**Newly Released** **Perinatology Corner Module - Shoulder Dystocia**

A great resource for information and / or free CEU / CME

![](media/image1.png){width="5.998611111111111in"
height="0.9895833333333334in"}

 

OB/GYN Chief Clinical Consultant's Corner

Volume 3, No. 10, October 2005

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

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

Family cohesion and conflict in an American Indian Community

Guest Editorial: Peter Stuart, Chinle

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

Carolyn Aoyama

-Children and Teens Told by Doctors That They Were Overweight

-CDC Childhood Obesity Fact Sheets

Burt Attico

-Health Status of American Indians, Alaska Natives Still Lagging Behind

Tony Dekker

-Opioid Use for Moderate to Severe Pain

Mary Lynn Eaglestaff

-Preterm Labor: Signs and Symptoms - Patient Education Brochure

James Galloway

-Sunday Morning Program**:** Cardiovascular Disease in AI/AN

Ben Garnett

#### -Passive immunization during pregnancy for congenital cytomegalovirus infection {#passive-immunization-during-pregnancy-for-congenital-cytomegalovirus-infection .Style-Heading-4-+-Arial-14-pt-Underline}

Chuck North

-FIT test - Toward a better fecal occult blood test: Comparison with
colonoscopy

Judy Thierry:

-Maternal Mortality in Indian Country: Follow-up to September CCCC
Abstract

-Using Geographic Information Systems (GIS) to Analyze MCH Epi Data

-Health Care Services Are Not Always Available to Native Americans

-Birth Defects Prevention: Realizing the Full Potential of Folic Acid

-Scrub Club: As we enter flu, coughs and cold season - hand washing

...and more

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

##### Obstetrics page 11

-Do Pregnant Women Require Rectal Swabs for GBS?

-First Validated Model Predicts Risk of Failed Vaginal Birth After
Cesarean

-Both obesity and excessive weight gain decrease the likelihood for VBAC

-MRSA Infection Emerging Problem in Pregnant Patients

-Postnatal Depression - What are the effects of drug treatments?

....and more

**Gynecology page 15**

-Paroxetine Curbs Premenstrual Dysphoric Disorder

-Social and cultural barriers to Pap test screening: Fatalistic
attitudes, lack of support

-Tension-free vaginal tape procedure is effective over a period of 7
years

-IDSA Guidelines for Diagnosis and Treatment of Asymptomatic Bacteriuria

#### -Management of Spontaneous Abortion {#management-of-spontaneous-abortion .Style-Heading-4-+-Arial-14-pt-Underline}

....and more

**Child Health page 17**

#1 cause of pediatric deaths!!!

-Broad portrait of what adolescents are doing and thinking

-Concussion tool kit for coaches

-AAP Report on Pregnancy in Adolescents

-Children's Health Month

....and more

**Chronic Illness and Disease page 19**

-Native Americans with highest rates of major depressive disorder

-\"Menopausal Arthritis\" May Develop in Women Receiving Aromatase
inhibitors

-Metformin for Overweight and Obese Adults: Not proven outside of DM or
PCOS yet

-Systematic review: TCAs and SSRIs effective, low-dose TCAs also
effective - primary care

-Blood pressure reading is one of the most inaccurately performed

....and more

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

#### Features: page 22 {#features-page-22 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician

-Does a Low Glycemic Index Diet Reduce CHD?

American College of Obstetricians and Gynecologists

-Racial and Ethnic Disparities in Women\'s Health

-The Role of the Obstetrician--Gynecologist in the Assessment and
Management of Obesity

-Smoking Cessation During Pregnancy

-Screening for Tay--Sachs Disease

**Agency for Healthcare Research and Quality**

-Supracervical and TAH result in similar sexual functioning and quality
of life

-Women with atherosclerosis / high cholesterol receive less intense
management than men

-Estrogen with progestin higher discontinuation rates in women with
diabetes and CVD

**Ask a Librarian**

-Help Us Establish a Free Electronic Patient Education Resource Center

**Breastfeeding**

**-Katrina: The Role of Human Milk and Breastfeeding**

**Case Managers Corner**

-Great opportunity for any AI/AN nurses with Masters or PhDs - Request
from HRSA

**CCC Corner Digest**

-Cesarean delivery in AI/AN women: How are low rates explained?

-Diabetes prevention and control - Prenatal program

-Maternal Morbidity in AI/AN Women, 2002-2004

-Meperidine for Dystocia During First Stage of Labor: Limit Use

-PID: Outpatient treatment was as effective in preventing reproductive
morbidity

-Adolescents Prefer Honesty and Patient-Centered Care

-One Third of Deaths From GI Bleeding Due to NSAIDs

-Elaine Locke: Key Contributor to Improve AI/ AN Women's Health for 35
years

-Management of abnormal cervical cytology and histology, ACOG Practice
Bulletin

-AHRQ Research Activities Relevant to the American Indian and Alaska
Native Community

-Glyburide nor glipizide compatible with breast-feeding

-Wouldn't it be nice if there was more distance education available to
nurses?

-Cancer screening in elderly patients: a framework for individualized
decision making

-EC in adolescents: No compromise of family planning or increased sexual
behavior

-CDC "Key Facts about Flu Vaccine"

-Magical Mystery Tour: Overbooked clinic and next patient with chronic
pelvic pain

-Public health approach to suicide prevention in an American Indian
Tribal Nation

-Follow-up of Last month's Corner Ortho Evra discussion

-Electronic Health Record for care of women and children

-First trimester prenatal genetic screening:  Is it ready for 'Prime
Time' at your facility?

-Primary Care Discussion Forum-November 1, 2005 - Rectal bleeding: Is it
hemorrhoids?         

-Appropriate use of narcotics for chronic non-malignant pain, Chuck
North, ABQ

-Screening for sexually transmitted diseases in non-traditional
settings: a personal view

**Domestic Violence**

-October is Domestic Violence Awareness Month

-Domestic Violence Prevention Enhancement and Leadership Through
Alliances (DELTA)

-Indian Health Violence Against Women web site

-50 Tribal TANF sites, updated August 2005

**Elder Care News**

-Cancer screening in elderly patients: a framework for individualized
decision making

-Stop Abuse and Sexual Assault against older individuals: Grants
available

**Family Planning**

# -ParaGard^®^ T 380A Approved for Nulliparous Women in Stable Relationships from Age 16

-Extension of the ring cycle reduced bleeding days, well tolerated and
desired by many

-Lower- vs. Higher-Dose Estrogen for Contraception Clinical Question

**Featured Web Site**

-Newly Released Perinatology Corner Module - Shoulder Dystocia

**Frequently asked questions**

-Are there any clinical pointers for alcohol withdrawal in pregnancy?

-If a patient has an IUD and develops a Chlamydia infection, should you
remove the IUD?

**Indian Child Health Notes**

-Is gambling good for you?

-Guidelines for Menactra, the new quadrivalent meningitis vaccine

-Oral health therapists - a low cost and low tech approach to the
problem of dental access

-Community Acquired Methicillin - coming to a clinic near you

**Information Technology**

-Still doing GYN surgery the old fashioned way? Robotic surgery in
remote settings

International Health

-After Katrina: Health Professionals\' Notes From the Field

#### MCH Alert

-Association between neighbor characteristics and adolescent sexual
behavior

-Racial and Ethnic Disparities in Health Knowledge Path

#### Medical Mystery Tour

#### -HCG curves redefined: Symptomatic patients with an early viable intrauterine pregnancy Medscape

######### -Complications of Cesarean Deliveries

######### -Racial and Ethnic Health Disparities, Women, and Cancer - CME

**Menopause Management**

#### -What really causes hot flashes and how to fix them? {#what-really-causes-hot-flashes-and-how-to-fix-them .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Gabapentin May Control Hot Flashes in Women With Breast Cancer {#gabapentin-may-control-hot-flashes-in-women-with-breast-cancer .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

-Increased risk of overall major congenital malformations with
paroxetine

**Navajo News**

-Syphilis Treatment Issues---Azithromycin Use Not Encouraged for
Syphilis Treatment

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

-Cesarean Rates for First Births and Repeat Cesarean for Low-Risk Women:
1990-2003

-Sexual Behavior and Health Measures: Men and Women 15-44 Years of Age

-Births: Final Data for 2003

**Oklahoma Perspective**

-Less quantity of prenatal visits with higher quality: Outcome based
analysis

Osteoporosis

-Secondary Fracture Prevention with Calcium and Vitamin D

-Can Examination Findings Predict Osteoporosis Risk?

-Soy Consumption Reduces Bone Fracture Risk in Postmenopausal

Patient Education

-Preterm Labor: Signs and Symptoms -- Aberdeen Area Brochure

#### -Diverticular Disease: What You Should Know? {#diverticular-disease-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Newly Released Perinatology Corner Module - Shoulder Dystocia

-Thyroid-stimulating hormone decreases significantly during the first
trimester

Primary Care Discussion Forum

November 1, 2005, Rectal bleeding: Is it hemorrhoids Morbidity and
Mortality Rounds

STD Corner

-Goodbye Laura Shelby, Welcome Lori de Ravello

-Which Comes First in Adolescence---Sex and Drugs or Depression?

#### -Inaccurate, Outdated Serologic Tests for Genital Herpes Still in Use {#inaccurate-outdated-serologic-tests-for-genital-herpes-still-in-use .Style-Heading-4-+-Arial-14-pt-Underline}

#### -HIV Screening Health-Care Settings: Adolescents, Pregnancy, Adult Recommendations {#hiv-screening-health-care-settings-adolescents-pregnancy-adult-recommendations .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Annual Screening for C. trachomatis Is Cost-Effective {#annual-screening-for-c.-trachomatis-is-cost-effective .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Testing for primary HIV infection with p24 antigen EIA may be a sound use of resources {#testing-for-primary-hiv-infection-with-p24-antigen-eia-may-be-a-sound-use-of-resources .Style-Heading-4-+-Arial-14-pt-Underline}

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

-Pedometers Increase Activity for Patients

-Prevalence of Diabetes Among Adult Alaskans: 2002-2004

-Women who eat breakfast are less likely to be overweight than those who
fast till lunch

-Implementing health behavior change in primary care: lessons from
prescription for health

-Vinegar Significantly Lowers Blood Glucose, Insulin Response, and
Increases Satiety

and more...

###### Save the Dates: Upcoming events of interest page 44

#### What's new on the ITU MCH web pages page 45

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

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

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

#  {#section-2 .Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5%)}

**Family cohesion and conflict in an American Indian Community**\
This American Indian sample reflects a support-oriented family profile
despite the coexistence of high conflict. Despite the recognized
importance of family environment in influencing health behaviors, few
studies have attempted to assess or address distinctive attributes of
American-Indian families. The article presents findings from an
assessment of specific characteristics of the family environment within
one American-Indian community.

[Study Design]{.underline}

The study was conducted as part of a formative assessment of diet,
activity, and family behaviors prior to the implementation of a
community-based family wellness program. Members of one American-Indian
community were trained to administer the assessment instrument by random
household sample to participants ages 16 and older. The assessment
analyzed responses to a survey instrument composed of a food and
physical activity frequency questionnaire as well as four subscales of
the Family Environment Scale (FES). Use of the FES with American-Indian
families has not been previously reported in the published literature.

[Methods]{.underline}

The present analysis assessed the following four dimensions of the
family

environment: (1) cohesion, defined as the degree of commitment, help,
and support family members provide for one another; (2) expressiveness,
defined as the extent to which family members are encouraged to express
their feelings openly; (3) conflict, defined as the amount of openly
expressed anger among family members; and (4) active-recreational
orientation, defined as the amount of participation in social and
recreational activities. Results from the survey were compared to
nationwide scores reported for individuals from non-native,
nondistressed, and distressed families and from nondistressed non-native
minority (African-American and Latino) families.

[Results]{.underline}

\* In comparison to the non-native, nondistressed family sample,
American -Indian families were comparable in expressiveness and
cohesion, higher in conflict, and lower in participation in social and
recreational activities.

\* In comparison to the national sample of distressed families, the
American-Indian family sample was more cohesive and expressive but no
different in conflict and in participation in social and recreational
activities.

\* In comparison with nondistressed minorities, the American-Indian
sample scored higher in expressiveness and conflict but lower in
cohesion.

[Summary]{.underline}

In comparison to these national samples, the American Indian sample
projects a distinctive family profile, FES results can be useful in
establishing a baseline assessment of family strengths and challenges
and could serve as an evaluation tool in tracking the impact of social
and public health services within Native communities.\
Teufel-Shone NI, Staten LK, Irwin S, et al. 2005. Family cohesion and
conflict in an American Indian community. American Journal of Health
Behavior 29(5):413-422.\
[http://www.ajhb.org/2005/5/SepOct0405Teufel-Shone.pdf](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ajhb.org/2005/5/SepOct0405Teufel-Shone.pdf)

#### [Guest Editorial comment]{.underline}: Peter Stuart, Chinle

**What exactly does "being culturally sensitive" mean?**

Someone somewhere will certainly take a study such as this and say "We
need to develop programming for American Indian families to help them
reduce conflict, and participate more in social and recreational
activities".

This study demonstrates well some of the hazards in research involving
American Indians / Alaskan Natives. When does a study reflect conditions
for "American Indians" as a whole, and when should we be particularly
sensitive to the unique cultural, economic, social, and environmental
contributors to distress and wellness? The most one can argue from a
study of this nature is that a particular community demonstrated a
particular constellation of family environmental processes. Even calling
the study a study of American Indians is problematic as it conflates all
of our communities under that label despite their incredible diversity.

The study also raises issues around the construction of goodness and the
assigning of precedence to culturally-moderated perceptions of behavior
in a scale such as the FES. Is "expressiveness" as defined by the study
a universal good? Is "conflict" a universal negative? What are the risks
involved using research such as this in the design of community
interventions? What types of processes need to be in place to respect
the perspectives of the communities involved and to avoid the
neo-colonialist error of attributing ascendance to the researcher's
community norms? How can providers and health managers involved in
funding and program priority issues acknowledge their own inherent
biases and make balanced and respectful decisions? Peter Stuart, Chinle

**Here are some helpful resources**

**Relationships between poverty and psychopathology: a natural
experiment**

CONCLUSIONS: An income intervention that moved families out of poverty
for reasons that cannot be ascribed to family characteristics had a
major effect on some types of children\'s psychiatric disorders, but not
on others. Results support a social causation explanation for conduct
and oppositional disorder, but not for anxiety or depression.

[Costello
EJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Costello+EJ"%5BAuthor%5D),
et al Relationships between poverty and psychopathology: a natural
experiment. JAMA. 2003 Oct 15;290(15):2023-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14559956&query_hl=10>

**Socioeconomic disparities in health change in a longitudinal study of
US adults**

The results suggest that the higher prevalence of major health-risk
behaviors among those in lower socioeconomic strata is not the dominant
mediating mechanism that can explain socioeconomic disparities in health
status among US adults.

[Lantz
PM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Lantz+PM"%5BAuthor%5D)
et al Socioeconomic disparities in health change in a longitudinal study
of US adults: the role of health-risk behaviors. Soc Sci Med. 2001
Jul;53(1):29-40.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11380160&query_hl=1>

**Socioeconomic factors, health behaviors, and mortality**

CONCLUSION: Although reducing the prevalence of health risk behaviors in
low-income populations is an important public health goal, socioeconomic
differences in mortality are due to a wider array of factors and,
therefore, would persist even with improved health behaviors among the
disadvantaged.

[Lantz
PM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Lantz+PM"%5BAuthor%5D)
et al Socioeconomic factors, health behaviors, and mortality: results
from a nationally representative prospective study of US adults. JAMA.
1998 Jun 3;279(21):1703-8\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9624022&query_hl=8>

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

**Carolyn Aoyama, HQE**

**Children and Teens Told by Doctors That They Were Overweight**

The percentage of children and teens aged 6-19 years in the United
States who are overweight nearly tripled to 16% during 1980-2002. To
determine what percentage of overweight children (or their parents) and
teens were ever told their weight status by doctors or other health-care
professionals, CDC analyzed data from the 1999-2002 National Health and
Nutrition Examination Survey. This report summarizes the results of that
analysis, which determined that: 36.7% of overweight children and teens
aged 2-19 years had been told by a doctor or other health-care
professional that they were overweight, and teens aged 16-19 years were
more likely to be told than parents of children aged 2-11 years.

[[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5434a3.htm]{.underline}](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5434a3.htm)

**CDC Childhood Obesity Fact Sheets**

Youth Risk Behavior Survey (YRBS) and School Health Profiles (Profiles)

Parameters: overweight, engage in unhealthy dietary behaviors, or are
physically inactive.

The Profiles results describe characteristics of health education,
physical education, opportunities for physical activity, and the school
environment among middle/junior and senior high schools that may help
address the problem.

[[http://www.cdc.gov/healthyyouth/obesity/facts.htm]{.underline}](http://www.cdc.gov/healthyyouth/obesity/facts.htm)

 

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

**Health Status of American Indians, Alaska Natives Still Lagging
Behind**

The U.S. health care system still has far to go before the needs of
American Indians and Alaska Natives are equitably met, according to a
May forum on the issue. Sponsored by APHA, the Kaiser Family Foundation
and the Morris K. Udall Foundation, the Washington, D.C., forum focused
on disparities in health care for American Indians and Alaska Natives.
Research has long shown that the country\'s 3 million to 4 million
American Indians and Alaska Natives have significantly higher mortality
rates than the general population and suffer disproportionately from
chronic conditions such as diabetes.

American Indians and Alaska Natives also face greater barriers to care,
with more than one-third of the population lacking health insurance.
About 17 percent of American Indians and Alaska Natives are Medicaid
recipients, compared to 5 percent of whites.

Suicide, violence and depression are also prevalent among American
Indians and Alaska Natives, noted Michael Bird, MSW, MPH, executive
director of the National Native American AIDS Prevention Center. The
March shootings on a reservation in Red Lake, Minn., in which a teen who
had been treated for depression killed nine people, underscore the need
for more interventions, Bird said.

One way to resolve some of the health concerns for American Indians and
Alaska Natives would be to devote more resources to the issue,
especially to the Indian Health Service, according to speakers at the
forum.

IHS, which provides or pays for health care of about 1.8 million
American Indians and Alaska Natives, has a proposed budget of about
\$3.8 billion for fiscal year 2006. However, tribes estimate that about
\$19.4 billion is required to adequately meet all health care needs,
according to Yvette Roubideaux, MD, MPH, an assistant professor at the
University of Arizona.

When broken down per person, IHS spent about \$1,776 per user in 2001,
compared to about \$5,490 spent per enrollee by Medicare in 2000,
according to Roubideaux.

To resolve the resource issue, funding for IHS should become a mandatory
line item in the federal budget instead of a discretionary one,
according to Tim Westmoreland, JD, a research professor at Georgetown
University.

While the nation has pledged to care for the health of American Indians
and Alaska Natives, \"that promise has been hollowed out\" by the budget
classification, he said.

By changing to a mandatory budget, health officials would better be able
to address health care needs and close the growing gap in per capita
spending, Westmoreland said.

Despite the challenges in providing health care for American Indians and
Alaska Natives, there have been some recent accomplishments, according
to Leo Nolan, MEd, an IHS senior policy analyst.

Tribes have become more involved in their own self-governance, he said,
and more than half of the IHS budget is now allocated through tribal
nations. The Native American Research Centers for Health program, which
encourages research on diseases and health conditions of importance to
American Indians and Alaska Natives, was established by IHS and the
National Institutes of Health, and plans are under way to allow more IHS
employees to publish research. And while IHS spending lags behind some
federal programs, the agency\'s annual budget is still larger than the
budget of most of the world\'s countries, Nolan said.

#### The May forum tied into the release of the May issue of APHA\'s American Journal of Public Health, which focused on American Indian and Alaska Native health policy. The issue was supported in part by the Kaiser Family Foundation. [[www.kaisernetwork.org/healthcast/kff/09may05]{.underline}](../www.kaisernetwork.org/healthcast/kff/09may05) {#the-may-forum-tied-into-the-release-of-the-may-issue-of-aphas-american-journal-of-public-health-which-focused-on-american-indian-and-alaska-native-health-policy.-the-issue-was-supported-in-part-by-the-kaiser-family-foundation.-www.kaisernetwork.orghealthcastkff09may05 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Tony Dekker, Phoenix {#tony-dekker-phoenix .Style-Heading-4-+-Arial-14-pt-Underline}

**Opioid Use for Moderate to Severe Pain**

In the United States, many visits to physician offices are for
complaints of pain. Patients who have moderate to severe pain can be
effectively treated with different modalities, including the use of
opioids. Effective management requires that the physicians be open
minded and thorough. Physicians should take a complete history and do a
complete physical examination, including an osteopathic structural
examination, to help develop a comprehensive treatment plan. This plan
should include follow-up visits for continued assessment of the
treatment plan. A continued reassessment of the treatment plan and the
patient\'s response to the treatment has been shown to be most
beneficial to the patient and the physician. Osteopathic physicians
using the osteopathic medical model of treatment should identify
psychosocial as well as somatic dysfunctions and appropriately treat
patients for them. They should not avoid the use of opioids because of
fear of patients becoming addicted, but rather they should integrate the
use of opioids in a multidisciplinary treatment plan. Opioids are potent
drugs that require monitoring and dosing according to patient response.

[Rasor J
3rd](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Rasor+J+3rd"%5BAuthor%5D),
[Harris
G](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Harris+G"%5BAuthor%5D).
Opioid use for moderate to severe pain. J Am Osteopath Assoc. 2005
Jun;105(6 Suppl 3):S2-7.\
<http://www.jaoa.org/cgi/content/full/105/6_suppl_3/S2>

From the Phoenix Indian Medical Center, Indian Health Service, United
States Public Health Service, where Mr Rasor is on staff in the
Department of Physical Therapy and Dr Harris is a full-time attending
physician in the Department of Internal Medicine. Mr Rasor is a
third-year osteopathic medical student at Midwestern University\'s
Arizona College of Osteopathic Medicine in Glendale; he participates in
the Hoop of Learning programs that encourage Native American youth to
pursue careers in healthcare.

See the Primary Care Discussion Forum on this Topic....and many more
resources

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

#### Mary Lynn Eaglestaff, Aberdeen {#mary-lynn-eaglestaff-aberdeen .Style-Heading-4-+-Arial-14-pt-Underline}

#### Preterm Labor: Signs and Symptoms - Patient Education Brochure Aberdeen Area Women's Health Program {#preterm-labor-signs-and-symptoms---patient-education-brochure-aberdeen-area-womens-health-program .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/Pr01.cfm#preLabor**](http://www.ihs.gov/MedicalPrograms/MCH/M/Pr01.cfm#preLabor) {#httpwww.ihs.govmedicalprogramsmchmpr01.cfmprelabor .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### James Galloway, Tucson {#james-galloway-tucson .Style-Heading-4-+-Arial-14-pt-Underline}

**Sunday Morning Program**: **Cardiovascular Disease in AI/AN**

The 46th Annual American Heart Association Conference on CVD
Epidemiology and Prevention is being held from March 2 - 4, 2006 at the
Pointe Hilton Squaw Peak Resort, in Phoenix, Arizona. Following interest
generated by our May Prevention of CVD & DM Conference in Denver,
a special program focused on CVD among American Indians and Alaska
Natives is being held as part of this conference with the heaviest
emphasis on Sunday. If interested in submitting, abstracts are due by
October 3rd\....

**Sunday Morning Program**: **Cardiovascular Disease in American Indians
and Alaska Natives.**

The AHA is pleased to announce an added Sunday Morning Program that will
take place on March 5, 2006. We plan a breakfast scientific symposium
focused on research with American Indians and Alaska Natives. The
program will include invited speakers discussing subclinical
atherosclerosis, dietary, behavioral and classical risk factors, with
emphasis on genetics of cardiovascular risk factors. Presentations will
also review the science of translation of epidemiology and clinical
trial results into practice in these special populations. Registration
to this Program will include breakfast and will be complimentary to
Epidemiology Conference Attendees. The session will adjourn at 11:30 am.
We hope to see you there!

Warm regards, Jim

James M. Galloway, M.D., F.A.C.P., F.A.C.C.\
Director, Native American Cardiology Program\
Tucson Office   (520) 694-7000

[http://www.ihs.gov/medicalprograms/cardiology/card/index.cfm](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/medicalprograms/cardiology/card/index.cfm)

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

#### Ben Garnett, Anchorage {#ben-garnett-anchorage .Style-Heading-4-+-Arial-14-pt-Underline}

#### Passive immunization during pregnancy for congenital cytomegalovirus infection {#passive-immunization-during-pregnancy-for-congenital-cytomegalovirus-infection-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Treatment of pregnant women with CMV-specific hyperimmune globulin is safe, and the findings of this nonrandomized study suggest that it may be effective in the treatment and prevention of congenital CMV infection. A controlled trial of this agent may now be appropriate. {#conclusions-treatment-of-pregnant-women-with-cmv-specific-hyperimmune-globulin-is-safe-and-the-findings-of-this-nonrandomized-study-suggest-that-it-may-be-effective-in-the-treatment-and-prevention-of-congenital-cmv-infection.-a-controlled-trial-of-this-agent-may-now-be-appropriate. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**Nigro G**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Nigro+G"%5BAuthor%5D) et al. Passive immunization during pregnancy for congenital cytomegalovirus infection. N Engl J Med. 2005 Sep 29;353(13):1350-62. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16192480&query_hl=12**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16192480&query_hl=12) {#nigro-g-et-al.-passive-immunization-during-pregnancy-for-congenital-cytomegalovirus-infection.-n-engl-j-med.-2005-sep-29353131350-62.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16192480query_hl12 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**FIT test - Toward a better fecal occult blood test: Comparison with
colonoscopy**

METHODS: Asymptomatic adults underwent 1-time immunochemical FOBT and
total colonoscopy simultaneously. The prevalence and location of
colorectal neoplasia were determined by colonoscopy. The results of
immunochemical FOBT and the colonoscopic findings were compared.

CONCLUSIONS: Although the screening of asymptomatic patients with
immunochemical FOBT can identify patients with colorectal neoplasia to a
certain extent, the sensitivity is relatively low and different
according to the tumor location. Therefore, programmatic and repeated
screening by immunochemical FOBT may be necessary to increase
sensitivity for colorectal cancer detection.

[Morikawa
T](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Morikawa+T"%5BAuthor%5D),
et al A comparison of the immunochemical fecal occult blood test and
total colonoscopy in the asymptomatic population. Gastroenterology. 2005
Aug;129(2):422-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16083699&query_hl=2>

Editorial

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16083728>

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

The FIT immunochemical tests are based on human globin so one doesn\'t
need to have patients avoid red meat and peroxidase containing
vegetables. Slow bleeding from H. pylori disease will still give false
positive test results. Colonoscopy should be the preferred test in
populations with high rates of H. pylori. The FIT tests may have a
future in a colon cancer screening program after future studies
replicate the above findings.

**Q. When should we start colon cancer screening in low risk adults?**

A. Start colon cancer screening at age 50 years old. See details.

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ColonScr10205.doc**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ColonScr10205.doc) {#httpwww.ihs.govmedicalprogramsmchmdocumentscolonscr10205.doc .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Maternal Mortality in Indian Country: Follow-up to September
Abstract**

With the RPMS analysis of maternal Morbidity ICD 9 codes gleaned from
over 6,000 files over a two year period from 5 IHS sites with surgical
obstetric capacity now provides MCH health care providers,
epidemiologists, researchers and program planner's access to data not
previously available.

Maternal morbidity figures prominently in IHS admissions, outpatient
services, lab assessment and medical imaging. Outcomes must be framed in
both maternal and infant indicators. Hidden morbidities of injury and
mental health while queried were found to be universally underreported.
This was not unexpected, but we need the data to tell us what we could
observe. Data quality is being addressed through several ventures. One
of these is with the Office of Information Technology and the analysis
of reported data entered at the service unit and captured through
exports to the national data warehouse. Ultimately a MCH Data Mart will
be able to frame key MCH health issues and protective factors as we
advance in both quantity and quality of data entry and timeliness.

The goal of a MCH Data Mart would is a perinatal data set of real time
clinical utility for service units and one that in the aggregate could
reliably describe AI/AN maternal trends in health. Just as we rely on
timely information for medical action, so to for health care planning
and health policy. Census data, mid-census data, mortality vital
statistics are essential public health data sets but cannot describe the
MCH population here and now. Delivery log aggregate information,
contract health referred patients aggregate information placed in a
registry of some sort can and will meet the needs of those providing the
health care and those seeking to improve MCH health care at the
population level.

The development of the RPMS data query and resultant poster presentation
entitled **Maternal Morbidity during Delivery Hospitalizations in
American Indian and Alaska Native Women** sought to address several
underlying questions. The basic morbidity questions which are addressed
in the poster and which will be presented in manuscript in draft for
publication are nicely laid out in tables and correlated with
intervention of cesarean section and length of stay. Back to the
underlying questions.

1.  Could we get reliable data from RPMS using ICD9 codes to describe
    maternal morbidity? Would there be consistency in the use of codes.

```{=html}
<!-- -->
```
1.  Would the data quality hold up across area and between service
    units? Were we indeed seeing and documenting the same morbidities
    across facilities?

2.  Could we describe somewhat the workforce parameters and provision of
    care by professional category i.e. midwife and obstetrician?

3.  Could we capture such elements as length of stay (LOS), health
    factors (tobacco, alcohol), patient education, injuries (E&M codes)
    and outpatient visits?

4.  We wanted the data to answer questions that OB department chiefs, as
    well as MCH committee's, Directors of Nursing, Health Educators, and
    IHS leadership would want to know.

The RPMS data required statistical software to provide percent
prevalence from this non random sample population. We wanted a workable
number of files. We wanted direct IHS and tribal hospitals to
participate -- they did. The basic question of could we obtain useable
data to make sense of maternal morbidity was answered in the 4 tables
presented. Could we do this for all area's, tribal, direct and contract
health care program -- perhaps. Our CHS data was nil to nonexistent and
would require a specific query and follow-up. Insurance data was
obtained through a second query. Nashville United South and Eastern
Tribes Tribal Epidemiology Center is currently developing and testing a
prenatal registry working directly with CHS personnel in the entry and
tracking of prenatal care as rendered to AI/AN patients in the private
sector. This will have great impact as only 10,000 of the near 40,000
AI/AN births each year are delivered in IHS facilities.

This brings us to the denominator issue and what this study can say
about prenatal care and maternal morbidity and what it cannot. We have
insufficient information from our participating facilities to say what
occurs around patients transferred antenatally or intrapartum and how
this might have altered the picture of maternal morbidity. Fetal
maternal issues that may drive transfer cannot be described here. A
fundamental issue arises in our inability to link maternal parameters
with fetal and infant outcomes. Prematurity, low birth weight, infant
complications are not to be found in this data. The individual sites can
be expected to use their individual files for further secondary
analysis. Linkage of files to a chart audit sampling type methodology is
required. I look forward to these secondary analyses as they are
important and necessary next steps in using this data to inform local
care, staff training, community awareness and the women themselves.

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

This dataset is available to 5 Areas now, but if your Area isn't one of
them, then you can request a review data from your Area data. This is a
great opportunity for you to tease out trends in maternal mortality that
might save future 'near misses' or actual fatalities in your own patient
population. Contact <Judith.Thierry@ihs.gov>

**Here are other resources**

**Maternal Mortality in AI/AN Women: Abstract in September CCCC**

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0905_Coll.cfm>

(scroll down to Dr. Thierry in alphabetical order)

**Underreporting of Pregnancy-Related Mortality in the United States and
Europe**

CONCLUSION: This study shows the limitations of maternal mortality
statistics based on International Classification of Diseases
cause-of-death codes alone. Linkage of births and deaths registers
should routinely be used in the ascertainment of pregnancy-related
deaths. In addition, extension of the definition of a maternal death
should be considered. Beyond pregnancy-related mortality ratios,
considering the specific distribution of causes-of-death is important to
define prevention strategies. LEVEL OF EVIDENCE: II-2

Deneux-Tharaux C et al Underreporting of Pregnancy-Related Mortality in
the United States and Europe Obstetrics & Gynecology 2005;106:684-692

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16199622&dopt=Abstract>

## Maternal Mortality -- The Correct Assessment Is Everything 

Editorial, Green Journal

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16199619&dopt=Abstract>

**Health Care Services Are Not Always Available to Native Americans**

Indian Health Service: GAO-05-789, August 31. Useful graphics

<http://www.gao.gov/new.items/d05789.pdf>

**Using Geographic Information Systems (GIS) to Analyze MCH Epi Data**

Eleventh Annual Maternal and Child Health Epidemiology Conference **-**
AMCHP is partnering with CDC\'s Division of Reproductive Health and
HRSA\'s Maternal and Child Health Bureau to offer training on *Using
Geographic Information Systems (GIS) to Analyze MCH Epi Data*.  The
training will take place on December 5-6, 2005 in Miami, Fla

<http://www.cdc.gov/reproductivehealth/MCHEpi/2005/AboutConference.htm>

**Birth Defects Prevention: Realizing the Full Potential of Folic Acid**

Archived webcast
<http://www.publichealthgrandrounds.unc.edu/folic/webcast.htm>

**Scrub Club: As we enter flu, coughs and cold season - hand washing**

Scrub club is for elementary school children and perhaps Head start --
reinforcing hand washing and spread of respiratory and enteric pathogens
-- interactive, entertaining and includes health facts that would reach
the general classroom, tools for teachers and communities -- the link
opens to a Ann Arbor Michigan school based study video press release and
narrative.

[[http://www.nsf.org/business/newsroom/press_release.asp?p_id=11321]{.underline}](http://www.nsf.org/business/newsroom/press_release.asp?p_id=11321)

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

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

**Do Pregnant Women Require Rectal Swabs for GBS?**

CONCLUSION: The group B streptococci detection rate from
vaginal-perianal specimens is not significantly different from the
detection rate from vaginal-rectal specimens. Therefore, pregnant women
do not need to be subjected to the discomfort of collection of a rectal
specimen. LEVEL OF EVIDENCE: II-2.

Jamie WE, et al. Vaginal-perianal compared with vaginal-rectal cultures
for identification of group B streptococci. Obstet Gynecol November
2004;104:1058-61.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15516402&query_hl=8>

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

While this article is of interest, it is Level II-2 evidence based on a
small study of 200 patients in a prospective cohort. The current CDC
Guidelines still recommend a combined vaginal rectal swab.
<http://www.ihs.gov/MedicalPrograms/MCH/M/DP44.asp#top>

**First Validated Model Predicts Risk of Failed Vaginal Birth After
Cesarean**

The factors that were predictive of emergency c-section were increasing
maternal age, decreasing maternal height, male fetus, no previous
vaginal birth, prostaglandin induction of labor, and birth at later than
40 weeks\' gestation.

CONCLUSIONS: We present, to our knowledge, the first validated model for
antepartum prediction of the risk of failed vaginal birth after prior
cesarean section. Women at increased risk of emergency caesarean section
are also at increased risk of uterine rupture, including catastrophic
rupture leading to perinatal death

[Smith
GC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Smith+GC"%5BAuthor%5D)
et al Predicting cesarean section and uterine rupture among women
attempting vaginal birth after prior cesarean section. PLoS Med. 2005
Sep;2(9):e252.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16146414&query_hl=28>

<http://www.greenjournal.org/cgi/content/abstract/106/4/700>

**MRSA Infection Emerging Problem in Pregnant Patients**

Community-acquired MRSA in pregnancy is an emerging problem that most
commonly presents as recurrent skin and soft tissue infections.
Conclusion: Community-acquired MRSA is an emerging problem in our
obstetric population. Most commonly, it presents as a skin or soft
tissue infection that involves multiple sites. Recurrent skin abscesses
during pregnancy should raise prompt investigation for MRSA. Level of
Evidence: II-3.

[Laibl
VR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Laibl+VR"%5BAuthor%5D)
et al. Clinical Presentation of Community-Acquired Methicillin-Resistant
Staphylococcus aureus in Pregnancy. Obstet Gynecol. 2005
Sep;106(3):461-5.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16135574&query_hl=34>

**Both obesity and excessive weight gain decrease the likelihood for
VBAC**

RESULTS: Obese patients were almost 50% less likely to have a successful
VBAC when compared to underweight patients, odds ratio 0.53, 95%
confidence interval 0.29--0.98, P = .043. Similarly, patients who gained
more than 40 lb were almost 40% less likely to be successful at VBAC
than those who gained less than that amount, odds ratio 0.63, 95%
confidence interval 0.42--0.97, P = .034. They had a VBAC success rate
of 66.8%, whereas patients who gained less than 40 lb were successful
79.1% of the time, P \< .001.

CONCLUSION: Excessive weight gain during pregnancy and obesity both
decrease VBAC success. Proper patient selection will help increase the
likelihood of successful VBAC.

LEVEL OF EVIDENCE: II-2

Juhasz G et al Effect of Body Mass Index and Excessive Weight Gain on
Success of Vaginal Birth After Cesarean Delivery Obstetrics & Gynecology
2005;106:741-746

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16199630&dopt=Abstract>

Postnatal Depression - Clinical Evidence Concise

What are the effects of drug treatments?

likely to be beneficial

**Antidepressants (Fluoxetine \[Included on the Evidence of Its
Effectiveness in the Treatment of Depression in General\]).** One small
randomized controlled trial (RCT) showed limited evidence that
fluoxetine plus one or six cognitive behavior therapy sessions may
improve postnatal depression at four and 12 weeks compared with placebo
plus one or six cognitive behavior therapy sessions. The RCT had
methodologic weaknesses, a high withdrawal rate, and it excluded
breastfeeding women. However, fluoxetine is known to be effective in
managing depression in the general population and therefore is likely
beneficial for the management of postnatal depression.

unknown effectiveness

**Antidepressants Other Than Fluoxetine.** We found no RCTs on the
effects of other antidepressants in women with postnatal depression, and
we found no RCTs that compared other antidepressants with psychological
treatments.

**Hormones.** One small RCT that included women with severe postnatal
depression showed that estrogen treatment improved postnatal depression
at three and six months compared with placebo.

What are the effects of nondrug treatments?

likely to be beneficial

**Nondirective Counseling.** Limited evidence from two RCTs suggested
that, in the short term (immediately after treatment), nondirective
counseling improved postnatal depression compared with routine primary
care. One RCT, with follow-up beyond 12 weeks, showed no clear long-term
benefits (nine months to five years postpartum) from nondirective
counseling compared with routine primary care, individual cognitive
behavior therapy, or psychodynamic therapy.

**Cognitive Behavior Therapy (Individual).** One small RCT showed
limited evidence that individual cognitive behavior therapy and ideal
standard care improved depressive symptoms, but there was no significant
difference between the two interventions. Limited evidence from one RCT
suggested that individual cognitive behavior therapy may improve
postnatal depression in the short term compared with routine primary
care. The RCT found no clear long-term benefits from individual
cognitive behavior therapy compared with routine primary care,
nondirective counseling, or psychodynamic therapy.

**Interpersonal Psychotherapy.** One RCT showed that interpersonal
psychotherapy improved postnatal depression compared with waiting list
controls at 12 weeks.

**Psychodynamic Therapy.** One RCT provided limited evidence that
psychodynamic therapy may improve postnatal depression in the short term
compared with routine primary care. The RCT showed no clear long-term
benefits from psychodynamic therapy compared with routine primary care,
nondirective counseling, or cognitive behavior therapy.

unknown effectiveness

**Light Therapy.** We found no RCTs on the effects of light therapy.

**Cognitive Behavior Therapy (Group).** One small RCT that included
women with a high level of depressive symptoms on screening showed that
group cognitive behavior therapy improved symptoms at six months
compared with routine primary care.

**Psychoeducation with Partner.** One small RCT showed that
psychoeducation with partners reduced patients\' depression scores and
partners\' psychiatric morbidity at 10 weeks compared with
psychoeducation without partners.

**Mother-Infant Interaction Coaching.** One RCT showed that
mother-infant interaction coaching had no significant effect on maternal
depression scores compared with usual treatment, but it improved
maternal responsiveness to the infant within 10 weeks of starting
treatment.

**Telephone-Based Peer Support (Mother-to-Mother).** One small RCT
showed that telephone-based peer support reduced depression scores
compared with usual treatment at four months.

A Publication of BMJ Publishing Group
[***http://www.aafp.org/afp/20051001/bmj.html***](http://www.aafp.org/afp/20051001/bmj.html)

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

**Spotlight on Postpartum Depression - ACOG Co-Sponsors National
Depression Screening**

For the first time in its 15-year history, National Depression Screening
Day (NDSD) is incorporating screening for postpartum depression in its
Mental Health Screening Kits. In an effort to raise awareness about this
often overlooked yet serious condition, the American College of
Obstetricians and Gynecologists (ACOG) is among several health
organizations co-sponsoring NDSD on October 6, 2005
<http://www.acog.org/from_home/publications/press_releases/nr09-30-05-2.cfm>

**Obesity and Diabetes Independently Linked to Adverse Pregnancy
Outcomes**

CONCLUSIONS: In this large, population-based study, obesity and diabetes
were independently associated with adverse pregnancy outcomes,
highlighting the need for women to undergo lifestyle changes to help
them control their weight during the childbearing years and beyond.

[Rosenberg
TJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Rosenberg+TJ"%5BAuthor%5D),
et al Maternal obesity and diabetes as risk factors for adverse
pregnancy outcomes: differences among 4 racial/ethnic groups. Am J
Public Health. 2005 Sep;95(9):1545-51
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16118366&query_hl=6>

**Fetal Pulse Oximetry Reduces Operative Deliveries**

Fetal pulse oximetry does reduce the number of operative deliveries and
the need for fetal scalp sampling in term pregnancies when there is a
nonreassuring FHR pattern. They add that fetal pulse oximetry during
active labor provides a more accurate assessment of fetal well-being and
may reduce the need for interventions.

Kühnert M, Schmidt S. Intrapartum management of nonreassuring fetal
heart rate patterns: a randomized controlled trial of fetal pulse
oximetry. Am J Obstet Gynecol December 2004;191:1989-95.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15592281&query_hl=12>

**Weigh gain correlated with complications in glucose tolerant pregnant
women**

CONCLUSIONS: Increasing weight gain in obese women is associated with
increasing pregnancy complications. Our data suggest that minimal
gestational weight gain might normalize birth weight. Prospective
studies should be performed to clarify the safety of recommending
limited gestational weight gain

[Jensen
DM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Jensen+DM"%5BAuthor%5D),
et al Gestational weight gain and pregnancy outcomes in 481 obese
glucose-tolerant women. Diabetes Care. 2005 Sep;28(9):2118-22.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16123476&query_hl=1>

**Does Mifepristone Induce Labor in Term Pregnancies**?

Up to 600 mg of mifepristone does not induce labor in patients with
unfavorable cervical status. They add that the failure of mifepristone
in this study may be secondary to the conditions in which it was used.
Other studies are needed to determine whether mifepristone effectively
induces labor. Berkane N, et al. Use of mifepristone to ripen the cervix
and induce labor in term pregnancies. Am J Obstet Gynecol January
2005;192:114-20.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15672012&query_hl=19>

**Antibiotics for preterm rupture of the membranes: a systematic
review**

Number needed to treat to avoid neonatal complication: 7 to 17

The authors conclude that the use of antibiotics after PROM reduces
maternal and neonatal morbidity. The data support the routine use of
erythromycin or other penicillins to improve outcomes for mothers and
infants. The authors also advise against the use of
amoxicillin-clavulanate because of its increased risk of necrotizing
enterocolitis. Further long-term follow-up will need to be completed to
assess the health and development of the children involved in this
trial.

Benefit was demonstrated in trials involving penicillins and
erythromycin, but data were insufficient to compare different antibiotic
regimens. Because erythromycin was used in larger trials, the evidence
supporting its use was more robust. The incidence of necrotizing
enterocolitis rose significantly when amoxicillin-clavulanate
(Augmentin) was used.

Kenyon S, et al. Antibiotics for preterm rupture of the membranes: a
systematic review. Obstet Gynecol November 2004;104:1051-7

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15516401&query_hl=8>

**Progesterone Reduces Preterm Birth in High-Risk Mothers**

CONCLUSION: The use of progestational agents and
17alpha-hydroxyprogesterone caproate reduced the incidence of preterm
birth and low birth weight newborns.

Sanchez-Ramos L, et al. Progestational agents to prevent preterm birth:
a meta-analysis of randomized controlled trials. Obstet Gynecol February
2005;105:273-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15684151&query_hl=10>

**Attitudes About Elective Primary Cesarean Delivery**

Approximately two thirds of participants would agree to primary elective
Cesarean delivery, but a much lower percentage would choose this
strategy for their own families-correlate with those of researchers in
other countries. They draw attention to the differences between the
responses from the urogynecology and maternal-fetal medicine
subspecialists and speculate that this reflects the main concerns of the
respective subspecialties. The authors also point out the possibility of
selection bias because of the low response rate.

Wu JM, et al. Elective primary Cesarean delivery: attitudes of
urogynecology and maternal-fetal medicine specialists. Obstet Gynecol
February 2005;105:301-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15684156&query_hl=14>

**Screening for Rh(D) Incompatibility: USPSTF Recommendation Statement**

Summary of Recommendations

**A recommendation** The USPSTF strongly recommends Rh(D) blood typing
and antibody testing for all pregnant women during their first visit for
pregnancy-related care.

**B recommendation** The USPSTF found good evidence that Rh(D) blood
typing, anti-Rh(D) antibody testing, and intervention with Rh(D)
immunoglobulin, as appropriate, prevent maternal sensitization and
improve outcomes for newborns. The benefits substantially outweigh any
potential harms.

The USPSTF recommends repeated Rh(D) antibody testing for all
unsensitized Rh(D)-negative women at 24 to 28 weeks\' gestation, unless
the biologic father is known to be Rh(D) negative.

The USPSTF found fair evidence that repeated antibody testing for
unsensitized Rh(D)-negative women (unless the father also is known to be
Rh\[D\] negative) and intervention with Rh(D) immunoglobulin, as
appropriate, provide additional benefit over a single test at the first
prenatal visit in preventing maternal sensitization and improving
outcomes for newborns. The benefits of repeated testing substantially
outweigh any potential harms.

The USPSTF found no new evidence addressing the role of screening, new
screening tests, new treatment protocols, or potential harms associated
with screening and treatment of Rh(D) incompatibility. However, there is
preexisting good evidence for the efficacy and effectiveness of blood
typing, anti-Rh(D) antibody screening, and postpartum Rh(D)
immunoglobulin prophylaxis.

[http://www.preventiveservices.ahrq.gov](http://www.preventiveservices.ahrq.gov/)

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

**Paroxetine Curbs Premenstrual Dysphoric Disorder**

CONCLUSION: For the treatment of PMDD, luteal phase dosing with 12.5 mg
and 25 mg of paroxetine CR is effective and generally well tolerated

[Steiner
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Steiner+M"%5BAuthor%5D),
et al Luteal phase dosing with paroxetine controlled release (CR) in the
treatment of premenstrual dysphoric disorder. Am J Obstet Gynecol. 2005
Aug;193(2):352-60.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16098854&query_hl=8>

Social and cultural barriers to Pap test screening: Fatalistic
attitudes, lack of support

Fatalistic attitudes, lack of family support, and low levels of
information about cervical cancer are associated significantly with lack
of Pap screening in women with cervical cancer, as are the previously
identified risk factors of recent immigration and low levels of
education. The authors argue that attitudinal, financial, and cultural
barriers must be overcome to improve cervical cancer screening in the
United States, and that development of home testing may have only
limited acceptability. The authors recommend mobilization of community
resources to address attitudinal barriers to cervical cancer screening.

Behbakht K, et al. Social and cultural barriers to Papanicolaou test
screening in an urban population. Obstet Gynecol December
2004;104:1355-61.

[**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15572502&query_hl=6**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15572502&query_hl=6)

Tension-free vaginal tape procedure is effective over a period of 7
years

RESULTS: The follow-up time was a mean of 91 months (range 78-100
months). Both objective and subjective cure rates were 81.3% for the 80
women available for follow-up. Asymptomatic pelvic organ prolapse was
found in 7.8%, de novo urge symptoms in 6.3%, and recurrent urinary
tract infection in 7.5% of the women. No other long-term adverse effects
of the procedure were detected. CONCLUSION: The tension-free vaginal
tape procedure for treatment of female urinary stress incontinence is
effective over a period of 7 years.

Nilsson CG, et al. Seven-year follow-up of the tension-free vaginal tape
procedure for treatment of urinary incontinence. Obstet Gynecol December
2004;104:1259-62.

[**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15572486&query_hl=4**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15572486&query_hl=4)

IDSA Guidelines for Diagnosis and Treatment of Asymptomatic Bacteriuria

The Infectious Diseases Society of America (IDSA) has released
evidence-based recommendations for the diagnosis and treatment of
asymptomatic bacteriuria in adults. The IDSA guidelines, are as follows:

• Diagnosis of asymptomatic bacteriuria should be based on the results
of a urine culture collected in a way that prevents contamination.
Diagnosis of bacteriuria in asymptomatic women is defined as two
consecutive voided urine specimens in which the same strain of bacteria
is isolated in quantitative counts of at least 10^5^ cfu per mL. In men,
diagnosis of bacteriuria is defined as one bacterial species isolated in
a quantitative count of at least 10^5^ cfu per mL in a clean-catch
voided urine sample. In women and men, bacteriuria is diagnosed when, in
a single catheterized urine sample, one bacterial species is isolated in
a quantitative count of at least 10^2^ cfu per mL.

• Antimicrobial treatment is not indicated when pyuria accompanies
asymptomatic bacteriuria.

• Pregnant women should be screened for bacteriuria during early
pregnancy and given antimicrobial therapy for three to seven days if the
results are positive. Women with a positive screen should be monitored
for recurrence of bacteriuria after treatment.

• Shortly before transurethral resectioning of the prostate, patients
should be screened and treated for bacteriuria, but treatment should not
be continued after the procedure unless a catheter remains in place.

• Screening and treatment are recommended before any urologic procedure
in which mucosal bleeding is expected.

• Screening and treatment are not recommended for premenopausal women
who are not pregnant, women with diabetes, older persons living in the
community or institutions, patients with spinal cord injury, or
catheterized patients while the catheter is in situ.

• Physicians should consider antimicrobial treatment of asymptomatic
women with catheter-acquired bacteriuria if it persists for 48 hours
after catheter removal.

• The IDSA does not recommend for or against screening or treatment of
patients with renal or other solid-organ transplants.

March 1, 2005, *Clinical Infectious Diseases*
<http://www.sochinf.cl/documentos/bacteriuria.pdf>

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

#### Management of Spontaneous Abortion {#management-of-spontaneous-abortion-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Spontaneous abortion, which is the loss of a pregnancy without outside intervention before 20 weeks\' gestation, affects up to 20 percent of recognized pregnancies. Spontaneous abortion can be subdivided into threatened abortion, inevitable abortion, incomplete abortion, missed abortion, septic abortion, complete abortion, and recurrent spontaneous abortion. Ultrasonography is helpful in the diagnosis of spontaneous abortion, but other testing may be needed if an ectopic pregnancy cannot be ruled out. Chromosomal abnormalities are causative in approximately 50 percent of spontaneous abortions; multiple other factors also may play a role. Traditional treatment consisting of surgical evacuation of the uterus remains the treatment of choice in unstable patients. Recent studies suggest that expectant or medical management is appropriate in selected patients. Patients with a completed spontaneous abortion rarely require medical or surgical intervention. For women with incomplete spontaneous abortion, expectant management for up to two weeks usually is successful, and medical therapy provides little additional benefit. When patients are allowed to choose between treatment options, a large percentage will choose expectant management. Expectant management of missed spontaneous abortion has variable success rates, but medical therapy with intravaginal misoprostol has an 80 percent success rate. Physicians should be aware of psychologic issues that patients and their partners face after completing a spontaneous abortion. Women are at increased risk for significant depression and anxiety for up to one year after spontaneous abortion. Counseling to address feelings of guilt, the grief process, and how to cope with friends and family should be provided. {#spontaneous-abortion-which-is-the-loss-of-a-pregnancy-without-outside-intervention-before-20-weeks-gestation-affects-up-to-20-percent-of-recognized-pregnancies.-spontaneous-abortion-can-be-subdivided-into-threatened-abortion-inevitable-abortion-incomplete-abortion-missed-abortion-septic-abortion-complete-abortion-and-recurrent-spontaneous-abortion.-ultrasonography-is-helpful-in-the-diagnosis-of-spontaneous-abortion-but-other-testing-may-be-needed-if-an-ectopic-pregnancy-cannot-be-ruled-out.-chromosomal-abnormalities-are-causative-in-approximately-50-percent-of-spontaneous-abortions-multiple-other-factors-also-may-play-a-role.-traditional-treatment-consisting-of-surgical-evacuation-of-the-uterus-remains-the-treatment-of-choice-in-unstable-patients.-recent-studies-suggest-that-expectant-or-medical-management-is-appropriate-in-selected-patients.-patients-with-a-completed-spontaneous-abortion-rarely-require-medical-or-surgical-intervention.-for-women-with-incomplete-spontaneous-abortion-expectant-management-for-up-to-two-weeks-usually-is-successful-and-medical-therapy-provides-little-additional-benefit.-when-patients-are-allowed-to-choose-between-treatment-options-a-large-percentage-will-choose-expectant-management.-expectant-management-of-missed-spontaneous-abortion-has-variable-success-rates-but-medical-therapy-with-intravaginal-misoprostol-has-an-80-percent-success-rate.-physicians-should-be-aware-of-psychologic-issues-that-patients-and-their-partners-face-after-completing-a-spontaneous-abortion.-women-are-at-increased-risk-for-significant-depression-and-anxiety-for-up-to-one-year-after-spontaneous-abortion.-counseling-to-address-feelings-of-guilt-the-grief-process-and-how-to-cope-with-friends-and-family-should-be-provided. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Am Fam Physician 2005;72:1243-50. {#am-fam-physician-2005721243-50. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20051001/1243.html**](http://www.aafp.org/afp/20051001/1243.html) {#httpwww.aafp.orgafp200510011243.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**#1 cause of pediatric deaths!!!**

The number one cause of death for children younger than 14 years is
vehicular injury. Child safety seats and automobile safety belts protect
children in a crash if they are used correctly, but if a child does not
fit in the restraint correctly, it can lead to injury. A child safety
seat should be used until the child correctly fits into an adult seat
belt. It is important for physicians caring for children to know what
child safety seats are available and which types of seats are safest.
Three memory keys will help guide appropriate child safety seat choice:

\(1\) Backwards is Best;

\(2\) 20-40-80; and

\(3\) Boost Until Big Enough.

\"Backwards is Best\" cues the physician that infants are safest in a
head-on crash when they are facing backward. \"20-40-80\" reminds the
physician that children may need to transition to a different seat when
they reach 20, 40, or 80 lb. \"Boost Until Big Enough\" emphasizes that
children need to use booster seats until they are big enough to fit
properly into an adult safety belt. [Biagioli
F](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Biagioli+F"%5BAuthor%5D).
Child safety seat counseling: three keys to safety. Am Fam Physician.
2005 Aug 1;72(3):473-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16100862&query_hl=11>

**Broad portrait of what adolescents are doing and thinking**

Freeze Frame: A Snapshot of America\'s Teens presents data on a wide
variety of topics, from adolescents\' sexual behavior to their religious
beliefs. The chart book, produced by the National Campaign to Prevent
Teen Pregnancy in conjunction with Child Trends, groups data into seven
areas of influence \-- health, family, peers and partners, school,
community, media and consumer behavior, and religious and spiritual
beliefs. The chart book is intended to help correct many common
misconceptions about adolescents as well as to provide adults and those
working directly with adolescents with a more textured understanding of
adolescents.
[[http://www.teenpregnancy.org/works/pdf/FreezeFrame.pdf]{.underline}](http://www.teenpregnancy.org/works/pdf/FreezeFrame.pdf)

**Concussion tool kit for coaches**

The Heads Up: Concussion in High School Sports tool kits will be
distributed by CDC to coaches, principals, and athletic directors at
high schools throughout the United States. The tool kits can be ordered
or downloaded free of charge at
[[http://www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm]{.underline}](http://www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm).

CDC Injury Center Media Relations, telephone 770-488-4902

AAP Report on Pregnancy in Adolescents

The American Academy of Pediatrics (AAP) published a clinical report on
the state of adolescent pregnancy in the United States. \"Adolescent
Pregnancy: Current Trends and Issues\"

Recently the percentage of adolescents who are sexually active has
decreased; however, more than 45 percent of current high school-aged
females and 48 percent of high school-aged males report having had
sexual intercourse. The average age at first intercourse is 16 years for
males and 17 years for females.

According to the report, use of contraception by adolescents is
increasing, but 50 percent of all adolescent pregnancies occur within
six months of first intercourse. In 2003, almost one half of sexually
active adolescents reported not using a condom the last time they had
intercourse. Many adolescents who reported using prescription
contraceptives indicated a gap of at least one year between the time
that they first had intercourse and the time that they visited a
physician to seek a prescription contraceptive.

The United States has the highest adolescent birth rate among
industrialized nations. Nearly 900,000 U.S. teenagers become pregnant
each year, according to the report, and four in 10 women have been
pregnant at least once before 20 years of age. Approximately 51 percent
of adolescent pregnancies end in live birth, 35 percent in induced
abortion, and 14 percent in miscarriage or stillbirth. Twenty-five
percent of adolescent births are not first births, and the risk for
pregnancy increases after an adolescent has had one infant.

Significantly more adolescents who live in poverty become pregnant than
do those from higher-income families. The total percentage of
adolescents who live in low-income families is 38 percent; however, 83
percent of adolescents who give birth and 61 percent who have abortions
are from low-income families. Similar to adolescent mothers, adolescent
fathers are more likely than their peers to come from low-income
families, have poor academic performance, drop out of school, and have
decreased income potential.

The report indicates that in 2001, almost 79 percent of all adolescents
who gave birth were unmarried, a statistic that has been rising since
1971. More than 90 percent of pregnant patients 15 to 19 years of age
said their pregnancies were unplanned.

Pregnant patients younger than 17 years have a higher risk of medical
complications than do older patients. Compared with adults, adolescents
give birth to twice as many low birth weight infants, and the neonatal
mortality rate is three times higher. Although still low, the maternal
mortality rate is twice as high for adolescents. Adolescent pregnancy is
associated with poor maternal weight gain, prematurity,
pregnancy-induced hypertension, anemia, sexually transmitted diseases,
substance abuse, and poor nutritional intake. Adolescent pregnancy also
causes psychosocial problems such as interruption of school, persistent
poverty, limited vocational opportunities, separation from the child\'s
father, divorce, and repeat pregnancy. The children of adolescent
mothers are at higher risk for developmental delays, academic
difficulties, behavior disorders, substance abuse, early sexual
activity, depression, and adolescent pregnancy.

The AAP reports that the most successful programs to prevent adolescent
pregnancy include the promotion of abstinence along with information on
and dissemination of contraception, sexuality education,
school-completion programs, and job training. Parents, schools,
religious institutions, physicians, social and government agencies, and
adolescents themselves all should be a part of successful prevention
programs. Research shows that discussion of contraception does not
increase sexual activity, and programs that promote abstinence along
with contraception do not decrease contraceptive use.
[http://www.pediatrics.org](http://www.pediatrics.org/)

**Children's Health Month CDC**

Contains several agency helpful web sites
[[http://www.childrenshealth.gov/]{.underline}](http://www.childrenshealth.gov/)

**Toxicity and Exposure Assessment for Children\'s Health (TEACH)**

<http://www.epa.gov/teach/>

**The ABCs of Raising Healthy Kids: Steps to Staying Safe and Healthy-
CDC**

[[http://www.cdc.gov/od/spotlight/nwhw/kids/abc.htm]{.underline}](http://www.cdc.gov/od/spotlight/nwhw/kids/abc.htm)

**How Parents can Encourage Girls to Play Sports **

[[http://www.cdc.gov/tobacco/sport_initiatives/daugthertips.htm]{.underline}](http://www.cdc.gov/tobacco/sport_initiatives/daugthertips.htm)

**7-Valent Pneumococcal Conjugate Vaccine Impact on Invasive
Pneumococcal Disease**

Direct and Indirect Effects of Routine Vaccination of Children with
7-Valent Pneumococcal Conjugate Vaccine on Incidence of Invasive
Pneumococcal Disease \-\-- United States, 1998---2003. September 16,
2005 / 54(36);893-897
[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5436a1.htm](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5436a1.htm)   

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

**Native Americans with highest rates of major depressive disorder**

Findings from the largest survey ever mounted on the co-occurrence of
psychiatric disorders among U.S. adults afford a sharper picture than
previously available of major depressive disorder\* (MDD) in specific
population subgroups and of MDD\'s relationship to alcohol use disorders
(AUDs) and other mental health conditions. The new analysis of data From
the 2001-2002 National Epidemiologic Survey of Alcohol and Related
Conditions (NESARC) shows for the first time that middle age and Native
American race increase the likelihood of current or lifetime MDD, along
With female gender, low income, and separation, divorce, or widowhood.

Asian, Hispanic, and black race-ethnicity reduce that risk.

Among race-ethnic groups, Native Americans showed the highest (19.17
percent) lifetime MDD prevalence, followed by whites (14.58 percent),
Hispanics (9.64 percent), Blacks (8.93 percent), and Asian or Pacific
Islanders (8.77 percent). Since information is scarce on diagnosed
Mental disorders among Native Americans, this finding appears to warrant
Increased attention to the mental health needs of that group, the
authors maintain.

Major depression is a prevalent psychiatric disorder and a pressing
Public health problem. That it so often accompanies alcohol dependence
raises questions about when and how to treat each diagnosis. Today\'s
results both inform clinical practice and Provide researchers with
information to advance hypotheses about common biobehavioral factors
that may underlie both conditions.

The NESARC results demonstrate a strong relationship of MDD to substance
\"dependence\" and a weak relationship to substance \"abuse\", a finding
that suggests focusing on dependence when studying the relationship of
Depression to substance use disorders. This research direction is
supported by earlier genetic studies that identified factors common to
MDD and alcohol Dependence and at least one epidemiologic study that
demonstrated excess MDD among long-abstinent former alcoholics.

Coexisting substance dependence disorder and MDD predict poor outcome
among clinic patients. A decade ago, many treatment leaders discouraged
Treating MDD in patients with substance dependence on the grounds that
arresting substance dependence was the more immediate need and that its
resolution well might also resolve MDD. Results from foregoing
epidemiologic surveys and several clinical trials over time altered that
picture, so that treating both disorders simultaneously is today common
practice.

Grant BR et al Epidemiology of Major Depressive Disorder 2005 Archives
of General Psychiatry October 3 National Institute on Alcohol Abuse and
Alcoholism (NIAAA) Laboratory of Epidemiology and Biometry, NIH
<http://niaaa.census.gov/>
[[www.jamamedia.org]{.underline}](../www.jamamedia.org)

**\"Menopausal Arthritis\" May Develop in Women Receiving Aromatase
inhibitors**

Estrogen deprivation may be associated with increased arthralgias in
women secondary to greater sensitivity to nociceptive stimuli, which is
mediated by NO and prostaglandin E~2~; production of enkephalin in the
spinal cord; and opioid effects on the CNS.

The arthralgias of estrogen deprivation are typically characterized by
joint pains in the hands, knees, hips, lower back, and shoulders, and by
early morning stiffness.

[Felson
DT](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Felson+DT"%5BAuthor%5D),
[Cummings
SR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Cummings+SR"%5BAuthor%5D).
Aromatase inhibitors and the syndrome of arthralgias with estrogen
deprivation. Arthritis Rheum. 2005 Sep;52(9):2594-2598.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16142740&query_hl=5>

**Metformin for Overweight and Obese Adults: Not proven outside of DM or
PCOS yet**

CONCLUSION Insufficient evidence exists for the use of metformin as
treatment of overweight or obese adults who do not have diabetes
mellitus or polycystic ovary syndrome. Further studies are needed to
answer this clinical question.

Levri KM et al Metformin as Treatment for Overweight and Obese Adults: A
Systematic Review Annals of Family Medicine 3:457-461 (2005)
<http://www.annfammed.org/cgi/content/full/3/5/457>

**Systematic review: TCAs and SSRIs effective, low-dose TCAs also
effective - primary care**

CONCLUSION This systematic review is the first comparing antidepressants
with placebo for treatment of depression in primary care. Both TCAs and
SSRIs are effective. This review is also the first to show that low-dose
TCAs are effective in primary care. Prescribing antidepressants in
primary care is a more effective clinical activity than prescribing
placebo

Bruce Arroll, et al Efficacy and Tolerability of Tricyclic
Antidepressants and SSRIs Compared With Placebo for Treatment of
Depression in Primary Care: A Meta-Analysis Annals of Family Medicine
3:449-456 (2005) <http://www.annfammed.org/cgi/content/full/3/5/449>

**Blood pressure reading is one of the most inaccurately performed
measurements**

Updated Hypertension Guidelines - Diagnosis and treatment of
hypertension depend on accurate measurement of auscultatory blood
pressure. The lowering of target blood pressure for patients with
diabetes or renal disease has made detection of small differences more
important. However, blood pressure reading is one of the most
inaccurately performed measurements in clinical medicine.

\"True\" blood pressure is defined as the average level over a prolonged
duration. Thus, in-clinic blood pressure measurement, which generally
makes no allowance for beat-to-beat variability, can be a poor
estimation and may fail to catch high blood pressure that occurs only
outside the clinic setting. In addition, faulty methods and the \"white
coat effect\" (an increase in blood pressure when a physician is
present) may lead to misdiagnosis of hypertension in normotensive
patients. To increase accuracy of clinic readings, and in recognition of
major changes over the past 10 years (including the prohibition of
mercury in many countries), the American Heart Association (AHA) has
published a new set of recommendations for the measurement of blood
pressure.

[Pickering
TG](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Pickering+TG"%5BAuthor%5D)
et al Recommendations for blood pressure measurement in humans and
experimental animals: Part 1: blood pressure measurement in humans: a
statement for professionals from the Subcommittee of Professional and
Public Education of the American Heart Association Council on High Blood
Pressure Research.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15611362&dopt=Abstract>

**Exercise Training Beneficial for Older Women with CAD**

CONCLUSIONS: Older women with CAD should perform aerobic and strength
training to attain optimal improvements in overall physical fitness and
quality of life

Hung C, et al. Exercise training improves overall physical fitness and
quality of life in older women with coronary artery disease. Chest
October 2004;126:1026-31.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15486358&query_hl=4>

**Should all patients with fever, rash, and pharyngitis be tested for
acute HIV infection?**

**PURPOSE** Recognizing primary human immunodeficiency virus (HIV)
infection is important for public health. The prevalence in outpatient
settings is largely unknown but would be useful in developing testing
guidelines. The objective of this study is to estimate the national
prevalence of primary HIV infection in symptomatic ambulatory patients
regardless of risk factors. **RESULTS** Patients complaining of fever
and other visit reasons consistent with primary HIV infection had a
disease prevalence of 0.66% (0.57%--1.02%), those with rash had a
prevalence of 0.50% (0.31%--0.82%), and those with pharyngitis had a
prevalence of 0.16% (0.11%--0.22%). Patients with other symptoms
represented numbers of visits insufficient for reliable estimates of
their prevalence. **CONCLUSIONS** These estimates of the prevalence of
primary HIV infection in ambulatory patients with fever, rash, and
pharyngitis can aid with development of clinical testing guidelines and
clinical decisions around testing for acute HIV infection.

Coco A. Prevalence of Primary HIV Infection in Symptomatic Ambulatory
Patients *Annals of Family Medicine* 3:400-404 (2005)
<http://www.annfammed.org/cgi/content/full/3/5/400>

**New Guidelines for Diagnosis and Management of Metabolic Syndrome**

The AHA and NHLBI writing group found the NCEP-ATP III criteria to be
robust and clinically useful, and they recommended maintaining them with
minor modifications

[Grundy
SM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Grundy+SM"%5BAuthor%5D),
et al Diagnosis and Management of the Metabolic Syndrome. An American
Heart Association/National Heart, Lung, and Blood Institute Scientific
Statement. Circulation. 2005 Sep 12
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16157765&query_hl=7>

**Diverticular Disease: Diagnosis and Treatment**

Diverticular disease refers to symptomatic and asymptomatic disease with
an underlying pathology of colonic diverticula. Predisposing factors for
the formation of diverticula include a low-fiber diet and physical
inactivity. Approximately 85 percent of patients with diverticula are
believed to remain asymptomatic. Symptomatic disease without
inflammation is a diagnosis of exclusion requiring colonoscopy because
imaging studies cannot discern the significance of diverticula. Fiber
supplementation may prevent progression to symptomatic disease or
improve symptoms in patients without inflammation. Computed tomography
is recommended for diagnosis when inflammation is present. Antibiotic
therapy aimed at anaerobes and gram-negative rods is first-line
treatment for diverticulitis. Whether treatment is administered on an
inpatient or outpatient basis is determined by the clinical status of
the patient and his or her ability to tolerate oral intake. Surgical
consultation is indicated for disease that does not respond to medical
management or for repeated attacks that may be less likely to respond to
medical therapy and have a higher mortality rate. Prompt surgical
consultation also should be obtained when there is evidence of abscess
formation, fistula formation, obstruction, or free perforation. Am Fam
Physician 2005;72:1229-34, 1241-2.
<http://www.aafp.org/afp/20051001/1229.html> (also see Patient
Education, below)

**Herpes Zoster and Postherpetic Neuralgia: Prevention and Management**

The recognizable appearance and the dermatomal distribution of herpes
zoster lesions usually enable a clinical diagnosis to be made easily.
Herpes zoster and postherpetic neuralgia occur mainly in older patients.
The role of the varicella vaccine in preventing herpes zoster is
uncertain, but is being studied. There is evidence to support using
antiviral therapy and possibly low-dose tricyclic antidepressants to
prevent postherpetic neuralgia. There is good evidence that treating
herpes zoster with antiviral medication is beneficial, particularly in
patients older than 50 years with severe outbreaks. The use of steroids
has an unfavorable risk-benefit ratio. In patients who develop
postherpetic neuralgia, there is good evidence to support treatment with
gabapentin and tricyclic antidepressants. More evidence for treatment
with capsaicin cream, lidocaine patch, and opioids is needed.
Intrathecal methylprednisolone is an option for patients with persistent
pain. Am Fam Physician 2005;72:1075-80, 1082.
<http://www.aafp.org/afp/20050915/1075.html>

**Respecting End-of-Life Treatment Preferences**

Most patients eventually must face the process of planning for their
future medical care. However, few Americans have a living will or a
durable power of attorney for health care. Although advance directives
provide a legal basis for physicians to carry out treatment using a
health care proxy or a living will, they also should reflect the
patient\'s values and preferences. Family physicians are in a position
to integrate medical knowledge, individual values, and cultural
influences into end-of-life care. Family physicians can best respect the
autonomy of patients by allowing the patient and family to prospectively
identify relevant health care preferences, by sustaining an ongoing
discussion about end-of-life preferences, and by abiding by the
decisions their patients have made. Am Fam Physician 2005;72:1263-8,1270
<http://www.aafp.org/afp/20051001/1263.html>

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

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

Does a Low Glycemic Index Diet Reduce CHD?

Clinical Question - Cochrane Briefs

For patients with risk factors for coronary heart disease (CHD), does a
low glycemic index diet reduce heart disease or improve risk factors?

Evidence-Based Answer

There is limited, weak evidence that a low glycemic index diet improves
risk factors for CHD, but there are no randomized controlled trials
(RCTs) showing a reduction in morbidity or mortality. (SORT rating C)

Practice Pointers

CHD is associated with high fat intake. However, there is uncertainty
regarding how rapidly-metabolized dietary carbohydrates may affect the
risk for heart attack and stroke. The glycemic index is a measure of the
effect of dietary carbohydrate on blood glucose, on a scale from zero to
100; higher numbers correspond to a greater effect.

Kelly and colleagues systematically reviewed RCTs to determine whether a
low glycemic index diet decreased mortality or CHD events
(patient-oriented outcomes) or had a beneficial effect on risk factors
for CHD such as abnormal lipids, glucose metabolism, blood pressure,
weight, and clotting factors (surrogate markers that may or may not
affect patient outcomes). Fifteen trials lasting four weeks or more were
identified. Interventions included dietary advice or a prescribed diet
for adult outpatients with at least one major risk factor. None of the
studies reported morbidity or mortality. The studies were of poor
quality and had too few patients to identify clinically important
effects. There was a small reduction in A1C (0.45 percent) and total
cholesterol levels (6.6 mg per 100 mL \[0.17 mmol per L\]). However,
these outcomes were not sufficient to recommend low glycemic index diets
for patients with risk factors for CHD.

Despite the lack of supporting evidence, several organizations recommend
diets rich in complex carbohydrates for patients with risk factors for
CHD. The National Cholesterol Education Program (NCEP) recommends that
50 to 60 percent of calories come from foods rich in complex
carbohydrates, including grains (especially whole grains), fruits, and
vegetables; this is essentially a low glycemic index diet. The American
Dietetic Association supports the dietary recommendations of the NCEP
for patients with hyperlipidemia. The U.S. Preventive Services Task
Force recommends intensive behavioral dietary counseling for adult
patients with hyperlipidemia and other known risk factors for
cardiovascular **disease**, but does not specify which diet should be
recommended.

Kelly S, et al. Low glycaemic index diets for coronary heart disease.
Cochrane Database Syst Rev 2004;(4):CD004467.
[**http://www.aafp.org/afp/20051001/cochrane.html**](http://www.aafp.org/afp/20051001/cochrane.html)

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

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

**Racial and Ethnic Disparities in Women\'s Health**

ACOG Committee Opinion No. 317

ABSTRACT: Significant racial and ethnic disparities exist in women\'s
health. These health disparities largely result from differences in
socioeconomic status and insurance status. Although many disparities
diminish after taking these factors into account, some remain because of
health care system-level, patient-level, and provider-level factors. The
American College of Obstetricians and Gynecologists strongly supports
the elimination of racial and ethnic disparities in the health and the
health care of women. Health professionals are encouraged to engage in
activities to help achieve this goal.

Racial and Ethnic Disparities in Women\'s Health. ACOG Committee Opinion
No. 317. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2005;106:889-92.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16199655&query_hl=4>

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

The College has long been dedicated to the improvement of AI / AN
women\'s health disparities through the many projects of the ACOG
Committee on American Indian Affairs. A few of those projects include:

ACOG /IHS Postgraduate Course on Obstetric, Neonatal, and Gynecologic
Care

<http://www.ihs.gov/MedicalPrograms/MCH/M/ACOG01.cfm>

ACOG Fellows in Service Program

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

ACOG Committee on American Indian Affairs --see for many activities

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHacogAIA.asp#AIAtop>

Annual IHS Area Site Visits

<http://www.ihs.gov/MedicalPrograms/MCH/M/ACOG01_nAlaska.cfm#northToAk>

Liaison Relationship -- AAP, Committee on Native American Child Health
(CONACH)

<http://www.aap.org/nach/>

**The Role of the Obstetrician--Gynecologist in the Assessment and
Management of Obesity**

ACOG Committee Opinion No. 319

ABSTRACT: Approximately one third of all women in the United States are
obese. Obstetrician--gynecologists should evaluate all women for obesity
by calculating a body mass index (BMI) measurement and should offer
appropriate interventions or referrals to promote a healthy weight and
lifestyle.

The role of the obstetrician--gynecologist in the assessment and
management of obesity. ACOG Committee Opinion No. 319. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2005;106:895--9.

Press release

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16199657&query_hl=6>

**Smoking Cessation During Pregnancy**

ACOG Committee Opinion No. 316

ABSTRACT: Smoking is one of the most important modifiable causes of poor
pregnancy outcomes in the United States. An office-based protocol that
systematically identifies pregnant women who smoke and offers treatment
has been proved to increase quit rates. For pregnant women who are light
to moderate smokers, a short counseling session with pregnancy-specific
educational materials often is an effective intervention for smoking
cessation. The 5 A\'s is an office-based intervention developed for use
by trained practitioners. Techniques for smoking reduction,
pharmacotherapy, and health care support systems can help smokers quit.

Smoking cessation during pregnancy. ACOG Committee Opinion No. 316.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2005;106:883--8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16199654&query_hl=8>

**Screening for Tay--Sachs Disease**

Committee Opinion No. 318

ABSTRACT: Tay--Sachs disease (TSD) is a severe progressive neurologic
disease that causes death in early childhood. Carrier screening should
be offered before pregnancy to individuals and couples at high risk,
including those of Ashkenazi Jewish, French--Canadian, or Cajun descent
and those with a family history consistent with TSD. If both partners
are determined to be carriers of TSD, genetic counseling and prenatal
diagnosis should be offered.

Screening for Tay--Sachs disease. ACOG Committee Opinion No. 318.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2005;106:893--4.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16199656&query_hl=11>

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

**Supracervical and total abdominal hysterectomy result in similar
sexual functioning and quality of life 2 years later**
<http://www.ahrq.gov/research/aug05/0805RA11.htm>

**Women with atherosclerosis and high cholesterol receive less intense
cholesterol management than men**
<http://www.ahrq.gov/research/aug05/0805RA10.htm>

**Estrogen therapy with progestin has higher discontinuation rates in
women with diabetes and cardiovascular disease**
<http://www.ahrq.gov/research/aug05/0805RA12.htm>

#### 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}

**Help Us Establish a Free Electronic Patient Education Resource
Center**

Studies show that Native Americans react more favorably when educational
materials include Native Americans in the pamphlets, videos, and
posters. While there is an abundance of patient educational materials
out there, few of them on Native American-specific. But now a new
project will collect Native American oriented patient education
materials for IHS clinicians. You can help.

The goal is to have an electronic resource that is available IHS-wide.
Clinicians will be able to download and print materials in the clinic or
hospital setting, at the point-of-care. Providing patient education
materials in conjunction with the clinician's advice strengthens the
message and improves health behavior.

This project is the joint effort of Mary Wachacha, IHS Health Education
Consultant and Dr. Charles (Ty) Reidhead, Internal Medicine Chief
Clinical Consultant. If you have any questions, please contact Mary
Wachacha, Dr. Reidhead or myself, Diane Cooper, via email. We are all on
the Global Outlook email system.

Help build this IHS-wide electronic National Patient Education Library.
Send me any patient education materials that you are using now and have
found useful in your patient care. If they are in electronic format you
can send by email. If not just mail a copy and, it can be scanned to
make it an electronic version. Please note in your correspondence if the
material is copyrighted. I will get the permission from the originating
organization if it is used. <cooperd@mail.nih.gov>

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

An Open Letter to Health Care Providers Attending to Families Affected
by Hurricane Katrina: The Role of Human Milk and Breastfeeding

You are caring for children and adults under the most stressful and
distressing situations during this post-Katrina period.  We all thank
you and honor you for this heroic effort.  Please consider the value of
human milk and breastfeeding as an important component of this care of
both young children and their mothers.  Human milk is a valuable
resource that can not only protect the vulnerable infant from disease,
but can also promote psychological health and comfort during stressful
times.  Human milk reduces pain and promotes more rapid healing after
injuries and infections.  While maternal health is of great importance,
it should be recognized that even the malnourished mother will produce
milk of good quality for her infant.

The American Academy of Pediatrics (AAP) states that "breastfeeding
ensures the best possible health as well as the best developmental and
psychosocial outcomes for infants."  Under situations of displacement,
poor sanitation, inadequate food resources, threats of infection, and
severe anxiety, human milk and breastfeeding have a particularly
important role to play in protecting the vulnerable infant from
infection and psychological trauma.  One example of this protection is
the remarkable reduction in diarrhea in breastfed infants who are
exposed to shigella, a common cause of dysentery. 

During this post-Katrina, health care workers should make every effort
to promote breastfeeding of newborn infants by:

> 1)      urging pregnant women to breastfeed immediately after delivery
> of their infant,
>
> 2)      urging new mothers to start breastfeeding at any time during
> the early weeks after
>
> birth
>
> 3)      urging breastfeeding mothers to continue exclusive
> breastfeeding for six months
>
> 4)      urging breastfeeding mothers to continue breastfeeding for at
> least one year and
>
> longer, even after starting other foods.

La Leche League International and the Section on Breastfeeding of the
American Academy of Pediatrics, as well as many other experts on
breastfeeding stand ready to assist you in your efforts to promote,
protect and support breastfeeding and the use of human milk.

Lawrence M. Gartner, M.D.

Member, Professional Advisory Board of LLLI

Chair, Section on Breastfeeding of the AAP

Professor Emeritus, The University of Chicago

**Case Managers Corner**

**Great opportunity for any AI/AN nurses with Masters or PhDs - Request
from HRSA**

Here is a great opportunity for any AI/AN nurses with Masters or PhDs
who are Tribal Employees (not federal). If you have anyone who comes to
mind as highly recommend, please forward their name and contact
information to me ASAP. Details of what is expected or how reviews are
handled will be between HRSA and the nurse. As such, I cannot answer any
specific questions. Thanks, Sandy <Sandra.Haldane@ihs.gov>

[HRSA is seeking]{.underline} additional nurses who have American Indian
or Alaska Native background who would be interested in serving as peer
reviewers for the Advanced Education Nursing program applications. They
are also seeking those who in the future might be interested in chairing
these reviews. For FY 2006, the review is expected to be in Washington,
DC area in late February or early March.

####  {#section-11 .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}

-Cesarean delivery in AI/AN women: How are low rates explained?

-Diabetes prevention and control - Prenatal program

-Maternal Morbidity in AI/AN Women, 2002-2004

-Meperidine for Dystocia During First Stage of Labor: Limit Use

-PID: Outpatient treatment was as effective in preventing reproductive
morbidity

-Adolescents Prefer Honesty and Patient-Centered Care

-One Third of Deaths From GI Bleeding Due to NSAIDs

-Elaine Locke: Key Contributor to Improve AI/ AN Women's Health for 35
years

-Management of abnormal cervical cytology and histology, ACOG Practice
Bulletin

-AHRQ Research Activities Relevant to the American Indian and Alaska
Native Community

-Glyburide nor glipizide compatible with breast-feeding

-Wouldn't it be nice if there was more distance education available to
nurses?

-Cancer screening in elderly patients: a framework for individualized
decision making

-EC in adolescents: No compromise of family planning or increased sexual
behavior

-CDC "Key Facts about Flu Vaccine"

-Magical Mystery Tour: Overbooked clinic and next patient with chronic
pelvic pain

-Public health approach to suicide prevention in an American Indian
Tribal Nation

-Follow-up of Last month's Corner Ortho Evra discussion

-Electronic Health Record for care of women and children

-First trimester prenatal genetic screening:  Is it ready for 'Prime
Time' at your facility?

-Primary Care Discussion Forum-November 1, 2005 - Rectal bleeding: Is it
hemorrhoids?         

-Appropriate use of narcotics for chronic non-malignant pain, Chuck
North, ABQ

-Screening for sexually transmitted diseases in non-traditional
settings: a personal view

September 2005 CCC Corner Online

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0905.cfm>

####  {#section-12 .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-13 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**October is Domestic Violence Awareness Month**

Every October, Domestic Violence Awareness Month activities are planned
across the country. National, state, and community-based domestic
violence prevention and victim service organizations, corporations,
health care providers, faith-based groups, and other organizations. To
keep up to date with the latest events, news, and materials, go to 
[www.ncadv.org](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ncadv.org/)

 

[The Impact of Disaster on Battered Women]{.underline}

Battered women and their children are less safe than ever in the wake of
a disaster.  When hurricane Katrina struck the Gulf Coast on August
29th, at least seven domestic violence shelters, transitional housing
programs, and outreach organizations were impacted by the storm's
severity.  \...

[VAWA]{.underline}

The Violence Against Women Act (VAWA) of 2000 expires in September of
2005 and the remarkable gains we\'ve made in ending domestic and sexual
violence could come to a halt if Congress does not act quickly. During
the past decade, VAWA of 1994 and 2000 have provided tremendous
resources and protections for victims of domestic violence and sexual
assault. \...

**Domestic Violence Prevention Enhancement and Leadership Through
Alliances (DELTA)**

Primary prevention is the cornerstone of the DELTA Program. Program
activities are guided by a set of prevention principles including:

-   Preventing first-time perpetration and first-time victimization;

-   Reducing risk factors associated with IPV perpetration or
    victimization;

-   Promoting protective factors that reduce the likelihood of IPV;

-   Evidence-based program planning;

-   Using behavior and social change theories in prevention program
    planning and evaluation; and

-   Evaluating prevention programs and using results to inform future
    program plans.

<http://www.ihs.gov/MedicalPrograms/MCH/W/DV08.cfm#Delta>

**Indian Health Violence Against Women web site**

A large number of helpful resources
<http://www.ihs.gov/MedicalPrograms/MCH/W/DV00.cfm>

**50 Tribal TANF sites, updated August 2005**

<http://www.acf.hhs.gov/programs/dts/ttanfcont_1002.htm>

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

**Cancer screening in elderly patients: a framework for individualized
decision making**

Most cancers increase in incidence with age, while the benefit of
screening for elders is diluted by competing mortality from age and
chronic disease. How do we properly counsel elders about the benefits
and risks of cancer screening in advanced age? In this article the
authors suggest an interesting strategy for evaluating the value of
screening for cancer in the elderly. They note that the likelihood of
benefit from screening to detect cancer depends on several quantifiable
factors, including the risk of death from the specific cancer, life
expectancy, and screening factors (how well the screening test works).
Based on this data, they calculate the number needed to screen (NNS) to
prevent one cancer death at selected ages for the highest, middle, and
lowest quartiles of life expectancy.

The results of this analysis can be quite striking. For women in the
highest quartile of life expectancy at age 80 (vigorous, health
octogenarians without chronic disease), 240 mammograms would be needed
to prevent one death from breast cancer, comparing favorably to 226
mammograms needed to prevent a single death by breast cancer in women at
age 50 in the lowest quartile of life expectancy. For men in the highest
quartile of life expectancy at age 85 the benefits of colorectal cancer
screening (NNS=554) are greater than for men in the lowest quartile of
life expectancy at age 50 (NNS=630). Tables published in the paper
outline these relationships in selected ages in very useful ways.

These findings match our clinical understanding that it is the overall
health and vigor of the elder, not his or her age, that is important in
these decisions and provide real information to bolster and clarify that
understanding. The authors take pains to point out that the decision to
screen or not screen, at any age, should be driven by the individual's
health goals, values and preferences, informed by the best information
we can offer.

[Walter LC, Covinsky
KE.](http://www.ncbi.nlm.nih.gov.libproxy.unm.edu/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11386931&query_hl=1)
Cancer screening in elderly patients: a framework for individualized
decision making. JAMA. 2001 Jun 6;285(21):2750-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11386931&query_hl=23>

**Guest Comment: Bruce Finke, IHS Elder Care Initiative**

It does no one any good (and can do significant harm) to urge cancer
screening for frail elders who are unlikely to benefit. At the same
time, we do a disservice to vigorous, health elders if we underestimate
the possible benefit of screening based on age alone. The tables
provided in this paper allow us give our elders real and specific
information about the possible benefit of cancer screening to help them
make their decisions*.*

**Stop Abuse and Sexual Assault against older individuals: Grants
available**\
This discretionary grant program was created by the Violence Against
Women Act of 2000 to increase and strengthen training for law
enforcement, prosecutors, and the judiciary in recognizing,
investigating, and prosecuting instances of abuse, neglect,
exploitation, domestic\
violence, and sexual assault against older individuals and individuals
with disabilities.  OVW will release a solicitation for the Training
Grants Program in January 2006. The solicitation will include detailed
information about specific requirements and funding levels and will be
available on the OVW website. Contact Janice Green at (202) 616-6728 or
at <Janice.A.Green@usdoj.gov>

#### Family Planning Forwarded by Tony Ogburn, M.D., University of New Mexico {#family-planning-forwarded-by-tony-ogburn-m.d.-university-of-new-mexico .Style-Heading-4-+-Arial-14-pt-Underline}

# ParaGard^®^ T 380A Approved for Nulliparous Women in Stable Relationships from Age 16

The U.S. Food and Drug Administration (FDA) has approved an updated
label for its intrauterine device (IUD), ParaGard^®^ T 380A Intrauterine
Copper Contraceptive. 

The new prescribing information for ParaGard excludes nulliparity as a
contraindication, confirming that the risk of pelvic infection is more
related to a patient's sexual behavior than her contraceptive choice. 
Hormone-free ParaGard is also no longer contraindicated for women with a
history of sexually transmitted diseases or pelvic inflammatory disease
unless a patient currently has acute PID or engages in sexual behavior
suggesting a high risk for PID.   Finally, mutual monogamy is no longer
a user requirement, although use by women is a stable relationship is
encouraged. 

\"The FDA's approval of a less restrictive patient profile for ParaGard
confirms what many health care providers have known for years," said Dr.
Laura MacIsaac, director of family planning at Albert Einstein Medical
College and chief medical officer at FEI Women's Health.  "ParaGard is
safe, effective and the most appropriate contraceptive for many women to
use throughout their reproductive lives -- from age 16 through
menopause."

ParaGard is the only IUD available with no hormonal side effects,
potentially making it a great choice for women who cannot -- or prefer
not -- to take hormones.  Also due to ParaGard's hormone-free mechanism
of action, it is the recommended contraceptive choice by the American
College of Obstetricians and Gynecologists, as well as the World Health
Organization, for breastfeeding women and patients who prefer a
predictable menstrual pattern.  The most common side effects of ParaGard
are heavier and longer periods for a few months after placement; some
women have spotting between periods.  For most women, these side effects
typically subside after a few months.

ParaGard may also be appropriate for women who have a hard time with
contraceptive methods that require highly compliant behavior.  Because
ParaGard does not require daily, weekly or monthly administration, user
compliance becomes minimal in achieving efficacy.  In addition, the
largest study to date reports that 96 percent of patients who use
intrauterine contraception are satisfied with their choice. 

\"For over 20 years, ParaGard^®^ has provided reliable efficacy without
the side effects associated with hormones," explains Dr. MacIsaac.  "Now
physicians are free to comfortably modernize their current IUD practice
and better address the contraceptive needs of their patients.\" 
ParaGard does not protect against HIV/AIDS or other sexually transmitted
diseases.  Women who currently have acute Pelvic Inflammatory Disease
(PID) or engage in sexual behavior suggesting a high risk for PID should
not use ParaGard.  It is also not an option for women who might be
pregnant, have had a post-pregnancy or post-abortion uterine infection
in the past 3 months, have cancer of the uterus or cervix, an infection
in the cervix, an allergy to any component of ParaGard, or have Wilson's
disease.

The website below offers a diverse tool kit of programs for health care
professionals, providing accurate and easy-to-understand information to
advance the usage of IUDs in their practice.   Programs include
insertion training and an \"Ask the Nurse\" hotline to provide answers
to questions about IUD\'s and ParaGard.  It is important to know that,
while reimbursement for contraceptives can be complicated and
time-consuming, most insurance companies fully cover ParaGard at a
minimal patient expense.  For assistance in providing patients with
accurate and timely reimbursement information -- or for information
about any of the tools FEI offers -- health care providers are urged to
call 800-322-4966 or visit [www.ParaGard.com](http://www.ParaGard.com/)

**Extension of the ring cycle reduced bleeding days, well tolerated and
desired by many**

Conclusion: The combination vaginal contraceptive ring can be used for
extended cycles to alter the bleeding schedule. Women willing to
tolerate some spotting might choose the longer extensions to have fewer
menstrual periods. Level of Evidence: I.

[Miller
L](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Miller+L"%5BAuthor%5D),
Extended Regimens of the Contraceptive Vaginal Ring: A Randomized Trial.
Obstet Gynecol. 2005 Sep;106(3):473-482.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16135576&dopt=Abstract>

Lower- vs. Higher-Dose Estrogen for Contraception

Clinical Question -- Cochrane Briefs

Compared with higher-dose pills, are combination oral contraceptives
with 20 mcg of estrogen (ethinyl estradiol) equally effective and well
tolerated?

Evidence-Based Answer

Although no difference in effectiveness has been demonstrated in
existing trials, too few patients have been studied to detect small but
clinically important differences in pregnancy rates. Low-dose estrogen
pills have higher rates of discontinuation and bleeding disturbances.

Practice Pointers

Although complications are rare with these pills, combination oral
contraceptives have been linked to breast cancer, cerebral vascular
complications, thrombosis, and myocardial infarction. Therefore, many
physicians and patients prefer to use the lowest-dose pill that will
provide adequate cycle control and effectiveness.

Gallo and colleagues reviewed the literature to determine how pills
containing 20 mcg of ethinyl estradiol compare with higher-dose pills.
They found 69 randomized controlled trials. Most trials followed
patients for six to 12 cycles. The trials varied in dose of estrogen and
in type and dose of progesterone; therefore, meta-analysis was not
possible. No trial found a difference in contraceptive effectiveness;
however, because pregnancy in women who take oral contraceptives is
uncommon, the studies were insufficiently powered to show such a
difference. In many of the lower-dose groups, early discontinuation
occurred because of amenorrhea, adverse events, or bleeding
irregularities. More specific information about which pills are most
effective or which estrogen-progestin combinations have the fewest
bleeding problems could not be determined. Furthermore, it could not be
determined whether lower-dose estrogen pills have the same advantages as
higher-dose pills for prevention of ovarian and endometrial cancer and
reduction of acne.

Current data indicate disadvantages, but no clear advantages, to
combined contraceptive pills with 20 mcg of estrogen. Therefore, it is
reasonable to prescribe pills with more than 20 mcg of ethinyl estradiol
for most women. The American College of Obstetricians and Gynecologists
(ACOG) finds little or no increased risk of oral contraceptives for
women with fibroadenoma, benign breast disease with epithelial
hyperplasia with or without atypia, or a family history of breast
cancer.^1^ ACOG recommends progesterone-only pills for lactating women
and those with increased risk of thromboembolism. Caution should be used
when prescribing combination pills for women older than 35 years who
smoke. ACOG recommends pills with less than 35 mcg of estrogen for women
younger than 35 years who have hypertension.^1^

For all women, the best form of birth control is the one that will be
used consistently. For women who wish to reduce side effects and have
regular periods, pills with 30 to 35 mcg of ethinyl estradiol may be a
better choice than those with only 20 mcg.

Gallo MF, et al. 20 mcg versus \>20 mcg estrogen combined oral
contraceptives for contraception. Cochrane Database Syst Rev
2004;(4):CD003989 <http://www.aafp.org/afp/20051001/cochrane.html>

#### Featured website David Gahn, Tahlequah {#featured-website-david-gahn-tahlequah .Style-Heading-4-+-Arial-14-pt-Underline}

**Newly Released** **Perinatology Corner Module - Shoulder Dystocia**

This is a great resource of information on one of the modest devastating
(an unpredictable) problems in maternity care. You can also use the
module for free CEU / CMEs

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

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

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

Q. If a patient has an IUD and develops a Chlamydia infection, should
you remove the IUD?

**A.** The safest approach is to remove the IUD, but you can keep the
IUD [**in certain
cases**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/IUDchl91405.doc).

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/IUDchl91405.doc>

**Q. How can I compare my facility's Pap result patterns to the national
average?**

A. Each lab should have a quality assurance process, but providers
should evaluate as well.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/AbnPapRate10205.doc>

**Q. When should we start colon cancer screening in low risk adults?**

A. Start colon cancer screening at age 50 years old. See details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ColonScr10205.doc>

**Q. Are there any clinical pointers for alcohol withdrawal in
pregnancy?**

A. Here are a few details that might help

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/AlcoWithdPreg91905.doc>

**Indian Child Health Notes**

**October 2005 -- Steve Holve, Pediatrics Chief Clinical Consultant**

[Highlights]{.underline}

\- Is gambling good for you? A remarkable natural experiment in which a
cohort of children were lifted out of poverty by the opening of an
Indian Casino and how it affected their psychopathology

-Guidelines for Menactra, the new quadrivalent meningitis vaccine.
Should we give it to children in boarding schools?

-Oral health therapists - a low cost and low tech approach to the
problem of dental access in remote areas. Read Dr. Esposito\'s tirade
against the American Dental Association

-Community Acquired Methicillin - coming to a clinic near you

<http://www.ihs.gov/MedicalPrograms/MCH/C/documents/ICHN1005.doc>

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

**Still doing GYN surgery the old fashioned way? Robotic surgery in
remote settings**

Although still in its infancy, robotic surgery is a cutting-edge
development in surgery that will have far-reaching implications. While
improving precision and dexterity, this emerging technology allows
surgeons to perform operations that were traditionally not amenable to
minimal access techniques. As a result, the benefits of minimal access
surgery may be applicable to a wider range of procedures. Safety has
been well established, and many series of cases have reported favorable
outcomes. However, randomized, controlled trials comparing
robotic-assisted procedures with laparoscopic or open techniques are
generally lacking.

Robotic surgery has successfully addressed the limitations of
traditional laparoscopic and thoracoscopic surgery, thus allowing
completion of complex and advanced surgical procedures with increased
precision in a minimally invasive approach. In contrast to the awkward
positions that are required for laparoscopic surgery, the surgeon is
seated comfortably on the robotic control consol, an arrangement that
reduces the surgeon\'s physical burden.^\[15\]^ Instead of the flat,
2-dimensional image that is obtained through the regular laparoscopic
camera, the surgeon receives a 3-dimensional view that enhances depth
perception; camera motion is steady and conveniently controlled by the
operating surgeon via voice-activated or manual master controls. Also,
manipulation of robotic arm instruments improves range of motion
compared with traditional laparoscopic instruments, thus allowing the
surgeon to perform more complex surgical movements.

In a relatively short time, robotic procedures spanning the whole
spectrum of surgery have been successfully executed. Initial results
show that mortality, morbidity, and hospital stay compare favorably to
conventional laparoscopic operations. However, only a limited number of
randomized, prospective studies that compare outcomes of robotic
techniques with conventional methods exist. More procedure-specific,
randomized trials need to be performed before robotic surgery can find
its way into everyday surgical practice

Telerobotic surgery stands out as a way of delivering surgical care to
patients who have no direct access to a surgeon; however, costs are
prohibitive to the spread of such technology to underserved areas that
need it most. Even in the United States, surgical robots are mainly
available in large academic centers. The issues of cost, technical
drawbacks, and clinical effectiveness need to be resolved before robotic
procedures can become mainstream, everyday surgical procedures.

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

These technologies could have tremendous benefit in Indian Country in
time. New technologies, such as virtual reality, haptics (i. e., systems
that recreate the \"feel\" of tissues through force feedback), and
telementoring, can powerfully ally with surgical robots to create a new
medium for acquisition and assessment of surgical skills through
simulation of all operations that can be done via the robot. Performance
of robotic procedures requires specialized training. However, the
majority of residency programs in the United States do not provide
formal training in robotic surgery skills. Students, residents, and
residency programs should strive to keep up with this new development in
surgical technology that is likely to reshape the way we practice
surgery.\*

**Reference:**

Guillonneau B, Cappele O, Martinez JB, Navarra S, Vallancien G. Robotic
assisted, laparoscopic pelvic lymph node dissection in humans. J Urol.
2001;165:1078-1081.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11257641&query_hl=7>

Advincula AP, Falcone T. Laparoscopic robotic gynecologic surgery.
Obstet Gynecol Clin North Am. 2004;31:599-609.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15450321&query_hl=9>

Falcone T, Goldberg J, Garcia-Ruiz A, Margossian H, Stevens L. Full
robotic assistance for laparoscopic tubal anastomosis: a case report. J
Laparoendosc Adv Surg Tech A. 1999; 9:107-113

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10194702&query_hl=11>

Margossian H, Falcone T. Robotically assisted laparoscopic hysterectomy
and adnexal surgery. J Laparoendosc Adv Surg Tech A. 2001;11:161-165.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11441994&query_hl=13>

Marchal F, Rauch P, Vandromme J, et al. Telerobotic-assisted
laparoscopic hysterectomy for benign and oncologic pathologies: initial
clinical experience with 30 patients. Surg Endosc. 2005;19:826-831.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15868258&query_hl=15>

\* Medscape <http://www.medscape.com/viewarticle/511854_3> (see Medscape
below for access)

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

**After Katrina: Health Professionals\' Notes From the Field**

In the days since Hurricane Katrina struck the United States Gulf Coast,
healthcare professionals have responded to help the thousands of
homeless survivors. Physicians, nurses, and other healthcare workers
have shared their moving stories about the relief efforts with
Medscape\*. Here are some highlights of those reports
<http://www.medscape.com/viewarticle/512207?src=mp>

\* see information on access to Medscape below

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

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

**Association between neighbor characteristics and adolescent sexual
behavior**

Neighborhood context may be positively or negatively associated with
sexual initiation, depending on gender. The neighborhood-level analysis
varied by gender as follows:

\* Males living in neighborhoods in which more than 10% of households
were below the poverty level had an elevated likelihood of reporting
sexual initiation, compared with those in areas in which 5% or fewer
households were below the poverty level. Conversely, males in
neighborhoods in which more than 2% of households were affluent had
decreased odds of having sexual experience compared with males in areas
in which 2% or fewer households were affluent. No significant
associations for these socioeconomic characteristics were found for
females.

\* Both males and females in neighborhoods with any idle youth were more
likely to report sexual initiation, compared with their counterparts in
areas with no idle youth.

\* A high concentration of women workers in neighborhoods was marginally
associated with a reduced likelihood of sexual initiation for males. A
high concentration of married-couple households in neighborhoods was
associated with a reduced likelihood of sexual initiation for females.

\* Females living in neighborhoods with the highest concentration of
idle youth were more likely to report nonuse of contraceptives at first
sex, compared with females in neighborhoods with the lowest
concentration.

In summary, an exclusive focus on behavior and personal responsibility
will have a limited effect on sexual initiation unless contextual
influences at the neighborhood level are also addressed.

Cubbin C, Santelli J, Brindis C, et al. 2005. Neighborhood context and
sexual behaviors among adolescents: Findings from the National
Longitudinal Study of Adolescent Health. Perspectives on Sexual and
Reproductive Health 37(3):125-134
[[http://www.agi-usa.org/pubs/journals/3712505.html]{.underline}](http://www.agi-usa.org/pubs/journals/3712505.html)

**Racial and Ethnic Disparities in Health Knowledge Path: New release**

The new edition of Knowledge Path: Racial and Ethnic Disparities in
Health offers a selection of current, high-quality resources about
identifying and eliminating racial and ethnic disparities in health.
Produced by the MCH Library, the knowledge path includes information on
(and links to) Web sites, electronic and print publications, Webcasts,
and databases. It is intended for use by health professionals,
policymakers, program administrators, researchers, and families who are
interested in tracking timely information on this topic. The knowledge
path is available at
[[http://www.mchlibrary.info/KnowledgePaths/kp_race.html]{.underline}](http://www.mchlibrary.info/KnowledgePaths/kp_race.html)

MCH Library knowledge paths on other maternal and child health topics
are available at
[[http://www.mchlibrary.info/KnowledgePaths/index.html]{.underline}](http://www.mchlibrary.info/KnowledgePaths/index.html)

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

#### HCG curves redefined: Symptomatic patients with an early viable intrauterine pregnancy {#hcg-curves-redefined-symptomatic-patients-with-an-early-viable-intrauterine-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

#### Just to review, last month we described a patient with an early pregnancy with symptoms of pelvic pain and bleeding. Pelvic ultrasound performed 2 days prior revealed a 3 cm right adnexal structure thought to be a possible an ovarian cystic structure with complex elements or a curved hydrosalpinx. The structure had the appearance of a donut. The radiologist's dictation stated that the study was consistent with a hydrosalpinx or corpus luteum cyst, but that ectopic pregnancy needed to be considered clinically. There were also indistinct intrauterine contents not unlike a gestational sac, but no distinct fetal pole or yolk sac. The radiologist could not rule out a pseudosac. The radiologist's DRAFT report suggested appropriate medical / surgical intervention depending the patient's condition. Her lab values were: {#just-to-review-last-month-we-described-a-patient-with-an-early-pregnancy-with-symptoms-of-pelvic-pain-and-bleeding.-pelvic-ultrasound-performed-2-days-prior-revealed-a-3-cm-right-adnexal-structure-thought-to-be-a-possible-an-ovarian-cystic-structure-with-complex-elements-or-a-curved-hydrosalpinx.-the-structure-had-the-appearance-of-a-donut.-the-radiologists-dictation-stated-that-the-study-was-consistent-with-a-hydrosalpinx-or-corpus-luteum-cyst-but-that-ectopic-pregnancy-needed-to-be-considered-clinically.-there-were-also-indistinct-intrauterine-contents-not-unlike-a-gestational-sac-but-no-distinct-fetal-pole-or-yolk-sac.-the-radiologist-could-not-rule-out-a-pseudosac.-the-radiologists-draft-report-suggested-appropriate-medical-surgical-intervention-depending-the-patients-condition.-her-lab-values-were .Style-Heading-4-+-Arial-14-pt-Underline}

Quantitative HCG [Value]{.underline} [Percent increase]{.underline}

6 days prior 850 -

4 days prior 1400 54% increase

2 day prior 2142 53% increase

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

The patient said that Emergency Department (ED) provider told her that
you would know what dose of methotrexate to prescribe in this particular
situation. She said she heard the ED physician was concerned that her
HCG had not increased by 66% during the previous serial 2 day intervals.
She said the ED physician said that you might want to call a specialist
to find out, because this was her third ectopic pregnancy.

**What dose of methotrexate would you prescribe to this patient?**

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

#### The answer is zero {#the-answer-is-zero .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The clinical pearl here is that normal pregnancies can be associated with a 53 percent HCG rise over 48 hours. If clinically stable, this particular patient should have a repeat HCG in 48 hours.  {#the-clinical-pearl-here-is-that-normal-pregnancies-can-be-associated-with-a-53-percent-hcg-rise-over-48-hours.-if-clinically-stable-this-particular-patient-should-have-a-repeat-hcg-in-48-hours. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The patient's HCG was 2142, e. g., slightly over a discriminatory zone of 2000. Shouldn't we be able to demonstrate an intrauterine pregnancy in all cases by an HCG of 2000?  {#the-patients-hcg-was-2142-e.-g.-slightly-over-a-discriminatory-zone-of-2000.-shouldnt-we-be-able-to-demonstrate-an-intrauterine-pregnancy-in-all-cases-by-an-hcg-of-2000 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Actually, some would argue that the discriminatory zone should be an HCG up to 2,500. Or better yet, each institution should determine their own discriminatory zone based on their local HCG lab techniques and ultrasound capability. {#actually-some-would-argue-that-the-discriminatory-zone-should-be-an-hcg-up-to-2500.-or-better-yet-each-institution-should-determine-their-own-discriminatory-zone-based-on-their-local-hcg-lab-techniques-and-ultrasound-capability. .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### The beta-hCG concentration in a normal intrauterine pregnancy rises in a curvilinear fashion until 41 days of gestation at which time it plateaus at approximately 100,000 IU/L and the mean doubling time for the hormone is from 1.4 to 2.1 days. Studies in viable intrauterine pregnancies have demonstrated that in 85 percent of these gestations the beta-hCG concentration rises by at least 66 percent every 48 hours during the first 40 days of pregnancy; in only 15 percent of viable pregnancies is the rate of rise less than this threshold.  {#the-beta-hcg-concentration-in-a-normal-intrauterine-pregnancy-rises-in-a-curvilinear-fashion-until-41-days-of-gestation-at-which-time-it-plateaus-at-approximately-100000-iul-and-the-mean-doubling-time-for-the-hormone-is-from-1.4-to-2.1-days.-studies-in-viable-intrauterine-pregnancies-have-demonstrated-that-in-85-percent-of-these-gestations-the-beta-hcg-concentration-rises-by-at-least-66-percent-every-48-hours-during-the-first-40-days-of-pregnancy-in-only-15-percent-of-viable-pregnancies-is-the-rate-of-rise-less-than-this-threshold. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The data on the old adage that normal pregnancies increase by 66 percent every 48 hours was based on studies of 29 and 36 patients. (Daya, Kadar) More recent data from 287 patients showed the slowest or minimal rise for a normal viable intrauterine pregnancy was 24% at 1 day and 53% at 2 days. (Barnhart) {#the-data-on-the-old-adage-that-normal-pregnancies-increase-by-66-percent-every-48-hours-was-based-on-studies-of-29-and-36-patients.-daya-kadar-more-recent-data-from-287-patients-showed-the-slowest-or-minimal-rise-for-a-normal-viable-intrauterine-pregnancy-was-24-at-1-day-and-53-at-2-days.-barnhart .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The Barnhart et al data re-define the slowest rise in serial hCG values for a potentially viable gestation and will aid in distinguishing a viable early pregnancy from a miscarriage or ectopic pregnancy. The minimal rise in serial hCG values for women with a viable intrauterine pregnancy is \"slower\" than previously reported, suggesting that intervention to diagnosis and treat an abnormal gestation should be more conservative. The use of the more conservative data on HCG rise will hopefully lead to less need for invasive procedures and/or unnecessary use of methotrexate. {#the-barnhart-et-al-data-re-define-the-slowest-rise-in-serial-hcg-values-for-a-potentially-viable-gestation-and-will-aid-in-distinguishing-a-viable-early-pregnancy-from-a-miscarriage-or-ectopic-pregnancy.-the-minimal-rise-in-serial-hcg-values-for-women-with-a-viable-intrauterine-pregnancy-is-slower-than-previously-reported-suggesting-that-intervention-to-diagnosis-and-treat-an-abnormal-gestation-should-be-more-conservative.-the-use-of-the-more-conservative-data-on-hcg-rise-will-hopefully-lead-to-less-need-for-invasive-procedures-andor-unnecessary-use-of-methotrexate. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### One thought to ponder for next month, if the HCG curve has been redefined in symptomatic patients with an early viable intrauterine pregnancy.....just how accurate is our other major diagnostic modality in diagnosing ectopic?  {#one-thought-to-ponder-for-next-month-if-the-hcg-curve-has-been-redefined-in-symptomatic-patients-with-an-early-viable-intrauterine-pregnancy..just-how-accurate-is-our-other-major-diagnostic-modality-in-diagnosing-ectopic .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### What it accuracy of ultrasound in this setting?  {#what-it-accuracy-of-ultrasound-in-this-setting .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### Daya S Human chorionic gonadotropin increase in normal early pregnancy Am J Obstet Gynecol 1987 Feb;156(2):286-90. {#daya-s-human-chorionic-gonadotropin-increase-in-normal-early-pregnancy-am-j-obstet-gynecol-1987-feb1562286-90. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=3826161&query_hl=1**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=3826161&query_hl=1) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids3826161query_hl1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Kadar N; DeCherney AH; Romero R. Receiver operating characteristic (ROC) curve analysis of the relative efficacy of single and serial chorionic gonadotropin determinations in the early diagnosis of ectopic pregnancy. Fertil Steril 1982 Apr;37(4):542-7. {#kadar-n-decherney-ah-romero-r.-receiver-operating-characteristic-roc-curve-analysis-of-the-relative-efficacy-of-single-and-serial-chorionic-gonadotropin-determinations-in-the-early-diagnosis-of-ectopic-pregnancy.-fertil-steril-1982-apr374542-7. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7067849&query_hl=3**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7067849&query_hl=3) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids7067849query_hl3 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [**Kadar N**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Kadar+N"%5BAuthor%5D), [**Caldwell BV**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Caldwell+BV"%5BAuthor%5D), [**Romero R**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Romero+R"%5BAuthor%5D). A method of screening for ectopic pregnancy and its indications. Obstet Gynecol. 1981 Aug;58(2):162-6. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6454867&query_hl=8**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6454867&query_hl=8) {#kadar-n-caldwell-bv-romero-r.-a-method-of-screening-for-ectopic-pregnancy-and-its-indications.-obstet-gynecol.-1981-aug582162-6.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids6454867query_hl8 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Barnhart KT et al Symptomatic patients with an early viable intrauterine pregnancy: HCG curves redefined Obstet Gynecol 2004 Jul;104(1):50-5. {#barnhart-kt-et-al-symptomatic-patients-with-an-early-viable-intrauterine-pregnancy-hcg-curves-redefined-obstet-gynecol-2004-jul104150-5. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15229000&query_hl=5**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15229000&query_hl=5) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15229000query_hl5 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Clinical manifestations and diagnosis of ectopic pregnancy, UpToDate {#clinical-manifestations-and-diagnosis-of-ectopic-pregnancy-uptodate .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.uptodateonline.com/application/topic.asp?file=gen_gyne/8302&type=A&selectedTitle=1\~25**](http://www.uptodateonline.com/application/topic.asp?file=gen_gyne/8302&type=A&selectedTitle=1~25) {#httpwww.uptodateonline.comapplicationtopic.aspfilegen_gyne8302typeaselectedtitle125 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

######### Complications of Cesarean Deliveries

Three in 10 women in the United States now give birth by cesarean
section. Both unplanned and planned cesarean deliveries are associated
with substantial risk; clinicians need to know what they are.
<http://www.medscape.com/viewprogram/4546?src=mp>

######### Racial and Ethnic Health Disparities, Women, and Cancer - CME

<http://www.medscape.com/viewprogram/4412?src=nlpromo>

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

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

######### 

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

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

**Clinical Discussion Board Index, Medscape**

Hundreds of ongoing clinical discussions available

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

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

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

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

**Menopause Management**

#### What really causes hot flashes and how to fix them? {#what-really-causes-hot-flashes-and-how-to-fix-them-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Hot flashes are the most common symptom of menopause. Although the appearance of hot flashes coincides with estrogen withdrawal, this does not entirely explain the phenomenon because estrogen levels do not differ between symptomatic and asymptomatic women. Luteinizing throughout? hormone pulses do not produce hot flashes nor do changes in endogenous opiates. Recent studies suggest that hot flashes are triggered by small elevations in core body temperature (T(c)) acting within a reduced thermoneutral zone in symptomatic postmenopausal women. This narrowing may be due to elevated central noradrenergic activation, a contention supported by observations that clonidine and some relaxation procedures ameliorate hot flashes. Because hot flashes are triggered by T(c) elevations, procedures to reduce T(c), such as lowering ambient temperature, are beneficial. Estrogen ameliorates hot flashes by increasing the T(c) sweating threshold, although the underlying mechanism is not known. Recent studies of hot flashes during sleep call into question their role in producing sleep disturbance {#hot-flashes-are-the-most-common-symptom-of-menopause.-although-the-appearance-of-hot-flashes-coincides-with-estrogen-withdrawal-this-does-not-entirely-explain-the-phenomenon-because-estrogen-levels-do-not-differ-between-symptomatic-and-asymptomatic-women.-luteinizing-throughout-hormone-pulses-do-not-produce-hot-flashes-nor-do-changes-in-endogenous-opiates.-recent-studies-suggest-that-hot-flashes-are-triggered-by-small-elevations-in-core-body-temperature-tc-acting-within-a-reduced-thermoneutral-zone-in-symptomatic-postmenopausal-women.-this-narrowing-may-be-due-to-elevated-central-noradrenergic-activation-a-contention-supported-by-observations-that-clonidine-and-some-relaxation-procedures-ameliorate-hot-flashes.-because-hot-flashes-are-triggered-by-tc-elevations-procedures-to-reduce-tc-such-as-lowering-ambient-temperature-are-beneficial.-estrogen-ameliorates-hot-flashes-by-increasing-the-tc-sweating-threshold-although-the-underlying-mechanism-is-not-known.-recent-studies-of-hot-flashes-during-sleep-call-into-question-their-role-in-producing-sleep-disturbance .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**Freedman RR**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Freedman+RR"%5BAuthor%5D).Pathophysiology and treatment of menopausal hot flashes. Semin Reprod Med. 2005 May;23(2):117-25. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15852197&query_hl=1**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15852197&query_hl=1) {#freedman-rr.pathophysiology-and-treatment-of-menopausal-hot-flashes.-semin-reprod-med.-2005-may232117-25.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15852197query_hl1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Gabapentin May Control Hot Flashes in Women With Breast Cancer {#gabapentin-may-control-hot-flashes-in-women-with-breast-cancer-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### INTERPRETATION: Gabapentin is effective in the control of hot flashes at a dose of 900 mg/day, but not at a dose of 300 mg/day. This drug should be considered for treatment of hot flashes in women with breast cancer. {#interpretation-gabapentin-is-effective-in-the-control-of-hot-flashes-at-a-dose-of-900-mgday-but-not-at-a-dose-of-300-mgday.-this-drug-should-be-considered-for-treatment-of-hot-flashes-in-women-with-breast-cancer. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**Pandya KJ**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Pandya+KJ"%5BAuthor%5D), et al Gabapentin for hot flashes in 420 women with breast cancer: a randomised double-blind placebo-controlled trial. Lancet. 2005 Sep 3-9;366(9488):818-24 [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16139656&query_hl=37**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16139656&query_hl=37) {#pandya-kj-et-al-gabapentin-for-hot-flashes-in-420-women-with-breast-cancer-a-randomised-double-blind-placebo-controlled-trial.-lancet.-2005-sep-3-93669488818-24-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16139656query_hl37 .Style-Heading-4-+-Arial-14-pt-Underline}

####  HRT Increases Risk of Breast Cancer Across Racial Groups {#hrt-increases-risk-of-breast-cancer-across-racial-groups .Style-Heading-4-+-Arial-14-pt-Underline}

#### Current EPT use was associated with increased risk for ER+/PR+, ER+/PR- and ER-/PR- tumors. There was little difference in risk by stage of disease or histologic subtype. The increase with EPT use was clearly seen in all 5 ethnic groups; and the increase with ET in 4 of the 5 groups. {#current-ept-use-was-associated-with-increased-risk-for-erpr-erpr--and-er-pr--tumors.-there-was-little-difference-in-risk-by-stage-of-disease-or-histologic-subtype.-the-increase-with-ept-use-was-clearly-seen-in-all-5-ethnic-groups-and-the-increase-with-et-in-4-of-the-5-groups. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**Lee S**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Lee+S"%5BAuthor%5D) et al Postmenopausal hormone therapy and breast cancer risk: The multiethnic cohort. J Cancer. 2005 Sep 16; [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16170777&query_hl=26**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16170777&query_hl=26) {#lee-s-et-al-postmenopausal-hormone-therapy-and-breast-cancer-risk-the-multiethnic-cohort.-j-cancer.-2005-sep-16-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16170777query_hl26 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Paxil Use in Early Pregnancy May Cause Birth Defects**

A study suggested an increase in the risk of overall major congenital
malformations for paroxetine as compared to other antidepressants \[OR
2.2; 95% confidence interval, 1.34-3.63\]. Healthcare professionals are
advised to carefully weigh the potential risks and benefits of using
paroxetine therapy in women during pregnancy and to discuss these
findings as well as treatment alternatives with their patients.
GlaxoSmithKline (GSK) and FDA notified healthcare professionals of
changes to the Pregnancy/PRECAUTIONS section of the Prescribing
Information for Paxil and Paxil CR Controlled-Release Tablets to
describe the results of a GSK retrospective epidemiologic study of major
congenital malformations in infants born to women taking antidepressants
during the first trimester of pregnancy <http://www.fda.gov/medwatch>

<http://www.fda.gov/medwatch/safety/2005/Paxil_dearhcp_letter.pdf>

**Navajo News**

**Syphilis Treatment Issues---Azithromycin Use Not Encouraged for
Syphilis Treatment**

Navajo Area is continuing to cope with a syphilis outbreak. Over the
past five years, more than 275 cases of syphilis have been documented in
Navajo Area, leading to aggressive screening efforts in many care
settings including emergency departments, detox facilities, and
community outreach campaigns. All patients diagnosed with any STD are
offered syphilis screening. In pregnancy, patients are screened on entry
to care, early in the third trimester, and on admission to Labor and
Delivery. Although progress has been made, more than 35 cases have been
diagnosed in the first 8 months of 2005.

Concurrently, we have experienced intermittent shortages of penicillin G
benzathine (LA-Bicillin), the treatment of choice for syphilis. Thus a
recent article suggesting that Azithromycin may be an acceptable
treatment alternative was of great interest locally. This article
described a randomized trial of a 2 gram oral dose of Azithromycin vs. a
2.4MU IM dose of LA-Bicillin in 328 subjects in Tanzania. Patients were
evaluated based on a two-fold dilution in titer by 9 months or by
healing of the primary lesion. Cure rates are reported as:

97.7 % in the Azithromycin group (CI 94 -- 99.4%)

95% in the LA-Bicillin group (CI 90.6-97.8%)

Despite these findings, and the ease of use of a single-dose oral
preparation, there may be cause to hold off on adopting this new
treatment regimen. In a commentary accompanying the article, King Holmes
points out that penicillin has been the mainstay of treatment for 5
decades with no demonstrated resistance. Azithromycin resistance has
been documented. He suggests that the upcoming 2006 CDC STD treatment
guidelines continue to recommend the use of Penicillin. Efforts to
secure and maintain an adequate supply of LA-Bicillin are indicated and
working with local pharmacies to assure appropriate use of limited
supplies may be necessary.

Centers for Disease Control, Sexually Transmitted Diseases Treatment
Guidelines 2002, MMWR, May 10, 2002, 51(RR-6)

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5106a1.htm>

Centers for Disease Control, Brief Report: Azithromycin Treatment
Failures in Syphilis Infections\-\--San Francisco, California,
2002-2003. MMWR, March 12, 2004, 53(09);197-198.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5309a4.htm>

Reidner, G, Rusizoka, M, Todd, J., et al., "Single-Dose Azithromycin
versus Penicillin G Benzathine for the Treatment of Early Syphilis", The
New England Journal of Medicine, 2005;353:1236-44.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16177249&dopt=Abstract>

Holmes, K. "Azithromycin versus Penicillin G Benzathine for Early
Syphilis", The New England Journal of Medicine, 2005;353:1291-93.

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16177256&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16177256&dopt=Abstract) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids16177256doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Cesarean Rates for First Births and Repeat Cesarean for Low-Risk
Women: 1990-2003**

With a decrease between 1990 and 1996 and an increase between 1996 and
2003, the trend in the cesarean rate for low-risk women having a first
birth paralleled trends in the primary (regardless of parity) and total
cesarean rates. During 1996--2003 the cesarean rate for low-risk women
having a first birth has consistently been at least 13 percent lower
than the rate for all women having a first birth. For 2003 the cesarean
rate for all primiparous women was 27.1 percent; for low-risk women the
rate was 23.6 percent.

<http://www.cdc.gov/nchs/products/pubs/pubd/nvsr/54/nvsr54_04.htm>

####  {#section-35 .Style-Heading-4-+-Arial-14-pt-Underline}

**Sexual Behavior and Health Measures: Men and Women 15-44 Years of
Age**

This report presents national estimates of several measures of sexual
behavior among males and females 15--44 years of age in the United
States in 2002, as collected in the 2002 National Survey of Family
Growth (NSFG). These data are relevant to demographic and public health
concerns, including fertility and sexually transmitted diseases among
teenagers and adults.
[[http://www.cdc.gov/nchs/products/pubs/pubd/ad/361-370/ad362.htm]{.underline}](http://www.cdc.gov/nchs/products/pubs/pubd/ad/361-370/ad362.htm)

**Births: Final Data for 2003**

In 2003 there were 4,089,950 live births reported in the United States
and 43,052 AIAN registered births.

The US all races total was 2 percent more than the number in 2002.
Childbearing among teenagers and birth rates for women aged 20--24 years
declined, whereas rates for women aged 25--44 years increased 2--6
percent, reaching highs not reported since the mid-to late 1960s. The
cesarean delivery rate jumped another 5 percent to another all-time
high, and the rate of vaginal birth after previous cesarean dropped 16
percent, an all-time low.
<http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_02.pdf>

![](media/image2.png){width="2.5833333333333335in"
height="3.1041666666666665in"}![](media/image3.png){width="5.135416666666667in"
height="3.1458333333333335in"}

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

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

**Less quantity of prenatal visits with higher quality: Outcome based
analysis**

The natural disasters Katrina and Rita that have hit the coastal Gulf
States hard are having an effect nationally. We have all heard about the
affects on the offshore rigs and the refineries and how gas prices are
going to affect the cost of living from food costs to cost of stamps.
Here in Oklahoma we are beginning to see the affect on prenatal care. As
the cost of gasoline has topped the \$3 mark, we are seeing more
patients missing appointments due to the gas costs. Additionally, I have
had patients ask if they could space out some appointments in order to
keep their gas costs down.

-We all know that prenatal care is vital to decreasing the maternal and
neonatal morbidity, however, does missing a few visits really affect the
patient?

-How about if my facility systematically looks into the content our
prenatal care and intentionally decides to reduce our average number of
visits to increase our overall access\* to patients?

A systematic review of ten randomized trials (over 60,000 women) in the
Cochrane Review by Villar et al revealed that decreasing the number of
visits did not jeopardize health outcomes. A reduction in the number of
antenatal care visits with or without an increased emphasis on the
content of the visits could be implemented without any increase in
adverse biological maternal and perinatal outcomes.

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

The Cochrane Review by Villar et al confirms the tenets of the 1989
Public Health Service Expert Panel on the Content of Prenatal. The Panel
looked carefully at the data supporting the quantity and quality of
prenatal care and suggested 9 visits. This is reduction of approximately
3-6 visits depending on many facilities current pattern. That reduction
represents a decrease of 25-40 percent of appointments per patient with
no change in outcome. McDuffie et al. RCT reported a decrease of 2.7
visits per patient with good patient outcomes and patient satisfaction.

In addition, the PHS Panel suggested an emphasis on use of proven
screening techniques vs traditional testing methods with little
supporting data, e. g., discontinue practice of routine urine testing
for glucose and protein at each visit.

When a facility changes to the more effective prenatal system, I would
suggest that patients' expectations be managed from the outset to
maintain patient satisfaction. This can include a careful setting of
expectations starting at their first appointment, or first prenatal
educational session. The nature of what to expect should be reinforced
throughout the gestation.

Villar J, Carroli G, Khan-Neelofur D, Piaggio G, Gülmezoglu M. Patterns
of routine antenatal care for low-risk pregnancy. *The Cochrane Database
of Systematic Reviews* 2001, Issue 4. Art. No.: CD000934. DOI:
10.1002/14651858.CD000934.

<http://www.update-software.com/abstracts/AB000934.htm>

[McDuffie RS
Jr](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="McDuffie+RS+Jr"%5BAuthor%5D)
et al Effect of frequency of prenatal care visits on perinatal outcome
among low-risk women. A randomized controlled trial. JAMA. 1996 Mar
20;275(11):847-51.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8596222&query_hl=1>

Public Health Service Expert Panel on Prenatal Care. Caring for our
Future: The Content of Prenatal Care. Washington, D.C.: Public Health
Service, US Dept of Health and Human Services, NIH Publication No.
90-3182, 1989

\*(See [Open access can work for any type of practice]{.underline},
OB/PEDS Chief Clinical Consultants' Corner, Volume 3, No. 8, August
2005) <http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN01.cfm>

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

Secondary Fracture Prevention with Calcium and Vitamin D

**Clinical Question:** In older persons who have already experienced an
osteoporosis-related fracture, does vitamin D, calcium, or the
combination prevent secondary fractures?

**Bottom Line:** The combination of 1,000 mg of calcium and 800 IU of
vitamin D~3~ was ineffective in preventing fractures in two studies that
involved more than 8,500 participants, almost all of whom were women, at
least 70 years of age, with a previous osteoporotic fracture or high
risk for a fracture. The dosage of calcium is lower than the 1,500 mg
per day commonly recommended. These results conflict with a
meta-analysis showing that combination therapy reduced the rate of
fractures, including hip fracture, in older patients who had not had a
previous hip or nonvertebral fracture

Bischoff-Ferrari HA, et al. Fracture prevention with vitamin D
supplementation: a meta-analysis of randomized controlled trials. JAMA
May 11, 2005;293:2257-6 (Level of Evidence: 1b)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15886381&query_hl=10>

**Can Examination Findings Predict Osteoporosis Risk?**

Although no single examination finding was sufficient to make a
diagnosis of osteoporosis, low body weight, wall-occiput distance, low
tooth count, self-reported kyphosis, and low rib-pelvis distance
effectively predicted higher fracture and osteoporosis risk. The authors
suggest that these findings are effective screening tools in patients
who do not meet current BMD screening

Green AD, et al. Does this woman have osteoporosis? JAMA December 15,
2004;292:2890-900.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15598921&query_hl=17>

**Soy Consumption Reduces Bone Fracture Risk in Postmenopausal Women**

CONCLUSION: Soy food consumption may reduce the risk of fracture in
postmenopausal women, particularly among those in the early years
following menopause

[Zhang
X](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Zhang+X"%5BAuthor%5D),
et al Prospective cohort study of soy food consumption and risk of bone
fracture among postmenopausal women. Arch Intern Med. 2005 Sep
12;165(16):1890-5\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16157834&query_hl=32>

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

#### Preterm Labor: Signs and Symptoms - Patient Education Brochure Aberdeen Area Women's Health Program, Mary Lynn Eaglestaff, Aberdeen {#preterm-labor-signs-and-symptoms---patient-education-brochure-aberdeen-area-womens-health-program-mary-lynn-eaglestaff-aberdeen .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/Pr01.cfm#preLabor**](http://www.ihs.gov/MedicalPrograms/MCH/M/Pr01.cfm#preLabor) {#httpwww.ihs.govmedicalprogramsmchmpr01.cfmprelabor-1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Diverticular Disease: What You Should Know? {#diverticular-disease-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20051001/1241ph.html**](http://www.aafp.org/afp/20051001/1241ph.html) {#httpwww.aafp.orgafp200510011241ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Perinatology Picks {#perinatology-picks .Style-Heading-4-+-Arial-14-pt-Underline}

**Newly Released** **Perinatology Corner Module - Shoulder Dystocia**

A great resource of information and / or free CEU / CME

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

**Thyroid-stimulating hormone decreases significantly during the first
trimester**

OBJECTIVE: To estimate a normal reference range for thyroid-stimulating
hormone (TSH) at each point in gestation in singleton and twin
pregnancies.

METHODS: All women enrolling for prenatal care from December 2000
through November 2001 underwent prospective TSH screening at their first
visit. Separate nomograms were constructed for singleton and twin
pregnancies using regression analysis. Values were converted to
multiples of the median (MoM) for singleton pregnancies at each week of
gestation.

RESULTS: Thyroid-stimulating hormone was evaluated in 13,599 singleton
and 132 twin pregnancies. Thyroid-stimulating hormone decreased
significantly during the first trimester, and the decrease was greater
in twins (both *P* \< .001). Had a nonpregnant reference (0.4--4.0 mU/L)
been used rather than our nomogram, 28% of 342 singletons with TSH
greater than 2 standard deviations above the mean would not have been
identified. For singleton first-trimester pregnancies, the approximate
upper limit of normal TSH was 4.0 MoM, and for twins, 3.5 MoM.
Thereafter, the approximate upper limit was 2.5 MoM for singleton and
twin pregnancies.

CONCLUSION: If thyroid testing is performed during pregnancy, nomograms
that adjust for fetal number and gestational age may greatly improve
disease detection. Values expressed as multiples of the median may
facilitate comparisons across different laboratories and populations.

LEVEL OF EVIDENCE: II-2

## **Dashe JS et al** Thyroid-Stimulating Hormone in Singleton and Twin Pregnancy: Importance of Gestational Age--Specific Reference Ranges. Obstetrics & Gynecology 2005;106:753-757

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16199632&dopt=Abstract>

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

This article presents more evidence that we must remember that
thyroid-stimulating hormone decreases significantly early in pregnancy.
This is clinically significant because many patients have their TSH
level checked for various clinical indications during the first
trimester and early second trimester, e.g., hyperemesis gravidarum.
Though the TSH is physiologically decreased some clinicians assume the
decreased TSH is related to true hyperthyroidism and the patient is
begun on antithyroid agents.

If the patient is not clinically hyperthyroid, then a better approach is
not to consider treatment based on TSH levels until after 20 weeks
gestation. See pseudohyperthyroidism below.

Pearl: The best way to screen/evaluate a pregnant woman for thyroid
disease is to look at the free T4. The free T4 tells you directly what
amount of thyroid hormone she and the fetus are seeing. If it\'s normal,
and you still suspect hyperthyroidism, then get a free T3. In the woman
with known hypothyroidism, the free T4 may still be low normal, but a
then a high TSH may clue you that you need more L-thyroxine replacement.

The Indian Health system continuing education module (free CEU / CME) on
this topic offers many more details and resources.

**Thyroid Disorders in Pregnancy Module**

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

**Hyperemesis Gravidarum \"Pseudohyperthyroidism\" page**

<http://www.ihs.gov/MedicalPrograms/MCH/M/THYR05.cfm#top>

**Other Perinatology Corner Modules**

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

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

**November 1, 2005**\
**Morbidity and Mortality Rounds - Web Based\***

**Rectal bleeding: Is it hemorrhoids?**

40 year old American Indian female presents to a remote ambulatory care
clinic with intermittent blood in her stool for the last 3 months.

-She has had chronic constipation.

-She believes that the blood is due to her hemorrhoids.

Moderator: Terry Cullen

### 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**

**Laura Shelby's exciting opportunity**

Laura Shelby will be leaving her Centers for Disease Control assignment
with the IHS Division of Epidemiology Program as STD Program Manager
after 9 years of dedicated service to Indian Country. Laura leaves IHS
with a heavy heart as she will miss all the wonderful people she has
been working with throughout the years. However, the IHS STD Program
will be left in very capable hands. Lori de Ravello will be acting STD
Program Manager until Laura's position is filled by CDC.

Laura was accepted to a Master of Public Health program at the London
School of Hygiene and Tropical Medicine. She is looking forward to this
new adventure. If you would like to contact her while she is in London,
her e-mail address is <laurakaye42@yahoo.com>

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Welcome Lori de Ravello**

Lori de Ravello will be Acting Program Manager of the IHS national STD
Program until Laura's replacement is hired. Like Laura, Lori is a CDC
Public Health Advisor assigned to the IHS National STD Program in
Albuquerque, New Mexico. Since December 2003, Lori has been
jointly-funded by CDC's Divisions of STD Prevention and Reproductive
Health to support the efforts of the STD Program and to promote
integration of STD, HIV, and reproductive health services.

Lori has worked for CDC since 1993, both domestically and
internationally. She has worked on a wide range of projects addressing
women's health issues, including family planning, managed care, Safe
Motherhood, HIV prevention, services integration, training-related
efforts, information technology, informatics, and surveillance. During
her assignment to the IHS, she has worked with the STD/HIV Prevention
Training Centers to support the development and delivery of provider
training in Indian Country, represented the program at regional and
national Infertility Prevention Project meetings, and developed and
disseminated tribal jail STD screening guidelines, among other things.

Lori has a bachelors degree in international relations from the
University of New Mexico (1989) and a masters degree in international
public health from the University of Alabama at Birmingham (1993). She
served as a Peace Corps Volunteer in Honduras (1990-1991).

Lori is looking forward to continuing the great collaboration and
networking that Laura has perfected over the years. Please contact her
for any STD-related questions, ideas, suggestions, or needs:
<lori.deravello@ihs.gov>, 505-248-4202.

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

The Indian Health system will very much miss Laura Shelby's help and
energy that she added to our system. Laura innovations and networking
have transformed our approach to the care of sexually transmitted
infections in Indian Country. Though we are very excited about Laura's
new opportunities, she will be sorely missed. Good luck and thanks very
much for all the help over the years, Laura njm

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

#### From Lori de Ravello {#from-lori-de-ravello .Style-Heading-4-+-Arial-14-pt-Underline}

# Which Comes First in Adolescence---Sex and Drugs or Depression?

**Background:**  The notion that adolescents "self-medicate" depression
with substance use and sexual behaviors is widespread, but the temporal
ordering of depression and these risk behaviors is not clear. This study
tests whether gender-specific patterns of substance use and sexual
behavior precede and predict depression or vice versa.

**Results:**  Overall, sex and drug behavior predicted an increased
likelihood of depression, but depression did not predict behavior. Among
girls, both experimental and high-risk behavior patterns predicted
depression. Among boys, only high-risk behavior patterns increased the
odds of later depression. Depression did not predict behavior in boys,
or experimental behavior in girls; but it decreased the odds of
high-risk behavior among abstaining girls (RRR=0.14) and increased the
odds of high-risk behavior (RRR=2.68) among girls already experimenting
with substance use.

**Conclusions:**  Engaging in sex and drug behaviors places adolescents,
and especially girls, at risk for future depression. Future research is
needed to better understand the mechanisms of the relationship between
adolescent behavior and depression, and to determine whether
interventions to prevent or stop risky behaviors will also reduce the
risk of later depression.

#### **Hallfors DD et al.** Which comes first in adolescence-sex and drugs or depression? Am J Prev Med. 2005 Oct;29(3):163-70 {#hallfors-dd-et-al.-which-comes-first-in-adolescence-sex-and-drugs-or-depression-am-j-prev-med.-2005-oct293163-70 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16168864&query_hl=29**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16168864&query_hl=29) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16168864query_hl29 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### Inaccurate, Outdated Serologic Tests for Genital Herpes Still in Use {#inaccurate-outdated-serologic-tests-for-genital-herpes-still-in-use-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### In recent proficiency testing of herpes simplex virus type-specific serologic evidence by the College of American Pathologists, commercially available herpes simplex virus antibody assays that were not glycoprotein-G based demonstrated high false-positive rates (14%-88%) for herpes simplex virus type-2 antibodies in sera that were positive for herpes simplex virus type-1 antibodies but negative for herpes simplex virus type-2 antibodies. Herpes simplex virus serologic testing should be performed with only glycoprotein-G-based tests. {#in-recent-proficiency-testing-of-herpes-simplex-virus-type-specific-serologic-evidence-by-the-college-of-american-pathologists-commercially-available-herpes-simplex-virus-antibody-assays-that-were-not-glycoprotein-g-based-demonstrated-high-false-positive-rates-14-88-for-herpes-simplex-virus-type-2-antibodies-in-sera-that-were-positive-for-herpes-simplex-virus-type-1-antibodies-but-negative-for-herpes-simplex-virus-type-2-antibodies.-herpes-simplex-virus-serologic-testing-should-be-performed-with-only-glycoprotein-g-based-tests. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**Morrow RA**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Morrow+RA"%5BAuthor%5D), [**Brown ZA**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Brown+ZA"%5BAuthor%5D). Common use of inaccurate antibody assays to identify infection status with herpes simplex virus type 2. Am J Obstet Gynecol. 2005 Aug;193(2):361-2. {#morrow-ra-brown-za.-common-use-of-inaccurate-antibody-assays-to-identify-infection-status-with-herpes-simplex-virus-type-2.-am-j-obstet-gynecol.-2005-aug1932361-2. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16098855&query_hl=4**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16098855&query_hl=4) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16098855query_hl4 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### HIV Screening Health-Care Settings: Adolescents, Pregnancy, Adult Recommendations {#hiv-screening-health-care-settings-adolescents-pregnancy-adult-recommendations-1 .Style-Heading-4-+-Arial-14-pt-Underline}

On NOVEMBER 17, 2005, a satellite broadcast is available that highlights
the revised recommendation for HIV screening of adults, adolescents, and
pregnant women in health care settings. Please go to following website
for details on how you can view the broadcast, find local viewing
stations, or utilize the web cast feature.
[http://www.cdcnpin-broadcast.org/](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.cdcnpin-broadcast.org/)

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

#### Annual Screening for C. trachomatis Is Cost-Effective {#annual-screening-for-c.-trachomatis-is-cost-effective-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Annual C. trachomatis screening for all women 15 to 29 years of age and selective targeting of those with a history of infection for semiannual screening is very cost-effective compared with other well-accepted clinical interventions. {#conclusions-annual-c.-trachomatis-screening-for-all-women-15-to-29-years-of-age-and-selective-targeting-of-those-with-a-history-of-infection-for-semiannual-screening-is-very-cost-effective-compared-with-other-well-accepted-clinical-interventions. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Actual practice falls far short of recommended practice. Screening of male adolescents is key: with urine-based nucleic acid amplification test assays to uncover an important reservoir of infection. At present, implementing current guidelines is a clear imperative {#actual-practice-falls-far-short-of-recommended-practice.-screening-of-male-adolescents-is-key-with-urine-based-nucleic-acid-amplification-test-assays-to-uncover-an-important-reservoir-of-infection.-at-present-implementing-current-guidelines-is-a-clear-imperative .Style-Heading-4-+-Arial-14-pt-Underline}

#### Hu D, et al. Screening for ***Chlamydia trachomatis*** in women 15 to 29 years of age: a cost-effectiveness analysis. Ann Intern Med October 5, 2004:141:501-13. {#hu-d-et-al.-screening-for-chlamydia-trachomatis-in-women-15-to-29-years-of-age-a-cost-effectiveness-analysis.-ann-intern-med-october-5-2004141501-13. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15466767&query_hl=6**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15466767&query_hl=6) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15466767query_hl6 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Testing for primary HIV infection with p24 antigen EIA may be a sound use of resources {#testing-for-primary-hiv-infection-with-p24-antigen-eia-may-be-a-sound-use-of-resources-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### METHODS: We undertook a cost-effectiveness analysis of testing a hypothetical cohort of more than 3 million outpatients with fever and other viral symptoms regardless of HIV risk factors using 3 diagnostic assays: p24 antigen enzyme immunosorbent assay (EIA), HIV-1 RNA assay, and third-generation HIV-1 EIA. Antiretroviral therapy was started when the CD4 cell count decreased to 350/µL. Outcome measures were the incremental cost-effectiveness of the diagnostic assays, number of cases identified, cases avoided in sexual partners, and threshold prevalence. For sensitivity analyses, we used \$50,000 as the threshold for cost-effectiveness. {#methods-we-undertook-a-cost-effectiveness-analysis-of-testing-a-hypothetical-cohort-of-more-than-3-million-outpatients-with-fever-and-other-viral-symptoms-regardless-of-hiv-risk-factors-using-3-diagnostic-assays-p24-antigen-enzyme-immunosorbent-assay-eia-hiv-1-rna-assay-and-third-generation-hiv-1-eia.-antiretroviral-therapy-was-started-when-the-cd4-cell-count-decreased-to-350µl.-outcome-measures-were-the-incremental-cost-effectiveness-of-the-diagnostic-assays-number-of-cases-identified-cases-avoided-in-sexual-partners-and-threshold-prevalence.-for-sensitivity-analyses-we-used-50000-as-the-threshold-for-cost-effectiveness. .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS Expanded testing for primary HIV infection with p24 antigen EIA may be a sound expenditure of health care resources. {#conclusions-expanded-testing-for-primary-hiv-infection-with-p24-antigen-eia-may-be-a-sound-expenditure-of-health-care-resources. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Coco A. The Cost-Effectiveness of Expanded Testing for Primary HIV Infection. **Annals of Family Medicine** 3:391-399 (2005) [**http://www.annfammed.org/cgi/content/full/3/5/391**](http://www.annfammed.org/cgi/content/full/3/5/391) {#coco-a.-the-cost-effectiveness-of-expanded-testing-for-primary-hiv-infection.-annals-of-family-medicine-3391-399-2005-httpwww.annfammed.orgcgicontentfull35391 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-44 .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}

**Pedometers Increase Activity for Patients**

The frequency of walking short trips improved significantly more in the
pedometer group relative to the comparison group. The results of this
pilot study highlight the need for further research on the use of
pedometers as a motivational tool in the context of medical encounters
with inactive patients.

[Stovitz
SD](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Stovitz+SD"%5BAuthor%5D)
et a; Pedometers as a means to increase ambulatory activity for patients
seen at a family medicine clinic. J Am Board Fam Pract. 2005
Sep-Oct;18(5):335-43.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16148243&query_hl=9>

**Prevalence of Diabetes Among Adult Alaskans: 2002-2004**

Currrently Alaska Natives do no appear to have higher diabetes
prevalence than other Alaskans.

Hall LD, Stillwater B, Stoltz G, Utermohle CJ. The Prevalence of
Diabetes Among Adult Alaskans: 2002-2004. Section of Epidemiology
Bulletin, Vol. 9, No. 3, September 30, 2005

<http://www.epi.alaska.gov/bulletins/docs/rr2005_03.pdf>

**Women who eat breakfast are less likely to be overweight than those
who fast till lunch**

Women who ate breakfast were 24% less likely to be overweight than those
who did not.

Furthermore, women who preferred breakfast cereal were 30% less likely
to be overweight than their breakfast-skipping counterparts. The
benefits of breakfast meals and choice of breakfast foods seem to be
important in counteracting overweight in the United States..

A breakfast meal low in fat and high in fiber contributes to a
beneficial nutritional profile.

Additional benefit from cereal consumption includes increased calcium
intake from fortified cereals as well as from the milk usually eaten
with cereal.

Song WO et al. Is consumption of breakfast associated with body mass
index in US adults? Journal of the American Dietetic Association, volume
105, Issue 9, Pg 1373-1382, Sept. 2005\
[http://www.adajournal.org/article/PIIS0002822305010278/abstract](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.adajournal.org/article/PIIS0002822305010278/abstract)

**Implementing health behavior change in primary care: lessons from
prescription for health**

CONCLUSIONS: A more versatile, multifaceted solution involving new
tools, technologies, and multidisciplinary care teams is needed in order
to integrate health behavior change into everyday primary care routines.
Even the best interventions require a model to articulate how to
integrate an innovation into practices.

[Cohen
DJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Cohen+DJ"%5BAuthor%5D)
et al Implementing health behavior change in primary care: lessons from
prescription for health. Ann Fam Med. 2005 Jul-Aug;3 Suppl 2:S12-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16049075&dopt=Abstract>

**Vinegar Significantly Lowers Blood Glucose, Insulin Response, and
Increases Satiety**

CONCLUSION: Supplementation of a meal based on white wheat bread with
vinegar reduced postprandial responses of blood glucose and insulin, and
increased the subjective rating of satiety. There was an inverse
dose-response relation between the level of acetic acid and glucose and
insulin responses and a linear dose-response relation between acetic
acid and satiety rating. The results indicate an interesting potential
of fermented and pickled products containing acetic acid.

Östman E et al. Vinegar supplementation lowers glucose and insulin
responses and increases satiety after a bread meal in healthy subjects,
Eur J Clin Nutr. 2005 Sep;59(9):983-8

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16015276&query_hl=4>

**Cinnamon may benefit patients with type 2 diabetes**

CONCLUSIONS: The results of this study demonstrate that intake of 1, 3,
or 6 g of cinnamon per day reduces serum glucose, triglyceride, LDL
cholesterol, and total cholesterol in people with type 2 diabetes and
suggest that the inclusion of cinnamon in the diet of people with type 2
diabetes will reduce risk factors associated with diabetes and
cardiovascular diseases.

[Khan
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Khan+A"%5BAuthor%5D),
et al Cinnamon improves glucose and lipids of people with type 2
diabetes. Diabetes Care. 2003 Dec;26(12):3215-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14633804&query_hl=1>

**Women living alone have an increased risk to develop diabetes
Lifestyle factors**

CONCLUSIONS: Women living alone had a higher risk to progress from IGT
to diabetes, mostly explained by smoking, alcohol, and dietary habits.
Household conditions should be accounted for when assessing future risk
for diabetes.

[Lidfeldt
J](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Lidfeldt+J"%5BAuthor%5D),
et al Women living alone have an increased risk to develop diabetes,
which is explained mainly by lifestyle factors. Diabetes Care. 2005
Oct;28(10):2531-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16186292&query_hl=5>

**Is patriarchy the source of men\'s higher mortality?**

Systematic male dominance -- patriarchy - explains half the discrepancy
in death rates (i.e. life expectancy) between the sexes, suggests
research spanning four continents\...The researchers base their findings
on a comparison of the rates of female homicide (which are an indicator
of patriarchy) and male death rates from all causes in 51
countries\...Rates of violence against women are used to indicate the
extent of societal male dominance over women ― otherwise known as
patriarchy. The results showed that women lived longer than men in every
single country included in the study  [Stanistreet
D](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Stanistreet+D"%5BAuthor%5D),
et al Is patriarchy the source of men\'s higher mortality? Journal of
Epidemiology and Community Health 2005; 59: 873-6
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16166362&query_hl=2>

**Diabetes Data available**

The Alaska Diabetes Prevention and Control Program (AKDPCP) monitors the
burden of diabetes in the state using numerous data sources. In an
effort to share available data with the statewide community, the AKDPCP
will be posting a series of tables with diabetes-related data from some
of our data sources.

The first tables in the series to be posted are from the Behavioral Risk
Factor Surveillance System (BRFSS).

The BRFSS is a random-digit dial telephone survey conducted annually to
track health risks in Alaska. The information from the survey is used to
improve the health of Alaskans. Diabetes questions have been a part of
the BRFSS since 1991, and data from this source is used by the State of
Alaska to estimate the prevalence of diabetes in the state

<http://www.epi.hss.state.ak.us/cd/diabetes/diabetesdata.html>

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

**21st Annual Midwinter Indian Health OB / PEDS Conference**

-   For providers caring for Native women and children

-   January 27-29, 2006

-   Telluride, CO

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

**Advances in Indian Health, 6^th^ Annual**

-   May 2-6, 2006

-   Albuquerque, NM

-   Save the dates brochure

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#May06>

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

-   May 3--6, 2006

-   Anchorage, Alaska

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

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

**ACOG 2006 Annual Clinical Meeting (ACM)**

-   May 6-10, 2006

-   Washington, DC

-   Save the dates brochure
    [http://www.acog.org/abstract%2Dsubmission/](http://www.acog.org/abstract-submission/)

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

-   September 17 -- 21, 2006

-   Denver, CO

-   Contact <YMalloy@acog.org> or call Yvonne Malloy at 202-863-2580

```{=html}
<!-- -->
```
-   Last year's brochure link below (2005 Brochure) (PDF 145k)

-   <http://www.ihs.gov/MedicalPrograms/MCH/M/Documents/FinalACOGBrochure.pdf>

-   NEONATAL RESUSCITATION PROGRAM available

# 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%)}

**Newly Released** **Perinatology Corner Module - Shoulder Dystocia**

A great resource of information and / or free CEU / CME

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

**Domestic Violence Prevention Enhancement and Leadership Through
Alliances (DELTA)**

<http://www.ihs.gov/MedicalPrograms/MCH/W/DV08.cfm#Delta>

There are several upcoming **Conferences**

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

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

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

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

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

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

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

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

The **September 2005 OB/GYN CCC Corner** is available at:\
<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0905.cfm>

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

**Cesarean delivery in Native American women: are low rates explained by
practices common to the Indian health service?**

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

Terry Cullen

-UpToDate available even while you are deployed

-The Commonwealth Fund/Harvard Fellowship in Minority Health Policy

Chuck North

-Summary: Appropriate use of narcotics for chronic non-malignant pain

**Meera Ramesh**

**-**Diabetes prevention and control - Prenatal program

Judy Thierry

-Maternal Morbidity in AI/AN Women, 2002-2004

-Methamphetamine in Indian Country: Good Resources

-FDA Director of the Office of Women\'s Health resigns

-Women\'s Health USA 2005 is online

-Healthy People 2010 midcourse review seeks your comments

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

##### Obstetrics: page 8

-Meperidine for Dystocia During First Stage of Labor: Limit Use

-Progesterone therapy ameliorates other risk factors in previous preterm
delivery

-Misoprostol: Effective and safe treatment option in term premature
rupture of membranes

-Risk of stillbirth is substantially elevated among very and extremely
high parity gravidas

-The 4P\'s Plus screen for substance use in pregnancy: clinical
application and outcomes

and more....

**Gynecology: page 10**

-PID: Outpatient treatment was as effective in preventing reproductive

-Every woman matters study: Improving female health care through
practice change

-Metformin for Anovulation in Normoandrogenic Women

-Virtually all women with prolapse can be treated and their symptoms
alleviated

-Colposcopy: An Evidence-Based Update

and more.....

**Child Health: page 11**

-Adolescents Prefer Honesty and Patient-Centered Care

-Parent Intervention in Risky Adolescent Behaviors Can Help

-Clustering of fast food restaurants around schools

-AMA releases findings on sources of alcohol for adolescents

-School-based dental sealant program manual now available online

and more....

**Chronic Illness and Disease: page 12**

-One Third of Deaths From GI Bleeding Due to NSAIDs

-Withdrawing Aspirin May Significantly Increase Stroke Risk 

-Dietary Calcium Intake and Obesity

-Intertrigo and Common Secondary Skin Infections

-Screening for HCV Infection: Understanding the USPSTF Recommendation

and more....

**Features:** **page 13**

##### American Family Physician -- Cochrane for Clinicians

-Room Air vs. Oxygen for Resuscitating Infants at Birth

-Short-Acting Insulin Analogues vs. Human Insulin for Diabetes

American College of Obstetricians and Gynecologists

-Elaine Locke: Key Contributor to Improve AI/ AN Women's Health for 35
years

-Management of abnormal cervical cytology and histology, ACOG Practice
Bulletin No. 66

-Obesity in Pregnancy

-The Importance of Preconception Care in the Continuum of Women's Health
Care

-Meningococcal Vaccination for Adolescents

**Agency for Healthcare Research and Quality**

-AHRQ Research Activities Relevant to the American Indian and Alaska
Native Community

### -Omega-3 Fatty Acids, Effects on Child and Maternal Health

-Prenatal screening and Tx needed to identify pregnant women with Asx
chlamydia infection

-Screening asymptomatic, low-risk pregnant women for hepatitis C virus
is not cost effective

-AHRQ-Supported Study Finds Medical Disparities Narrowing

**Ask a Librarian**

-The Known and the Unknown - Clinical Evidence Summarized

**Breastfeeding**

-Glyburide nor glipizide compatible with breast-feeding

**Case Managers Corner**

#### -Wouldn't it be nice if there was more distance education available to nurses? {#wouldnt-it-be-nice-if-there-was-more-distance-education-available-to-nurses .Style-Heading-4-+-Arial-14-pt-Underline}

-What are some resources for nurse staffing ratios in L/D and
postpartum**?**

**CCC Corner Digest**

**-**Open access can work for any type of practice. It is the wave of
the future

-New IHS Women's Health Consultant / Advanced Practice Nurse Consultant

-Relative value of physical exam of the breast as a screening tool

-Trial of Labor After Cesarean: Evidence based guidelines

-Ovarian conservation benefits survival in women undergoing hysterectomy

-AAP Releases Report on Excessive Sleepiness in Adolescents

-Existing heart disease is undiagnosed in 1/2 of women with first heart
attack

-Management of Endometrial Cancer ACOG Practice Bulletin NUMBER 65

-The Known and the Unknown - Clinical Evidence Summarized

-Stress and verbal abuse in nursing

-Toward optimal screening strategies for older women: Should cost matter
the most?

-Over-The-Counter Sales of Emergency Contraception Do Not Increase
Unsafe Sex

-Magical Mystery Tour: The Answer: 2 positive blood cultures in a
postpartum patient with fever

-Please help us build the Midwives Indian Health Patient Education
Resources page

-Is the patch more dangerous than the pill?

-Glyburide, Glargine, and Effects of Obesity

-Condom effectiveness for prevention of *Chlamydia trachomatis*
infection

-Women the stronger gender? Men more carbohydrate intolerant / less
physical endurance

**Domestic Violence**

-Patients May Prefer That Physicians Ask About Family Conflict

-Guides to Investigating Child Abuse

**Elder Care News**

-Cancer screening in elderly patients: a framework for individualized
decision making

**Family Planning**

-EC in adolescents: No compromise of family planning or increased sexual
behavior

#### -Contraception, the 'Patch', and reports of adverse events including death {#contraception-the-patch-and-reports-of-adverse-events-including-death .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

-CDC "Key Facts about Flu Vaccine"

**Frequently asked questions**

-Should a urine test be performed on every pregnant patient each
prenatal visit?

-Should we be performing some type of long term follow-up on our GDM
patients?

-Should we do a test of cure for Chlamydia in pregnancy? If so, when?

-What is the safest, most effective approach to prodromal labor?

-Should we use glargine use in pregnancy?

and more.....

**Indian Child Health Notes**

-Early Childhood Longitudinal Study provides a wealth of background
information

-Roslayn Singleton, ANMC: Information on the new adolescent pertussis
booster vaccination

-Doug Esposito of Fort Defiance, AZ: Effort to reduce suicide in AI/AN
communities

**Information Technology**

-Physicians\' Use of Electronic Medical Records

-NCHS Statistics on the Use of Electronic Medical Records

-ISAC Request for Issues/Recommendations

International Health

-Indigenous peoples\' health\--why are they behind everyone, everywhere?

-Volunteer Opportunities - Hurricane Katrina

#### MCH Alert

-Adolescent pregnancy prevention

-Cost effectiveness of interventions for major depression in low income
minority women

#### Medical Mystery Tour

-Overbooked clinic and next patient with chronic pelvic pain

**Menopause Management**

-AHRQ Releases Evidence Report on Managing Menopause-Related Symptoms

-Tibolone and Low-Dose Hormone Therapy Seen as Postmenopausal

#### -Natural History of Menopause Symptoms in Primary Care Patients {#natural-history-of-menopause-symptoms-in-primary-care-patients .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

#### -Centering Pregnancy -- Group Prenatal Care, Amy Doughty, Zuni {#centering-pregnancy-group-prenatal-care-amy-doughty-zuni .Style-Heading-4-+-Arial-14-pt-Underline}

-Public health approach to suicide prevention in an AI/AN, Marsha
Tahquechi, GIMC

**Navajo News**

-Annual Navajo Area Women's Health Provider Meeting, September 23^rd^ in
Chinle

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

-Breast and Cervical Cancer Program Highlights

**Oklahoma Perspective**

-Electronic Health Record for care of women and children

Osteoporosis

#### -Osteoporosis Prevention in Postmenopausal Women {#osteoporosis-prevention-in-postmenopausal-women .Style-Heading-4-+-Arial-14-pt-Underline}

#### -New Report on Soy Finds Limited Evidence for Health Outcomes {#new-report-on-soy-finds-limited-evidence-for-health-outcomes .Style-Heading-4-+-Arial-14-pt-Underline}

Patient Education

-The "talk-sing test" -- If patient can sing, then the pace can be
increased

#### -Intertrigo: What You Should Know {#intertrigo-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

First trimester prenatal genetic screening: Is it ready for 'Prime Time'
at your facility?

Primary Care Discussion Forum

Rectal bleeding: Is it hemorrhoids? November 1, 2005\
Morbidity and Mortality Rounds - Web Based - Moderator: Terry Cullen

STD Corner

-Evaluating a teen STD prevention Web site

-Screening for sexually transmitted diseases in non-traditional
settings: a personal view

-Should we do a test of cure for Chlamydia in pregnancy? If so, when?

#### Barbara Stillwater Alaska Diabetes Prevention and Control

-Reduce insulin resistance during pregnancy

The past CCC Corners are archived at:

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

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

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

10/8/05njm