribe).  The Topics Based listserv will be
updated quarterly with 3 new topics. The topics for the first quarter
are **VRE, MRSA, and Influenza**. In addition to being sent out on the
listserv, the information can also be found on the PHS Nursing web site
at
[http://phs-nurse.org/TopicsBasedListserv.htm](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://phs-nurse.org/TopicsBasedListserv.htm)

 If there are subjects you would like to see addressed in this venue, we
welcome your suggestions. Send your suggestions, and any additional
information you may have related to the topic, to CDR Sue Fawkes at
<sfawkes@bop.gov>

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

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

**Umbilical Cord Blood Banking**

**Should we help patients decide on storage of umbilical cord stem
cells? Yes**

"....The weight of current evidence, then, suggests that
government-funded public umbilical blood banking is an idea whose time
has come. From a cost-benefit and ethical perspective, it is hard, at
present, to justify the value of private umbilical cord blood banking.
However, in certain families at high risk for conditions that can be
remedied by autologous stem cell therapy, the costs may be justified.
Moreover, if cord blood proves a non-controversial source of embryonic
stem cells, a far stronger case could be made for private banking. For
all these reasons, when a patient asks me whether she should \"collect
the baby\'s cord blood,\" my short answer remains, \"Maybe, but probably
not.\" Charles Lockwood. Editorial: Should we encourage storage of
umbilical cord stem cells? *Contemporary Ob/Gyn* 2002;11:8-12.

<http://www.contemporaryobgyn.net/obgyn/article/articleDetail.jsp?id=139457>

and

Perlow, JH Cord Blood Banking: An Ob\'s Perspective Contemporary Ob/Gyn
2002;11

<http://www.cordblood.com/cord_blood_news/stem_cell_news/ob_perspective.asp>

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

Umbilical cord blood banking is vastly under-represented among minority
populations in the US, including AI/AN. Much like other organ donation
programs, AI/ANs have but to gain from donation to a public cord blood
bank. If the individual AI/AN family has the resources for a private
cord blood bank, then there are particular advantages for certain
genetic AI/AN lineages. I have attached two resources to share with your
patients to help in their decision making process.

In the meantime, health facilities in Indian Country should:

-provide non-directed patient education about public and private cord
blood banking

-be willing to help in the logistical steps of collection for those
AI/AN patients interested in pursuing cord blood banking, e.g., either
with public cord blood banks, or for families using their own resources
to pay for private cord blood banks.

**A Parent\'s Guide to Cord Blood Banks**

How much do your patients know about this potentially life saving
technique?

There are private and public umbilical cord blood banks both with
advantages and disadvantages. A Parent\'s Guide to Cord Blood Banks is a
web site that places an emphasis on how to evaluate private bank
services from a parent's viewpoint.
[http://www.parentsguidecordblood.com](http://www.parentsguidecordblood.com/)

Other reference: **US Cord Blood Stem Cell Act of 2003**
<http://www.theorator.com/bills108/hr2852.html>

**Brief interventions for prenatal alcohol use reduce subsequent
consumption the most**

CONCLUSION: Pregnant women with the highest levels of alcohol use
reduced their drinking most after a brief intervention that included
their partners. Recommendations include consistent screening for
prenatal alcohol use followed by diagnostic assessment when indicated,
and if confirmed by other studies, a patient-partner brief intervention
for the heaviest drinkers. LEVEL OF EVIDENCE: I. Chang G, et al. Brief
intervention for prenatal alcohol use: a randomized trial. Obstet
Gynecol. 2005 May;105(5):991-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15863535&dopt=Abstract>

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

In your increasingly harried office you may rarely have time for lengthy
counseling session with your patients. It seems that may not be a
problem for prenatal alcohol consumption reduction according to this
randomized trial.

As luck would have it, Judy Thierry, IHS MCH Coordinator in Rockville,
has given just us two quick and simple tools for substance abuse
screening, e.g., the 4 P(s) and the 5 P(s)

(See From Your Colleagues, above)

**Time has come to take on the professional responsibility of reducing
episiotomy use**

CONCLUSIONS: Evidence does not support maternal benefits traditionally
ascribed to routine episiotomy. In fact, outcomes with episiotomy can be
considered worse since some proportion of women who would have had
lesser injury instead had a surgical incision. Hartmann K, et al.
Outcomes of routine episiotomy: a systematic review. JAMA. 2005 May
4;293(17):2141-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15870418&dopt=Abstract>

**Subcutaneous drain is ineffective in preventing wound complications in
obese women**

CONCLUSION: The additional use of a subcutaneous drain along with a
standard subcutaneous suture reapproximation technique is not effective
for the prevention of wound complications in obese women undergoing
cesarean delivery. LEVEL OF EVIDENCE: I.

Ramsey PS, et al Subcutaneous tissue reapproximation, alone or in
combination with drain, in obese women undergoing cesarean delivery.
Obstet Gynecol. 2005 May;105(5):967-73.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15863532&dopt=Abstract>

Cesarean and Vaginal Birth After Previous Cesarean Delivery

Data from the National Center for Health Statistics on the total and
primary cesarean rates and vaginal birth after previous cesarean
delivery (VBAC) rate in the United States from 1989 to 2003 were
published in the January 21, 2005, recommendations and reports series of
*Morbidity and Mortality Weekly Report.* Preliminary data from 2003
indicated that 27.6 percent of all U.S. births resulted from cesarean
deliveries, representing the highest percentage ever reported in the
United States and a 6 percent increase from 2002. The total cesarean
delivery rate and the primary cesarean delivery rate (i.e., percentage
among women with no previous cesarean delivery) have increased every
year since 1997 after declines during 1989 to 1996. The rate of VBAC
decreased by 63 percent to 10.6 percent in 2003, after increasing from
1989 to 1996. Among women with previous cesarean deliveries, the
likelihood of future cesarean deliveries was approximately 90 percent in
2003. *The accompanying figure* shows the trends in rates of VBAC, total
cesarean deliveries, and primary cesarean deliveries from 1989 to 2003.

<http://www.aafp.org/afp/20050501/practice.html>

Centers for Disease Control and Prevention. QuickStats: total and
primary cesarean rate and vaginal birth after previous cesarean (VBAC)
rate-United States, 1989-2003:
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5402a5.htm>.

**Epidural Analgesia During Labor Increases Risk of Abnormal Fetal Head
Position**

CONCLUSION: Fetal position changes are common during labor, with the
final fetal position established close to delivery. Our demonstration of
a strong association of epidural with fetal occiput posterior position
at delivery represents a mechanism that may contribute to the lower rate
of spontaneous vaginal delivery consistently observed with epidural.
LEVEL OF EVIDENCE: II-2. Lieberman E, et al Changes in fetal position
during labor and their association with epidural analgesia. Obstet
Gynecol. 2005 May;105(5):974-82\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15863533&dopt=Abstract>

**Evidence-Based Prenatal Care: Part II. 3^rd^ Trimester Care,
Infectious Disease Screening**

<http://www.aafp.org/afp/20050415/1555.html>

(see also Patient Education and Part I
<http://www.aafp.org/afp/20050401/1307.html> )

**Perinatal Depression: Prevalence, Screening Accuracy, and Screening
Outcomes: AHRQ**

<http://www.ahrq.gov/clinic/epcsums/peridepsum.htm>

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

**Testosterone patch effective in hypoactive sexual desire in surgically
menopausal**

CONCLUSION: In surgically menopausal women with hypoactive sexual desire
disorder, a 300 mug/d testosterone patch significantly increased
satisfying sexual activity and sexual desire, while decreasing personal
distress, and was well tolerated through up to 24 weeks of use. LEVEL OF
EVIDENCE: I. Buster JE, et al Testosterone patch for low sexual desire
in surgically menopausal women: a randomized trial. Obstet Gynecol. 2005
May;105(5):944-52.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15863529&dopt=Abstract>

and this Editorial

Guzick DS. Can postmenopausal women patch up their sex lives with
testosterone? Obstet Gynecol. 2005 May;105(5):938-40.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15863527&dopt=Abstract>

**Negative LEEP Is Not Reassuring**

Negative histology, while not rare, should not be interpreted as a
benign finding, as subsequent abnormality rates were similar in women
with negative LEEP samples and those with histologic abnormality. They
note that the incidence of factors limiting complete pathological
examination was significantly higher in negative LEEP specimens than in
positive, and recommend close monitoring of all women who are treated
for dysplasia, regardless of LEEP histology.

Livasy CA, et al. The clinical significance of a negative loop
electrosurgical cone biopsy for high-grade dysplasia. Obstet Gynecol
August 2004;104:250-4.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15291995>

**Human Papillomavirus Quadrivalent Vaccine May Be Effective**

INTERPRETATION: A vaccine targeting HPV types 6, 11, 16, 18 could
substantially reduce the acquisition of infection and clinical disease
caused by common HPV types.

Villa LL, et al Prophylactic quadrivalent human papillomavirus (types 6,
11, 16, and 18) L1 virus-like particle vaccine in young women: a
randomised double-blind placebo-controlled multicentre phase II efficacy
trial. Lancet Oncol. 2005 May;6(5):271-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15863374>

**Oophorectomy and Hysterectomy No Curb on Sexuality**

CONCLUSION(S): Hormonal changes after oophorectomy in conjunction with
perimenopausal hysterectomy do not significantly change postoperative
(1-year) sexual or psychological well-being. Aziz A, et al
Perimenopausal androgen decline after oophorectomy does not influence
sexuality or psychological well-being. Fertil Steril. 2005
Apr;83(4):1021-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15820815>

**Randomised comparison of microwave endometrial ablation with
transcervical resection**

CONCLUSIONS: Both techniques achieve significant and comparable
improvements in menstrual symptoms, and health-related quality of life.
While high rates of satisfaction with treatment and acceptability of
treatment are achieved by TCRE, these are significantly lower than
levels following MEA. These long term data, when combined with the
trials\' operative findings and known costs of both procedures, now
inform us that MEA is a more effective and efficient treatment for heavy
menstrual loss than TCRE. Cooper KG, et al A randomised comparison of
microwave endometrial ablation with transcervical resection of the
endometrium; follow up at a minimum of five years. BJOG. 2005
Apr;112(4):470-5.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15777447>

**The physiologic effects of pneumoperitoneum in the morbidly obese**

CONCLUSIONS: Morbidly obese patients undergoing laparoscopic bariatric
surgery are at risk for intraoperative complications relating to the use
of CO2 pneumoperitoneum. Surgeons performing laparoscopic bariatric
surgery should understand the physiologic effects of CO2
pneumoperitoneum in the morbidly obese and make appropriate
intraoperative adjustments to minimize the adverse changes. Nguyen NT,
Wolfe BM. The physiologic effects of pneumoperitoneum in the morbidly
obese. Ann Surg. 2005 Feb;241(2):219-26.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15650630>

**Hypertension Boosts Uterine Fibroid Risk**

Elevated blood pressure has an independent, positive association with
risk for clinically detected uterine leiomyomata among premenopausal
women. Investigating this association may suggest possible pathways to
prevent fibroids.

Boynton-Jarrett R et al. A prospective study of hypertension and risk of
uterine leiomyomata. Am J Epidemiol. 2005 Apr 1;161(7):628-38.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15781952>

**Failure to simply get a Pap test often to blame for cervical cancer
diagnosis**

RESULTS: The majority of cases (n = 464; 56%) were in women who had no
Pap tests during the period 4-36 months prior to diagnosis. Of the
remaining cases, 263 (32%) were attributed to Pap test detection failure
and 106 (13%) to follow-up failure. Eighty-one percent of the women who
had not been screened for cervical cancer had had at least one
non-OB/GYN encounter with the healthcare system during the 3 years prior
to their cancer diagnosis. [Of note,]{.underline} many of these women
had been seen multiple times. These were missed opportunities to
intervene and remind them that they were overdue for Pap screening.

Leyden WA, et al Cervical cancer in women with comprehensive health care
access: attributable factors in the screening process. J Natl Cancer
Inst. 2005 May 4;97(9):675-83\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15870438>

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

**To eat fruit and vegetables or not? Factors that influence consumers'
decisions**

Understanding Economic and Behavioral Influences on Fruit and Vegetable
Choices provides information on the economic, social, and behavioral
factors influencing consumers\' fruit and vegetable choices. The article
examines how cost, household composition and cultural background, and
food-related lifestyle changes influence consumers\' fruit and vegetable
choices.[[http://www.ers.usda.gov/AmberWaves/April05/Features/FruitAndVegChoices.htm]{.underline}](http://www.ers.usda.gov/AmberWaves/April05/Features/FruitAndVegChoices.htm)

**School nutrition resources**

A resource and tool kit FREE from the USDA. It addresses school
nutrition and can help local people or community groups take action to
improve their school\'s nutrition environment.
[http://www.fns.usda.gov/tn/Resources/changing.html](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.fns.usda.gov/tn/Resources/changing.html)

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

**What are the best ways to quit smoking?**

First you have to want to quit. Next here are some other methods to
augment the will power.

Numerous effective pharmacotherapies for smoking cessation now exist.
Except in the presence of contraindications, these should be used with
all patients who are attempting to quit smoking.

-Five *first-line* pharmacotherapies were identified that reliably
increase long-term smoking abstinence rates:\
Bupropion SR.\
Nicotine gum.\
Nicotine inhaler.\
Nicotine nasal spray.\
Nicotine patch.\
-Two *second-line* pharmacotherapies were identified as efficacious and
may be considered by clinicians [if first-line pharmacotherapies are not
effective]{.underline}:

Clonidine.\
Nortriptyline.\
-Over-the-counter nicotine patches are effective relative to placebo,
and their use should be encouraged.

*Treating Tobacco Use and Dependence---Clinician\'s Packet*. A How-To
Guide For Implementing the Public Health Service Clinical Practice
Guideline, March 2003. U.S. Public Health Service.
[http://www.surgeongeneral.gov/tobacco/clinpack.html](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.surgeongeneral.gov/tobacco/clinpack.html)

Or

AHCPR Supported Clinical Practice Guidelines 18. Treating Tobacco Use
and Dependence

<http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.7644>

**Screening for Asymptomatic Bacteriuria: Recommendation Statement:
USPSTF**

Summary of Recommendations

The USPSTF strongly recommends screening for asymptomatic bacteriuria
with urine culture in pregnant women at 12 to 16 weeks\' gestation. **A
recommendation**.

The USPSTF found good evidence that screening pregnant women for
asymptomatic bacteriuria with urine culture significantly reduces
symptomatic urinary tract infections, low birth weight, and preterm
delivery. The benefits of screening and treatment substantially outweigh
any potential harms.

The USPSTF recommends against routine screening for asymptomatic
bacteriuria in men and nonpregnant women. **D recommendation.**

<http://www.aafp.org/afp/20050415/us.html>

**The Living to 100 Life Expectancy Calculator**

One tool APHA and its partners are promoting to help identify and reduce
the barriers that keep older Americans from getting the health care and
information they need is The Living to 100 Life Expectancy Calculator.
The tool was designed to translate what we have learned from studies of
centenarians and other longevity research into a practical and
empowering tool for individuals to estimate their longevity potential.

The average person is born with a set of genes that would allow them to
live to 85 years of age and maybe longer. People who take appropriate
preventive steps may add as many as 10 quality years to that. People who
fail to heed the messages of preventive medicine may subtract
substantial years from their lives.
<http://www.agingresearch.org/calculator/>

Improving the Quality of Care for Adults with Type 2 Diabetes Mellitus

AHRQ \"Closing the Quality Gap: A Critical Analysis of Quality
Improvement Strategies. Volume 2-Diabetes Mellitus Care"
<http://www.ahrq.gov/clinic/evrptpdfs.htm#qualgap2>

**Acupuncture: a clinical review**

The ancient method of acupuncture has gained significant popularity in
our era, particularly among non-Asian populations. Because of its long
history of use, safety, and reports of efficacy, more patients select
acupuncture as part of their therapeutic plan. Although thorough
clinical trials of the reported benefits of acupuncture as well as
understanding of its mechanism of action lag behind its widespread use,
physicians ought to become familiar with its potential applications for
their patients. Some physicians may wish to expand the scope of his or
her practice by taking additional training to administer acupuncture.
However, even if one does not add this training, knowing how to refer to
credible, well-trained acupuncturists and for what indications is
increasingly important in the evolving model of integrative medicine,
combining the best of both scientific medicine and traditional systems
of care

Sierpina VS, Frenkel MA. Acupuncture: a clinical review. South Med J.
2005 Mar;98(3):330-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15813160>

Benefits of Omega-3 Fatty Acids

Consumption of fish oil can help reduce deaths from heart disease, but
its effects on other outcomes are inconclusive, according to evidence
reports from the Agency for Healthcare Research and Quality (AHRQ). The
reports are available online at
<http://www.ahrq.gov/clinic/epcindex.htm#dietsup>.

An analysis of 10 randomized controlled trials (RCTs) and nine other
studies addressed the effects of omega-3 fatty acids on respiratory
outcomes. Overall, strong evidence shows that fish oils have a strong,
dose-dependent beneficial effect on triglyceride levels. There also is
evidence of possible small beneficial effects on blood pressure and
coronary artery restenosis after angioplasty, exercise capacity in
patients with coronary atherosclerosis, and heart rate variability,
particularly in patients with recent MI. Omega-3 fatty acids do not
appear to affect total cholesterol, high-density lipoprotein
cholesterol, low-density lipoprotein cholesterol, fasting blood sugar,
or glycosylated hemoglobin levels, and they had no effect on plasma
insulin levels and insulin resistance in patients with type 2 diabetes.

<http://www.aafp.org/afp/20050201/practice.html>

**One size doesn\'t fit all**

The US Department of Agriculture today presented its new guidelines that
for the first time advise consumers to personalize their diet and
exercise, geared to their specific calorie needs and levels of physical
activity. MyPyramid Plan can help you choose the foods and amounts that
are right for you. For a quick estimate of what and how much you need to
eat, enter your age, sex, and activity level in the MyPyramid Plan box.
<http://www.mypyramid.gov/>

**Evidence-Based Guidelines for Cardiovascular Disease Prevention in
Women**

<http://www.ihs.gov/NonMedicalPrograms/nc4/Documents/CVDWomenAFP.doc>

**Evaluation of Palpable Breast Masses**

<http://www.aafp.org/afp/20050501/1731.html>

**AHRQ Recent Findings: Cardiovascular Disease**

<http://www.ahrq.gov/research/womenh1.htm#cardio>

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

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

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

Does Lipid Lowering Decrease Stroke Risk?

**Clinical Question:** In patients with or without heart disease, does
lipid lowering decrease stroke risk?

**Bottom Line:** Statins produce a statistically significant reduction
of 25 percent on average in the risk of experiencing a fatal or nonfatal
stroke. Other approaches to lipid lowering do not. However, physicians
need to realize that this reduction translates into one fewer stroke in
every 2,778 patients at low risk (i.e., without heart disease) and one
fewer stroke for every 617 patients with preexisting heart disease.
(Level of Evidence: 1a)

<http://www.aafp.org/afp/20050415/tips/2.html>

Hyperbaric Oxygen Therapy in Patients with Chronic Wounds

**Clinical Question:** Does hyperbaric oxygen improve outcomes in
patients with chronic wounds?

Bottom Line**:** In patients with diabetic foot ulcers, hyperbaric
oxygen therapy reduces the number of major amputations for up to one
year. These data, however, are based on fewer than 200 patients among
all six studies in the literature. (Level of Evidence: 1a-)

[**http://www.aafp.org/afp/20050501/tips/23.html**](http://www.aafp.org/afp/20050501/tips/23.html)

Mammography Screening Intervals Questioned

**Clinical Question:** Does annual mammography offer advantages over
biennial screening?

###### Bottom Line: In this observational study, women in their 40s were less likely to have advanced breast cancer if they were screened annually. This benefit did not occur with older women who were screened more frequently. The latter result is consistent with the most rigorous review of mammography screening trials. Given the significant baseline differences, what role might other intervening factors play in the interpretation of these data? Because many fewer women were screened every two years, did these women differ in other important, but hidden, ways from those who were screened annually? (Level of Evidence: 2b)

<http://www.aafp.org/afp/20050415/tips/6.html>

Estrogen Increases the Risk of Gallbladder Disease

**Clinical Question:** Does estrogen therapy increase the risk of
gallbladder disease among postmenopausal women?

**Bottom Line:** Evidence from the Women\'s Health Initiative, the
largest randomized trial available, confirms an increase in gallbladder
disease and related procedures among postmenopausal women treated with
supplemental estrogen. This is one more risk to consider when helping
each patient weigh the risks and benefits of estrogen therapy. (Level of
Evidence: 1b)

<http://www.aafp.org/afp/20050501/tips/24.html>

Fibroids (Uterine Myomatosis, Leiomyomas)

Clinical Evidence Concise - A Publication of BMJ Publishing Group

**What are the effects of medical treatment alone?**

**likely to be beneficial**

*Gonadorelin Analogues (GnRHa) Plus Progestogen (No Significant
Difference in Heavy Bleeding Compared with GnRHa Alone, but Adding
Progestogen Reduces Vasomotor Symptoms and Hot Flashes Associated with
GnRHa).* One small randomized controlled trial (RCT) found no
significant difference between leuprorelin acetate plus progestogen and
leuprorelin acetate alone in the proportion of women who had heavy
bleeding at 12 months. One small RCT found that GnRHa plus
medroxyprogesterone acetate significantly reduced vasomotor symptoms
over 12 months compared with GnRHa alone. One small RCT found that
leuprorelin acetate plus progestogen significantly reduced the
proportion of women with hot flashes over 24 weeks compared with
leuprorelin acetate alone.

*Gonadorelin Analogues Plus Tibolone (No Significant Difference in
Fibroid Symptoms Compared with GnRHa Alone but Adding Tibolone Reduces
Hot Flashes and Prevents Loss in Bone Mineral Density Associated with
GnRHa).* Two small RCTs found no significant difference between GnRHa
alone and GnRHa plus tibolone in fibroid-related symptoms or uterine and
fibroid size. They found that adding tibolone reduced hot flashes,
vaginal dryness, and night sweats and prevented loss in bone mineral
density.

**trade-off between benefits and harms**

*Gonadorelin Analogues Alone.* RCTs found that GnRHa reduced
fibroid-related symptoms compared with placebo, but were associated with
important adverse effects. Two RCTs found that GnRHa increased
amenorrhea compared with placebo after about three months. One RCT
provided insufficient evidence to compare nafarelin versus buserelin.
One RCT found that higher doses of nafarelin increased amenorrhea at 16
weeks compared with lower doses. Two RCTs found that nafarelin reduced
bone density from baseline after 16 weeks\' treatment compared with
placebo, but that bone density returned to pretreatment levels six
months after treatment was stopped. Two RCTs found that hot flashes were
more common with nafarelin than with placebo or buserelin. One RCT found
that hot flashes and sweating were more common with goserelin than
placebo.

**unknown effectiveness**

*Gonadorelin Analogues Plus Combined Estrogen-Progestogen (Insufficient
Evidence on Effects Compared with GnRHa Plus Progestogen)*. One small
RCT provided insufficient evidence to compare GnRHa plus combined
estrogen-progestogen hormone therapy versus GnRHa plus progestogen
hormone therapy.

*Gonadorelin Analogues Plus Raloxifene (Insufficient Evidence on Effects
Compared with GnRHa Alone)*. One RCT found that adding raloxifene to
GnRHa reduced fibroid size compared with GnRHa alone. It found no
significant difference in fibroid-related symptoms or hot flashes.

*Nonsteroidal Anti-inflammatory Drugs.* Two small RCTs provided
insufficient evidence to assess nonsteroidal anti-inflammatory drugs in
women with fibroids.

*Gestrinone; Levonorgestrel Intrauterine System; Mifepristone.* We found
no RCTs on the effects of these interventions.

**In women scheduled for fibroid surgery, what are the effects of
preoperative medical treatments?**

**likely to be beneficial**

*Gonadorelin Analogues.* One systematic review found that GnRHa for at
least three months before fibroid surgery improved preoperative
hemoglobin concentration and hematocrit, and reduced uterine and pelvic
symptoms compared with placebo or no pretreatment. Preoperative
gonadorelin also reduced the rate of vertical incisions during
laparotomy. Women having hysterectomy were more likely to have a vaginal
rather than an abdominal procedure after GnRHa pretreatment compared
with placebo or no pretreatment. Preoperative goserelin reduced
intraoperative blood loss, although the difference was small, and the
clinical importance is uncertain. One subsequent RCT found no
significant difference between preoperative triptorelin and immediate
surgery in intraoperative blood loss. One small RCT found that GnRHa
combined with endometrial resection reduced the need for further
treatment (medical or surgical) over one year compared with GnRHa alone.
However, preoperative GnRHa is associated with adverse hypoestrogenic
effects, such as hot flashes, vaginal symptoms, and sweating, and women
receiving GnRHa were more likely to withdraw from treatment because of
adverse effects.

**What are the effects of surgical treatments?**

**beneficial**

*Laparoscopic Myomectomy (Maintains Fertility Compared to Hysterectomy;
Reduces Recovery Time and Postoperative Pain Compared with Abdominal
Myomectomy).* Two RCTs found limited evidence that laparosopic
myomectomy reduced postoperative pain, fever, and recovery time compared
with abdominal myomectomy. We found no RCTs comparing laparoscopic
myomectomy with total abdominal, vaginal, or laparoscopic hysterectomy,
but the main benefit of myomectomy compared with hysterectomy is that it
maintains fertility.

**likely to be beneficial**

*Laparoscopically Assisted Vaginal Hysterectomy (Reduces Recovery Time
and Postoperative Pain Compared with Total Abdominal Hysterectomy, but
Increases* *Operating Time* *and Blood Loss Compared with Total Vaginal
Hysterectomy).* Two RCTs found that women having laparoscopically
assisted vaginal hysterectomy had shorter recovery times and less
postoperative pain compared with women having total abdominal
hysterectomy. One RCT found that women having laparoscopically assisted
vaginal hysterectomy had longer operating times and more blood loss than
women having total vaginal hysterectomy.

*Total Abdominal Hysterectomy (Reduces Fibroid-Related Symptoms Compared
with No Treatment.)* We found no RCTs comparing total abdominal
hysterectomy with no treatment or sham surgery. An RCT is unlikely to be
conducted. There is consensus that total abdominal hysterectomy is
superior to no treatment in reducing fibroid-related symptoms. RCTs
found that women having total abdominal hysterectomy had longer surgery,
more blood loss, more pain and fever, longer hospital stays, later
return to work, and less satisfaction than women having total vaginal
hysterectomy. Two RCTs found that women having total abdominal
hysterectomy had longer recovery times and more postoperative pain but
shorter operating times and less blood loss than women having
laparoscopically assisted vaginal hysterectomy. One RCT found that women
having total abdominal hysterectomy had more postoperative fever, longer
hospital stays, and longer recovery times than women having total
laparoscopic hysterectomy.

*Total Laparoscopic Hysterectomy (Reduces Postoperative Fever, Hospital
Stay, and Recovery Time Compared with Total Abdominal Hysterectomy).*
One RCT found that women having total laparoscopic hysterectomy had less
postoperative fever, shorter hospital stays, and shorter recovery times
compared with women having total abdominal hysterectomy.

*Total Vaginal Hysterectomy (Reduces Operation Time, Blood Loss, Pain,
Fever, and Hospital Stay Compared with Total Abdominal Hysterectomy, and
Increases Satisfaction with Operation).* Two RCTs found that women
having total vaginal hysterectomy had shorter operating times, less
blood loss, less pain and fever, shorter hospital stays, earlier return
to work, and greater satisfaction than women having total abdominal
hysterectomy. One RCT found that women having total vaginal hysterectomy
had shorter operating times and less blood loss than women having
laparoscopically assisted vaginal hysterectomy.

**unknown effectiveness**

*Thermal Balloon Ablation.* We found no RCTs comparing thermal balloon
ablation with nonsurgical treatment or hysterectomy. One RCT compared
thermal balloon ablation with rollerball endometrial ablation in women
with fibroids smaller than the average size of a 12-week pregnancy, all
of whom had been pretreated with gonadorelin analogues. The trial found
no significant difference between thermal balloon and rollerball
ablation in amenorrhea rates, pictorial bleeding assessment chart
scores, hemoglobin, or hysterectomy rates at 12 months. It found that
thermal balloon ablation reduced operation time and intraoperative
complicating rate compared with rollerball ablation. About one third of
women reported being \"not very satisfied" with either operation.

<http://www.aafp.org/afp/20050501/bmj.html>

Cochrane for Clinicians

Putting Evidence into Practice

Anticonvulsant Medications for Migraine Prevention

Clinical Scenario

A 31-year-old woman asks for help with frequent migraines. She gets good
response from abortive medication but had no success with the two
preventive medications she has tried. You consider trying an
anticonvulsant.

Clinical Question

Do anticonvulsant medications reduce headache frequency in patients with
migraine headache?

Evidence-Based Answer

Good evidence supports the use of anticonvulsants as a class with
overall reduction in number of headaches per month and overall increase
in patients achieving 50 percent reduction of headache frequency. Of the
medications within this heterogeneous group, valproic acid and
divalproex have the strongest evidence to support their use for this
indication.

<http://www.cochrane.org/cochrane/revabstr/AB003266.htm>

and

<http://www.aafp.org/afp/20050501/cochrane.html>

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

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

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

**Intrapartum fetal heart rate monitoring. ACOG Practice Bulletin No.
62**

**Summary of Recommendations and Conclusions**

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

-   The false-positive rate of EFM for predicting adverse outcomes is
    high.

-   The use of EFM is associated with an increase in the rate of
    operative interventions (vacuum, forceps, and cesarean delivery).

-   The use of EFM does not result in a reduction of cerebral palsy
    rates.

-   With persistent variable decelerations, amnioinfusion reduces the
    need to proceed with emergent cesarean delivery and should be
    considered.

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

-   The labor of parturients with high-risk conditions should be
    monitored continuously.

-   Reinterpretation of the FHR tracing, especially knowing the neonatal
    outcome, is not reliable.

-   The use of fetal pulse oximetry in clinical practice cannot be
    supported at this time.

Intrapartum fetal heart rate monitoring. ACOG Practice Bulletin No. 62.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2005;105:1161--69.

**Non-ACOG members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15863569>

**ACOG Members**

<http://www.acog.org/publications/educational_bulletins/pb062.cfm>

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

**Recent findings (Alphabetical order)**

Cancer Screening and Treatment

<http://www.ahrq.gov/research/womenh1.htm#cancer>

Complementary/Alternative Medicine

<http://www.ahrq.gov/research/womenh4.htm#alt>

Health Care Access, Quality, and Costs

<http://www.ahrq.gov/research/womenh2.htm#health>

HIV/AIDS

<http://www.ahrq.gov/research/womenh3.htm#hiv>

Homelessness

<http://www.ahrq.gov/research/womenh3.htm#homeless>

Hysterectomy and Other Treatments for Uterine Conditions

<http://www.ahrq.gov/research/womenh2.htm#hyster>

Medical Expenditure Panel Survey

<http://www.ahrq.gov/research/womenh4.htm#survey>

Women and Medications

<http://www.ahrq.gov/research/womenh4.htm#meds>

Pregnancy, Birth Outcomes, and Family Planning

<http://www.ahrq.gov/research/womenh3.htm#pregnancy>

Prevention

<http://www.ahrq.gov/research/womenh3.htm#prevention>

Reproductive Health

<http://www.ahrq.gov/research/womenh2.htm#reprod>

Research

<http://www.ahrq.gov/research/womenh4.htm#other>

Women and Working Conditions

<http://www.ahrq.gov/research/womenh4.htm#work>

**AHRQ Patient Safety Network (PSNet), the new \"one-stop\" patient
safety portal**

The site features the latest tools, literature, and news in patient
safety, as well as a comprehensive and carefully annotated collection of
patient safety resources. Here\'s what\'s new:

-Electronic alerts to prevent venous thromboembolism among hospitalized
patients. Kucher N, Koo S, Quiroz R, et al. N Engl J Med.
2005;352:969-977 <http://psnet.ahrq.gov/resource.aspx?resourceID=1953>\
-Hospitalization and death associated with potentially inappropriate
medication prescriptions among elderly nursing home residents. Lau DT,
Kasper JD, Potter DE, Lyles A, Bennett RG. Arch Intern Med.
2005;165:68-74
[[http://psnet.ahrq.gov/resource.aspx?resourceID=1957]{.underline}](http://psnet.ahrq.gov/resource.aspx?resourceID=1957)\
-Effects of computerized clinical decision support systems on
practitioner performance and patient outcomes: a systematic review. Garg
AX, Adhikari NK, McDonald H, et al. JAMA. 2005;293:1223-1238
[[http://psnet.ahrq.gov/resource.aspx?resourceID=1955]{.underline}](http://psnet.ahrq.gov/resource.aspx?resourceID=1955)\
-Improving clinical practice using clinical decision support systems: a
systematic review of trials to identify features critical to success.
Kawamoto K, Houlihan CA, Balas EA, Lobach DF. BMJ. 2005;330:765
[[http://psnet.ahrq.gov/resource.aspx?resourceID=1954]{.underline}](http://psnet.ahrq.gov/resource.aspx?resourceID=1954)\
-Has the Leapfrog Group had an impact on the health care market? Galvin
RS, Delbanco S, Milstein A, Belden G. Health Aff (Millwood).
2005;24:228-233
[[http://psnet.ahrq.gov/resource.aspx?resourceID=1950]{.underline}](http://psnet.ahrq.gov/resource.aspx?resourceID=1950)\
-FACT SHEET/FAQS: Thirty Safe Practices for Better Health Care. National
Quality Forum. Rockville, MD: Agency for Healthcare Research and
Quality; March 2005. AHRQ Publication No. 04-P025
[[http://psnet.ahrq.gov/resource.aspx?resourceID=1966]{.underline}](http://psnet.ahrq.gov/resource.aspx?resourceID=1966)

#### 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}

[**Vitamin C reduced premature rupture of the membranes
(PROM)**](../../../../../../../../C:%5CDocuments%20and%20Settings%5Ccooperd%5CMy%20Documents%5Cvitamin%20c.pdf)

 A randomized trial assessed the outcomes of 120 pregnant women who were
randomly assigned to take 100 mg of vitamin C or a placebo daily,
starting in their 20^th^ week of gestation.  The researchers found
vitamin C levels decreased in the control group and increased in the
supplement group.  PROM occurred in 14 of 57 pregnancies in the control
group (25%) and only 4 of 52 pregnancies (8%) in the vitamin C group.  

CONCLUSION: Daily supplementation with 100 mg vitamin C after 20 wk of
gestation effectively lessens the incidence of PROM.

Casanueva E, et al Vitamin C supplementation to prevent premature
rupture of the chorioamniotic membranes: a randomized trial. Am J Clin
Nutr 2005 April; 81(4): 859-863.** **

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15817864>

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

**Making Every Mother and Child Count - Through Breastfeeding, One Baby
at a Time**

La Leche League International has produced a document demonstrating that
breastfeeding is the cornerstone for life-long good health for mothers
and children. In light of the fact that less than 35% of all infants
around the world are exclusively breastfed even for the first four
months of life,

1\) Consider the following: Exclusive breastfeeding for the first six
months of life could save at least 1.3 million lives a year---that\'s
about 3,500 children EACH DAY.

2\) Breastfeeding provides invaluable immunological protection from a
whole host of diseases---including ear infections, allergies, intestinal
disorders, meningitis, Sudden Infant Death Syndrome (SIDs), diarrhea and
pneumonia.

 3) The health benefits of breastfeeding extend to the mother as
well---lowering her risk of breast, endometrial, and ovarian cancer,
osteoporosis and postpartum hemorrhaging.

#### [[www.lalecheleague.org]{.underline}](../www.lalecheleague.org) {#www.lalecheleague.org .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Breast-feeding initiation in low-income women {#breast-feeding-initiation-in-low-income-women-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Despite the documented health and emotional benefits of breast-feeding to women and children, breast-feeding rates are low among subgroups of women. The breast-feeding initiation rate in this population was 38%. Women who were older, white, non-Hispanic, college-educated, married, not certified for the Supplemental Nutrition Program for Women, Infants, and Children, and not working full-time were more likely to breast-feed than formula-feed at hospital discharge. Attitudes regarding benefits and barriers to breast-feeding, as well as health care system and social support, were associated with breast-feeding initiation at the multivariate level. Adding the health care system support variables to the regression model, and specifically support from lactation specialists and hospital nurses, explained the association between breast-feeding initiation and women\'s perceived control over the time and social constraints barriers to breast-feeding.  {#despite-the-documented-health-and-emotional-benefits-of-breast-feeding-to-women-and-children-breast-feeding-rates-are-low-among-subgroups-of-women.-the-breast-feeding-initiation-rate-in-this-population-was-38.-women-who-were-older-white-non-hispanic-college-educated-married-not-certified-for-the-supplemental-nutrition-program-for-women-infants-and-children-and-not-working-full-time-were-more-likely-to-breast-feed-than-formula-feed-at-hospital-discharge.-attitudes-regarding-benefits-and-barriers-to-breast-feeding-as-well-as-health-care-system-and-social-support-were-associated-with-breast-feeding-initiation-at-the-multivariate-level.-adding-the-health-care-system-support-variables-to-the-regression-model-and-specifically-support-from-lactation-specialists-and-hospital-nurses-explained-the-association-between-breast-feeding-initiation-and-womens-perceived-control-over-the-time-and-social-constraints-barriers-to-breast-feeding. .Style-Heading-4-+-Arial-14-pt-Underline}

Khoury AJ, Moazzem SW, Jarjoura CM, et al. 2005. Breast-feeding
initiation in low-income women: Role of attitudes, support, and
perceived control. Women\'s Health Issues 15(2):64-72

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15767196**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15767196) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15767196 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Interested in the US Breastfeeding Committee Task Force and Coalition
Conference?**

In preparation for the USBC Task Force and Coalition Conference, NABA
needs to again update its database on task forces and coalitions to
provide as complete a mailing list as possible. Would all of you
e-mail Marsha <marshalact@aol.com>  any breastfeeding task forces or
coalitions that you either belong to or know about in your State. Also,
would you ask your organization\'s members to forward any information
they may have to me.

AAP Releases Updated Breastfeeding Recommendations

The American Academy of Pediatrics (AAP) has issued a revised policy
statement on \"Breastfeeding and the Use of Human Milk" that reflects
new research on the importance of breastfeeding. This statement replaces
the policy developed by the AAP in 1997.

Studies have shown that breastfeeding can decrease the incidence and
severity of conditions such as diarrhea, bacterial meningitis, and ear
infections. Some studies suggest that breastfeeding may offer protection
against sudden infant death syndrome, obesity, diabetes, and asthma.
Research also indicates that breastfeeding can be beneficial for the
mother by possibly reducing the risk of ovarian cancer, breast cancer,
and hip fractures and osteoporosis in the postmenopausal period. Other
benefits include the potential to decrease annual health costs in the
United States by \$3.6 billion; decreasing employee absenteeism; and
reducing the environmental burden of disposal of formula cans and
bottles and energy demands for production and transportation of formula.

Although breastfeeding initiation rates have increased steadily since
1990, the rate of exclusive breastfeeding (i.e., no water, juice,
nonhuman milk, or food) has shown little or no increase. The proportion
of infants who are breastfed exclusively until six months of age also
has increased at a much slower rate than that of infants who received
mixed feedings (i.e., breast milk plus infant formula).

American Academy of Pediatrics Breastfeeding Recommendations

• Exclusive breastfeeding is recommended for approximately the first six
months; breastfeeding should be supported for the first year and beyond
as long as mutually desired by the mother and child.

• The mother and infant should sleep near each other to facilitate
breastfeeding.

• Self-examination of the mother\'s breasts for lumps is recommended
throughout lactation, not just after weaning.

• Physicians should support efforts of parents and the courts to ensure
continuation of breastfeeding in cases involving separation, custody,
and visitation.

• Adoptive mothers should be counseled on the benefits of induced
lactation through hormonal therapy or mechanical stimulation.

• Physicians should recognize and incorporate cultural diversity in
breastfeeding practices.

• A pediatrician or other knowledgeable and experienced health care
professional should evaluate a newborn breastfed infant at three to five
days of age and again at two to three weeks to be sure the infant is
feeding and growing well.

<http://www.aafp.org/afp/20050501/practice.html>

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

#### Exclusive Breast-feeding May Reduce Risk of Postnatal HIV Transmission {#exclusive-breast-feeding-may-reduce-risk-of-postnatal-hiv-transmission-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Exclusive Breast-feeding may substantially reduce breastfeeding-associated HIV transmission. Iliff PJ, et al. Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS. 2005 Apr 29;19(7):699-708. {#conclusion-exclusive-breast-feeding-may-substantially-reduce-breastfeeding-associated-hiv-transmission.-iliff-pj-et-al.-early-exclusive-breastfeeding-reduces-the-risk-of-postnatal-hiv-1-transmission-and-increases-hiv-free-survival.-aids.-2005-apr-29197699-708. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15821396**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15821396) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15821396 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

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

-Human Papillomavirus ACOG Practice Bulletin

-Burt Attico, Phoenix: DMPA / BMD, and Teens: Recent and Reassuring Data

-Tx for BV or T. vaginalis does not reduce Preterm birth or adverse
outcome

-Antibiotics for Recurrent Urinary Tract Infections: Cochrane for
Clinicians

-FASlink: The approach is directed at maternal drinking behavior and
dose

-Can Patients with Cancer Postpone Death for Important Events?

##### -Access to the NIH Library web resources being explored - Indian Health Tribal staff

-'The patch': Trouble getting it on your formulary?

-Midwifery care of poor and vulnerable women, 1925-2003

-Natural mentoring relationships and adolescent health: evidence from a
national study

-A Decline in Life Expectancy in the US

-Should you be using the quad screen?

-Prenatal Genetic Screening -- Serum and Ultrasound 

-New Perinatology Corner Module -- Good information with optional free
CEU/CME 

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05AprOL.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05AprOL.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocuments05aprol.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

#### If you want a copy of the CCC Digest mailed to you each month, please contact [**nmurphy@scf.cc**](mailto:nmurphy@scf.cc) {#if-you-want-a-copy-of-the-ccc-digest-mailed-to-you-each-month-please-contact-nmurphyscf.cc .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Upcoming Child Abuse Project**

There are still a couple of slots open for this two year cycle of the
IHS Child Abuse Project - a course in the medical evaluation of child
maltreatment for physicians, nurse practitioners, and physician
assistants in IHS and Tribal programs. This is a very unique opportunity
so please don\'t miss it!!
[www.ovccap.ihs.gov](http://www.ovccap.ihs.gov/) Jane Powers APRN, BC,
MS

**Intimate Partner Violence using PRAMS data - group studied age 20+**

Intimate partner violence MCH epi slides/ audio and text of Oregon PRAMS
study of women over age 20. Introduction includes national statistics,
nice Q&A - adolescent age group not addressed.

[[http://www.uic.edu/sph/cade/mchepi/meetings/april2005/index.htm]{.underline}](http://www.uic.edu/sph/cade/mchepi/meetings/april2005/index.htm)

**AHRQ Recent Findings: Violence Against Women**

<http://www.ahrq.gov/research/womenh3.htm#violence>

**McCain introduces safety to Indian Women Act**

This legislation creates a new federal criminal offense authorizing
federal prosecutors to charge repeat domestic violence offenders before
they seriously injure or kill someone and to use tribal court
convictions for domestic violence for that purpose. It authorizes the
creation of tribal criminal history databases to document these
convictions and protection orders for use by all law enforcement. The
bill authorizes BIA and tribal officers to make arrests for domestic
violence assaults committed outside of their presence and would
authorizes a comprehensive study of domestic violence in Indian Country
to determine its impact to Indian tribes

<http://mccain.senate.gov/index.cfm?fuseaction=Newscenter.ViewPressRelease&Content_id=1564>

**PREVENT WORKSHOP: Moving Towards Violence Prevention**

Chapel Hill, NC: June 21-23, 2005

San Diego, CA: August 29-31, 2005

Washington, DC: October 26-28, 2005

You must be part of a team of 3-5 individuals to participate in this
workshop. Each member of the team must register for the workshop on the
PREVENT website [www.PREVENT.unc.edu](http://www.PREVENT.unc.edu/)

[**Preventing Sexual and Intimate Partner Violence Within Racial/Ethnic
Minority
Communities**](http://fedgrants.gov/Applicants/HHS/CDC/PGO/CDC-RFA-05043/listing.html)
Funding Available #: CDC-RFA-05043 CFDA #: 93.136

<http://fedgrants.gov/Applicants/HHS/CDC/PGO/CDC-RFA-05043/listing.html>

**Injury Prevention Fact Sheet Focuses on Child Maltreatment**

Child Maltreatment, Abuse, and Neglect presents information for
policymakers on child maltreatment in the United States, including the
economic costs of child maltreatment and opportunities for prevention.
The fact sheet defines child maltreatment and presents data on child
deaths resulting from injuries sustained as a result of neglect and
shaken baby syndrome. Information on who is at risk for child
maltreatment, long-term results of child maltreatment, and current
funding and research initiatives are also included.

<http://www.astho.org/pubs/Childmaltreatmentfactsheet4-05.pdf>

**Hidden Problem of Child Abuse**

Listen to the interview between CDC\'S Jim Mercy and WABE-FM's Ted
Vigodsky. Link provided courtesy of WABE-FM. (Non-CDC link)

[http://publicbroadcasting.net/wabe/news.newsmain?action=article&ARTICLE_ID=740174](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://publicbroadcasting.net/wabe/news.newsmain?action=article%26ARTICLE_ID=740174)

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

#### Funding available to engage elders in service and mentor youth {#funding-available-to-engage-elders-in-service-and-mentor-youth-1 .Style-Heading-4-+-Arial-14-pt-Underline}

The Corporation for National and Community Service is encouraging
organizations to apply for approximately \$1.5 million in grant funds to
support "the next generation" of national service programs.  The special
competition will support organizations meeting community needs that have
not previously received Corporation support.

 Each program selected must contain innovative strategies for engaging
volunteers in community service activities, and must be designed so as
to achieve measurable outcomes to both program participants and
beneficiaries.  Proposals must fall under one or both of two areas:

-   Programs that engage adults age 50 and above in full or part-time
    service

-   Improving the lives of disadvantaged youth through mentoring and
    service.

Applications for this competition are due to the Corporation no later
than June 7, 2005. 
[http://www.nationalservice.gov/funding_initiatives](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.nationalservice.gov/funding_initiatives)
For further information call 202-606-5000 ext 309 or email
<NextGenerations@cns.gov>

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

**Oral Contraceptives: Their Mode of Action and Dermatologic
Applications**\
The choice of the optimal OC must take into account the patient\'s
dermatological complaints (acne, hirsutism), health history (obesity,
deep vein thrombosis, cardiovascular history, ovarian and breast cancer,
migraine), age, and habits (smoking). As with any other drug, there are
contraindications to oral contraceptives: smokers over the age of 35,
history of thromboembolism, cerebrovascular disease, coronary disease,
uncontrolled hypertension, hepatic failure, abnormal vaginal bleeding of
unknown cause, focal migraine, and suspected or known breast cancer.

Pitashny M et al Oral contraceptives: their mode of action and
dermatologic applications. Skinmed. 2005 Mar-Apr;4(2):101-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15788893>

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

**Q. What types of drug testing are indicated in pregnancy?**

A. Universal screening questions **AND** targeted biochemical clinical
testing. See details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/DgSc41205.doc>

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

A. There is evidence to obtain one ultrasound. The optimal timing is at
16 to 20 weeks

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/USPreg42005.doc>

Q. What kind of availability is necessary for vaginal birth after
cesarean?

**A.** V.B.A.C. should be attempted in institutions equipped to respond
with physicians immediately available to provide emergency delivery. See
below

[**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/VBAC5705.doc**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/VBAC5705.doc)

**Q. Does there have to be Pediatrician at all emergency deliveries?**

A. The standard is a healthcare worker experienced in neonatal
resuscitation. See details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/PedEmerDel5705.doc>

**Q. Does the active management of the third stage of labor really
work?**

A. Yes, active management of the third stage of labor decreases blood
loss. See details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Activ3rdManag5905.doc>

**Q. What is the significance of ultrasound (US) 'soft markers' for Down
Syndrome?**

A. 2^nd^ trimester US markers for Down syndrome are varied in their
significance. See details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/DSultra42205.doc>

**Q. What are the main risks for expectant mothers in day care
settings?**

A. The most common perinatal pathogens are cytomegalovirus and
parvovirus B19. See details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Daycare5905.doc>

**Q. Do you need help documenting Patient Education or GPRA items?**\
A. Here are some helpful tips or \'cheat sheets\'

<http://www.ihs.gov/MedicalPrograms/MCH/m/PROG01.cfm#cheatsheets>

#### Hormone Replacement Update {#hormone-replacement-update .Style-Heading-4-+-Arial-14-pt-Underline}

**Estrogen plus progestin: WHI showed relief of menopausal symptoms but
adverse effects**

CONCLUSION: Estrogen plus progestin relieved some menopausal symptoms,
such as vasomotor symptoms and vaginal or genital dryness, but
contributed to treatment-related effects, such as bleeding, breast
tenderness, and an increased likelihood of gynecologic surgery. LEVEL OF
EVIDENCE: I. Barnabei VM et al Menopausal Symptoms and Treatment-Related
Effects of Estrogen / Progestin in the Women\'s Health Initiative.
Obstet Gynecol. 2005 May;105(5):1063-73.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15863546&dopt=Abstract>

**Exercise: Alternative to estrogen for endothelial dysfunction in
postmenopausal women**

CONCLUSIONS: In postmenopausal women, both acute exercise and estrogen
therapy normalize FMD. However, their effects are not additive, possibly
because of redundancy of nitric oxide signaling pathways activated by
these 2 interventions. When considered in the context of recent trials
with adverse cardiovascular outcomes, these results reinforce the
therapeutic potential of exercise as an alternative nonpharmacological
intervention to estrogen in postmenopausal women with endothelial
dysfunction.

Harvey PJ, et al Exercise as an alternative to oral estrogen for
amelioration of endothelial dysfunction in postmenopausal women. Am
Heart J. 2005 Feb;149(2):291-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15846267>

**Black cohosh extract is more effective than placebo in treating
climacteric symptoms**

CONCLUSION: This isopropanolic extract of black cohosh root stock is
effective in relieving climacteric symptoms, especially in early
climacteric women. LEVEL OF EVIDENCE: I.

Osmers R et al Efficacy and safety of isopropanolic black cohosh extract
for climacteric symptoms. Obstet Gynecol. 2005 May;105(5):1074-83.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15863547&dopt=Abstract>

**Does Beginning HT Earlier Decrease Mortality?**

CONCLUSIONS: Hormone replacement therapy reduced total mortality in
trials with mean age of participants under 60 years. No change in
mortality was seen in trials with mean age over 60 years. Salpeter SR,
et al. Mortality associated with hormone replacement therapy in younger
and older women. J Gen Intern Med July 2004;19:791-804.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15209595>

**The Impact of Comorbidities on Hormone Use**

CONCLUSIONS: Diabetes and cardiovascular disease were associated with
higher EPT discontinuation rates post-WHI compared to women without
comorbidity; comorbidity had little impact on changes in prevalence or
initiation of ET/EPT after release of the WHI

Newton KM, et al The impact of comorbidities on hormone use. After the
2000 release of the Women\'s Health Initiative. J Gen Intern Med. 2005
Apr;20(4):350-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15857493>

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

**IHS Office of Information Technology (OIT) latest edition of the IT
News:**

-   The EHR

-   Recently released RPMS applications

-   Information Security

-   RPMS training

-   Clinical Reporting System (CRS)

-   vBNS+ and Active Directory migration

-   Plus, much more\...

<http://home.ihs.gov/ITSC-CIO/Publications/index.asp>

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

**10.6 million children die before age five, and half a million women
die in childbirth**

WHO report calls for new approach to save lives of mothers and children

[[http://www.who.int/whr/2005/en/index.html]{.underline}](http://www.who.int/whr/2005/en/index.html)

**Neonatal survival: a call for action**

One myth about NMR is the absence of cheap, effective interventions. In
fact several low-cost interventions are effective in reducing mortality,
including tetanus toxoid vaccination, exclusive breastfeeding, kangaroo
mother care for low birth weight infants, and antibiotics for neonatal
infections. Martines J, et al Neonatal survival: a call for action.
Lancet. 2005 Apr;365(9465):1189-97.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15794974>

**Make Every Mother and Child Count: The World Health Report 2005**

This year almost 11 million children under five years of age will die
from causes that are largely preventable. Among them are 4 million
babies who will not survive the first month of life. At the same time,
more than half a million women will die in pregnancy, childbirth or soon
after. The

report says that reducing this toll in line with the Millennium
Development Goals depends largely on every mother and every child having
the right to access to health care from pregnancy through childbirth,
the neonatal period and childhood.
[[www.who.int/whr]{.underline}](../www.who.int/whr)

**Some countries will not achieve millennium development goals for
health by 2015**

WHO concludes that \"reaching all children with a package of essential
child health interventions necessary to comply with and even go beyond
the MDGs \[millennium development goals\] is technically feasible within
the next
decade.\"                                                        \
Dyer O Some countries will not achieve millennium development goals for
health by 2015, WHO says. BMJ. 2005 Apr 16;330(7496):863.
<http://bmj.bmjjournals.com/cgi/content/extract/330/7496/863> or

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15831857&dopt=Abstract>

**Children having children: The state of the World's mothers 2004**

by Save the Children
<http://www.savethechildren.org/mothers/report_2004/images/pdf/SOWM_2004_final.pdf>

**Improving Aboriginal Health:** **First Ministers' and Aboriginal
Leaders' Meeting**

An Aboriginal Health Transition Fund to enable
Federal-Provincial-Territorial governments, First Nations governments
who deliver health care services, and Aboriginal communities to devise
new ways to integrate and adapt existing health services to better meet
the needs of all Aboriginal peoples, including First Nations, Inuit and
Métis.

<http://www.pm.gc.ca/eng/news.asp?category=1&id=261>

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

**Randomized controlled trial: Risk of Adolescent Suicide Screening
Programs**

Our findings can allay concerns about the potential harm of high
school-based suicide screening.

Conclusions: No evidence of iatrogenic effects of suicide screening
emerged. Screening in high schools is a safe component of youth suicide
prevention efforts.

Gould MS, Marrocco FA, Kleinman M, et al. 2005. Evaluating iatrogenic
risk of youth suicide screening programs: A randomized controlled trial.
JAMA, The Journal of the American Medical Association 293(13):1635-1643
[[http://jama.ama-assn.org/cgi/content/abstract/293/13/1635?etoc]{.underline}](http://jama.ama-assn.org/cgi/content/abstract/293/13/1635?etoc)

**Reduce the Risk of SIDS: New Tools from American Academy of
Pediatrics**

The American Academy of Pediatrics\' Healthy Child Care America Back to
Sleep Campaign has published three brochures about reducing the risk of
sudden infant death syndrome (SIDS). A Child Care Provider\'s Guide to
Safe Sleep presents data and information about SIDS and safe sleep
practices.
[[http://www.healthychildcare.org/pdf/SIDSchildcaresafesleep.pdf]{.underline}](http://www.healthychildcare.org/pdf/SIDSchildcaresafesleep.pdf)

A Parent\'s Guide to Safe Sleep includes information about working with
child care providers to ensure that safe sleep practices are used both
at home and in child care settings. It is available at
[[http://www.healthychildcare.org/pdf/SIDSparentsafesleep.pdf]{.underline}](http://www.healthychildcare.org/pdf/SIDSparentsafesleep.pdf)

Tummy Time contains information about the importance of allowing infants
to spend supervised time lying or playing on their stomachs
[[http://www.healthychildcare.org/pdf/SIDStummytime.pdf]{.underline}](http://www.healthychildcare.org/pdf/SIDStummytime.pdf)

**Interventions to improve cultural competence among health
professionals**

Cultural competence training shows promise as a strategy for improving
health care professionals\' knowledge, attitudes, and skills and
patients\' ratings of care

<http://www.lww-medicalcare.com/pt/re/medcare/abstract.00005650-200504000-00007.htm;jsessionid=C4jRKw3hbJy1dkR8DnJqwcmtHcHy27pgkXVR4WxXxgwAyHC2cvW8!1563931552!-949856031!9001!-1>

**Medical Mystery Tour**

**#1 The Case of the Mystery Question**

Here is case scenario: Please let us know: what is the one mystery
question?

While I was cross country skiing near an abandoned gold mine in
Southcentral Alaska this winter... I heard about a 20 year old gravida 1
para 0 at 39 weeks has just delivered a 3250 gm healthy female infant
after a prolonged second stage. The patient's pregnancy was complicated
by severe pre-eclampsia diagnosed on the basis of serial blood pressures
\> 160/110 and over 5 grams of protienuria. The patient received
magnesium sulfate prophylaxis with a 4 gram bolus followed by 2 grams
per hour IV. The patient received pitocin IV after delivery of the fetal
shoulder.

Soon after delivery of an intact placenta, the patient is noted to have
had a \> 1500 cc blood loss. The patient is then managed with pitocin
IV, two large bore IVs, crystalloid resuscitation, carboprost
tromethamine 250 mcg x 2 IM, uterine exploration, bimanual massage,
exploration of the uterus, and a thorough examination for trauma.

The patient's uterus was then packed with two 30 cc bulb foley
catheters. The patient's history is re-reviewed and no history of blood
dyscrasia is noted. The patient had received 1000 mcg of rectal
misoprostol, but has now developed a copious clear diarrhea from her
carboprost. The uterus is intermittently reported as firm, and then
boggy throughout the course.

The patient has received 2 units of packed red blood transfusion, but
continues to hemorrhage, as additional units are requested STAT. The
patient is becoming hemodynamically unstable. The interventional
radiology guideline only allows for treatment of stable patients from
9:00 am to 4:30 PM during weekdays. The operating room is prepared for
immediate surgery.

In the meantime, the attending staff member walks in to evaluate the
patient before she is rushed to the operative suite. The attending asks
the 2 senior residents in attendance one question.

**What was that question?**

**Go here to find out**

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CaPPH41005.doc>

**Extra credit: Who asked the question?**

**A hint: This MFM is well know in obstetric circles for his early
misspelling of this word,**

**'H E L P'**

Please contact <nmurphy@scf.cc> with your answer

If you have other illustrative clinical scenario(s) you would like to
share in the Medical Mystery Corner, please contact <nmurphy@scf.cc>

**#2**

**March Medical Mystery follow-up:**

**Who prescribed that really potent clomiphene in 1978?**

In the March CCC Corner we posed this issue: a budding IHS infertility
specialist above the Arctic Circle prescribed Clomiphine over the phone
in 1978. The patient who benefited for this early telemedicine
consultation went on to have 6 more children over the next 14 years.
Clearly an elegant maneuver.

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0305_Coll.cfm>

Some CCC Corner readers correctly pointed out that the prescribing
health care provider, who went on to work in the IHS for 24 years, was
none other than Alan Waxman, MD.

Dr. Waxman served Indian women primarily at Gallup Indian Medical
Center, after a 2 year rotation at Alaska Native Medical Center, and is
now on the faculty at the University of New Mexico.

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

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

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

######### 

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

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

**Clinical Discussion Board Index, Medscape**

Hundreds of ongoing clinical discussions available

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

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

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

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

#### Midwives Corner: Virginia Glifort, CNM, ANMC {#midwives-corner-virginia-glifort-cnm-anmc .Style-Heading-4-+-Arial-14-pt-Underline}

**Antibiotic Treatment for Bacterial Vaginosis Does Not Prevent Preterm
Birth**

Antibiotic therapy for bacterial vaginosis or Trichomonas vaginalis
during pregnancy does not cut the risk of preterm birth according to the
results of a systematic review. This finding runs counter to the
conclusions reached by three previous findings. They are based on
analysis of data from studies including 14 that were used in a
meta-analysis.

Okun N et al Antibiotics for Bacterial Vaginosis or Trichomonas
vaginalis in Pregnancy: A Systematic Review. Obstet Gynecol. 2005
Apr;105(4):857-868.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15802417&dopt=Abstract>

**Elective Cesarean Section; How informed is informed?**

The national c-section rate has sky rocketed to nearly 25% of all
births, although its widespread use has no documented outcomes. Elective
Cesarean surgery for non-medical reasons is now available to women. The
ethical dilemmas of Cesarean are perceived as involving confusion about
what constitutes informed consent and exposure of women surgical risk.
The midwifery model is presented as an alternative method for birthing
considerations. This model encompasses health promotion, risk reduction
and active family participation in prenatal care decision making.
Zeidenstein L. Elective Cesarean Section: How Informed is Informed?
[Online Journal of Health
Ethics](http://ethicsjournal.umc.edu/ojs/index.php) [Vol. 1, No. 1
(2005)](http://ethicsjournal.umc.edu/ojs/viewissue.php?id=2)
<http://ethicsjournal.umc.edu/ojs/viewarticle.php?id=7&layout=html>

**Share These With Women -- ACNM Patient/ client hand- outs**

Postpartum Depression (Vol 47, Number 5)

Osteoporosis (Vol 48, #1)

Group B Strep in Pregnancy (Vol 47, Number 6)

Get Moving! (Vol 48 #6)

Weight gain during Pregnancy (Vol 48 #3)Sexually Transmitted

Am I in Labor? (Vol 48, #4)

Genital Warts (Vol #1)

Folic Acid -- what's it all about? (Vol 48 #5)

Should I have a cesarean Section (Vol49 #2)

Prenatal Tests for Birth Defects (Vol 49 #3)

Eating Safely during Pregnancy (Vol 49 \# 4)

When does the bag of waters break? (Vol 49 \# 5)

Pain during Childbirth (Vol 49 \# 6)

Perineal massage in Pregnancy (Vol 50 \# 1)

<http://www.midwife.org/focus/sharewithwomen.cfm>

**New low and high -- Tech calendar methods of family planning**

Calendar --based methods are not usually considered effective or useful
methods of family planning among health professionals. However, new
"high" -- and "low"-tech calendar methods have been developed, which are
easy to teach, to use, and may be useful in helping couples avoid
pregnancy. The low-tech modals are based on a fixed-day calendar system.
The high-tech models are based on monitoring urinary metabolites of
female reproductive hormones. Both systems have high levels of
satisfaction. This article describes these new models of family planning
and the research on their effectiveness. The author proposes a new
algorithm for determining the fertile phase of the menstrual cycle for
either achieving or avoiding pregnancy.

Fehring RJ. New low- and high-tech calendar methods of family planning.
J Midwifery Womens Health. 2005 Jan-Feb;50(1):31-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15637512>

**Herbs and the childbearing woman: Guidelines for midwives**

The use of herbs to promote health or treat disease has become popular,
and midwives increasingly encounter questions from childbearing clients
regarding herbs. This article provides an overview of key concepts
regarding the incorporation of herbs into clinical practice and
discusses the preparation and administration of herbal treatments for
common concerns of pregnancy. Safety issues are emphasized throughout.

Belew C Herbs and the childbearing woman. Guidelines for midwives. J
Nurse Midwifery. 1999 May-Jun;44(3):231-52.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10380443>

#### Office of Women's Health, CDC {#office-of-womens-health-cdc-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Health Characteristics of the American Indian and Alaska Native Adult
Population**

This report compares national estimates for selected health status
indicators, health behaviors, health care utilization, and health
conditions of American Indians and Alaska Natives (AIAN) with those of
white, black, and Asian non-AIAN adults 18 years of age and over. AIAN
adults were more likely to be current smokers than other adults. They
were as likely as white adults to be moderate or heavier drinkers and as
likely as black adults to be obese or never engage in leisure-time
physical activity. American Indian or Alaska Native women (11.8%) were
about three times as likely as black women (4.0%), three and a half
times as likely as white women (3.4%), and five times as likely as Asian
women (2.4%) to have experienced serious psychological distress within
the past 30 days. American Indian or Alaska Native women (29.4%) were
less likely than black women (36.6%) and more likely than white women
(20.3%) and Asian women (5.8%) to be obese.
[http://www.cdc.gov/nchs/data/ad/ad356.pdf](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.cdc.gov/nchs/data/ad/ad356.pdf)

#### Oklahoma Perspective  {#oklahoma-perspective .Style-Heading-4-+-Arial-14-pt-Underline}

#### Greggory Woitte -- Hastings Indian Medical Center {#greggory-woitte-hastings-indian-medical-center .Style-Heading-4-+-Arial-14-pt-Underline}

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

VBACs have once again come under fire and are the subject of
controversy. ACOG updated it's practice bulletin in July 2004.
Highlights of the 2004 Practice Bulletin included selection criteria for
VBAC candidates. Recently, the main insurer of physicians in Oklahoma
decided to no longer cover the malpractice suits involving VBAC
procedures as of December 31, 2004.
<http://kfor.com/Global/story.asp?S=2160222&nav=6uyAPkmP>

Insurance companies appear to be weighing in on the debate in other
states as well.

<http://www.findarticles.com/p/articles/mi_m0CYD/is_3_40/ai_n11832004>

As the pendulum about VBACs continues to swing, where do you stand?
"Once a cesarean, always a cesarean" or "Trial of labor for all". I
suspect it is somewhere in the middle.

ACOG Practice Bulletin Number 54, Vaginal Birth after Cesarean Section

Non-ACOG Members

<http://www.guidelines.gov/summary/summary.aspx?ss=15&doc_id=6374&nbr=4043>

ACOG Members

<http://www.acog.org/publications/educational_bulletins/pb054.cfm>

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

This is the first installment of what we hope will be a new regular
Feature to share some of the issues of interest from the Oklahoma Area.
We are grateful to Greggory Woitte, Hastings Indian Medical Center, for
taking the time to share this timely first issue with us.

Each local Indian Health system facility must decide how they can meet
the ACOG recommended 'immediately' available personnel for emergency
delivery. As symptomatic uterine rupture is an uncommon event, it is
highly recommended that all Indian Health system facilities that provide
obstetric delivery be prepared for an emergency delivery, regardless if
it is a VBAC, or a shoulder dystocia.

One helpful method is for the entire L/D unit to perform periodic
emergency delivery drills. PIMC recently reported on a successful
approach to this in the March 2005 Midwives Corner.

[http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0305_Feat.cfm#MidWives](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0305_Feat.cfm%23MidWives)

Many facilities have incorporated other Emergency Delivery Drills on L/D
to improve overall process issues. These drills have helped the whole
team get used to the many process issues that only arise in a practical
setting, e.g., not just on paper. These types of exercises can also be
presented to JCAHO and other oversight agencies as a practical example
of quality improvement.

Here are 2 helpful presentations from the Biennial Indian Women's Health
meeting

Emergency Delivery Simulations: How to Develop Teamwork

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/Talk.ppt>

VBAC: Is There Such a Thing as Low Risk?

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/NewMexico.ppt>

**Other Resources**

**Vaginal Birth After Cesarean, IHS C.E.U./C.M.E. Module**

<http://www.ihs.gov/MedicalPrograms/MCH/M/VB01.cfm>

**Vermont, New Hampshire Sections Recognized for Effort Project Focuses
on VBAC**

<http://www.ihs.gov/MedicalPrograms/MCH/m/ACOG01_vbac.cfm#vbac>

**Informed Consent form for trial of labor after cesarean (TOLAC)**

<http://www.ihs.gov/MedicalPrograms/MCH/M/mchdownloads/TOLAC2.doc>

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

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

**Statins and osteoporosis: a clinical review**

Osteoporosis is a leading public health threat affecting approximately
44 million people in the United States. Most of the therapies for this
disease work to prevent further bone loss, improve bone mineral density,
and reduce the risk of fractures. These agents, however, have not been
proved to increase bone formation significantly. Therefore, the ideal
agent would not only improve bone strength by decreasing bone breakdown,
but also promote bone formation in the ultimate quest to prevent
fractures. The 3-hydroxy-3-methylglutaryl coenzyme A reductase
inhibitors (statins) have become an area of research in the battle
against osteoporosis. Two mechanisms for beneficial effects of statins
on bones have been proposed, and although in vitro, in vivo, and animal
studies have shown positive effects on bone mineralization and
reductions in bone resorption, clinical data on surrogate markers and
fracture rates are conflicting. The inherent problems with observational
studies also must be addressed. Until that time, the use of statins in
the prevention of fractures or the treatment of osteoporosis requires
further study.

Gonyeau MJ.Statins and osteoporosis: a clinical review. Pharmacotherapy.
2005 Feb;25(2):228-43.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15767237>

**Guidelines Unclear on Screening for Osteoporosis**

Screening guidelines were lacking in uniform recommendations, that
screening rates generally were low, and that few interventions to
improve screening rates have been studied. Predictors of testing also
have not been studied sufficiently, making it difficult to determine
whether testing is being carried out on the appropriate patients.
Furthermore, even if the criteria for testing were clearly defined, it
is unclear what interventions could be used to improve screening rates.

Morris CA, et al. Patterns of bone mineral density testing. J Gen Intern
Med July 2004;19:783-90.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15209594>

**AHRQ Recent Findings: Osteoporosis**

<http://www.ahrq.gov/research/womenh4.htm#osteo>

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

**Infections During Pregnancy: What You Should Know?**

<http://www.aafp.org/afp/20050415/1561ph.html>

**A Guide to Perimenopause: Patient FAQs -- Cleveland Clinic**

<http://www.medscape.com/viewarticle/502585?src=mp>

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

**August 1, 2005**

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

Moderator: Charles North

-Are you comfortable using narcotics to treat chronic pain? 

-Is there abuse of prescription controlled medications in your
community? 

-What controls should health professionals have in place to regulate the
use of controlled substances? 

-Do you use pain contracts?  Are they useful?

-What services are available to serve your chronic pain patients in
addition to primary care? 

-Are you successful in obtaining mental health services for your
patients?

**Other issues**

-Describe your level of comfort based and your experience.

-What are the most popular drugs?  Are narcotics, benzodiazepines or
stimulants most popular? 

-Are particular brand names valued more than others? 

-Do you know the local \"street value\" of prescription pills?

-Would you like to consult with a psychiatrist yourself about some of
your patients?

**Fall 2005**

**Web based Indian Health M + M**

Moderator: Terry Cullen

Details TBA

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

Subscribe to the Primary Care listserv

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

Unsubscribe from the Primary Care listserv

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

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

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

**After the promise: The STD consequences of adolescent virginity
promises**

The purpose of this study was to examine the effectiveness of virginity
pledges in reducing STD infection rates among young adults (ages
18--24). Pledgers are consistently less likely to be exposed to risk
factors across a wide range of indicators, but their STD infection rate
does not differ from nonpledgers. Possible explanations are that
pledgers are less likely than others to use condoms at sexual debut and
to be tested and diagnosed with STDs.

Brückner H et al After the promise: The STD consequences of adolescent
virginity promises Journal of Adolescent Health, Volume 36, Issue 4 ,
April 2005, Pages 271-278

 <http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15780782>

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

#### 2005 4-Corners STD/HIV Summit June 22 -- 24, 2005, Farmington, NM {#corners-stdhiv-summit-june-22-24-2005-farmington-nm .Style-Heading-4-+-Arial-14-pt-Underline}

#### Contact: [**laura.shelby@mail.ihs.gov**](mailto:laura.shelby@mail.ihs.gov) {#contact-laura.shelbymail.ihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

**Oral versus vaginal sex among adolescents: Perceptions, attitudes, and
behavior**

Despite studies indicating that a significant proportion of adolescents
are having oral sex, the focus of most empirical studies and
intervention efforts concerning adolescent sexuality have focused on
vaginal intercourse. This narrow focus has created a void in our
understanding of adolescents\' perceptions of oral sex. Halpern-Felsher
BL et al Oral versus vaginal sex among adolescents: Perceptions,
attitudes, and behavior PEDIATRICS 115 (4) 2005, pp. 845-851

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15805354>

**Young age at first sexual intercourse and sexually transmitted
infections in adolescents**

The authors examined the relation between age at first vaginal
intercourse and a positive nucleic acid amplification test for sexually
transmitted infection (STI). Younger ages at first intercourse were
associated with higher odds of STI in comparison with older ages, but
the effect diminished with increasing current age.

Kaestle CE et al Young age at first sexual intercourse and sexually
transmitted infections in adolescents and young adults Am. J. Epidemiol.
161: April 2005 774-780.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15800270>

####  {#section-13 .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}

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

There is a new International Definition for the Metabolic Syndrome. A
person has the metabolic syndrome if they have central obesity (waist
circumference \> 94cm for Europid men and \> 80cm for Europid women)
plus any 2 of the following factors: increased triglyceride
concentrations, reduced HDL cholesterol levels, increased blood pressure
(systolic \>130mmHg or diastolic \>85mmHg), and increased fasting plasma
glucose (\>100mg/dL \[5.6mmol/L\]) or previously diagnosed type 2
diabetes. Definitions of obesity based on gender and ethnicity are
provided. Recommendations for treatment, including primary and secondary
interventions and recommended strategies for the individual components
of the metabolic syndrome, are given. International Diabetes Federation
[www.idf.org](http://www.idf.org/)

**Waistline of one meter or more are at serious risk of insulin
resistance**

Waist circumference was a very strong independent predictor of insulin
sensitivity. A waist circumference of less than 100 cm excluded insulin
resistance in both sexes. It replaces body mass index, waist:hip ratio,
and other measures of total body fat as a predictor of insulin
resistance. Waist circumference is a simple tool to exclude insulin
resistance and to identify those at greatest risk (therefore those who
would benefit most from lifestyle changes).

Wahrenberg H, et al Use of waist circumference to predict insulin
resistance: retrospective study. BMJ. 2005 Apr 15
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15833749>

**Rosiglitazone Crosses Placenta in First Trimester**

CONCLUSION(S): The risk of placental transfer of rosiglitazone is much
higher at or after 10 weeks of gestation. Absence of detectable
rosiglitazone in amniotic fluid despite its presence in fetal tissue
suggests that fetuses may have the ability to metabolize rosiglitazone,
and little parent drug was excreted unchanged in urine.

Chan LY, et al. Placental transfer of rosiglitazone in the first
trimester of human pregnancy. Fertil Steril. 2005 Apr;83(4):955-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15820806>

**Happy People Are Healthier - Song \"Don\'t Worry, Be Happy,\" - Sound
medical advice**

Positive affect in middle-aged men and women is associated with reduced
neuroendocrine, inflammatory, and cardiovascular activity. Positive
affect was assessed by aggregating momentary experience samples of
happiness over a working day and was inversely related to cortisol
output over the day, independently of age, gender, socioeconomic
position, body mass, and smoking. Similar patterns were observed on a
leisure day. Happiness was also inversely related to heart rate assessed
by using ambulatory monitoring methods over the

Steptoe A, Wardle J, Marmot M. Positive affect and health-related
neuroendocrine, cardiovascular, and inflammatory processes. Proc Natl
Acad Sci U S A. 2005 Apr 19

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15840727>

**Depressed diabetics die sooner than depressed non-diabetics**

Individuals with diabetes are prone to depression and show that over a
10-year period depressive symptoms significantly increase the risk of
death among persons with diabetes but not among persons without
diabetes.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15781954>

**Be surprised**: **Portion size, calories, amount of activity needed to
expend those calories**

Click on Portion Distortion Slides 1, you will get an interactive quiz
re: portion size, calories, and the amount of physical activity needed
to expend those calories. You will be surprised.

<http://hin.nhlbi.nih.gov/portion/>

**Step Counting Increases Exercise More Than Timed Walking**

CONCLUSION: Women walk more when told to take 10,000 steps per day
compared with those instructed to take a brisk 30-min walk. On days when
women took a 30-min walk, their average step count was near 10,000.
Hultquist CN, et al Comparison of walking recommendations in previously
inactive women. Med Sci Sports Exerc. 2005 Apr;37(4):676-83.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15809569>

**Carrying weight around waist increases risk of metabolic syndrome even
if BMI is normal**

CONCLUSION: In addition to general obesity, the distribution of body fat
is independently associated with the metabolic syndrome in older men and
women, particularly among those of normal body weight. Goodpaster BH, et
al Obesity, regional body fat distribution, and the metabolic syndrome
in older men and women. Arch Intern Med. 2005 Apr 11;165(7):777-83.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15824297>

**Diabetes Increases Risk of Urinary Infection in Postmenopausal Women**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15746472>

**USDA Food Pyramid now 12 pyramids**

One size doesn\'t fit all. MyPyramid Plan can help you choose the foods
and amounts that are right for you. <http://www.mypyramid.gov/>

**National Employee Health & Fitness Day: Wednesday, May 18, 2005**

The National Association for Health & Fitness announced that its 16th
Annual Celebration of National Employee Health & Fitness Day is
Wednesday, May 18, 2005 <http://www.physicalfitness.org/>

# 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%)}

**New Perinatology Corner Module Should you be using the quad screen?**

**Prenatal Genetic Screening -- Serum and Ultrasound**

<http://www.ihs.gov/MedicalPrograms/MCH/m/TM01.cfm>

**US OB/GYNs helping to create residency program in Kabul**

<http://www.ihs.gov/MedicalPrograms/MCH/M/ACOG01_afghan.cfm#kabul>

**Royal College of OB/GYN Guidelines**

<http://www.rcog.org.uk/index.asp?PageID=1042>

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

<http://www.ihs.gov/MedicalPrograms/MCH/W/WHmature.asp#PT>

There are several upcoming **Conferences**

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

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

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

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

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

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

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

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

**2005 U.S. Public Health Conference/Global Health Summit**

-   June 5-9, 2005

-   Philadelphia, PA, Development of the Report on Global Health

-   40^th^ Annual U.S. Public Health Professional Conference, June 6-9,
    2005

-   [www.coausphsconference.org](../../../../../../../../exchweb/bin/redir.asp%3FURL=http://www.coausphsconference.org/)

**I.H.S. / A.C.O.G. Postgraduate Course: Obstetric, Neonatal, and
Gynecologic Care Late fees = waived**

-   June 19 - 23, 2005

-   Denver, CO

-   Contact [Yvonne Malloy](mailto:YMalloy@acog.org) <YMalloy@acog.org>
    202-863-2580

-   Save the date info
    <http://www.ihs.gov/MedicalPrograms/MCH/M/documents/pgcoursesavethedate.doc>

-   2005 Brochure

```{=html}
<!-- -->
```
-   <http://www.ihs.gov/MedicalPrograms/MCH/M/Documents/Brochure2005EL.doc>

-   June 19th at 8:00 am: NEONATAL RESUSCITATION PROGRAM

```{=html}
<!-- -->
```
-   NRP Class size limited. Sign up now
    <http://www.ihs.gov/MedicalPrograms/MCH/M/documents/NeonatalResuscitationProvider2.doc>

```{=html}
<!-- -->
```
-   Meeting Website
    <http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#June05>

**National Summit on Preconception Care**

-   JUNE 21-22, 2005

-   Atlanta, Georgia

-   Catalyst for national recommendations for preconception care, CDC

-   <http://www.signup4.net/Public/ap.aspx?EID=NATI14E>

# 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 **April 2005 OB/GYN CCC Corner** is available at:\
<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0405.cfm>

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

**Human Papillomavirus - ACOG Practice Bulletin**

**NUMBER 61, APRIL 2005**

#### From your colleagues: page 5 {#from-your-colleagues-page-5 .Style-Heading-4-+-Arial-14-pt-Underline}

Burt Attico: DMPA, Bone Mineral Density, and Teens: Recent and
Reassuring Data

James Galloway: A previously under recognized disparity in CVD mortality
exists for AIAN

**Steve Holve:** April Indian Child Health Notes: Highlights

**Lori de Ravello:** Reproductive Health 2005 - Call for Abstracts

**Phil Smith:** Commodity or Public Work? Two Perspectives on Health
Care

**Judy Thierry:**

-School wellness (nutrition and PE focused) policies 

-Improve your effectiveness in home visits, family and new parent
interactions

-Fitness in Kids by State

-SAMHSA Releases Garret Lee Smith Requests for Applications

-Send me your translation of \"Make every mother and child count\" in
your tribal language

-The population you serve may be in a county represented by the National
Children's study

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

##### Obstetrics: page 8

-Gestational Diabetes Rising at Alarming Rate in U.S. Women

-Ginger: effective and safe treatment in managing nausea and vomiting in
pregnancy.

-Treatment for BV or T. vaginalis does not reduce of PTD or adverse
perinatal outcomes

\- Obstetric Anal Sphincter Injury Persists Over Long Term

\- Effects of Discontinuing Epidurals in Late Labor: Cochrane Briefs

**Gynecology: page 11**

-Antibiotics for Recurrent Urinary Tract Infections: Cochrane for
Clinicians

-Two Criteria May Be Sufficient to Diagnose Bacterial Vaginosis

-Vaginal Tape vs. Surgery for Stress Incontinence

\- Polycystic ovarian syndrome: marked differences in diagnosis and
management

\- Laparoscopic Radiofrequency Thermal Ablation Safe and Effective for
Fibroids

**Child Health: page 12**

-FASlink

\- Prevalence of Overweight Among Children and Teenagers, by Age Group

**Chronic Illness and Disease: page 12**

-Can Patients with Cancer Postpone Death for Important Events?

-Impact of Community-Based Yoga on Quality of Life

\- Antioxidant Vitamin Supplements and Cardiovascular Disease Risk
Reduction

\- Comparison of Short-Term Treatments for GERD

\- Parenteral dihydroergotamine for acute migraine headache: a
systematic review

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

##### American Family Physician

-Raloxifene Reduces the Risk of Breast Cancer

-Trial of Labor Carries Small but Real Increase in Risk

-Bariatric Surgery Effective for Long-Term Weight Loss

American College of Obstetricians and Gynecologists

-Appropriate Use of Laparoscopically Assisted Vaginal Hysterectomy

-Endometriosis in Adolescents - ACOG Committee Opinion No. 310

**Agency for Healthcare Research and Quality**

-Compare and Contrast: AHRQ Web M + M

-Use of certain antidepressants may increase risk of hip fractures among
older patients

**Ask a Librarian**

##### -Access to the NIH Library web resources availability being explored for Indian Health staff

**Breastfeeding**

#### -Decline in breastfeeding rates: 2003 Ross breastfeeding stats {#decline-in-breastfeeding-rates-2003-ross-breastfeeding-stats .Style-Heading-4-+-Arial-14-pt-Underline}

-Section on Breastfeeding: American Academy of Pediatrics

**CCC Corner Digest**

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

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

\-[Routine Population-Wide HIV Screening May Be
Cost-Effective](http://mp.medscape.com/cgi-bin1/DM/y/hmEa0G875W0Dzc0GQ3m0ET)

-Q. What is the Indian Health policy for HIV screening in pregnancy?

-Early epidural provided shorter labor and did not increase cesarean
delivery

-How many deliveries does a provider need to maintain active privileges?

-What is the significance of the latest NEJM article on trial of labor
after cesarean?

-Vaginal pH for Diagnosing Status of Menopause

-Pregnancy, Birth, and Abortion Rates Decline for Teenagers Aged 15-17
Years

\- Emergency OB Drills: The Phoenix Indian Medical Center Experience

**Domestic Violence**

###### -IHS Child Abuse Project: **Training Deadline extended**

-The Truth About Rape

**Elder Care News**

-Helping elderly drivers stay on the road: Signs of an unsafe driver

-One-time screening for abdominal aortic aneurysm: B Recommendation

**Family Planning**

-'The patch': Trouble getting it on your formulary?

-One half of women who express desire for postpartum sterilization do
not get procedure.

-Post-vasectomy semen analysis: are men following up?

**Frequently asked questions**

-In pregnancy, is a one hr. screening result \> 185 or \> 200 mg/dL
diagnostic for GDM?

-Are there alternatives to the oral glucose tolerance test? A breakfast
tolerance test?

-What is the value of biochemical markers in diagnosis or treatment of
osteoporosis?

-What are some of the issues involved with vacuum assisted deliveries?

-What are the issues involved in adoption of an American Indian or
Alaska Native child? 

**Hormone Replacement Update**

-Modifiable Lifestyle Factors That May Affect Hot Flashes

**Information Technology**

-Free Native American Continuing Education online

-EHR INTRODUCTORY COURSE ANNOUNCEMENT

-IHS Technology Conference June 27 - July 1, 2005 - Save the Dates!!

International Health

-Patients' Beliefs About Racism, Preferences for Physician Race,
Satisfaction With Care

-Spectrum of dysfunctional organizational cultures can be diagnosed and
managed

#### MCH Alert

-Ethical implications of health literacy and the steps needed to promote
it

-Suicidal behavior in the family and adolescent risk behavior

#### Medscape

**Midwives Corner**

#### -Midwifery care of poor and vulnerable women, 1925-2003 {#midwifery-care-of-poor-and-vulnerable-women-1925-2003 .Style-Heading-4-+-Arial-14-pt-Underline}

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

-Methicillin-resistant *Staphylococcus aureus* Toxic Shock Syndrome

-Host a Women's Health Fair - National Women\'s Health Week of May 9th
2005

Osteoporosis

-Osteoporosis and Fracture Prevention in the Indian Health System

-Osteoporosis: Strategies for Screening and Intervention

Patient Education

-Pregnancy: Keeping Yourself and Your Baby Healthy

\-[**What Can You Do To Make Rheumatoid Arthritis (RA) Less
Debilitating?**](http://mp.medscape.com/cgi-bin1/DM/y/hnch0G875W0Dzc0F7G10Ey)

Primary Care Discussion Forum

-Methamphetamine use in Indian Country -- still can join in

STD Corner

-Natural mentoring relationships and adolescent health: evidence from a
national study

-Syphilis Elimination Effort (SEE) Toolkit

-Outbreak of Infectious Syphilis in Alaska\--Follow-up

-HIV Infection in Alaska, 2004

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

-A Decline in Life Expectancy in the US

-Dark Chocolate Improves Insulin Sensitivity/Resistance and Blood
Pressure

-Yogurt Promotes Fat Loss

-Physical Activity Increases Insulin Sensitivity 44%

-Knowing One\'s Hgb A1c Can Improve Results

#### What's new on the ITU MCH web pages page 24

-New Perinatology Corner module -- Should you be using quad screen?

FREE CEUs, CME Prenatal Genetic Screening -- Serum and Ultrasound

\-[Osteoporosis in Indian Health - A Systems
Approach](http://www.ihs.gov/MedicalPrograms/MCH/W/WHmature.asp#OsteoAIAN)

\-[Osteoporosis: Strategies for Screening and
Prevention](http://www.ihs.gov/MedicalPrograms/MCH/W/WHmature.asp#OsteoAIAN)

The past CCC Corners are archived at:

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

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

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

or 907 729 3154 (with voicemail)

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

5/14/05njm