News Flash

**Any new solutions to Nausea and Vomiting in Pregnancy?**

New Perinatology Corner Module: **Nausea and Vomiting in Pregnancy**

See What's New on the MCH page below

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

OB/GYN Chief Clinical Consultant's Corner

Volume 3, No. 6, June 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}

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

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

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

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

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

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

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

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

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

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

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

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

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

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

##### Obstetrics: page 10

-Slight delay in umbilical cord clamping better for preterm infants

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

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

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

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

-And more...

**Gynecology: page 12**

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

-Transdermal contraceptive promising for reducing bleeding and delaying
menses

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

-Menorrhagia and Screening for von Willebrand Disease

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

-And more...

**Child Health: page 13**

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

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

**Chronic Illness and Disease: page 13**

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

-Improving Adherence to Treatment for Hypertension

-American Cancer Society Guidelines for Early Detection of Cancer
Recommendations

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

-Untreated Depression Common in Minority Women With Cancer

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

##### American Family Physician

Pregnant Patients with Lupus Have High Rates of Fetal Loss

American College of Obstetricians and Gynecologists

-Urinary Incontinence in Women: Practice Bulletin

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

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

**Agency for Healthcare Research and Quality**

-Web M+M - Pregnant with Danger

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

-Caregiver characteristics influence the hospitalization / discharge of
elderly women

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

**Ask a Librarian**

AskUs Live! Now Available to all Indian Health Staff

**Breastfeeding**

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

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

**CCC Corner Digest**

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

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

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

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

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

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

-Negative LEEP Is Not Reassuring

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

-What are the best ways to quit smoking?

-Intrapartum fetal heart rate monitoring, ACOG Practice Bulletin

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

-Antibiotic Tx for Bacterial Vaginosis Does Not Prevent Preterm Birth

-Young age at first sexual intercourse and STIs in adolescents

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

**Domestic Violence**

-McCain introduces safety to Indian Women Act

-PREVENT WORKSHOP: Moving Towards Violence Prevention

**Elder Care News**

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

**Family Planning**

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

**Frequently asked questions**

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

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

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

**Hormone Replacement Update**

-Use of Soy Not effective for Menopausal Symptoms

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

-USPSTF Makes Recommendation Against Routine Use of Estrogen

**Information Technology**

-Tribal access to NIH library services

International Health

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

-International Electives: Maximizing the Opportunity to Learn and
Contribute

#### MCH Alert

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

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

-Effectiveness of school based programs to reduce drinking and driving

#### Medical Mystery Tour

-Follow-up: The Case of the Mystery Question

#### Medscape

-The Prevention and Treatment of Osteoporosis: A Review

**Midwives Corner**

-Primary Care for Midwives: Two Resources

#### -Screening for Genital Herpes: USPSTF

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

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

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

**Oklahoma Perspective**

-West Nile Virus in Women

Osteoporosis

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

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

Patient Education

-Post-term Pregnancy: What You Should Know

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

Primary Care Discussion Forum

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

-Fall 2005: Web based Indian Health M + M

STD Corner

-The National STD-related Infertility Prevention Program

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

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

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

#### Barbara Stillwater, There are 1440 minutes in a day. Make 30 of them active {#barbara-stillwater-there-are-1440-minutes-in-a-day.-make-30-of-them-active .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

-Any new solutions to Nausea and Vomiting in Pregnancy?

New Perinatology Corner Module: Nausea and Vomiting in Pregnancy

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

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

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

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

When highly active antiretroviral therapy (HAART) is prescribed within
48 to 72 hours of nonoccupational exposure to HIV and continued for 28
days, the likelihood of transmission may be reduced. The earlier the
nonoccupational postexposure prophylaxis (nPEP) is administered, the
higher the chance that it will interrupt transmission.

Recent data from human and animal studies, case reports, and
documentation of the use of nonoccupational postexposure prophylaxis
prompted the U.S. Department of Health and Human Services to update its
recommendation for the use of nonoccupational postexposure prophylaxis
in patients who seek treatment within 72 hours of high-risk exposure to
a person known to be HIV positive.

No specific antiretroviral medication or combination is optimal for
nonoccupational postexposure prophylaxis. However, preferred regimens
include efavirenz and lamivudine or emtricitabine with zidovudine or
tenofovir (as a nonnucleoside-based regimen) and lopinavir and ritonavir
(co-formulated in one tablet) and zidovudine with either lamivudine or
emtricitabine. No evidence suggests that a three-drug HAART regimen is
more effective than a two-drug regimen. When the source person is
available for interview, his or her medication history and most recent
viral load measurement should be considered when choosing medications
for nonoccupational postexposure prophylaxis. This could help prevent
prescription of medications to which the virus is already resistant.

All patients seeking treatment after HIV exposure should be tested for
antibodies at baseline, four to six weeks, three months, and six months.
Patients should be informed about the signs and symptoms of acute
retroviral infection and should be asked to return for evaluation if
these occur. Physicians who provide nonoccupational postexposure
prophylaxis also should monitor patients\' liver function, renal
function, and hematologic parameters.

When a patient\'s risk of transmission from contact is small or when
more than 72 hours have passed since exposure, nonoccupational
postexposure prophylaxis is not recommended. However, when a patient
seeks treatment more than 72 hours after exposure, but the risk of virus
transmission is severe, physicians may decide that the potential benefit
of nonoccupational postexposure prophylaxis is greater than the
potential risk of complications from antiretroviral therapy.

#### HIV Status of Source 

Patients who have had sexual, injection-drug\--use, or other
nonoccupational exposures to potentially infectious fluids of persons
known to be HIV infected are at risk for acquiring HIV infection and
should be considered for nPEP if they seek treatment within 72 hours of
exposure. If possible, source persons should be interviewed to determine
his or her history of antiretroviral use and most recent viral load
because this information might provide information for the choice of
nPEP medications.

Persons with exposures to potentially infectious fluids of persons of
unknown HIV status might or might not be at risk for acquiring HIV
infection. When the source is known to be from a group with a high
prevalence of HIV infection (e.g., a homosexual or bisexual man, an
injection\--drug user, or a commercial sex worker), the risk for
transmission might be increased. The risk for transmission might be
especially great if the source person has been infected recently, when
viral burden in blood and semen might be particularly high. However,
ascertaining this in the short time available for nPEP evaluation is
rarely possible. When the HIV status of the source is unknown, it should
be determined whether the source is available for HIV testing. If the
risk associated with the exposure is considered substantial, nPEP can be
started pending determination of the HIV status of the source and then
stopped if the source is determined to be noninfected.

#### Pregnant Women and Women of Childbearing Potential 

Considerable experience has been gained in recent years in the safe and
appropriate use of antiretroviral medications during pregnancy, either
for the benefit of the HIV-infected woman\'s health or to prevent
transmission to newborns. To facilitate the selection of antiretroviral
medications likely to be both effective and safe for the developing
fetus, clinicians should consult DHHS guidelines before prescribing nPEP
for a woman who is or might be pregnant.

Because of potential teratogenicity, efavirenz should not be used in any
nPEP regimen during pregnancy or among women of childbearing age at risk
for becoming pregnant during the course of antiretroviral prophylaxis. A
protease inhibitor- or nucleoside reverse transcriptase inhibitor-based
regimen should be considered in these circumstances. When efavirenz is
prescribed to women of childbearing potential, they should be instructed
about the need to avoid pregnancy. Because the effect of efavirenz on
hormonal contraception is unknown, women using such contraception should
be informed of the need to use an additional method (e.g., barrier
contraception). In addition, because of reports of maternal and fetal
mortality attributed to lactic acidosis associated with prolonged use of
d4T in combination with ddI in HIV-infected pregnant women, this
combination is not recommended for use in an nPEP regimen.

### **Evaluation for Sexually Transmitted Infections, Hepatitis, and Emergency Contraception** 

Evaluation for sexually transmitted infections is important because
these infections might increase the risk for acquiring HIV infection
from a sexual exposure. In 1996, an estimated 5,042 new HIV infections
were attributable to sexually transmitted infection at the time of HIV
exposure. In addition, any sexual exposure that presents a risk for HIV
infection might also place a patient at risk for acquiring other
sexually transmitted infections, including hepatitis B. Prophylaxis for
sexually transmitted disease, testing for hepatitis, and vaccination for
hepatitis B (for those not immune) should be considered.

For women of reproductive capacity who have had genital exposure to
semen, the risk for pregnancy also exists. In these instances, emergency
contraception should be discussed with the potentially exposed patient.

**Summary**

The most effective means of preventing human immunodeficiency virus
(HIV) infection is preventing exposure. The provision of antiretroviral
drugs to prevent HIV infection after unanticipated sexual or
injection-drug\--use exposure might be beneficial. The U.S. Department
of Health and Human Services (DHHS) Working Group on Nonoccupational
Postexposure Prophylaxis (nPEP) made the following recommendations for
the United States.

For persons seeking care [\<]{.underline}72 hours after nonoccupational
exposure to blood, genital secretions, or other potentially infectious
body fluids of a person known to be HIV infected, when that exposure
represents a substantial risk for transmission, a 28-day course of
highly active antiretroviral therapy (HAART) is recommended.
Antiretroviral medications should be initiated as soon as possible after
exposure. For persons seeking care [\<]{.underline}72 hours after
nonoccupational exposure to blood, genital secretions, or other
potentially infectious body fluids of a person of unknown HIV status,
when such exposure would represent a substantial risk for transmission
if the source were HIV infected, no recommendations are made for the use
of nPEP. Clinicians should evaluate risks and benefits of nPEP on a
case-by-case basis. For persons with exposure histories that represent
no substantial risk for HIV transmission or who seek care \>72 hours
after exposure, DHHS does not recommend the use of nPEP. Clinicians
might consider prescribing nPEP for exposures conferring a serious risk
for transmission, even if the person seeks care \>72 hours after
exposure if, in their judgment, the diminished potential benefit of nPEP
outweighs the risks for transmission and adverse events. For all
exposures, other health risks resulting from the exposure should be
considered and prophylaxis administered when indicated. Risk-reduction
counseling and indicated intervention services should be provided to
reduce the risk for recurrent exposures.

Antiretroviral Postexposure Prophylaxis After Sexual, Injection-Drug
Use, or Other Nonoccupational Exposure to HIV in the United States. MMWR
January 21, 2005 / Vol. 54 / No. RR---2
<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5402a1.htm>

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

#### Nonoccupational postexposure prophylaxis (nPEP) is a potentially life saving method that the Indian Health system should incorporate into clinical practice in Indian Country. The earlier the non-occupational post-exposure prophylaxis is administered, the higher the chance that it will interrupt transmission. It should be incorporated into selected post coital contraception or alleged sexual assault, among other acute post coital encounters.  {#nonoccupational-postexposure-prophylaxis-npep-is-a-potentially-life-saving-method-that-the-indian-health-system-should-incorporate-into-clinical-practice-in-indian-country.-the-earlier-the-non-occupational-post-exposure-prophylaxis-is-administered-the-higher-the-chance-that-it-will-interrupt-transmission.-it-should-be-incorporated-into-selected-post-coital-contraception-or-alleged-sexual-assault-among-other-acute-post-coital-encounters. .Style-Heading-4-+-Arial-14-pt-Underline}

#### When the HIV status of the source is not known and the patient seeks care within 72 hours after exposure, DHHS does not recommend for or against nPEP but encourages clinicians and patients to weigh the risks and benefits on a case-by-case basis. {#when-the-hiv-status-of-the-source-is-not-known-and-the-patient-seeks-care-within-72-hours-after-exposure-dhhs-does-not-recommend-for-or-against-npep-but-encourages-clinicians-and-patients-to-weigh-the-risks-and-benefits-on-a-case-by-case-basis. .Style-Heading-4-+-Arial-14-pt-Underline}

#### The Indian Health system should also take advantage of these types of 'teachable moments' to emphasize preconception folic acid therapy, safer sex techniques, and other sexually transmitted infections (STIs). {#the-indian-health-system-should-also-take-advantage-of-these-types-of-teachable-moments-to-emphasize-preconception-folic-acid-therapy-safer-sex-techniques-and-other-sexually-transmitted-infections-stis. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### When a patient\'s risk of transmission from contact is small or when more than 72 hours have {#when-a-patients-risk-of-transmission-from-contact-is-small-or-when-more-than-72-hours-have .Style-Heading-4-+-Arial-14-pt-Underline}

passed since exposure, nonoccupational postexposure prophylaxis is not
recommended.

However, when a patient seeks treatment more than 72 hours after
exposure, but the risk of virus transmission is severe, physicians may
decide that the potential benefit of nonoccupational postexposure
prophylaxis is greater than the potential risk of complications from
antiretroviral therapy.

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

#### Lastly, in follow up to the March 2005 CCC Corner Abstract of the Month, the Clinical Reporting System Project Team has completed a comprehensive document approach about HIV screening in pregnancy in Indian Country. The document outlines how the 'opt out' approach to prenatal HIV screening can be implemented. {#lastly-in-follow-up-to-the-march-2005-ccc-corner-abstract-of-the-month-the-clinical-reporting-system-project-team-has-completed-a-comprehensive-document-approach-about-hiv-screening-in-pregnancy-in-indian-country.-the-document-outlines-how-the-opt-out-approach-to-prenatal-hiv-screening-can-be-implemented. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Prenatal HIV Screen and Consent Procedures at the Indian Health Service,  {#prenatal-hiv-screen-and-consent-procedures-at-the-indian-health-service .Style-Heading-4-+-Arial-14-pt-Underline}

#### Clinical Reporting System, May 2005 {#clinical-reporting-system-may-2005 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/misc/links_gateway/download.cfm?doc_id=9808&app_dir_id=4&doc_file=HIV_Consent_Procedures-revised.pdf**](http://www.ihs.gov/misc/links_gateway/download.cfm?doc_id=9808&app_dir_id=4&doc_file=HIV_Consent_Procedures-revised.pdf) {#httpwww.ihs.govmisclinks_gatewaydownload.cfmdoc_id9808app_dir_id4doc_filehiv_consent_procedures-revised.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

Routine Population-Wide HIV Screening May Be Cost-Effective, March 2005
CCC Corner

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0305_AOM.cfm>

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

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

**Only Half of Women Requesting Postpartum Sterilization Undergo the
Procedure**

News From ACOG: Many pregnant women in the United States who request
postpartum sterilization ultimately do not undergo the procedure (46
percent). Consequently, health care providers should counsel all women
who desire postpartum sterilization about a wide array of contraceptive
methods, according to a report in the April issue of *Obstetrics &
Gynecology*.

<https://www.acog.com/from_home/publications/green_journal/2005/v105n4p794.pdf>

Researchers at the University of Illinois at Chicago studied 712 women
who expressed a desire for postpartum sterilization during their
prenatal care. Sterilization is the most commonly used method of
contraception for women in the United States. Sterilization performed
during the postpartum hospital stay offers many advantages, including
lower failure rates than other methods of sterilization. Yet the issue
of whether and why women do not obtain a postpartum sterilization
procedure they have requested has been poorly studied in the U.S.

Study authors noted that both personal factors and factors related to
the health care system (such as delays in operating room or staff
availability) may have an impact on why women do not obtain this
requested procedure postpartum. The study found that being young (21 to
25 years old), being African-American, making the request during the
second trimester of pregnancy, and having a vaginal delivery instead of
a cesarean delivery were factors significantly associated with not
undergoing sterilization.

While some women change their minds about being sterilized, there is the
possibility that their initial sterilization request reflected a concern
about whether they could successfully use reversible contraception to
prevent unintended pregnancy, note the study authors. Thus, some women
who request sterilization may need more rather than less counseling
about reversible contraception. The researchers are currently conducting
a longitudinal study to further investigate factors affecting women\'s
decisions on sterilization and contraception.

[**https://www.acog.com/from_home/publications/press_releases/nr03-31-05-2.cfm**](https://www.acog.com/from_home/publications/press_releases/nr03-31-05-2.cfm)

#### Carol Ballew, MCH Epi Center, Anchorage {#carol-ballew-mch-epi-center-anchorage .Style-Heading-4-+-Arial-14-pt-Underline}

#### Community-Based Child Abuse Programs for Tribes and Migrant Workers The federal Administration on Children, Youth, and Families has announced funding to support child abuse prevention programs and activities for selected tribes, tribal organizations, and migrant programs. The goal of this program is to prevent the occurrence or recurrence of abuse or neglect within the tribal and migrant populations. The funds are intended to support more effective and comprehensive child abuse prevention activities and family support services, including an emphasis on strengthening marriages and out reach activities. It is anticipated that three grants will be funded under this announcement for \$143,000 per grantee. Eligible applicants include tribal government and organizations, and nonprofit organizations. **Deadline: July 5, 2005** [**http://a257.g.akamaitech.net/7/257/2422/01jan20051800/edocket.access.gpo.**](http://a257.g.akamaitech.net/7/257/2422/01jan20051800/edocket.access.gpo.gov/2005/05-8897.htm) [**gov/2005/05-8897.htm**](http://a257.g.akamaitech.net/7/257/2422/01jan20051800/edocket.access.gpo.gov/2005/05-8897.htm) {#community-based-child-abuse-programs-for-tribes-and-migrant-workers-the-federal-administration-on-children-youth-and-families-has-announced-funding-to-support-child-abuse-prevention-programs-and-activities-for-selected-tribes-tribal-organizations-and-migrant-programs.-the-goal-of-this-program-is-to-prevent-the-occurrence-or-recurrence-of-abuse-or-neglect-within-the-tribal-and-migrant-populations.-the-funds-are-intended-to-support-more-effective-and-comprehensive-child-abuse-prevention-activities-and-family-support-services-including-an-emphasis-on-strengthening-marriages-and-out-reach-activities.-it-is-anticipated-that-three-grants-will-be-funded-under-this-announcement-for-143000-per-grantee.-eligible-applicants-include-tribal-government-and-organizations-and-nonprofit-organizations.-deadline-july-5-2005-httpa257.g.akamaitech.net7257242201jan20051800edocket.access.gpo.-gov200505-8897.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### NCAST- AVENUW Institute 2005 - Fri/Sat August 5 & 6, 2005, Seattle, WA  {#ncast--avenuw-institute-2005---frisat-august-5-6-2005-seattle-wa .Style-Heading-4-+-Arial-14-pt-Underline}

#### Our 11th Biennial Institute, Risky Beginnings: The Need for a System-Wide Focus on Infant Mental Health will feature many exciting workshops and speakers known nationally for their reputations as leaders in the field of child development and advocacy. Post-Institute Workshop, August 7 & 8, Promoting Maternal Mental Health During Pregnancy Training. Register for the Institute and Post-Institute at the below links. [**http://www.ncast.org/**](http://www.ncast.org/) {#our-11th-biennial-institute-risky-beginnings-the-need-for-a-system-wide-focus-on-infant-mental-health-will-feature-many-exciting-workshops-and-speakers-known-nationally-for-their-reputations-as-leaders-in-the-field-of-child-development-and-advocacy.-post-institute-workshop-august-7-8-promoting-maternal-mental-health-during-pregnancy-training.-register-for-the-institute-and-post-institute-at-the-below-links.-httpwww.ncast.org .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Tammy Brown, National Diabetes Program, ABQ {#tammy-brown-national-diabetes-program-abq .Style-Heading-4-+-Arial-14-pt-Underline}

**Seeking Recipes Using Traditional Foods**

The IHS Diabetes Treatment and Prevention Division is looking for
healthy, low-cost, and easy-to-prepare recipes that use traditional
foods.  The recipes are needed for a recipe book we are developing as
part of an obesity/diabetes prevention toolkit for parents of adolescent
girls that emphasizes healthy eating and regular physical activity.

We would appreciate, if available, nutritional content for recipes
submitted.  However, if you do not have this information, our staff will
conduct a nutritional analysis for recipes that will be included in the
toolkit.  We can later provide you with the analysis of any of your
recipes that are selected for the cookbook. Please send all recipes to
<tammy.brown@ihs.gov> If you would like the source for the recipes
credited, please provide that information too. Thanks for your help.

**Zelda Collett-Paule, Anchorage**

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

Prozac use during pregnancy has been well-studied, and many new mothers
are already taking it at delivery.  Its use during breast-feeding is
controversial, however.  Fluoxetine's long half-life and potential for
accumulation in breast milk has prompted some recommendations to avoid
its use in women who are breast-feeding young infants.

Spencer JP, Gonzalez LS 3rd, Barnhart DJ. Medications in the
breast-feeding mother. Am Fam Physician. 2001 Jul 1;64(1):119-26.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11456429&query_hl=4>

Sertraline (Zoloft) is likely to be the safest choice among the SSRI's
because it has been studied extensively and because drug levels found in
nursing infants are usually minimal.

Ruddock B. Antidepressant Use and Breastfeeding -- Focus on Patient
Care. CPJ / RPC 2004 October Vol. 137, No. 8:39-41

**Terry Cullen, Tucson**

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

#### Know a Family Physician, Midwife, PA, Nurse Practitioner, Staff Nurse, Pediatrician, OB/GYN, Administrator, or other staff member who wants to keep up on clinical and policy issues? {#know-a-family-physician-midwife-pa-nurse-practitioner-staff-nurse-pediatrician-obgyn-administrator-or-other-staff-member-who-wants-to-keep-up-on-clinical-and-policy-issues .Style-Heading-4-+-Arial-14-pt-Underline}

Go to this URL:

 <http://www.ihs.gov/cio/listserver/index.cfm>

 

Click the \"Available Lists\" link on the left of the page.

Scroll through the pages till you find the list of your choosing; Click
on that list

The last field is \"List Functions\".

Click on \"Subscribe\", which will generate an email message.

Replace \"\<your name here\>\" with your name.

Send the email message.

Follow the instructions in the return mail to complete your
subscription.

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

#### PS: You can also unsubscribe from your current listserv(s) there, too {#ps-you-can-also-unsubscribe-from-your-current-listservs-there-too .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

#### No, there is recent evidence from this blinded matched control study that shows untreated gestational diabetes mellitus carries significant risks for perinatal morbidity in all disease severity levels. Timely and effective treatment may substantially improve outcome. {#no-there-is-recent-evidence-from-this-blinded-matched-control-study-that-shows-untreated-gestational-diabetes-mellitus-carries-significant-risks-for-perinatal-morbidity-in-all-disease-severity-levels.-timely-and-effective-treatment-may-substantially-improve-outcome. .Style-Heading-4-+-Arial-14-pt-Underline}

Langer O, Yogev Y, Most O, Xenakis EM. Gestational diabetes: the
consequences of not treating. Am J Obstet Gynecol. 2005
Apr;192(4):989-97.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15846171&query_hl=1>

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

In Hunter's 1985 letter he raised the issue of whether "Gestational
diabetes is a diagnosis still looking for a disease". Two recent
articles show that glucose intolerance in pregnancy perinatal and
neonatal morbidity.

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

#### In the blinded study above reported by Langer et al which showed untreated gestational diabetes mellitus carried significant risks for perinatal morbidity in all disease severity levels. In addition, Saydah et al found similar results from a large nationally representative survey data. Saydah et al findings confirm that pregnancies in women with GDM are more likely to be associated with maternal medical complications compared with pregnancies in women without diabetes.  {#in-the-blinded-study-above-reported-by-langer-et-al-which-showed-untreated-gestational-diabetes-mellitus-carried-significant-risks-for-perinatal-morbidity-in-all-disease-severity-levels.-in-addition-saydah-et-al-found-similar-results-from-a-large-nationally-representative-survey-data.-saydah-et-al-findings-confirm-that-pregnancies-in-women-with-gdm-are-more-likely-to-be-associated-with-maternal-medical-complications-compared-with-pregnancies-in-women-without-diabetes. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Saydah SH, Chandra A, Eberhardt MS. Pregnancy experience among women with and without gestational diabetes in the U.S., 1995 National Survey of Family Growth. Diabetes Care. 2005 May;28(5):1035-40. {#saydah-sh-chandra-a-eberhardt-ms.-pregnancy-experience-among-women-with-and-without-gestational-diabetes-in-the-u.s.-1995-national-survey-of-family-growth.-diabetes-care.-2005-may2851035-40. .Style-Heading-4-+-Arial-14-pt-Underline}

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15855563&query_hl=3>

Hunter DJ, Milner R. Gestational diabetes and birth trauma. \[letter\]
Am J Obstet Gynecol. 1985 Aug 1;152(7 Pt 1):918-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=4025442&query_hl=1>

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

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

**Funds for small projects - Community Access To Child Health (CATCH)
Program**

Call for Proposals **-** 2006 CATCH Planning Funds and CATCH Resident
Funds Grants

For the 12th consecutive year, the American Academy of Pediatrics is
offering pediatricians an opportunity to put their ideas into action by
taking advantage of the funding available through the CATCH Program. The
CATCH mission and the focus of the Planning Funds grants are to enable
pediatricians to plan innovative community-based child health
initiatives that increase access to medical homes or specific health
services not otherwise available. A pediatrician or pediatric resident
must lead the project and be involved in the proposal development and
project activities.

 

CATCH Planning Funds grants are awarded in amounts from \$2,500 to
\$10,000 on a competitive basis for planning activities, such as needs
assessments and community asset mapping, feasibility studies, community
coalition/collaboration meetings, focus groups, and development of grant
proposals for project implementation after the planning phase is
complete. Priority is given to projects that will be serving communities
with the greatest health disparities.

 CATCH Resident Funds grants are limited to a maximum of \$3,000.
Resident grant projects must include planning activities, but also may
include some implementation activities. A pediatric resident must lead
the project and be involved in the proposal development and project
activities.

 For more information or to apply for a grant, visit
[www.aap.org/catch/planninggrants.htm](http://www.aap.org/catch/planninggrants.htm)
or
[www.aap.org/catch/residentgrants.htm](http://www.aap.org/catch/residentgrants.htm)
The deadline for submission is July 29.

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

\- Lower Respiratory Tract Infections: Major Health Disparity for AI/AN
infants and children

\- Comparison of health disparities rates in two indigenous populations:

Maori in New Zealand and AI/AN in the United States

<http://www.ihs.gov/MedicalPrograms/MCH/C/documents/ICHN0605.doc>

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

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

I thought you might be interested in this data for historical
comparisons. If you are interested in a copy of the power point
presentation, then contact <CNorth@abq.ihs.gov>

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

**Access to CDC\'s Guide to Community Preventive Services**

The CDC\'s *Guide to Community Preventive Services: What Works to
Promote Health?* is now available online and can be downloaded from the
Community Guide website, <http://www.thecommunityguide.org/> For
additional information on the *Guide to Community Preventive Services:
What Works to Promote Health*, please contact Peter Briss, MD, MPH,
Chief of the Community Guide Branch at CDC at <pbriss@cdc.gov>

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

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

**Leading Causes of Death Charts to drilldown to ICD codes: Enhancement
to WISQARS**

In the past couple of years, we have had many requests from injury
researchers to enhance WISQARS so that users could drilldown to the ICD
codes for mortality data.  Well, it is now a reality. Go to the
\"Leading Causes of Death\" option for Fatal Injuries in WISQARS. With a
few clicks of your mouse, you will be lead to the leading causes of ALL
death query page which now allows you to drilldown to ICD codes for
injury-related deaths. <http://www.cdc.gov/ncipc/wisqars/>

**Ideal for a network supporting women\'s health**

Establish Rural/Frontier Women's Health Coordinating Centers - Pre
solicitation announcement of RFP for rural and frontier WH education
projects. For those who would like to apply RFCC RFP will be posted
approximately June 15, 2005. You can register to be notified below at
this link.
<http://www1.eps.gov/spg/HHS/PSC/DAM/05T050034/SynopsisP.html>

#### Alan Waxman Retired IHS OB/GYN CCC {#alan-waxman-retired-ihs-obgyn-ccc .Style-Heading-4-+-Arial-14-pt-Underline}

**Covering Kids Act of 2005 - Bipartisan legislation**

Senators Frist (R-TN) and Bingaman (D-NM) are preparing to introduce
bipartisan legislation, the "Covering Kids Act of 2005," that would
provide \$100 million over two years to community-based organizations,
including faith-based organizations, and safety net providers, including
community health centers, DSH hospitals, 340B entities, IHS providers,
tribal organizations, and urban Indian programs, to conduct innovative
outreach and enrollment efforts to reach pregnant women and the
estimated 5 million children eligible but unenrolled in Medicaid and the
State Children\'s Health Insurance Program. We would appreciate any
support that you can offer. Bruce (Bingaman) Lesley
<Bruce_Lesley@bingaman.senate.gov>

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

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

Slight delay in umbilical cord clamping better for preterm infants

Cochrane for Clinicians: Putting Evidence into Practice

Clinical Question

What is the optimal time to clamp the umbilical cord for infants born at
less than 37 weeks\' gestation?

Evidence-Based Answer

In preterm infants, clamping the umbilical cord between 30 seconds and
two minutes after delivery is associated with lower rates of blood
transfusion and intraventricular hemorrhage.

[REVIEWERS\' CONCLUSIONS]{.underline}: Delaying cord clamping by 30 to
120 seconds, rather than early clamping, seems to be associated with
less need for transfusion and less intraventricular haemorrhage. There
are no clear differences in other outcomes.

Rabe H, et al. Early versus delayed umbilical cord clamping in preterm
infants. Cochrane Database Syst Rev 2004;(3):CD003248
<http://www.aafp.org/afp/20050601/cochrane.html>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15495045&query_hl=6>

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

An individual\'s chance of using the blood is low.

The possibility of a child\'s needing hematopoietic stem cell
transplantation is low. Best estimates suggest the risk is 1 in
2,700,and the risk advanced by private companies, which one might expect
to present the \"best case\" for cord blood need, is 1 in 1,400 Indeed,
the literature reports few cases of an individual\'s receiving back his
or her own banked cord blood, and industry publications, which one might
expect would be eager to promote such cases, cite no more. Further, of
reported cases, some involve families whose histories suggested the
potential need for stem cell therapy before delivery and collection.

[Public setting best at this time]{.underline}

In sum, our arguments are not about the potential of umbilical cord stem
cells, but are about the setting and system where that potential is best
realized. We argue for public umbilical cord blood banking as a matter
of good public health and economic sense. We foresee a day in which most
patients will volunteer their cord blood to such banks. Those who do so
will value real public benefits against the, sometimes, exaggerated
claims of individual benefit advanced by private cord blood banks. We
prefer, as a matter of public health and policy, to rely on public
institutions to manage such a valuable resource as umbilical cord blood
and trust that the integrity of these institutions and their obligation
to the public will insure the future safety and availability of banked
samples.

Although we offer this vision, we cannot predict the future. Some
private banks suggest that, in the future, stem cells and cord blood may
be used to treat a host of other diseases, such as diabetes or
Alzheimer\'s, in which specific cell lines are depleted or
dysfunctional. For now, however, such potentials are, at best,
hypothetical and, at worst, exaggerated claims designed to attract
business. Time may prove that umbilical cord stem cells have compelling
benefits to the individual, but for now the available evidence argues
for the promotion of public rather than private cord blood banking.

Ecker JL, Greene MF. The case against private umbilical cord blood
banking. Obstet Gynecol. 2005 Jun;105(6):1282-4.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15932817&dopt=Abstract>

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

CONCLUSION: Relative to pre-pregnancy performance, fitness and strength
declined in the early postpartum period but improved by 27 wk
postpartum.

Treuth MS, Butte NF, Puyau M. Pregnancy-related changes in physical
activity, fitness, and strength. Med Sci Sports Exerc. 2005
May;37(5):832-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15870638&query_hl=10>

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

CONCLUSION: The incidence of reactive hypoglycemia during the 100-g oral
glucose tolerance test in our population is 6.3%. Women who experience
hypoglycemia during the test have a significantly lower incidence of
gestational diabetes and neonatal birth weights. LEVEL OF EVIDENCE: III
Weissman A, et al Hypoglycemia During the 100-g Oral Glucose Tolerance
Test: Incidence and Perinatal Significance. Obstet Gynecol. 2005
Jun;105(6):1424-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15932839&dopt=Abstract>

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

CONCLUSION: The disruption of the internal os, as documented by
funneling, is a significant risk factor for adverse perinatal outcome
(ie, preterm labor, chorioamnionitis, abruption, rupture of the
membranes, and serious neonatal morbidity and mortality). Cervical
funneling is best measured as a categorical variable (present or
absent).

Rust OA, et al Does the presence of a funnel increase the risk of
adverse perinatal outcome in a patient with a short cervix? Am J Obstet
Gynecol. 2005 Apr;192(4):1060-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15846180&query_hl=5>

**Use of Prescription Drugs During Pregnancy**

almost one half of the women in this study received medications that
have no evidence of safety during pregnancy or for which evidence shows
a risk to the fetus in animals or humans. They add that these results
indicate the need to develop and implement systems that eliminate the
exposure of pregnant women to these medications. CONCLUSION: Our finding
that almost one half of all pregnant women received prescription drugs
from categories C, D, or X of the United States Food and Drug
Administration risk classification system highlights the importance of
the need to understand the effects of these medications on the
developing fetus and on the pregnant woman Andrade SE, et al.
Prescription drug use in pregnancy. Am J Obstet Gynecol August
2004;191:398-407.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15343213&query_hl=4>

**Emergence of Doulas as Childbirth Paraprofessionals**

Fourteen randomized trials have demonstrated that continuous caregiver
support during childbirth can lead to shorter labors and decrease the
need for intervention. Our survey findings suggest that a number of
challenges . . . present significant obstacles to the further growth of
doulas as childbirth paraprofessionals in the United States. Additional
research is needed to better understand the unique role and
contributions of doulas/labor assistants to maternity care teams in the
21st century. Lantz PM, Low LK, Varkey S, et al. 2005. Doulas as
childbirth paraprofessionals: Results from a national survey. Women\'s
Health Issues 15(3):109-116.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15894196&query_hl=1>

**Routine Use of Episiotomy in Uncomplicated Births Offers No Benefits
to Women**

AHRQ released a new evidence report that shows routine use of episiotomy
for uncomplicated vaginal births does not provide immediate or longer
term benefits for the mother. Episiotomy is the surgical cutting of the
perineum-the skin between the vaginal opening and the anus-and is a
common procedure used in an estimated one-third of vaginal deliveries to
hasten birth or prevent tearing of the skin during delivery. The routine
episiotomy, common in many practice settings, did not achieve any of the
goals it is commonly believed to achieve. The topic was nominated by the
American College of Obstetricians and Gynecologists, which intends to
translate the findings into clinical practice guidelines for OB/GYNs.
<http://www.ahrq.gov/clinic/epcsums/epissum.htm>

**IV bolus of 1,000 mL, lateral positioning, and oxygen administration
at 10 L/min via nonrebreather face mask significantly increase fetal
oxygen saturation during labor.**

CONCLUSION: An intravenous fluid bolus of 1,000 mL, lateral positioning,
and O(2) administration at 10 L/min via nonrebreather face mask are
effective in increasing FSpO(2) during labor. LEVEL OF EVIDENCE: II-2.

Simpson KR, James DC. Efficacy of intrauterine resuscitation techniques
in improving fetal oxygen status during labor. Obstet Gynecol. 2005
Jun;105(6):1362-8\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15932830&dopt=Abstract>

**A systematic literature review indicated that laser ablation produced
better survival for at least 1 twin and lower long-term neurodevelopment
morbidity in survivors.**

CONCLUSION: In a systematic review of observational and randomized
controlled studies, laser photocoagulation of chorionic plate vessels at
the intertwin membrane seems to be more effective than serial
amnioreduction in the treatment of twin-twin transfusion syndrome with
less associated perinatal morbidity and mortality. However, septostomy
and selective feticide have not been robustly evaluated. Fox C, Kilby
MD, Khan KS.Contemporary treatments for twin-twin transfusion syndrome.
stet Gynecol. 2005 Jun;105(6):1469-77.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15932845&dopt=Abstract>

**Management of Pregnancy Beyond 40 Weeks\' Gestation** (also see
Patient Education)

<http://www.aafp.org/afp/20050515/1935.html>

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

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

CONCLUSION: Chlorhexidine gluconate was more effective than povidone
iodine in decreasing the bacterial colony counts that were found in the
operative field for vaginal hysterectomy.

Although bacterial contamination may have a greater level of reduction
in the chlorhexidine group, this does not guarantee a difference in
postoperative infection. Among the 50 patients enrolled in this study,
none of them were noted to have a postoperative infection. The authors
also commented that if they were to structure the study to look at
postoperative infections, they would have to enroll 814 patients in each
arm to achieve a 50% reduction. Similar but larger studies may be
helpful to assess whether chlorhexidine prep should become the standard
prep for vaginal hysterectomies.

Culligan PJ et al A randomized trial that compared povidone iodine and
chlorhexidine as antiseptics for vaginal hysterectomy. Am J Obstet
Gynecol. 2005 Feb;192(2):422-5.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15695981&query_hl=17>

**Transdermal contraceptive promising for reducing bleeding and delaying
menses**

CONCLUSION: Compared with cyclic use, extended use of the
norelgestromin/ethinyl E2 transdermal patch delayed menses and resulted
in fewer bleeding days. This regimen may represent a useful alternative
for women who prefer fewer episodes of withdrawal bleeding. LEVEL OF
EVIDENCE: I. Stewart FH, et al Extended Use of Transdermal
Norelgestromin/Ethinyl Estradiol: A Randomized Trial. Obstet Gynecol.
2005 Jun;105(6):1389-1396\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15932834&dopt=Abstract>

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

CONCLUSIONS: One year after intervention, the success rate of collagen
injection as a treatment for stress urinary incontinence was about 19%
lower than that after surgery. This has to be tempered by the similar
changes in quality of life and satisfaction in both groups and that the
number and severity of complications were much greater after surgery
than after collagen injection. The results of this study indicate that
collagen injections might be a worthwhile alternative to surgery for the
treatment of stress urinary incontinence

Corcos J et al Multicenter randomized clinical trial comparing surgery
and collagen injections for treatment of female stress urinary
incontinence. Urology. 2005 May;65(5):898-904

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15882720&query_hl=11>

**Menorrhagia and Screening for von Willebrand Disease**

Although von Willebrand disease may be more prevalent in women with
menorrhagia than in the general population, it is difficult to identify
the proportion of menorrhagia cases attributable to this disease. In
addition, there are too few data to confirm the degree of enhanced
morbidity or surgical risk in women who have menorrhagia with von
Willebrand disease. Routine screening for von Willebrand disease in
women with menorrhagia therefore is not supported sufficiently by
current evidence. Further data are needed.

James A, Matchar DB, Myers ER. Testing for von Willebrand disease in
women with menorrhagia: a systematic review. Obstet Gynecol. 2004
Aug;104(2):381-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15292016&query_hl=1>

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

CONCLUSION: Supracervical and total abdominal hysterectomy result in
similar sexual functioning and health-related quality of life during 2
years of follow-up. This information can help guide physicians as they
discuss surgical options with their patients. LEVEL OF EVIDENCE: I\
Kuppermann M et al Sexual Functioning After Total Compared With
Supracervical Hysterectomy: A Randomized Trial. Obstet Gynecol. 2005
Jun;105(6):1309-1318.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15932822&dopt=Abstract>

**Uterine Fibroid Embolization - Patient Education**

"Known medically as uterine artery embolization, this approach to the
treatment of fibroids blocks the arteries that supply blood to the
fibroids causing them to shrink. It is a minimally-invasive procedure,
which means it requires only a tiny nick in the skin, and is performed
while the patient is conscious but sedated /drowsy and feeling no
pain\...." From Society of Interventional Radiology

<http://www.sirweb.org/patPub/uterineTreatments.shtml#uf>

**Recurrent vulvar itching. Green Journal "In the Trenches"**

This month\'s \"In the Trenches\" uses a practical question-based case
series to assess the evaluation and management of a woman with vulvar
itching thought to be due to recurrent vulvovaginitis. Boardman LA,
Botte J, Kennedy CM. Recurrent vulvar itching. Obstet Gynecol. 2005
Jun;105(6):1451-5.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15932843&dopt=Abstract>

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

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

Pregnancy factors, parental psychiatric history, and preterm delivery
may be associated with the risk of autism. Some of the specific factors
that the study found to be associated with the risk of autism included:
breech presentation at birth, delivery before 35 weeks, a parent who had
a diagnosis of schizophrenia-like psychosis before the date that autism
was diagnosed in the child, and low birth weight at delivery. The study
also found many of these factors were independently associated with
autism. For example, there was an association between adverse pregnancy
events and autism, regardless of whether one of the parents had a
diagnosed psychiatric illness.

<http://www.cdc.gov/od/oc/media/pressrel/r050516.htm>

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

The USPSTF recommends against the routine screening of asymptomatic
adolescents for idiopathic scoliosis. **D recommendation**.
<http://www.aafp.org/afp/20050515/us.html>

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

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

CONCLUSION: In white women in their mid-30s, the prevalence of the
metabolic syndrome is 3- to 5-fold increased in those with a history of
PIH in their first pregnancy. This emphasizes the importance of
long-term follow-up assessment for cardiovascular risk factors in these
women. LEVEL OF EVIDENCE: II-2. Forest JC, et al Early occurrence of
metabolic syndrome after hypertension in pregnancy. Obstet Gynecol. 2005
Jun;105(6):1373-80.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15932832&dopt=Abstract>

Improving Adherence to Treatment for Hypertension

Cochrane for Clinicians: Putting Evidence into Practice

Clinical Scenario

M.L. is a 58-year-old man with poorly controlled hypertension; he has
been prescribed 100 mg of metoprolol twice daily. He says he is so tired
when he gets home at night that he usually goes to bed without taking
the second dose of his medication.

Clinical Question

What methods are effective at improving adherence to treatment in
patients with hypertension?

The most effective strategy to improve patient compliance with
antihypertensive medication is to simplify the dosing regimen. There is
more limited evidence to support a variety of motivational strategies.
Patient education alone is ineffective.

The practice recommendations:
<http://www.cochrane.org/cochrane/revabstr/AB004804.htm>

<http://www.aafp.org/afp/20050601/cochrane.html>

American Cancer Society Releases Annual Guidelines for the Early
Detection of Cancer

Recommendations

breast cancer screening

Breast cancer screening should begin when women are 20 years of age and
should consist of clinical breast examinations, counseling to raise
awareness of symptoms, and regular mammography after the age of 39.
Clinical breast examinations should take place every three years in
women 20 through 39 years of age and annually in women 40 years and
older. Women at average risk should begin annual mammography at the age
of 40 and should continue the practice as long as they are in good
health and would be candidates for breast cancer treatment. The ACS no
longer recommends monthly breast self-examinations, but instead
recommends that women be informed of the potential limitations, risks,
and benefits associated with self-examination. The new guidelines
emphasize the physician\'s role in raising and reinforcing awareness of
breast cancer, early detection, and the importance of timely reporting
of any symptoms.

cervical cancer screening

Cervical cancer screening should begin three years after the onset of
vaginal intercourse but no later than 21 years of age. Screening should
be performed annually until the age of 30 with conventional cervical
cytology smears, or every two years until the age of 30 with
liquid-based cytology. Women older than 30 years who have had three
consecutive normal or negative cytology results may reduce the frequency
of screening to every two to three years. Women 70 years and older with
an intact cervix may cease cervical cancer screening if they have had
three or more consecutive normal or negative cytology results within the
10-year period before the age of 70.

Women with a history of cervical cancer or in utero exposure to
diethylstilbestrol should continue annual screening after age 30. Women
who are immunocompromised (i.e., organ transplant patients, those
receiving chemotherapy, those with human immunodeficiency virus
infection) should be tested twice in the first year after diagnosis and
annually thereafter as long as they are in good health and would benefit
from early detection and treatment.

Cervical cancer screening is not indicated for women who have had a
total hysterectomy for benign gynecologic disease. Women with subtotal
hysterectomy should follow the recommendations for women at average
risk.

colorectal cancer screening

Adults at average risk of developing colorectal cancer should begin
screening at 50 years of age using one of five options: (1) annual fecal
occult blood test or fecal immunochemical test, (2) flexible
sigmoidoscopy every five years, (3) annual fecal occult blood test or
fecal immunochemical test plus flexible sigmoidoscopy every five years,
(4) colonoscopy every 10 years, or (5) double-contrast barium enema
every five years.

More intensive surveillance is recommended for patients with a history
of adenomatous polyps, a history of curative-intent resection of
colorectal cancer, a family history of colorectal cancer or colorectal
adenomas diagnosed in a first-degree relative before the age of 60, a
history of inflammatory bowel disease of significant duration, or family
history of genetic testing indicating one of two hereditary syndromes.

endometrial cancer screening

Endometrial cancer screening is not recommended for women at average or
somewhat increased risk. However, the ACS recommends that women in these
categories be informed of the risks and symptoms of endometrial cancer
at the onset of menopause. Women at very high risk of endometrial cancer
(i.e., those with known hereditary nonpolyposis colon cancer-associated
genetic mutation carrier status, substantial likelihood of being a
mutation carrier, or absence of genetic testing results in families with
suspected autosomal dominant predisposition to colon cancer) should
consider annual screening beginning at 35 years of age.

**LUNG CANCER SCREENING**

Testing for early lung cancer detection is not recommended for
asymptomatic persons who are at risk. The ACS maintains that patients at
risk for lung cancer because of significant exposure to tobacco smoke or
occupational exposures may discuss with their physicians the benefits
and risks of testing and may decide to undergo testing on an individual
basis. Ideally, testing should be done only in experienced centers that
are linked to multidisciplinary subspecialty groups. Patients who
currently smoke should be informed that the immediate preventive health
priority is the elimination of tobacco use.

The American Cancer Society (ACS) has released its annual
recommendations for the early detection of cancer. The report was
published in the January/February 2005 issue of *CA: A Cancer Journal
for Clinicians*
<http://caonline.amcancersoc.org/cgi/content/full/55/1/31>

<http://www.aafp.org/afp/20050601/practice.html>

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

CONCLUSION: Cognitive therapy can be as effective as medications for the
initial treatment of moderate to severe major depression, but this
degree of effectiveness may depend on a high level of therapist
experience or expertise.

DeRubeis RJ, et al Cognitive therapy vs medications in the treatment of
moderate to severe depression. Arch Gen Psychiatry. 2005
Apr;62(4):409-16.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15809408&query_hl=16>

**Untreated Depression Common in Minority Women With Cancer**

CONCLUSION: Findings indicate that depressive disorder among ethnic
minority, low-income women with breast or gynecologic cancer is
prevalent and is correlated with pain, anxiety, and health-related
quality of life. Because these women are unlikely to receive depression
treatment or supportive counseling, there is a need for routine
screening, evaluation, and treatment in this population.

Ell K, et al Depression, correlates of depression, and receipt of
depression care among low-income women with breast or gynecologic
cancer. J Clin Oncol. 2005 May 1;23(13):3052-60.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15860863&query_hl=12>

**High cholesterol levels in elderly linked to lower dementia risk**

CONCLUSIONS: High cholesterol in late life was associated with decreased
dementia risk, which is in contrast to previous studies suggesting high
cholesterol in mid-life is a risk factor for later dementia. The
conflicting results may be explained by the timing of the cholesterol
measurements in relationship to age and the clinical onset of dementia.

Mielke MM, et al High total cholesterol levels in late life associated
with a reduced risk of dementia. Neurology. 2005 May 24;64(10):1689-95\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15911792&query_hl=8>

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

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

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

Pregnant Patients with Lupus Have High Rates of Fetal Loss

[Clinical Question:]{.underline} What is the outcome of pregnancy in
patients with systemic lupus erythematosus (SLE)?

###### **[Bottom Line:]{.underline}** Women with lupus who become pregnant have high rates of perinatal morbidity and mortality. The outcomes are even worse in women with severe SLE. (Level of Evidence: 1b)

<http://www.aafp.org/afp/20050601/tips/16.html>

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

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

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

**Urinary Incontinence in Women**

Practice Bulletin NUMBER 63, JUNE 2005

**Summary of Conclusions and Recommendations**

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

-   Behavioral therapy, including bladder training and prompted voiding,
    improves symptoms of urge and mixed incontinence and can be
    recommended as a noninvasive treatment in many women.

-   Pelvic floor training appears to be an effective treatment for adult
    women with stress and mixed incontinence and can be recommended as a
    noninvasive treatment for many women.

-   Pharmacologic agents, especially oxybutynin and tolterodine, may
    have a small beneficial effect on improving symptoms of detrusor
    overactivity in women.

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

-   Cystometric testing is not required in the routine or basic
    evaluation of urinary incontinence.

-   Bulking agents are a relatively noninvasive method of treatment for
    stress incontinence and can be used in women for whom any form of
    operative treatment is contraindicated.

-   Long-term data suggest that Burch colposuspension and sling
    procedures have similar objective cure rates; therefore, selection
    of treatment should be based on patient characteristics and the
    surgeon's experience.

-   The combination of a hysterectomy and a Burch colposuspension does
    not result in higher continence rates than a Burch procedure alone.

-   Tension-free vaginal tape and open Burch colposuspension have
    similar success rates.

-   Anterior colporrhaphy, needle urethropexy, and paravaginal defect
    repair have lower cure rates for stress incontinence than Burch
    colposuspension.

***The following recommendations are based primarily on consensus and
expert opinion (Level C):***

-   After the basic evaluation of urinary incontinence, simple
    cystometry is appropriate for detecting abnormalities of detrusor
    compliance and contractibility, measuring postvoid residual volume,
    and determining capacity.

-   Patients with urinary incontinence should undergo a basic evaluation
    that includes a history, physical examination, measurement of
    postvoid residual volume, and urinalysis.

**ACOG Members**

<http://www.acog.org/publications/educational_bulletins/pb063.cfm>

**Non- ACOG members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15932869&query_hl=1>

**Ob-Gyns Address Health Needs of Underserved Women With New
Publication: *Special Issues in Women\'s Health***

*Special Issues in Women\'s Health*, a unique new book released by The
American College of Obstetricians and Gynecologists (ACOG), will help
physicians address the health care needs of underserved women, including
women with disabilities, incarcerated women, lesbian and bisexual women,
and transgendered individuals.

<http://www.acog.org/from_home/publications/press_releases/nr05-26-05-2.cfm>

**ACOG Updates Definitive Guide to Pregnancy**

***Your Pregnancy & Birth*, Fourth Edition Gives Women the Latest News
on Genetic Disorders, Prenatal Tests, DOs and DON\'Ts, and Exercise**

The American College of Obstetricians and Gynecologists (ACOG) announced
that it has updated the most authoritative, medically vetted consumer
book on pregnancy and birth in the US. In releasing the fourth edition
of *Your Pregnancy & Birth* (previously known as *Planning Your
Pregnancy and Birth*), ACOG wants women to know the latest medical
recommendations on issues ranging from genetic screening to the safety
of foods to the use of alternative medicine during pregnancy.
<http://www.acog.org/from_home/publications/press_releases/nr05-10-05-2.cfm>

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

**Web M+M**

**Pregnant with Danger**

[A woman who was 38 weeks pregnant came to the emergency department (ED)
complaining of left leg pain. Ruled out for DVT, she was sent home, only
to die the following
morning.](http://www.webmm.ahrq.gov/case.aspx?caseID=97)\.....

<http://www.webmm.ahrq.gov/>

**Other AHRQ**

**Most obstetricians are reluctant to grant women a first-time cesarean
delivery without medical indications**
<http://www.ahrq.gov/research/apr05/0405RA15.htm#head15>

**Informal caregiver characteristics influence the hospitalization and
discharge of elderly women**
<http://www.ahrq.gov/research/apr05/0405RA16.htm#head16>

**Sociodemographic factors affect receipt of preventive care services
among women aged 65 and older**
<http://www.ahrq.gov/research/apr05/0405RA17.htm#head17>

#### 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}

**AskUs Live! Available to all Indian Health Staff**

The Health Services Research Library's (HSRL) offers an online reference
service called **AskUs Live!** With this service, when you pose a
question you get an immediate response. We'll use our expertise to help
you use HSRL Library information resources. While you are connected to
**AskUs Live!,** librarians can send you web pages with useful
information; help you fill out a form on the Library's website; or even
perform a literature search with you.

The **AskUs Live!** service is available Monday - Friday, 8:30 a.m. - 5
p.m. EST

To receive live interactive assistance from librarians, just click on
**the AskUs Live!** button located on the top left side of the HSRL
website
([http://hsrl.nihlibrary.nih.gov](http://hsrl.nihlibrary.nih.gov/)). The
button travels with you across the site, no matter what content area you
are in.

##### 

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

#### Metformin was excreted into breast milk, and neither hypoglycemia nor other adverse effects were observed in 3 nursing infants. {#metformin-was-excreted-into-breast-milk-and-neither-hypoglycemia-nor-other-adverse-effects-were-observed-in-3-nursing-infants. .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Metformin is excreted into breast milk, but the amounts seem to be clinically insignificant. No adverse effects on the blood glucose of the 3 nursing infants were measured. LEVEL OF EVIDENCE: III Briggs GG, et al Excretion of metformin into breast milk and the effect on nursing infants. Obstet Gynecol. 2005 Jun;105(6):1437-41. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15932841&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15932841&dopt=Abstract) {#conclusion-metformin-is-excreted-into-breast-milk-but-the-amounts-seem-to-be-clinically-insignificant.-no-adverse-effects-on-the-blood-glucose-of-the-3-nursing-infants-were-measured.-level-of-evidence-iii-briggs-gg-et-al-excretion-of-metformin-into-breast-milk-and-the-effect-on-nursing-infants.-obstet-gynecol.-2005-jun10561437-41.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids15932841doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Exclusive breastfeeding may reduce postnatal HIV transmission {#exclusive-breastfeeding-may-reduce-postnatal-hiv-transmission-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Early exclusive breastfeeding reduced postnatal transmission of HIV and increased HIV-free survival in a large trial conducted in Zimbabwe. International guidance currently recommends avoidance of all breastfeeding by HIV-infected mothers when replacement feeding is acceptable and safe, but such replacement feeding is commonly unavailable in Africa. **These** findings underscore the importance of supporting exclusive breastfeeding, particularly in areas of high HIV prevalence, where many women do not know their HIV status, and among HIV-positive mothers who choose to breastfeed. {#early-exclusive-breastfeeding-reduced-postnatal-transmission-of-hiv-and-increased-hiv-free-survival-in-a-large-trial-conducted-in-zimbabwe.-international-guidance-currently-recommends-avoidance-of-all-breastfeeding-by-hiv-infected-mothers-when-replacement-feeding-is-acceptable-and-safe-but-such-replacement-feeding-is-commonly-unavailable-in-africa.-these-findings-underscore-the-importance-of-supporting-exclusive-breastfeeding-particularly-in-areas-of-high-hiv-prevalence-where-many-women-do-not-know-their-hiv-status-and-among-hiv-positive-mothers-who-choose-to-breastfeed. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### CONCLUSION: EBF may substantially reduce breastfeeding-associated HIV transmission. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15821396&query_hl=9**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15821396&query_hl=9) {#conclusion-ebf-may-substantially-reduce-breastfeeding-associated-hiv-transmission.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15821396query_hl9 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-14 .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}

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

Yes, non-directive counseling for pregnant patients, but read the fine
print

-Medical Mystery Tour:

Case of the Mystery Question Asked During Post partum Hemorrhage

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

-Should you be using the quad screen? (New CME Module)

Prenatal Genetic Screening -- Serum and Ultrasound 

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

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

-Negative LEEP Is Not Reassuring

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

-What are the best ways to quit smoking?

-Intrapartum fetal heart rate monitoring, ACOG Practice Bulletin

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

-Antibiotic Tx for Bacterial Vaginosis Does Not Prevent Preterm Birth

-Young age at first sexual intercourse and STIs in adolescents

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

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05MayOL.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05MayOL.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocuments05mayol.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-15 .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-16 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**McCain introduces safety to Indian Women Act**

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

<http://www.ihs.gov/MedicalPrograms/MCH/W/DV03.cfm#top>

or

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

**PREVENT WORKSHOP: Moving Towards Violence Prevention**

Chapel Hill, NC: June 21-23, 2005

San Diego, CA: August 29-31, 2005

Washington, DC: October 26-28, 2005

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

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

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

In this study, as in previous studies, physical symptoms were common
among depressed patients. Even though depression initially improved
rapidly and continued to improve gradually over nine months, physical
symptom improvement plateaued after an initial change for the better.
Pain symptoms improved least. These findings suggest that physical
symptoms are at least somewhat separate from psychologic symptoms.
Targeting these symptoms independently may be helpful, although more
studies are needed to determine which interventions are effective.

Greco T, Eckert G, Kroenke K. The outcome of physical symptoms with
treatment of depression. J Gen Intern Med. 2004 Aug;19(8):813-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15242465&query_hl=4>

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

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

CONCLUSION: Our results suggest that being overweight may increase the
risk of becoming pregnant while using OCs. If causal, this association
translates to an additional 2-4 pregnancies per 100 woman-years of use
among overweight women, for whom consideration of additional or
effective alternative contraceptive methods may be warranted. Holt VL,
et al. Body mass index, weight, and oral contraceptive failure risk.
Obstet Gynecol. 2005 Jan;105(1):46-52.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15625141&query_hl=13>

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

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

A. It is reasonable to obtain one US. The optimal timing is at 16 to 20
weeks of gestation

<http://www.ihs.gov/medicalprograms/mch/m/documents/USPreg42105.doc>

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

A. Our goal is to maximize our care by using 'opt out' HIV screening.

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

**Q. If a pregnant woman is dependent on opiates, can I treat her
addiction?**

A. Yes acutely, but only if she needs ongoing care it must be properly
supervised.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Opiate52705.doc>

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

**Use of Soy Not effective for Menopausal Symptoms**

CONCLUSION: The available evidence suggests that phytoestrogens
available as soy foods, soy extracts, and red clover extracts do not
improve hot flushes or other menopausal symptoms.

Krebs EE, et al. Phytoestrogens for treatment of menopausal symptoms: a
systematic review. Obstet Gynecol October 2004;104:824-36.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15458907&query_hl=1>

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

CONCLUSION: Extended-release venlafaxine, 75 mg per day, is an effective
treatment for postmenopausal hot flushes in otherwise healthy women,
based on a significant decrease in patient-perceived hot flush score.

Evans ML, et al Management of postmenopausal hot flushes with
venlafaxine hydrochloride: a randomized, controlled trial. Obstet
Gynecol. 2005 Jan;105(1):161-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15625158&query_hl=15>

**USPSTF Makes Recommendation Against Routine Use of Estrogen**

The U.S. Preventive Services Task Force issued a new recommendation
against the routine use of estrogen to prevent chronic conditions such
as heart disease, stroke, and osteoporosis in postmenopausal women who
have undergone a hysterectomy.

-The U.S. Preventive Services Task Force (USPSTF) recommends against the
routine use of combined estrogen and progestin for the prevention of
chronic conditions in postmenopausal women.

Rating: [D
Recommendation](http://www.ahrq.gov/clinic/3rduspstf/ratings.htm#drec).

*Rationale*: The USPSTF found good evidence that the use of combined
estrogen and progestin results in both benefits and harms. Benefits
include reduced risk for fracture (good evidence) and colorectal cancer
(fair evidence). Combined estrogen and progestin has no beneficial
effect on coronary heart disease and may even pose an increased risk
(good evidence). Other harms include increased risk for breast cancer
(good evidence), venous thromboembolism (good evidence), stroke (fair
evidence), cholecystitis (fair evidence), dementia (fair evidence), and
lower global cognitive function (fair evidence).

Because of insufficient evidence, the USPSTF could not assess the
effects of combined estrogen and progestin on the incidence of ovarian
cancer, mortality from breast cancer or coronary heart disease, or
all-cause mortality. The USPSTF concluded that the harmful effects of
combined estrogen and progestin are likely to exceed the chronic disease
prevention benefits in most women.

-The USPSTF recommends against the routine use of unopposed estrogen for
the prevention of chronic conditions in postmenopausal women who have
had a hysterectomy.

Rating: [D
Recommendation](http://www.ahrq.gov/clinic/3rduspstf/ratings.htm#drec).

*Rationale*: The USPSTF found good evidence that the use of unopposed
estrogen results in both benefits and harms. The benefits include
reduced risk for fracture (good evidence). Harms include increased risk
for venous thromboembolism (fair evidence), stroke (fair evidence),
dementia (fair evidence), and lower global cognitive functioning (fair
evidence). There is fair evidence that unopposed estrogen has no
beneficial effect on coronary heart disease.

Because of insufficient evidence, the USPSTF could not assess the
effects of unopposed estrogen on the incidence of breast cancer, ovarian
cancer, or colorectal cancer as well as breast cancer mortality or
all-cause mortality. The USPSTF concluded that the harmful effects of
unopposed estrogen are likely to exceed the chronic disease prevention
benefits in most women.

<http://www.ahrq.gov/clinic/uspstf05/ht/htpostmenrs.htm>

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

**Tribal access to library services**

After much research it has been determined that all Tribal programs are
eligible to access the new library services through the NIH Library
system.  Diane Cooper from the NIH Library stated that \'We will have a
proxy built to include those not on IHS (HHS) computers so access can be
available to all\'.\" At the current time, this proxy is NOT available;
however you can still access the library and the librarian services.
Information on these resources is currently available at the IHS
Clinical Information Resource Web site/ medical library at

<http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_medical_library_sercives>

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

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

CONCLUSION: If valid conclusions can be drawn from one hundred years of
retrospective studies, there is considerable evidence to support a
reinstatement of symphysiotomy in the obstetric arsenal, for the benefit
of women in obstructed labour and their offspring.

Bjorklund K. Minimally invasive surgery for obstructed labour: a review
of symphysiotomy during the twentieth century (including 5000 cases).
BJOG. 2002 Mar;109(3):236-48.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11950177&query_hl=1>

**International Electives: Maximizing the Opportunity to Learn and
Contribute**

Interest in international electives is rising, particularly among
preclinical and clinical students, residents, and internists.
<http://www.medscape.com/viewarticle/503450?src=mp>

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

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

The Surgeon General\'s Tips to Keep Toddlers Safe and Happy outlines
information for parents on keeping toddlers healthy and safe as they
look forward to summer fun. The list is the second in a series of
Healthy Dozen Tips released by the Surgeon General as part of the Year
of the Healthy Child. Topics include healthy eating, oral health, the
health risks of smoking and secondhand smoke, giving positive feedback,
car seats, safety proofing a home, not leaving a child unattended, the
importance of having a primary care provider, immunizations, first aid
and CPR, prevention and safety, and having fun. Each tip includes a link
to a national resource.

[[http://www.surgeongeneral.gov/pressreleases/sg05192005.html]{.underline}](http://www.surgeongeneral.gov/pressreleases/sg05192005.html).
More information on the Year of the Healthy Child is available at
[[http://www.surgeongeneral.gov/healthychild]{.underline}](http://www.surgeongeneral.gov/healthychild)

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

These findings suggest a lack of connection between federal efforts to
eliminate childhood lead poisoning and current lead screening practices.
It is crucial to improve follow-up and to understand and develop
interventions to overcome these unexpected disparities in care.

[CONCLUSIONS:]{.underline} The rate of follow-up testing after an
abnormal screening blood lead level was low, and children with increased
likelihood of lead poisoning were less likely to receive follow-up
testing. At least half of the children had a missed opportunity for
follow-up testing. The observed disparities of care may increase the
burden of cognitive impairment among at-risk children.

Kemper AR, Cohn LM, Fant KE, et al. 2005. Follow-up testing among
children with elevated screening blood lead levels. JAMA, The Journal of
the American Medical Association 293(18):2232-2237.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15886378&dopt=Abstract>

**Effectiveness of school based programs to reduce drinking and
driving**

There is sufficient evidence to recommend as effective school-based
instructional programs for reducing drinking and driving and riding with
drinking drivers.

There is insufficient evidence to determine the effectiveness of these
programs for reducing DD.

Elder RW, Nichols JL, Shults RA, et al. 2005. Effectiveness of
school-based programs for reducing drinking and driving and riding with
drinking drivers: A systematic review. American Journal of Preventive
Medicine 28(5, Suppl 1):288-304.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15894162&query_hl=5>

The fact sheet is available at
[[http://www.factsontap.org/Transitions/NIAAA%20Grad%20Flyer_Transitions.pdf]{.underline}](http://www.factsontap.org/Transitions/NIAAA Grad Flyer_Transitions.pdf)

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

**Follow-up: The Case of the Mystery Question**

#### You may recall that the case involved a severe postpartum hemorrhage in a patient with pre-eclampsia. After a thorough medical and conservative clinical management the house staff were preparing the patient for immediate hysterectomy when the attending physician asked one question. [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0505_Feat.cfm#mmtour**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0505_Feat.cfm#mmtour) {#you-may-recall-that-the-case-involved-a-severe-postpartum-hemorrhage-in-a-patient-with-pre-eclampsia.-after-a-thorough-medical-and-conservative-clinical-management-the-house-staff-were-preparing-the-patient-for-immediate-hysterectomy-when-the-attending-physician-asked-one-question.-httpwww.ihs.govmedicalprogramsmchmobgyn0505_feat.cfmmmtour .Style-Heading-4-+-Arial-14-pt-Underline}

**What is that question?**

"Has the patient received her calcium yet?"

The resident staff has done an excellent job of managing the patient's
postpartum hemorrhage, but prior to surgical intervention it is very
reasonable to attempt short term reversal of the patient's prophylactic
magnesium sulfate. The risk of postpartum hemorrhage, possibly related
to uterine atony from magnesium\'s tocolytic effects, has been noted in
one trial (Belfort et al).

Calcium gluconate (1 g intravenously slowly over at 5 to 10 minutes) may
be administered to counteract magnesium toxicity, if necessary. As the
patient becomes more stable the magnesium can be restarted and the risk
of developing an eclamptic seizure in the meantime is small.

 

Another use for calcium can be to reverse the Magnesium sulfate before
starting a cesarean

delivery to decrease intra-operative blood loss. The magnesium sulfate
can be re-started 1 hour

after surgery.

On a slightly different tangent, there is a synergistic effect of
calcium with prostaglandin (Weinstein 1976, Droegemueller 1980) outside
the setting of postpartum hemorrhage. Though ineffective in this case,
the trial of rectal misoprostol may have been worth the effort.

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

This is a helpful anecdote to manage patients treated with magnesium
sulfate, either as pre-operative treatment in the case of cesarean
delivery or as in this case, severe postpartum hemorrhage.

Avoid too rapid I.V. administration and avoid extravasation. Use with
caution in digitalized patients, severe hyperphosphatemia, respiratory
failure or acidosis. **May produce cardiac arrest.** Hypercalcemia may
occur in patients with renal failure, frequent determination of serum
calcium is necessary.

**Go here for many resources**

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

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

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

'H E L P'

The CCC Corner learned about this technique from Louis Weinstein, MD
from Thomas Jefferson University, formerly of the University of Arizona,
Tucson. Dr. Weinstein was influential in the early delineation of the
HELLP syndrome.

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

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

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

**The Prevention and Treatment of Osteoporosis: A Review**

CME /CEUs available from Medscape. (Medscape is a free resource, but you
will need to create a username/password)
<http://www.medscape.com/viewarticle/502984>

######### 

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

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

######### 

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

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

**Clinical Discussion Board Index, Medscape**

Hundreds of ongoing clinical discussions available

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

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

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

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

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

**Primary Care for Midwives: Two Resources**

#1 ACNM approved home study program specifically for midwives available
through Midwife Publications 207-633-3479 or
[www.midwifepublications.com](http://www.midwifepublications.com/)

#2 Here is a source for cheap / free CME in Primary Care:

<http://www.pri-med.com/>

#### 

#### Screening for Genital Herpes: USPSTF

#### Summary of Recommendations

-   **The U.S. Preventive Services Task Force (USPSTF) recommends
    against routine serological screening for herpes simplex virus (HSV)
    in asymptomatic pregnant women at any time during pregnancy to
    prevent neonatal HSV infection.**

> **Rating: [D
> Recommendation](http://www.ahrq.gov/clinic/3rduspstf/ratings.htm#drec).**
>
> *Rationale*: The USPSTF found fair evidence that screening
> asymptomatic pregnant women using serological screening tests for HSV
> antibody does not reduce transmission of HSV to newborn infants. Women
> who develop primary HSV infection during pregnancy have the highest
> risk for transmitting HSV infection to their infants. Because these
> women are initially seronegative, serological screening tests for HSV
> (enzyme-linked immunosorbent assay \[ELISA\], immunoblot, and western
> blot assay \[WBA\]) do not accurately detect those at highest risk.
> There is no evidence that treating seronegative women decreases risk
> for neonatal infection. There is limited evidence that the use of
> antiviral therapy in women with a history of recurrent HSV, or
> performance of cesarean section in women with active HSV lesions at
> the time of delivery, decreases neonatal herpes infection. There also
> is limited evidence of the safety of antiviral therapy in pregnant
> women and neonates.
>
> The potential harms of screening include false-positive test results,
> labeling, and anxiety, as well as false negative tests and false
> reassurance, although these potential harms are not well studied. The
> USPSTF determined there are no benefits associated with screening, and
> therefore the potential harms outweigh the benefits.

-   **The USPSTF recommends against routine serological screening for
    HSV in asymptomatic adolescents and adults.**

> **Rating: [D
> Recommendation](http://www.ahrq.gov/clinic/3rduspstf/ratings.htm#drec).**
>
> *Rationale*: The USPSTF found no evidence that screening asymptomatic
> adolescents and adults with serological tests for HSV antibody
> improves health outcomes or symptoms or reduces transmission of
> disease. There is good evidence that serological screening tests can
> accurately identify those persons who have been exposed to HSV. There
> is good evidence that antiviral therapy improves health outcomes in
> symptomatic persons (e.g., those with multiple recurrences); however,
> there is no evidence that the use of antiviral therapy improves health
> outcomes in those with asymptomatic infection. The potential harms of
> screening include false-positive test results, labeling, and anxiety,
> although there is limited evidence of any potential harms of either
> screening or treatment. The USPSTF determined the benefits of
> screening are minimal, at best, and the potential harms outweigh the
> potential benefits.

According to ACOG Practice Bulletin #8 (Management of Herpes in
Pregnancy (October 1999):  

"**In which situations should cesarean delivery be considered?**

Cesarean delivery is indicated in women with active genital lesions or
symptoms of vulvar pain or burning, which may indicate an impending
outbreak. The incidence of infection in infants whose mothers have
recurrent infections is low, but cesarean delivery is warranted because
of the potentially serious nature of the disease. The low incidence of
neonatal HSV has raised concern that cesarean delivery is unwarranted
for recurrent genital herpes (41). The extent to which maternal
antibodies will protect a neonate from infection during a recurrence has
not been determined with certainty. Cesarean delivery is not warranted
in women with a history of HSV infection but with no active genital
disease during labor."

**Resources**

## Screening for Genital Herpes: U.S. Preventive Services Task Force

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

**Management of Herpes in Pregnancy**

**Practice Bulletin,** NUMBER 8, OCTOBER 1999

**ACOG members**

<http://www.acog.org/publications/educational_bulletins/pb008.cfm>

**Non-ACOG members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10717827&query_hl=1>

**Gynecologic Herpes Simplex Virus Infections**

Practice Bulletin NUMBER 57, NOVEMBER 2004

**ACOG members**

<http://www.acog.org/publications/educational_bulletins/pb057.cfm>

**Non-ACOG members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15516420&query_hl=3>

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

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

The *Atlas of Heart Disease and Stroke Among American Indians and Alaska
Natives* documents geographic disparities in heart disease and stroke
mortality and risk factors among American Indians and Alaska Natives.
The county-level maps of heart disease and stroke death rates indicate
that, for American Indians and Alaska Natives, there is a nearly
five-fold gap between counties with the highest and lowest rates of
heart disease and stroke. High stroke death rates were found primarily
in Northwestern counties and Alaska, while high heart disease death
rates were located largely in the counties of the northern plains.

Fact Sheet - <http://www.cdc.gov/od/oc/media/pressrel/fs050517.htm>

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

CDC highlights some of the ways the WISEWOMAN program is making a
difference for women smokers. These stories will demonstrate how many
communities have established strong partnerships, overcome cultural and
geographic health barriers, and maximized resources to expand their
reach. <http://www.cdc.gov/wisewoman/pdf/vol_2/success_stories_vol2.pdf>

**Oklahoma Perspective - Greggory Woitte -- Hastings Indian Medical
Center**

**West Nile Virus in Women**

After moving to Oklahoma, I quickly realized that the summer months were
quite warm and humid from the large storms of the early summer. In this
warm humid climate, I found that the mosquitoes were quite plentiful.
Over the past couple of years, the transmission of West Nile virus has
been an equally hot topic when talking about mosquitoes. In spite of my
perception of swarms of mosquitoes, only 24 cases of West Nile Virus
were confirmed in Oklahoma during 2004. Despite this low number, the CDC
encourages clinicians to keep West Nile virus in the differential when
dealing with a woman presenting with unexplained fever or neurological
illness.

**CDC Guidelines: West Nile Virus and Pregnancy**

<http://www.cdc.gov/ncidod/dvbid/westnile/congenitalinterimguidelines.htm>

**West Nile Virus and Breast Feeding**

<http://www.cdc.gov/ncidod/dvbid/westnile/qa/breastfeeding.htm>

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

Gregg's comments are very helpful because the effects of West Nile (WN)
virus during pregnancy are new to all of us. Gregg had previously lived
in Illinois, Virginia, and Bethesda, MD, yet in Oklahoma, he had gotten
bitten by mosquitoes more frequently. Though Illinois had the largest
number of West Nile virus cases while he was in residency, it was unique
that Oklahoma did not have the same proportion of West Nile cases
according to the CDC. Despite our own swarms of mosquitoes in Alaska, we
have been spared West Nile virus to date.

As this illness is new to many of us throughout Indian Country, let us
review what is known about West Nile virus in women. First, there is
minimal information on the effects of West Nile (WN) virus during
pregnancy. Hence, the Centers for Disease Control (CDC) has established
a registry to track these pregnancies (call 970-221-6400 to enroll
patients).

The CDC also made the following recommendations:

  ![](media/image2.png){width="6.25e-2in"
height="7.152777777777777e-2in"} Pregnant women should take precautions
to protect themselves from bites from potentially infected mosquitoes
(eg, avoid being outdoors at dawn and dusk, wear protective clothing,
use insect repellants containing DEET).\
  ![](media/image2.png){width="6.25e-2in"
height="7.152777777777777e-2in"} Pregnant women with meningitis,
encephalitis, acute flaccid paralysis, or unexplained fever in an area
of ongoing WN virus transmission should have serum tested for antibody
to WN virus. If laboratory tests indicate recent infection with WN
virus, the infection should be reported to the local or state health
department, and the woman should be followed to determine the outcome of
her pregnancy.\
  ![](media/image2.png){width="6.25e-2in"
height="7.152777777777777e-2in"} If WN virus infection is diagnosed in
pregnancy, care is supportive. An ultrasound examination of the fetus to
screen for abnormalities should be considered no sooner than two to four
weeks after onset of symptoms. A causal relationship between WN virus
and fetal abnormalities has not been proven. There is a single report of
a woman who had WN virus encephalitis during the 27th week of her
pregnancy and subsequently delivered a term infant with chorioretinitis,
cystic destruction of cerebral tissue, and laboratory evidence of
congenitally acquired WN virus infection.

Amniotic fluid, chorionic villi, or fetal serum can be tested for
evidence of WN virus infection. However, the sensitivity, specificity,
and predictive value of these tests to evaluate fetal WN virus infection
are not known, and the clinical consequences of fetal infection have not
been determined. In cases of spontaneous or induced abortion, testing of
all products of conception for evidence of WN virus infection is advised
to document the effects of WN virus infection on pregnancy outcome.

####   ![](media/image2.png){width="6.25e-2in" height="7.152777777777777e-2in"} Screening asymptomatic women for WN virus infection is not recommended because there is no treatment and the consequences of infection during pregnancy have not been well-defined.   ![](media/image2.png){width="6.25e-2in" height="7.152777777777777e-2in"} Clinical evaluation is recommended for infants born to mothers known or suspected to have WN virus infection during pregnancy. Further evaluation should be considered if any clinical abnormality is identified or if laboratory testing indicates that an infant might have congenital WN virus infection. {#screening-asymptomatic-women-for-wn-virus-infection-is-not-recommended-because-there-is-no-treatment-and-the-consequences-of-infection-during-pregnancy-have-not-been-well-defined.-clinical-evaluation-is-recommended-for-infants-born-to-mothers-known-or-suspected-to-have-wn-virus-infection-during-pregnancy.-further-evaluation-should-be-considered-if-any-clinical-abnormality-is-identified-or-if-laboratory-testing-indicates-that-an-infant-might-have-congenital-wn-virus-infection. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Cord Blood Donation: Infectious Disease]{.underline} {#cord-blood-donation-infectious-disease .Style-Heading-4-+-Arial-14-pt-Underline}

West Nile virus in pregnancy has wider implications and points up other
pregnancy related issues, e.g., infectious disease and cord blood
banking. Potential donors, and their husbands, should be queried for
risk factors for infectious diseases, inherited immunologic and
hematologic diseases, cancer, and other conditions that could be
transmissible by blood.

Maternal blood testing is performed to screen for West Nile virus in
addition to hepatitis B, hepatitis C, HIV-1 and -2, HIV p24, CMV,
syphilis, and in some programs human T-lymphotropic virus (HTLV)-I/II.
Finally, upon delivery of the infant, the mother\'s hospital chart is
reviewed for labor and delivery factors that could put the infant donor,
and thus the collected stem cell product, at risk for infection

#### West Nile virus infection: Pregnancy {#west-nile-virus-infection-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.uptodateonline.com/application/topic.asp?file=cns_infe/9484&type=A&selectedTitle=1\~9**](http://www.uptodateonline.com/application/topic.asp?file=cns_infe/9484&type=A&selectedTitle=1~9) {#httpwww.uptodateonline.comapplicationtopic.aspfilecns_infe9484typeaselectedtitle19 .Style-Heading-4-+-Arial-14-pt-Underline}

**Collection and storage of umbilical cord blood for hematopoietic cell
transplantation**

#### [**http://www.uptodateonline.com/application/topic.asp?file=hcell_tr/10338&type=A&selectedTitle=3\~9**](http://www.uptodateonline.com/application/topic.asp?file=hcell_tr/10338&type=A&selectedTitle=3~9) {#httpwww.uptodateonline.comapplicationtopic.aspfilehcell_tr10338typeaselectedtitle39 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

Conclusion: BMD measurement remains the most useful diagnostic tool for
identifying patients with osteoporosis. Although they are helpful in
guiding decisions to initiate osteoporosis treatment, subsequent changes
in BMD provide an imperfect indicator of treatment efficacy. Analyses of
clinical trials show an inconsistent relationship between increased
spinal BMD and a decreased risk of vertebral fracture. Increased BMD
accounts for less than 25% of the overall reduction in fracture risk in
most instances. Consequently, fracture risk reduction itself remains the
most clinically relevant therapeutic outcome of osteoporosis therapy.
(Medscape is a free resource, but you will need to create a
username/password)

<http://www.medscape.com/viewarticle/503801?src=mp>

Fracture Prevention in Postmenopausal Women

Clinical Evidence Concise: A Publication of BMJ Publishing Group

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

beneficial

*Alendronate.* Two systematic reviews involving postmenopausal women
found that alendronate reduced vertebral and nonvertebral fractures
compared with placebo after one to four years.

*Risedronate.* One systematic review involving postmenopausal women
found that compared with control (i.e, placebo, calcium, or calcium plus
vitamin D) risedronate reduced vertebral and nonvertebral fractures
after four years.

*Parathyroid Hormone.* One randomized controlled trial (RCT) involving
women with prior vertebral fractures found that parathyroid hormone
reduced the proportion of women with vertebral and nonvertebral
fractures compared with placebo. Another RCT involving women with
osteoporosis found that parathyroid hormone plus estrogen reduced
vertebral fractures compared with estrogen alone after three years.

*Raloxifene.* One large RCT involving postmenopausal women with
osteoporosis found that raloxifene reduced vertebral fractures compared
with placebo, but no significant difference was found in nonvertebral
fractures. We found no RCTs examining the effects of other selective
estrogen receptor modulators.

likely to be beneficial

*Etidronate.* One systematic review involving postmenopausal women found
that etidronate reduced vertebral fractures compared with control
(placebo, calcium, or calcium plus vitamin D) over two years but found
no significant difference in nonvertebral fractures.

*Calcium Plus Vitamin D.* One large RCT involving women 69 to 106 years
of age living in nursing homes found that calcium plus vitamin D~3~
reduced hip fractures and all nonvertebral fractures after 18 months to
three years compared with placebo. One smaller RCT involving women and
men 65 years or older found that calcium plus vitamin D~3~ reduced
nonvertebral fractures after three years compared with placebo but found
no significant difference in hip fractures. Another small RCT involving
postmenopausal women found no significant difference between calcium
plus vitamin D~3~ and placebo in hip fractures after two years. The two
smaller RCTs may have lacked power to detect clinically important
differences.

*Vitamin D Analogue (Calcitriol).* One systematic review found limited
evidence from two small RCTs involving postmenopausal women that
calcitriol reduced vertebral fractures after three years compared with
placebo.

*Calcitonin.* One systematic review involving postmenopausal women found
that calcitonin reduced vertebral fractures compared with placebo one to
five years after treatment but found no significant difference between
calcitonin and placebo in nonvertebral fractures.

unlikely to be beneficial

*Calcium Alone.* One systematic review involving postmenopausal women
found no significant difference between calcium supplementation and
placebo in vertebral or nonvertebral fractures after one and one half to
four years.

*Vitamin D Alone.* One large RCT involving postmenopausal women and two
large RCTs involving postmenopausal women and older men provided no
evidence of a difference between vitamin D~3~ and placebo in hip,
vertebral, and nonvertebral fractures after two to five years.

likely to be ineffective or harmful

*Hormone Therapy.* We found insufficient evidence of benefit but
reliable evidence of harm.

One systematic review involving postmenopausal women found that hormone
therapy reduced vertebral fractures compared with control. However,
another systematic review and two subsequent RCTs involving
postmenopausal women found no significant difference in vertebral
fractures. Two systematic reviews and two subsequent RCTs provided
insufficient evidence about the effects of hormone therapy on
nonvertebral fractures. One large RCT, which focused on estrogen plus
progestin versus placebo for primary prevention of coronary heart
disease in healthy postmenopausal women, was stopped because hormonal
treatment increased risks of invasive breast cancer, coronary events,
stroke, and pulmonary embolism.

unknown effectiveness

*Environmental Manipulation.* We found no systematic reviews and no RCTs
assessing environmental manipulation alone.

*Exercise.* Three RCTs found no significant difference in falls
resulting in fracture after eight months to one year between exercise
(advice to walk briskly three times weekly, balance and strength
exercises plus walking, or low-intensity exercise plus incontinence
care) and control. One small RCT involving postmenopausal women found no
significant difference between a two-year back strengthening exercise
program and usual care in vertebral fractures over 10 years.

*Hip Protectors.* One systematic review involving older
community-dwelling patients or nursing home residents found no
significant difference in hip fractures after six months to two years
between hip protectors and no protectors in RCTs where individuals were
randomized. However, the review found that hip protectors reduced
fractures after 11 to 19 months in RCTs that used cluster analysis. The
review found no significant difference between hip protectors and no hip
protectors in the rate of other fractures.
<http://www.aafp.org/afp/20050601/bmj.html>

The evidence is available at
<http://www.clinicalevidence.com/ceweb/conditions/msd/1109/1109.jsp>

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

**Post-term Pregnancy: What You Should Know**

<http://www.aafp.org/afp/20050515/1942ph.html>

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

Consumption of farmed salmon at relatively low frequencies results in
elevated exposure to dioxins and dioxin-like compounds with commensurate
elevation in estimates of health risk.

Foran JA, et al Risk-based consumption advice for farmed Atlantic and
wild Pacific salmon contaminated with dioxins and dioxin-like compounds.
Environ Health Perspect. 2005 May;113(5):552-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15866762&query_hl=14>

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

**August 1, 2005**

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

Moderator: Charles North

-Are you comfortable using narcotics to treat chronic pain? 

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

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

-Do you use pain contracts?  Are they useful?

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

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

**Other issues**

-Describe your level of comfort based and your experience.

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

-Are particular brand names valued more than others? 

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

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

**Fall 2005**

**Web based Indian Health M + M**

Moderator: Terry Cullen

Details TBA

### 

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

Subscribe to the Primary Care listserv \*

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51>

Unsubscribe from the Primary Care listserv \*

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51>

\*The last field on the page is \"List Functions\".

Click on \"Subscribe\", which will generate an email message.

Replace \"\<your name here\>\" with your name.

Send the email message.

Follow the instructions in the return mail to complete your
subscription.

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

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

**The National STD-related Infertility Prevention Program**

Centers for Disease Control and Prevention, Coordinating Center for
Infectious Diseases, National Center for HIV, STD, and TB Prevention,
Division of STD Prevention

Gunter DC, Mosure DJ, Shelby LK

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/PROG01.cfm#stdPrevProg**](http://www.ihs.gov/MedicalPrograms/MCH/M/PROG01.cfm#stdPrevProg) {#httpwww.ihs.govmedicalprogramsmchmprog01.cfmstdprevprog .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

A historical follow-up study among 22,264 women tested for urogenital
Chlamydia trachomatis infection identified no elevated risk of ectopic
pregnancy or reduced reproductive capacity among those tested positive
compared with those tested negative for the infection.

Andersen B et al Ectopic Pregnancies and Reproductive Capacity After
Chlamydia trachomatis Positive and Negative Test Results: A Historical
Follow-Up Study. x Transm Dis. 2005 Jun;32(6):377-81

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15912085&query_hl=1>

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

For primary care physician offices participating in a national health
plan, offices with more black physicians and those located in lower
income areas had higher chlamydia screening rates

Ray M et al Chlamydia Screening of At-Risk Young Women in Managed Health
Care: Characteristics of Top-Performing Primary Care Offices. Sex Transm
Dis. 2005 Jun;32(6):382-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15912086&query_hl=3>

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

The U.S. Preventive Services Task Force (USPSTF) recommends that
clinicians screen all sexually active women, including those who are
pregnant, for gonorrhea infection if they are at increased risk for
infection (that is, if they are [\<]{.underline} 25 years old or have
other individual or population risk factors; see Clinical Considerations
for further discussion of risk factors). **B recommendation.**

Women with asymptomatic gonorrhea infection have high morbidity due to
pelvic inflammatory disease, ectopic pregnancy, and chronic pelvic pain.
Pregnant women with gonorrhea infection are at risk for preterm rupture
of membranes, preterm labor, and chorioamnionitis. There is fair
evidence that screening tests can accurately detect gonorrhea infection
and good evience that antibiotics can cure gonorrhea infection. There is
fair evidence that screening pregnant women at high risk for gonorrhea,
including women at high risk because of younger age, may prevent other
complications associated with gonococcal infection during pregnancy,
such as preterm delivery and chorioamnionitis. Potential harms of
screening and treatment for gonorrhea include false-positive test
results, anxiety, and unnecessary antibiotic use. There is insufficient
evidence (due to a lack of studies) to quantify the magnitude of these
potential harms. The USPSTF judges the magnitide of the potential harms
to be small. The USPSTF concludes that the benefits of screening women
at increased risk for gonorrhea infection outweigh the potential harms.

The USPSTF found insufficient evidence to recommend for or against
routine screening for gonorrhea infection in men at increased risk for
infection (see Clinical Considerations for discussion of risk factors).
**I recommendation.**

The morbidity from undiagnosed and untreated genital gonorrhea infection
is lower in men than in women. Clinical symptoms are more likely to lead
to diagnosis and treatment in men; thus, the prevalence of asymptomatic
infection in men is lower. There is fair evidence that noninvasive
screening tests can accurately detect gonorrhea infection and good
evidence that antibiotics cure gonorrhea infection. Potential harms of
screening and treatment for gonorrhea include false-positive test
results, anxiety, and unnecessary antibiotic use. There is insufficient
evidence (due to a lack of studies) to quantify the magnitude of these
potential harms. The USPSTF judges the magnitide of the potential harms
of screening men for gonorrhea to be small. Given the low prevalence of
asymptomatic infection in men, the USPSTF could not determine the
balance of benefits and harms of screening for gonorrhea infection in
men at increased risk for infection.

The USPSTF recommends against routine screening for gonorrhea infection
in men and women who are at low risk for infection (see Clinical
Considerations for discussion of risk factors). **D recommendation.**

There is a low prevalence of gonorrhea infection in the general
population and consequently a low yield from screening. Thus, the USPSTF
concludes that potential harms of screening (ie, false-positive test
results and labeling) in low-prevalence populations outweigh the
benefits.

The USPSTF found insufficient evidence to recommend for or against
routine screening for gonorrhea infection in pregnant women who are not
at increased risk for infection (see Clinical Considerations for
discussion of risk factors). **I recommendation.**

The prevalence of gonorrhea infection in pregnant women who are not at
increased risk for infection is low. The USPSTF could not determine the
balance between benefits and harms of screening for gonorrhea in
pregnant women who are not at increased risk for infection.

The USPSTF strongly recommends prophylactic ocular topical medication
for all newborns against gonococcal ophthalmia neonatorum. **A
recommendation.**

There is good evidence that blindness due to gonococcal ophthalmia
neonatorum has become rare in the United States since the implementation
of universal preventive medication of infants.

<http://www.annfammed.org/cgi/content/full/3/3/263>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15928231&dopt=Abstract>

#### Barbara Stillwater There are 1440 minutes in a day. Make 30 of them active {#barbara-stillwater-there-are-1440-minutes-in-a-day.-make-30-of-them-active-1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

How many steps is enough to show positive results and what can we save?
The answers are in!\
Now a study shows precisely how much exercise it takes to achieve
specific gains in blood glucose, blood pressure, total cholesterol and
triglyceride levels, along with the average annual medical costs that
can be avoided.

CONCLUSIONS: Energy expenditure \>10 METs . h(-1) . week(-1) obtained
through aerobic leisure time physical activity is sufficient to achieve
health and financial advantages, but full benefits are achieved with
energy expenditure \>20 METs . h(-1) . week(-1).

Di Loreto C et al Make Your Diabetic Patients Walk: Long-term impact of
different amounts of physical activity on type 2 diabetes. Diabetes
Care. 2005 Jun;28(6):1295-302.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15920042&query_hl=9>

# 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%)}

**Any new solutions to Nausea and Vomiting in Pregnancy?**

New Perinatology Corner Module: Nausea and Vomiting in Pregnancy

<http://www.ihs.gov/MedicalPrograms/MCH/M/NVP01.cfm>

**Prenatal HIV Screen and Consent Procedures, IHS**

<http://www.ihs.gov/MedicalPrograms/MCH/M/PROG01.cfm#prenatalHIV>

There are several upcoming **Conferences**

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

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

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

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

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

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

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

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

**National Summit on Preconception Care**

-   JUNE 21-22, 2005

-   Atlanta, Georgia

-   Catalyst for national recommendations for preconception care, CDC

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

**Comprehensive Colposcopy course, ASCCP**

-   August 4-7, 2005

-   San Francisco

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

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

**Primary Care Provider Training in Addictions**

-   August 8 - 12, 2005

-   Tacoma, WA

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

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

-   May 3--6, 2006

-   Anchorage, Alaska

-   Embracing Our Traditions, Values, and Teachings

-   [National Institutes of Health (NIH),
    DHHS](http://www.embracingourtraditions.org/conf_info.htm)

<http://www.embracingourtraditions.org/home.asp?flash=true>

# 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 **May 2005 OB/GYN CCC Corner** is available at:\
<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0505.cfm>

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

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

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

**Terry Cullen:** What is GPRA?

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

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

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

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

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

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

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

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

Judy Thierry:

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

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

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

-CDC web site with Repro health and SIDS and SUID

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

-Federal Registry HP/DP Grant Announcement

-Child abuse prevention Funding

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

##### Obstetrics: page 11

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

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

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

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

-Cesarean and Vaginal Birth After Previous Cesarean Delivery

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

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

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

**Gynecology: page 13**

-Testosterone patch effective in hypoactive sexual desire in surgically
menopausal

-Negative LEEP Is Not Reassuring

-Human Papillomavirus Quadrivalent Vaccine May Be Effective

-Oophorectomy and Hysterectomy No Curb on Sexuality

-Randomised comparison of microwave endometrial ablation with
transcervical resection

-The physiologic effects of pneumoperitoneum in the morbidly obese

-Hypertension Boosts Uterine Fibroid Risk

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

**Child Health: page 14**

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

-School nutrition resources

**Chronic Illness and Disease: page 14**

-What are the best ways to quit smoking?

-Screening for Asymptomatic Bacteriuria: Recommendation Statement:
USPSTF

-The Living to 100 Life Expectancy Calculator

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

-Acupuncture: a clinical review

-Benefits of Omega-3 Fatty Acids

-One size doesn\'t fit all

-Evidence-Based Guidelines for Cardiovascular Disease Prevention in
Women

-Evaluation of Palpable Breast Masses

-AHRQ Recent Findings: Cardiovascular Disease

#### Features: {#features-1 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician page 16

-Does Lipid Lowering Decrease Stroke Risk?

-Hyperbaric Oxygen Therapy in Patients with Chronic Wounds

-Mammography Screening Intervals Questioned

-Estrogen Increases the Risk of Gallbladder Disease

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

-Anticonvulsant Medications for Migraine Prevention: Cochrane for
Clinicians

American College of Obstetricians and Gynecologists

Intrapartum fetal heart rate monitoring. ACOG Practice Bulletin

**Agency for Healthcare Research and Quality**

-Recent findings

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

**Ask a Librarian**

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

**Breastfeeding**

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

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

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

-AAP Releases Updated Breastfeeding Recommendations

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

**CCC Corner Digest - Highlights include:**

-Human Papillomavirus ACOG Practice Bulletin

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

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

-Antibiotics for Recurrent Urinary Tract Infections: Cochrane for
Clinicians

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

-Can Patients with Cancer Postpone Death for Important Events?

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

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

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

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

-A Decline in Life Expectancy in the US

-Should you be using the quad screen?

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

**Domestic Violence**

-Upcoming Child Abuse Project

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

-AHRQ Recent Findings: Violence Against Women

-McCain introduces safety to Indian Women Act

-PREVENT WORKSHOP: Moving Towards Violence Prevention

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

-Injury Prevention Fact Sheet Focuses on Child Maltreatment

-Hidden Problem of Child Abuse

**Elder Care News**

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

**Family Planning**

Oral Contraceptives: Their Mode of Action and Dermatologic Applications

**Frequently asked questions**

-What types of drug testing are indicated in pregnancy?

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

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

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

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

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

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

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

**Hormone Replacement Update**

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

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

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

-Does Beginning HT Earlier Decrease Mortality?

-The Impact of Co-morbidities on Hormone Use

**Information Technology**

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

International Health

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

-Neonatal survival: a call for action

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

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

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

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

#### MCH Alert

-Randomized controlled trial: Risk of Adolescent Suicide Screening
Programs

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

-Interventions to improve cultural competence among health professionals

#### Medical Mystery Tour

-The Case of the Mystery Question

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

#### Medscape

**Midwives Corner**

-Antibiotic Treatment for Bacterial Vaginosis Does Not Prevent Preterm
Birth

-Elective Cesarean Section; How informed is informed?

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

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

-Herbs and the childbearing woman: Guidelines for midwives

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

Health Characteristics of the American Indian and Alaska Native Adult
Population

Oklahoma Perspective

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

Osteoporosis

-Statins and osteoporosis: a clinical review

-Guidelines Unclear on Screening for Osteoporosis

-AHRQ Recent Findings: Osteoporosis

Patient Education

-Infections During Pregnancy: What You Should Know?

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

Primary Care Discussion Forum

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

STD Corner

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

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

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

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

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

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

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

-Rosiglitazone Crosses Placenta in First Trimester

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

-Depressed diabetics die sooner than depressed non-diabetics

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

-Step Counting Increases Exercise More Than Timed Walking

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

-Diabetes Increases Risk of Urinary Infection in Postmenopausal Women

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

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

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

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

Prenatal Genetic Screening -- Serum and Ultrasound

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

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

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>

6/8/05