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OB/GYN Chief Clinical Consultant's Corner

Volume 4, No. 12, December 2006 / January 2007

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

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

Organizational silence threatens patient safety

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

Carolyn Aoyama

Diabetes on the rise in young Native Americans

Burt Attico

Reducing Cardiovascular Risk: Science, Treatment, and Culture

Steve Holve

The 2nd International Meeting on Indigenous Child Health

Judy Thierry

-Menstruation in girls and adolescents: using the menstrual cycle as a
vital sign

-ACOG Releases Revised Recommendations for Women\'s Health Screenings
and Care

-Smoking During Pregnancy May Influence Children\'s Smoking: 14 yr
cohort study

-Should a 1 year old be exposed to TV?

-US map with state health facts links on the following topics: 

and more....

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

##### Obstetrics page 12

-Emergency Simulation Practice: It's a Win x3

-Short course of hydrocortisone: Effective for intractable hyperemesis

-Majority of women with GDM not tested for glucose intolerance after
delivery

-Fetal Oximetry Plus Electronic Fetal Monitoring Does Not Reduce
Cesarean Delivery

-Leaner Women at Reduced Risk of Cesarean Delivery

and more....

**Gynecology page 15**

-HPV vaccine is effective: Why do we not provide it to most AI/AN?

-LEEP in adolescents, overly aggressive: High incidence of F/U abnormal
cytology

-Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic
endometriosis

-Overactive Bladder: the Importance of New Guidance 

-Preventing Eating Disorders in College-Age Women

and more....

**Child Health page 18**

-Why do disparities in infant mortality continue to persist between AIAN
and white infants?

-US Adults Prefer Comprehensive Teaching of Sex Education in Public
Schools

-Supersize This: Large entree portions may constitute an \"obesigenic\"
influence

-Perspectives on Confidential Care for Adolescent Girls

-61% of SIDS cases among smokers were attributable to maternal smoking

and more....

**Chronic Illness and Disease page 21**

-Firearm Safety in Homes with Adolescents

-Breast Cancers Within 1 Year of a Normal Screening Mammogram: How Are
They Found?

-Diabetic complications in 40 or older with undiagnosed DM is similar to
diagnosed DM

-Statins Should Be a Part of Preventive Management in Stroke Patients 

-Herniated Disk Improves With Either Surgical or Nonsurgical Treatment 

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

American College of Obstetricians and Gynecologists

-Treatment With Selective Serotonin Reuptake Inhibitors During Pregnancy

-Routine Cancer Screening

-Primary and Preventive Care: Periodic Assessments

-Innovative Practice: Ethical Guidelines

-Vaginal Agenesis: Diagnosis, Management, and Routine Care

##### American Family Physician

-Levothyroxine Reduces Preterm Birth in Euthyroid Women

-Opioids for Management of Breakthrough Pain in Cancer Patients

**Agency for Healthcare Research and Quality**

-Maternal psychological distress / use of seat belts: Children\'s low
use of vehicle restraints

-Less than half of parents infected with HIV tell their children about
the diagnosis

**Ask a Librarian**

Want to keep up with evidence-based medicine?

**Breastfeeding**

-Flu season and Breastfeeding

#### -Breast-Feeding Offers Resilience Against Psychosocial Stress in Children {#breast-feeding-offers-resilience-against-psychosocial-stress-in-children .Style-Heading-4-+-Arial-14-pt-Underline}

-More Evidence Showing Breastfeeding Protects Against Type 2 Diabetes

**CCC Corner Digest**

-Regular Cola Intake Reduces Bone Mineral Density in Women

-Perinatal depression evidence based care

-Magnesium sulfate tocolysis: time to quit

-'No touch' hysteroscopy much better tolerated

-Hot water bottles do work: Active Warming Cuts Pelvic Pain in
Pre-hospital Setting

-Early adolescents worry more as they age. . . .

-Health Behaviors among American Indian/Alaska Native Women, 1998--2000
BRFSS

-Please Get Umbilical Cord Blood Gas and Acid-Base Analysis When
Possible

-No Stirrups Preferred for Pelvic Examinations

-Want to keep up with evidence-based medicine?

-It is official, breastfeeding counts

-EC: Did not affect incidence of either pregnancy or STIs

-Telehealth Opportunity: Do you need nutrition services at your site?

-Anthropology in the clinic: the problem of cultural competency and how
to fix it

-The rest of the story RE: 'bizarre' and 'atypia' in the same
sentence...hmmm....

-What Women Want

-Prevalence of diabetes: Diagnosed Diabetes Among AI/AN Aged \<35 Years

-Preoperative Evaluation

-Assessment of Adult Health Literacy

-Be Prepared: The Boy Scout motto...er...the Maternity Care Provider
motto, too

-Causes of Type 2 Diabetes: Old and New Understandings

-IHS Consent Form 509 for an HIV Antibody Test is Hereby Cancelled

-Gestational Diabetes Linked to High Prevalence of Periodontal Disease

**Domestic Violence**

Improving the Health Care Response to Domestic Violence in AI/AN
Communities

**Elder Care News**

Moderate Alcohol Consumption May Be Beneficial to Older Women

**Family Planning**

-Bone Loss With Use of Depot Medroxyprogesterone Acetate Slows After 2
Years

#### -Few young pregnant women know about safety and effectiveness of intrauterine devices {#few-young-pregnant-women-know-about-safety-and-effectiveness-of-intrauterine-devices .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Pregnancy Rates Unchanged by Easy Access to Emergency Contraception {#pregnancy-rates-unchanged-by-easy-access-to-emergency-contraception .Style-Heading-4-+-Arial-14-pt-Underline}

-Scientific accuracy of materials for abstinence-until-marriage
education program

#### -Oral Contraceptive Use: Small Increased Risk for Premenopausal Breast Cancer {#oral-contraceptive-use-small-increased-risk-for-premenopausal-breast-cancer .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

The IHS Breastfeeding Home Page is live!

**Frequently asked questions**

-Is an informed consent necessary for all x-rays in pregnant women?

-Are there any Cochrane Reviews about problems with Ortho Evra or Nuva
Ring?

**Indian Child Health Notes**

-Diagnosis and management of bronchiolitis.

-Lower respiratory tract infections among American Indian and Alaska
Native children and the general population of U.S. Children

-Does in-home water service reduce the risk of infectious disease?

-Home-visiting intervention to improve child care among American Indian
adolescent mothers: a randomized trial

-Forty years in partnership: the American Academy of Pediatrics and the
Indian Health Service

**Information Technology**

-Exam Code and Health Factor Manual

-Self-study Course in Epidemiology Now Available Through CDC Web Site

-Patent Wellness Handout

International Health

A nurse, a doctor, and an epidemiologist were standing by the
river......

#### 

#### MCH Alert

-2007 Folic Acid Campaign Materials Released

-Three new programs proven to improve behavioral and mental health in
youth

-2006 Edition of Women's Health Data Book Released

#### Medical Mystery Tour

A boy has been born in Chile with a fetus in his stomach

#### Medscape

######### -Female Genital Cutting: Female Empowerment as a Means of Cultural Change

-Recurrent Pregnancy Loss

-Evaluation and Treatment of Overactive Bladder

**Menopause Management**

#### Estradiol less than 5 yrs, estriol, or vaginal estrogens not associated with breast cancer {#estradiol-less-than-5-yrs-estriol-or-vaginal-estrogens-not-associated-with-breast-cancer .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

Start 'Em Young for Future Success and Maybe No One Will Be Left Behind

**Navajo News**

GYN Spotlight: Endometrial ablation

**Nurses Corner**

-Nurses less satisfied than physicians or nurse managers: Perceptions of
teamwork on L/D

-Nurses play on important role in its detection and can reduce
depressive symptoms

-For Neonatal Nurses- Primer on Antenatal Testing: 2 Parts: Tests of
Fetal Well-Being / PTL

-6th Annual SUMMER INSTITUTE ON EVIDENCE-BASED PRACTICE '07

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

HPV Information for Clinicians

**Oklahoma Perspective**

Reduction in Teen Pregnancies

Osteoporosis

-Significant bone loss: Both low molecular weight heparin and
unfractionated heparin

-Updated Position Statement for Calcium Intake in Postmenopausal Women

-Teriparatide is less cost-effective than alendronate for severe
osteoporosis

Patient Education

#### -Preventing Injuries in School-age Children and Teenagers {#preventing-injuries-in-school-age-children-and-teenagers .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Lactose Intolerance: What You Should Know {#lactose-intolerance-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Myths and Facts About Food Allergies {#myths-and-facts-about-food-allergies .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Amniocentesis procedure-related loss risk of approximately 1 in 1600,
not prior 1 in 200

-Second twins: 97 cesarean deliveries (NNT) prevent a single serious
morbidity or mortality

-Iron / folate supplementation: Not replaced by a multiple-micronutrient
supplement

-Treatment of periodontitis does not alter PTB, low birth weight, or
fetal growth restriction

-Preterm babies have an increased risk of asthma compared with term
babies

Primary Care Discussion Forum

Causes of Type 2 Diabetes: Old and New Understandings

#### Ongoing Discussion - You still can join in

STD Corner

Less than half of parents infected with HIV tell their children about
the diagnosis

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

-Three Years Later, Participants in the Diabetes Prevention Study Still
Benefiting

-Stopping the Clock on Diabetes in Women: Strategies for Prevention and
Treatment

-Multiparity Increase Risk for Type 2 Diabetes

-New Study Weighs Benefits of Exercise, Diets

-Low-Carb Diets Reduce Coronary Disease Risk in Women

###### Save the Dates: Upcoming events of interest page 45

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

Diabetes: Understandings About the Causes of Type 2 - Old / New

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

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

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

**Organizational silence threatens patient safety**

Organizational silence refers to the tendency for people to do or say
very little when confronted with significant problems or issues in their
organization or industry.

The paper focuses on some of the less obvious factors contributing to
organizational silence that can serve as threats to patient safety.
Converging areas of research from the cognitive, social, and
organizational sciences and the study of socio-technical systems help to
identify some of the underlying factors that serve to shape and sustain
organizational silence. These factors have been organized under three
levels of analysis:

\(1\) individual factors, including the availability heuristic,
self-serving bias, and the status quo trap;

\(2\) social factors, including conformity, diffusion of responsibility,
and microclimates of distrust;

\(3\) organizational factors, including unchallenged beliefs, the good
provider fallacy, and neglect of the interdependencies. Finally, a new
role for health care leaders and managers is envisioned. It is one that
places high value on understanding system complexity and does not take
comfort in organizational silence.

[Henriksen
K](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Henriksen+K"%5BAuthor%5D),
[Dayton
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Dayton+E"%5BAuthor%5D).
Organizational silence and hidden threats to patient safety [Health Serv
Res.](javascript:AL_get(this, 'jour', 'Health Serv Res.');) 2006
Aug;41(4 Pt 2):1539-54 (reprints available below\*)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16898978>

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

**Value dissent and multiple perspectives as signs of organizational
health**

Henriksen and Dayton, M.S., of the Agency for Healthcare Research and
Quality (AHRQ), describe the individual, social, and organizational
factors that contribute to organizational silence and can threaten
patient safety. They cite several individual factors that contribute to
clinician silence. For example, the availability heuristic suggests that
if relatively infrequent events that harm patients go unreported and are
not openly discussed, clinicians don\'t believe these events are a
problem at their hospital. A second factor is self-serving bias. People
tend to view themselves as \"above average\" in their chosen field of
work and so \"why do things differently?\" Successes are attributable to
their own abilities but failures are blamed on situational factors.
Finally, members of all organizations display a strong tendency to
perpetuate the status quo and not speak up or rock the boat.

Several social factors also underlie clinician silence. There is great
pressure to conform in order to gain acceptance and work harmoniously
with coworkers. Diffusion of responsibility is also a problem. In
clinical settings, individual roles and responsibilities are often
assumed rather than clearly spelled out. Under these conditions of
diffused responsibility, components of care that should be attended to
are often missed. Also, managers who seek blame and attribute error to
the individual failings of careless or incompetent staff create a
microclimate of distrust.

Finally, three areas of organizational vulnerability that warrant closer
attention are unchallenged beliefs, the perceived qualities of the good
worker who \"works around\" problems rather than focusing on the
contributory factors to the problem, and lack of understanding of the
interdependence of complex clinical systems.

The authors recommend that health care leaders and managers value
dissent and multiple perspectives as signs of organizational health, and
question agreement, consensus, and unity when they are too readily
achieved.

Another successful example is the 100,000 Lives Campaign, which is an
initiative to engage US hospitals in a commitment to implement changes
in care proven to improve patient care and prevent avoidable deaths. The
Institute for Healthcare Improvement estimates that the lives saved as
of June 14, 2006 was 122,300.

To that end, the **National Indian Health MCH and Women's Health
meeting**, August 15-17, 2007 in Albuquerque will highlight speakers
from the Institute for Healthcare Improvement and others that have
evaluated and treated various health care systems. The meeting has
individual facility program review as well as many hours of CME/CEUs.

Your facility should send a team of staff to the above meeting, e. g.,
you and 2-3 other colleagues from different disciplines should start
planning now.

**National Indian Health MCH and Women's Health meeting**

<http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07>

\*Reprints (AHRQ Publication No. 06-R060) are available from the AHRQ
Publications Clearinghouse
<http://www.ahrq.gov/research/order.htm#clear>

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

**Carolyn Aoyama, HQE**

#### Diabetes on the rise in young Native Americans From 1994 to 2004, the rate of diagnosed diabetes among American Indians and Alaska Natives younger than 35 years of age increased from 8.5 to 17.1 cases per 1000 population.  {#diabetes-on-the-rise-in-young-native-americans-from-1994-to-2004-the-rate-of-diagnosed-diabetes-among-american-indians-and-alaska-natives-younger-than-35-years-of-age-increased-from-8.5-to-17.1-cases-per-1000-population. .Style-Heading-4-+-Arial-14-pt-Underline}

#### This trend is concerning, given the fact that diabetes has a greater potential to cause harm with onset at an early age, according to the authors of the article. The study, which was conducted by researchers from the Centers for Disease Control and Prevention, involved an analysis of patient data collected by the Indian Health Service (IHS), which provides healthcare to American Indian and Alaska Native populations. Roughly 60 percent of the almost 3 million American Indians and Alaska Natives living in the US reside in an area covered by the IHS. At the start of the 10-year period, 6001 American Indians and Alaska Natives younger than 35 years old had diabetes. By 2004, this number had increased to 12,313. {#this-trend-is-concerning-given-the-fact-that-diabetes-has-a-greater-potential-to-cause-harm-with-onset-at-an-early-age-according-to-the-authors-of-the-article.-the-study-which-was-conducted-by-researchers-from-the-centers-for-disease-control-and-prevention-involved-an-analysis-of-patient-data-collected-by-the-indian-health-service-ihs-which-provides-healthcare-to-american-indian-and-alaska-native-populations.-roughly-60-percent-of-the-almost-3-million-american-indians-and-alaska-natives-living-in-the-us-reside-in-an-area-covered-by-the-ihs.-at-the-start-of-the-10-year-period-6001-american-indians-and-alaska-natives-younger-than-35-years-old-had-diabetes.-by-2004-this-number-had-increased-to-12313. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Diagnosed Diabetes Among American Indians and Alaska Natives Aged \<35 Years \-\-- United States, 1994---2004 Morbidity and Mortality Weekly Report, November 10, 2006 / 55(44);1201-1203 [**http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5544a4.htm**](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5544a4.htm) {#diagnosed-diabetes-among-american-indians-and-alaska-natives-aged-35-years-----united-states-19942004-morbidity-and-mortality-weekly-report-november-10-2006-55441201-1203-httpwww.cdc.govmmwrpreviewmmwrhtmlmm5544a4.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Reducing Cardiovascular Risk: Science, Treatment, and Culture**

Here are 2 interesting articles from Medscape.  They are a bit long, but
they deals with important mechanisms in disease management. Issues
covered include:

Pharmacologic Management of Type 2 Diabetes\
A Profile of Metformin\
A Profile of Thiazolidinediones\
Mechanism of Action of Thiazolidinediones\
Effect of Thiazolidinediones on Fat Content\
Effect of Thiazolidinediones on Cardiovascular Disease Risk Factors\
Impact of Thiazolidinediones on Cardiovascular Events\
A Profile of Insulin Secretagogues\
A Profile of Alpha-Glucosidase Inhibitors\
Exenatide: A New Approach to Insulin Stimulation\
Designing an Oral Diabetes Treatment Program\
Integrating Culture Into the Design of an Effective Diabetes Management
Program\
Importance of Cultural Competence in Current Clinical Practice\
Experience in Culturally Oriented Programs\
Summary: Reducing Insulin Resistance and Cardiovascular Risk in People
With Type 2 Diabetes

<http://www.medscape.com/viewarticle/545748_10>

**Cardiovascular Disease in Type 2 DM: From Research to Clinical
Practice**

Type 2 Diabetes and Cardiovascular Disease\
The Genesis of Cardiovascular Disease\
C-Reactive Protein: Inflammatory Marker or Instigator?\
Insulin Resistance: An Important Pathophysiologic Factor\
Pathways of Insulin Resistance\
The Correlation Between Myocardial Infarction and Triglyceride Levels\
The Role of Hyperglycemia in Macrovascular Complications\
The Role of Advanced Glycation End Products in Diabetic Complications\
The Long-term Impact of Intensive Control

<http://www.medscape.com/viewarticle/545748_1>

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

**The 2nd International Meeting on Indigenous Child Health**

We are pleased to announce an exciting opportunity to present your
research at the 2nd International Meeting on Indigenous Child Health! 

Child health professionals, researchers, and others who work with
indigenous populations will be in attendance at this conference, which
will be held April 20-22, 2007 at the Fairmont-The Queen Elizabeth in
Montreal, Quebec.

There will be opportunities for both oral abstract presentations and
poster presentations.

 

For additional information, please visit the conference Web pages at

[www.aap.org/nach/2InternationalMeeting.htm](http://www.aap.org/nach/2InternationalMeeting.htm) -
US

> or 

<http://www.cps.ca/English/ProEdu/IMICH07.htm> Canada

 

We hope to see you in Montreal! 

 

![](media/image2.jpeg){width="6.75in" height="0.71875in"}

# Call for Abstracts

The 2nd International Meeting on Indigenous Child Health, is being
co-sponsored by the American Academy of Pediatrics (AAP), the Canadian
Paediatric Society (CPS), the Indian Health Service (IHS), and the First
Nations and Inuit Health Branch (FNIHB) of Health Canada. The purpose of
this seminal international and collaborative conference will be to focus
on innovative clinical care models and cross-border research issues for
children in First Nations, Inuit, Métis, American Indian and Alaska
Native communities. The program will be held April 20-22, 2007 at the
Fairmont The Queen Elizabeth in Montreal, Quebec.

Abstract on all topics pertaining to indigenous child health are
welcome. Submit your oral or poster presentation **by January 31,
2007.** Suggested topics include:  

> Access to Care, Adolescent Health, Alcohol and Substance Abuse,
> Asthma, Continuity of Care/Medical Home Models, Diabetes,
> Environmental Health, Epidemiology, Health Care Administration, Health
> Promotion and Disease Prevention, Health Services Research,
> Immunizations, Infectious Disease, Injury Prevention, Mental Health,
> Nutrition, Obesity, Oral Health, Telemedicine, Traditional Medicine,
> and Urban Health. 

Abstracts meeting one of the following criteria will be given special
consideration:

-   Submissions by First Nations, Inuit, or AI/AN students

-   Research that measures the effectiveness of innovative health care
    intervention, or that involves exemplary partnerships between
    researchers and tribes 

-   Research issues common to indigenous populations in both Canada and
    the US.

#### Additional conference information: [**http://www.aap.org/nach**](http://www.aap.org/nach) and [**http://www.cps.ca/English/ProEdu/IMICH07.htm**](http://www.cps.ca/English/ProEdu/IMICH07.htm) {#additional-conference-information-httpwww.aap.orgnach-and-httpwww.cps.caenglishproeduimich07.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Menstruation in girls and adolescents: using the menstrual cycle as a
vital sign**

Evaluation of the menstrual cycle is a viable tool to assess healthy
development of teen girls\' menstrual patterns. Young patients and their
parents often are unsure about what represents normal menstrual
patterns, and clinicians also may be unsure about normal ranges for
menstrual cycle length and amount and duration of flow through
adolescence.

It is important to be able to educate young patients and their parents
regarding what to expect of a first period and about the range for
normal cycle length of subsequent menses,\" the authors point out. \"It
is equally important for clinicians to have an understanding of bleeding
patterns in girls and adolescents, the ability to differentiate between
normal and abnormal menstruation, and the skill to know how to evaluate
young patients\' conditions appropriately.

[American Academy of Pediatrics Committee on
Adolescence](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="American+Academy+of+Pediatrics+Committee+on+Adolescence"%5BCorporate+Author%5D);
[American College of Obstetricians and Gynecologists Committee on
Adolescent Health
Care](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="American+College+of+Obstetricians+and+Gynecologists+Committee+on+Adolescent+Health+Care"%5BCorporate+Author%5D);
[Diaz
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Diaz+A"%5BAuthor%5D),
[Laufer
MR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Laufer+MR"%5BAuthor%5D),
[Breech
LL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Breech+LL"%5BAuthor%5D).
Menstruation in girls and adolescents: using the menstrual cycle as a
vital sign
[Pediatrics.](javascript:AL_get(this, 'jour', 'Pediatrics.');) 2006
Nov;118(5):2245-50

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17079600>

**ACOG Releases Revised Recommendations for Women\'s Health Screenings
and Care**

Recent recommendations for HIV screening, human papillomavirus (HPV)
vaccination, and preconception care are among those highlighted in the
revised primary and preventive care periodic assessments recommended for
women by The American College of Obstetricians and Gynecologists (ACOG).
The updated recommendations, published in the December issue of
Obstetrics & Gynecology, provide ob-GYNs with a comprehensive schedule
of age-appropriate screening exams, laboratory tests, immunizations, and
counseling for non-pregnant adolescents and adult women.

The document incorporates recent guidance from individual ACOG
committees on specific issues in women\'s health.

[HIV Testing]{.underline}\
Routine HIV testing should be offered to women ages 19 to 64 regardless
of personal risk factors, following the new Centers for Disease Control
and Prevention (CDC) guidelines. Ob-GYNs should be aware of and follow
their states\' HIV testing requirements. In addition, ACOG recommends
HIV testing for adolescents who are or ever have been sexually active.
ACOG previously recommended HIV testing only for women considered high
risk or for those in areas with high HIV prevalence.

[Preconception Care]{.underline}\
Ob-GYNs should encourage women of childbearing age to develop a
reproductive health plan to help conscientiously assess the desire for a
child or children or desire not to have children. The plan also should
address the optimal number, timing, and spacing of children; determine
the steps needed to prevent or plan for and optimize a pregnancy; and
evaluate current health status and other issues relevant to the health
of a pregnancy.

[Colorectal Cancer Screening]{.underline}\
Women age 50 and older should be screened for colorectal cancer using
one of five recommended screening strategies. If fecal occult blood
testing (FOBT) is used, patients should collect two or three samples at
home and return them for laboratory analysis. Single samples obtained by
digital rectal examination in the ob-gyn\'s office are not adequate for
colorectal cancer screening.

[HPV Vaccine]{.underline}\
An HPV vaccine was made available for the first time in 2006. ACOG
recommends that HPV vaccination be offered to all girls and women 9 to
26 who have not previously been vaccinated. The vaccine protects against
four HPV strains that cause most cervical cancers and genital warts and
is most effective when administered before the onset of sexual activity.

[Tdap Vaccine]{.underline}\
Pertussis has been added to the tetanus and diphtheria booster
recommendation in accordance with CDC recommendations. Adolescents
should receive the Tetanus, Diptheria, Pertussis (Tdap) booster once
between ages 11 and 16, then every 10 years thereafter up to age 64.

[Meningococcal Vaccine]{.underline}\
ACOG now recommends that adolescents not previously immunized receive
meningococcal conjugate vaccination before entry into high school. Older
women at high risk also should receive the vaccine.

Committee Opinion #357, \"Primary and Preventive Care: Periodic
Assessments,\" is published in the December 2006 issue of Obstetrics &
Gynecology.

<http://www.acog.org/from_home/publications/press_releases/nr12-01-06-2.cfm>

**Smoking During Pregnancy May Influence Children\'s Smoking: 14 yr
cohort study**

The smoking patterns among those adolescent offspring whose mothers
stopped smoking during pregnancy, but who then smoked at other times
during the child's life, were similar to those whose mothers had never
smoked. This association was robust to adjustment for a variety of
potential covariates.

Conclusions: The findings provide some evidence for a direct effect of
maternal smoking in utero on the development of smoking behaviour
patterns of offspring and provide yet another incentive to persuade
pregnant women not to smoke.

Al Mamun A et al Does maternal smoking during pregnancy predict the
smoking patterns of young adult offspring? A birth cohort study. [Tob
Control.](javascript:AL_get(this, 'jour', 'Tob Control.');) 2006
Dec;15(6):452-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17130374>

**Should a 1 year old be exposed to TV?**

The Effects of Electronic Media on Children Ages Zero to Six: A History
of Research

ISSUE BRIEF

The Kaiser Family Foundation Issue Brief prepared by the Center on Media
and Child Health, Children's Hospital Boston gives an overview of
findings and trends in the studies themselves during each decade from
the 1960s to 2000s. The info focuses on controlled experiments testing
the effects of media components on young children. The learning factor
of electronic media is vastly overvalued and is rapidly causing the
productive aspects of children's lives to become undervalued such as
physical and interactive time with family and friends. The Brief also
focuses on core research questions about affects of watching television
and draws conclusions as to what that could mean for children, i.e.
aggression, fear reactions to frightening content,
attention/comprehension, infant response, response to advertising and
cognitive development as a predictor of selective attention to
television (ability to learn from TV).  Lastly, the Brief gives overall
conclusions to the data stressing the "need to keep pace" with the
environmental exposure and suggests future directions for research.

-   "Due to research evidence linking media exposure to a variety of
    health risks from obesity to violent behavior, the AAP in its 2001
    Statement entitled Children, Adolescents, and Television recommends
    that children two years of age and older be limited to two hours of
    electronic entertainment per day." Children under age two should be
    discouraged from TV viewing and encouraged in interactive activities
    to promote proper brain development, such as talking, playing,
    singing and reading together.

-   "The Zero to Six study found that 74% of children under the age of
    two have watched television and 59% watch television on a typical
    day for an average of two hours and five minutes. Thirty percent of
    children four to six years old have televisions in their bedroom."

-    "Many leading media researchers believe that the evidence that
    media violence contributes to anxiety, desensitization, and
    increased aggression has been compelling and virtually unanimous."

-   "The positive influences of age-appropriate, curriculum-based
    educational television on children's cognitive abilities and school
    readiness have been well-documented. Basic scientific research on
    how children attend to and comprehend television has evolved into
    sophisticated studies of how children can learn from electronic
    media. This, in turn, has led to the design and production of a
    number of effective educational television programs, starting with
    Sesame Street, which many experts regard as one of the most
    important educational innovations of recent decades."

-   Future research is critical on: Advertising's affect on young
    children, educational media's true value, interactive media's true
    effects, infant media's repercussions, background media's impact,
    long-term outcomes of television and electronic exposure, and the
    need for media interventions.

<http://aappolicy.aappublications.org/cgi/reprint/pediatrics;107/2/423.pdf>
cited November 6, 2006

<http://www.kff.org/entmedia/upload/The-Effects-of-Electronic-Media-on-Children-Ages-Zero-to-Six-A-History-of-Research-Issue-Brief.pdf>
 

**US MAP with state health facts links on the following topics:** 

Limited AIAN data, but for some topics it is available.

**-Medicaid and Tobacco Dependence Treatments**

Updated information on Medicaid coverage of tobacco-dependence
treatments is now available for 2005 from the Centers for Disease
Control and Prevention (CDC). The status of coverage by medication and
counseling type is available for all states. 

<http://cme.kff.org/Key=11776.8q.F.C.HPmRnS>

**-Health Status: Deaths**

Updated data on mortality rates by gender and race/ethnicity for 2003
from the Centers for Disease Control and Prevention (CDC) have been
added and are available by state and region. Data on deaths caused by
diabetes are also available for 2003 by gender and race/ethnicity for
all states and the nation. 

<http://cme.kff.org/Key=11776.8q.G.C.HSfM30>

**-Child and Teen Deaths**

Updated data on child and teen mortality rates for 2003 from the Annie
E. Casey Foundation\'s analysis of CDC data have been added and are
available by state and region.

<http://cme.kff.org/Key=11776.8q.H.C.H5fsYQ>

**-Violent Crime**

Updated data on violent crime rates for 2005 from the United States
Department of Justice have been added and are available by state and
region.  

<http://cme.kff.org/Key=11776.8q.J.C.HcXysX>

 

**-HIV/AIDS: AIDS Drug Assistance Programs (ADAP)**

Updated information on AIDS Drug Assistance Program (ADAP) policies
related to the Medicare prescription drug benefit (Medicare Part D) is
now available for May 2006 from the National Alliance for State and
Territorial AIDS Directors (NASTAD). Updated topics include the payment
of premiums and copays, provision of medications in the coverage gap,
disenrollment of clients eligible for low-income subsidies, and
collaboration with State Pharmaceutical Assistance Programs (SPAPs) by
ADAPs for all states and the nation.

<http://cme.kff.org/Key=11776.8q.K.C.H9cjHR>  

**-Providers and Service Use: Medical Malpractice**

Data on medical malpractice claims and payments have been updated for
2005 using data from the National Practitioner Data Bank (NPDB). The
total number of paid claims, total dollars in paid claims, and average
claims payments are available for all states and the nation.

<http://cme.kff.org/Key=11776.8q.L.C.H3VHQh>

**-Demographics and the Economy \>\> Unemployment Rate**

The latest unemployment rates for September 2006 have been added and are
now available for all states and the nation. 
<http://cme.kff.org/Key=11776.8q.M.C.HZSNNq>

**-Want to Link to Your State\'s Data?**

We encourage non-profit organizations, government agencies, academic
institutions, and others interested in state health policy to link to
statehealthfacts.org. Find out how.

<http://cme.kff.org/Key=11776.8q.N.C.HVQlZN>

**Rural health indicators HRSA 2005**

The HRSA 2005 Chart Book using SLAITS (telephone survey) parent
reported data from the National Survey on Child Health has an emphasis
on rural populations compared to urban and urban rural mix, is
stratified by race, age cohorts and SES in many of the charts. 

Includes Indicators:

-    breastfeeding

-    tobacco

-    children with special health care needs

-    coverage

-    injury

-    obesity

-    health care access

-    missed school days

-    behavioral issues

-    Maternal health and maternal mental health

 Further queries of the data by state and other variables are also
available.

A free hard copy can be ordered - eminently readable, a useful advocacy
tool with management and Tribal leadership, reference for proposals,
Child health chart book comes out every 4 years and alternately every 4
years a Children with Special Health Care Needs Chart book also comes
out. <http://www.mchb.hrsa.gov/ruralhealth/>

**Births: Preliminary Data for 2005**

Results---The crude birth rate in 2005 was 14.0 births per 1,000 total
population, unchanged from 2004.  The general fertility rate, however,
rose to 66.7 births per 1,000 women age 15-44 years in 2005, the highest
level since 1993.  The birth rate for teenagers declined by 2 percent in
2005, falling to 40.4 births per 1,000 women aged 15-19 years, the
lowest ever recorded in the 65 years for which a consistent series of
rates are available.  The rate declined for teenagers aged 15-17 years
to 21.4 births per 1,000, but was essentially stable for older teenagers
aged 18-19 years.  The birth rate for women aged 20--24 years rose in
2005, whereas the rate for women aged 25--29 years was essentially
unchanged.  The birth rates for women age 30 years and over rose to
levels not seen in almost 40 years.  Childbearing by unmarried women
increased to record levels for the nation in 2005. The birth rate rose 3
percent to 47.6 births per 1,000 unmarried women aged 15-44 years; the
proportion of all births to unmarried women increased to 36.8 percent. 
The cesarean delivery rate rose by 4 percent in 2005 to 30.2 percent of
all births, another record high for the nation.  The preterm birth rate
continued to rise (to 12.7 percent in 2005) as did the rate for low
birthweight births (8.2 percent).  <http://www.cdc.gov/nchs>

By Hamilton BE, Martin, JA, Ventura SJ. Division of Vital Statistics

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

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

**Shoulder dystocia: Only 43% participants could achieve delivery before
training**

CONCLUSION: This study verifies the need for shoulder dystocia training;
before training only 43% participants could achieve delivery. All
training with mannequins improved the management of simulated shoulder
dystocia. Training on a high-fidelity mannequin, including force
perception teaching, offered additional training benefits. LEVEL OF
EVIDENCE: I\
[Crofts
JF](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Crofts+JF"%5BAuthor%5D),
et al Training for Shoulder Dystocia: A Trial of Simulation Using
Low-Fidelity and High-Fidelity Mannequins. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Dec;108(6):1477-1485

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17138783&dopt=Abstract>

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

**Regular Simulation Practice: Win x3**

[Crofts
JF](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Crofts+JF"%5BAuthor%5D),
et al randomized trial confirms previous recommendations that regular
drills should be part of ongoing health care expectations. Regular
drills and medical emergency preparedness improve patient care, as well
as satisfy JCAHO evaluations. In addition, this process is endorsed in
this month's ACOG Committee Opinion (see below).

To that end, the **National Indian Health MCH and Women's Health
meeting**, August 15-17, 2007 in Albuquerque will highlight speakers
from the Institute for Healthcare Improvement and others that have
developed simulation processes. The meeting has individual facility
program review as well as many hours of CME/CEUs.

Your facility should send a team of staff to the above meeting, e. g.,
you and 2-3 other colleagues from different disciplines should start
planning now.

**National Indian Health MCH and Women's Health meeting**

<http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07>

Phoenix Indian Medical Center offers a best practice example of a
successful model in Indian Country. Contact Judy Whitecrane for more
information <Judy.Whitecrane@ihs.gov>

The Advanced Life Support in Obstetrics Course is another great
resource.
<http://www.aafp.org/online/en/home/cme/aafpcourses/clinicalcourses/also.html>

**Related Emergency Obstetric items:**

**Two great sources of benchmark information on simulation processes**

## 1.) [National Capitol Area Medical Simulation Center](http://www.simcen.usuhs.mil/)

<http://www.simcen.usuhs.mil/>

**2.) Harvard Center for Medical Simulation**

<http://www.harvardmedsim.org/cms/>

**Medical Emergency Preparedness**, **ACOG Committee**

ABSTRACT: Patient care emergencies may occur at any time in a hospital
or an outpatient setting. To respond to these emergencies, it is
important that obstetrician--gynecologists prepare themselves by
assessing potential emergencies that might occur, creating plans that
include establishing early warning systems, designating specialized
first responders, conducting emergency drills, and debriefing staff
after actual events to identify what went well and what are
opportunities for improvement. Having such systems in place may reduce
or prevent the severity of medical emergencies.

Medical emergency preparedness. ACOG Committee Opinion No. 353. American
College of Obstetricians and Gynecologists. Obstet Gynecol
2006;108:1597--99.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17138800>

**Prophylactic interventions for preventing shoulder dystocia**

AUTHORS\' CONCLUSIONS: There are no clear findings to support or refute
the use of prophylactic manoeuvres to prevent shoulder dystocia,
although one study showed an increased rate of caesareans in the
prophylactic group. Both included studies failed to address important
maternal outcomes such as maternal injury, psychological outcomes and
satisfaction with birth. Due to the low incidence of shoulder dystocia,
trials with larger sample sizes investigating the use of such manoeuvres
are required.

Athukorala C; Middleton P; Crowther CA Intrapartum interventions for
preventing shoulder dystocia. [Cochrane Database Syst Rev.  2006;
(4):CD005543](http://www.medscape.com/medline/publicationbrowser/123?pmid=17054263) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17054263>

**Oral misoprostol in preventing PPH in resource-poor communities: NNT =
18**

FINDINGS: Oral misoprostol was associated with a significant reduction
in the rate of acute postpartum haemorrhage (12.0% to 6.4%, p\<0.0001;
relative risk 0.53 \[95% CI 0.39-0.74\]) and acute severe postpartum
haemorrhage (1.2% to 0.2%, p\<0.0001; 0.20 \[0.04-0.91\]. One case of
postpartum haemorrhage was prevented for every 18 women treated.
Misoprostol was also associated with a decrease in mean postpartum blood
loss (262.3 mL to 214.3 mL, p\<0.0001)

INTERPRETATION: Oral misoprostol was associated with significant
decreases in the rate of acute postpartum haemorrhage and mean blood
loss. The drug\'s low cost, ease of administration, stability, and a
positive safety profile make it a good option in resource-poor settings.

Derman RJ et al Oral misoprostol in preventing postpartum haemorrhage in
resource-poor communities: a randomised controlled trial.[Lancet.  2006;
368(9543):1248-53](http://www.medscape.com/medline/publicationbrowser/123?pmid=17027730) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17027730>

**Other**

**Short course of hydrocortisone is an effective treatment for
intractable hyperemesis**

RESULTS: There was a significant reduction in vomiting episodes in the
hydrocortisone group compared with the metoclopramide group (p \<
.0001). Within-patient analyses showed a significant reduction in mean
vomiting episodes in the hydrocortisone group within the first 3 days (p
\< .0001). No patients from the hydrocortisone group but six of the
patients receiving metoclopramide were readmitted for intractable
vomiting within 1 wk from discharge. Five of them showed improvement on
intravenous hydrocortisone therapy.

CONCLUSIONS: A short course of hydrocortisone is an effective treatment
for intractable hyperemesis gravidarum.

Bondok RS; El Sharnouby NM; Eid HE; Abd Elmaksoud AM Pulsed steroid
therapy is an effective treatment for intractable hyperemesis
gravidarum.[Crit Care Med.  2006;
34(11):2781-3](http://www.medscape.com/medline/publicationbrowser/123?pmid=16957638)\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16957638>

**Majority of women with GDM are not tested for glucose intolerance
after delivery**

CONCLUSION: Although persistent abnormal glucose tolerance was common in
our cohort, less than half of the women were tested for it. Our data
suggest that to increase rates of postpartum glucose testing, improved
attendance at the postpartum visit with greater attention to testing and
better continuity between antenatal and postpartum care are required.
LEVEL OF EVIDENCE: II-2. [Russell
MA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Russell+MA"%5BAuthor%5D)
et al Rates of postpartum glucose testing after gestational diabetes
mellitus. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Dec;108(6):1456-62\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17138780&dopt=Abstract>

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

**GDM women are not tested for glucose intolerance after delivery**

Though the Russell et al cohort was not from Indian Country, the same
result would be found here, despite our enormous burden of diabetes
related disease. Our Indian Health GDM guidelines recommend a 2 hour
oral glucose tolerance test at 6 weeks post partum and a fasting blood
glucose every 3 years thereafter.

How many of your GDM patients actually get that follow-up?

**Diabetes Mellitus in Pregnancy Screening and Management Guidelines**

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

**Fetal Oximetry Plus Electronic Fetal Monitoring Does Not Reduce
Cesarean Delivery**

CONCLUSIONS: Knowledge of the fetal oxygen saturation is not associated
with a reduction in the rate of cesarean delivery or with improvement in
the condition of the newborn

[Bloom
SL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Bloom+SL"%5BAuthor%5D)
et al Fetal pulse oximetry and cesarean delivery. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2006 Nov
23;355(21):2195-202

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17124017>

**Leaner Women at Reduced Risk of Cesarean Delivery**

CONCLUSION: There is a significant linear association between
pre-pregnancy maternal corpulence and risk of caesarean deliveries in
pregnancies at term. The authors discuss several interpretations
including the adaptability of fetal birthweights to maternal corpulence
and the concept of soft-tissue dystocia.

[Barau
G](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Barau+G"%5BAuthor%5D),
et al Linear association between maternal pre-pregnancy body mass index
and risk of caesarean section in term deliveries.
[BJOG.](javascript:AL_get(this, 'jour', 'BJOG.');) 2006
Oct;113(10):1173-7

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16972860>

**Cesarean deliveries and multiple births independently increase
peripartum hysterectomy**

CONCLUSION: Our results suggest that vaginal birth after cesarean,
primary and repeat cesarean deliveries, and multiple births are
independently associated with an increased risk for peripartum
hysterectomy. These findings may be of concern, given the increasing
rate of both cesarean deliveries and multiple births in the United
States. LEVEL OF EVIDENCE: III.

[Whiteman
MK](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Whiteman+MK"%5BAuthor%5D),
et al Incidence and Determinants of Peripartum Hysterectomy. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Dec;108(6):1486-1492\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17138784&dopt=Abstract>

**IV iron sucrose increases the Hgb level more rapidly than oral iron in
postpartum anemia**

CONCLUSIONS: Intravenous iron sucrose increases the Hb level more
rapidly than oral ferrous sulphate in women with postpartum iron
deficiency anemia. It also appears to replenish iron stores more
rapidly. However, this study was not large enough to address the safety
of this strategy.

Bhandal N; Russell R Intravenous versus oral iron therapy for postpartum
anaemia. [BJOG.  2006;
113(11):1248-52](http://www.medscape.com/medline/publicationbrowser/123?pmid=17004982)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17004982>

Is MRSA Infection a Potential Threat in Pregnancy?

Methicillin-resistant *Staphylococcus aureus* (MRSA) infections were
typically found in hospitals and long-term care facilities, but they
have now been reported in the community and in other health facilities.
These infections, including sepsis, necrotizing pneumonia, and a variety
of serious skin and soft tissue infections, often are caused by highly
virulent strains of MRSA that are resistant to several antibiotics. MRSA
infection outbreaks have been documented in pregnant and postpartum
women and in infants in neonatal intensive care units. Because the
prevalence of MRSA in pregnant women and the potential for outbreaks of
MRSA infections in obstetric and neonatal units are poorly understood,
Chen and colleagues conducted a prospective surveillance study of women
receiving prenatal care at a large urban university medical center.

Researchers used swabs collected from routine group B streptococcus
(GBS) screening. Rectal and vaginal specimens also were collected from
pregnant women who were between 35 and 37 weeks\' gestation and from
those at risk of preterm delivery. The specimens were cultured under
standard conditions for GBS and *S. aureus*. All *S. aureus* strains
were tested for susceptibility to various antimicrobial agents.

During the six-month study, 2,963 specimens were processed for *S.
aureus*; 507 (17 percent) were positive. In 190 cases, GBS and *S.
aureus* were present in the same patient. Of the *S. aureus* isolates,
14 (2.8 percent) were MRSA. Thirteen of these were determined to be
community-associated MRSA organisms that were susceptible to several
common antibiotics, as opposed to being health care-associated MRSA,
which is multidrug resistant.

The authors conclude that the overall prevalence of *S. aureus* in
vaginal-rectal cultures from pregnant women is about 17 percent. This is
significantly greater than previous estimates, which were based on
studies of cultures from different sites and from pregnant women in
other countries. They also note that *S. aureus* colonization was
significantly associated with GBS. Although the prevalence of MRSA in
the pregnant women screened was small (about 0.5 percent), it does raise
the possibility of outbreaks of serious infection in obstetric or
neonatal units. Case reports have suggested a potential for transmission
of MRSA from mothers to infants. The authors conclude that MRSA could be
an emerging threat of infection in maternal and neonatal populations.

Chen KT, et al. Prevalence of methicillin-sensitive and
methicillin-resistant Staphylococcus aureus in pregnant women. Obstet
Gynecol September 2006;108:482-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16946204>

**CDC Releases Guidelines on Improving Preconception Health Care**

The CDC developed recommendations for physicians and public health
officials that aim to improve women\'s health before conception, which
in turn will improve pregnancy outcomes (e.g., low birth weight, infant
mortality rates). Recommendations for physicians include helping
patients with reproductive planning, increasing patient awareness of the
importance of preconception health care, providing preventive care and
interventions for patients with identified risks, providing
interconception care, and performing prepregnancy checkups.

*Morbidity and Mortality Weekly Report,* August 21, 2006

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm>

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

**HPV vaccine is effective: Why do we not provide it to most AI/AN?**

CONCLUSION: Based on the data obtained in this study, widely-implemented
prophylactic HPV vaccination could make an important contribution to the
reduction of the risk for cervical cancer and could also prevent about
half the vulvar carcinomas in younger women and about two thirds of the
intraepithelial lesions in the lower genital tract. LEVEL OF EVIDENCE:
II-3.

[Hampl
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Hampl+M"%5BAuthor%5D),
et al Effect of Human Papillomavirus Vaccines on Vulvar, Vaginal, and
Anal Intraepithelial Lesions and Vulvar Cancer. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Dec;108(6):1361-1368

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17138767&dopt=Abstract>

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

**Honestly, are you actively giving out HPV to all your female patients
between 9 -- 26 yo?**

I didn't think so....but you should be.

[Hampl
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Hampl+M"%5BAuthor%5D),
et al is another example that the HPV vaccine is clearly beneficial as
HPV vaccination could important effect vulvar carcinomas and 2/3
intraepithelial lesions. Yet HPV vaccine is not widely available to most
AI/AN women 9-26 years old. How can this disparity be resolved?

On November 1, 2006, the Centers for Disease Control and Prevention
added the new human papillomavirus (HPV) vaccine to the federal Vaccines
for Children program, which provides free vaccines to children from
families with low incomes or who are uninsured. The following articles
in the Winter 2006 issue of the Guttmacher Policy Review discuss related
policy issues:

In Achieving Universal Vaccination Against Cervical Cancer in The United
States, the authors discuss the case for universal vaccination, the role
of school-entry requirements, financing challenges, the potential role
of family planning clinics in an HPV vaccine campaign, and solutions to
various challenges presented by the HPV vaccine.
[[http://click.icptrack.com/icp/relay.php?r=5681049&msgid=3477038&act=RRVH&c=6586&admin=0&destination=http%3A%2F%2Fwww.guttmacher.org%2Fpubs%2Fgpr%2F09%2F4%2Fgpr090412.html]{.underline}](http://click.icptrack.com/icp/relay.php?r=5681049&msgid=3477038&act=RRVH&c=6586&admin=0&destination=http%3A%2F%2Fwww.guttmacher.org%2Fpubs%2Fgpr%2F09%2F4%2Fgpr090412.html)

In The Public Health Promise and Potential Pitfalls of the World\'s
First Cervical Cancer Vaccine, the authors discuss what the science
says; targeting adolescents; the politics of adolescent sex; and key
scientific, logistical, and policy questions about the HPV vaccine.
[[http://click.icptrack.com/icp/relay.php?r=5681049&msgid=3477038&act=RRVH&c=6586&admin=0&destination=http%3A%2F%2Fwww.guttmacher.org%2Fpubs%2Fgpr%2F09%2F1%2Fgpr090106.html]{.underline}](http://click.icptrack.com/icp/relay.php?r=5681049&msgid=3477038&act=RRVH&c=6586&admin=0&destination=http%3A%2F%2Fwww.guttmacher.org%2Fpubs%2Fgpr%2F09%2F1%2Fgpr090106.html)

**The Ethics and Politics of Compulsory HPV Vaccination**

A large body of evidence demonstrates that school-based laws are an
effective and efficient way of boosting vaccine-coverage rates.
Requiring HPV vaccination by law will almost certainly achieve more
widespread protection against the disease than will policies that rely
exclusively on persuasion and education. In the view of advocates, this
effectiveness provides a clear justification. \"The only way to ensure
that A large body of evidence demonstrates that school-based laws are an
effective and efficient way of boosting vaccine-coverage rates.
Requiring HPV vaccination by law will almost certainly achieve more
widespread protection against the disease than will policies that rely
exclusively on persuasion and education. In the view of advocates, this
effectiveness provides a clear justification. \"The only way to ensure
that as many girls as possible receive the HPV vaccine is to require it
before they enter middle school,\" said Beverly Hammerstrom, the
Michigan state senator who introduced the legislation. Whether such a
mandate might extend to boys, should the product be approved for such
use, remains uncertain.

A critical question is whether achieving a higher level of coverage
justifies the infringement on parental autonomy that compulsory
vaccination inevitably entails. Different ethical frameworks that accord
varying weights to communitarian and individualistic values will lead to
contrasting answers to this question.

Ethical and epidemiologic analyses are essential to decisions about
mandating the HPV vaccine; so are political calculations. Any new
vaccine that a state adds to its list of requirements must be judged in
the context of both the increasingly lengthy and complex regimen of
vaccines that children now receive and the possibility that additional
mandates may inflame grassroots opposition, be it religious,
philosophical, or
ideological.^[5](http://content.nejm.org/cgi/content/full/355/23/2389#R5%23R5)^
Although issues of religion and adolescent sexuality have dominated the
discussion, the move to require HPV vaccination raises broad questions
about the acceptability of mandatory public health measures, the scope
of parental autonomy, and the role of political advocacy in determining
how preventive health measures are implemented.

girls as possible receive the HPV vaccine is to require it before they
enter middle school,\" said Beverly Hammerstrom, the Michigan state
senator who introduced the legislation. Whether such a mandate might
extend to boys, should the product be approved for such use, remains
uncertain.

A critical question is whether achieving a higher level of coverage
justifies the infringement on parental autonomy that compulsory
vaccination inevitably entails. Different ethical frameworks that accord
varying weights to communitarian and individualistic values will lead to
contrasting answers to this question.

Ethical and epidemiologic analyses are essential to decisions about
mandating the HPV vaccine; so are political calculations. Any new
vaccine that a state adds to its list of requirements must be judged in
the context of both the increasingly lengthy and complex regimen of
vaccines that children now receive and the possibility that additional
mandates may inflame grassroots opposition, be it religious,
philosophical, or
ideological.[5](http://content.nejm.org/cgi/content/full/355/23/2389#R5%23R5)
Although issues of religion and adolescent sexuality have dominated the
discussion, the move to require HPV vaccination raises broad questions
about the acceptability of mandatory public health measures, the scope
of parental autonomy, and the role of political advocacy in determining
how preventive health measures are implemented.

Colgrove J. The Ethics and Politics of Compulsory HPV Vaccination NEJM
2006 Volume 355(23):2389-2391

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17151362&dopt=Abstract>

**LEEP in adolescents overly aggressive therapy: High incidence of F/U
abnormal cytology**

CONCLUSION: Adolescents with abnormal cytology have a high incidence of
CIN2/3 and high rates of abnormal cytology after LEEP. Cervical
intraepithelial neoplasia 2/3 is common in adolescents with abnormal
cytology, yet no cases of cancer were identified. Importantly, LEEP
fails to meet its therapeutic goals given a high incidence of abnormal
follow-up cytology and may represent overly aggressive therapy because
the majority of human papillomavirus infections are transient with high
regression rates. LEVEL OF EVIDENCE: III.

[Case
AS](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Case+AS"%5BAuthor%5D),
et al Cervical intraepithelial neoplasia in adolescent women: incidence
and treatment outcomes. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Dec;108(6):1369-74

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17138768&dopt=Abstract>

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

**Beware of ablative procedures for cervical dysplasia in adolescents**

This is just the latest article in a growing literature that supports an
increasingly limited role for ablative procedures, like LEEP, in
adolescents. If the patient is judged to be adherent with follow-up,
then there is certainly a role for clinical follow-up of CIN 2 in
adolescents, rather than ablation.

**Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic
endometriosis**

AUTHORS\' CONCLUSIONS: One small study has shown that postoperative use
of the LNG-IUS reduces the recurrence of painful periods in women who
have had surgery for endometriosis. There is a need for further
well-designed RCTs of this approach.

Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic
endometriosis following surgery. [Cochrane Database Syst Rev.  2006;
(4):CD005072](http://www.medscape.com/medline/publicationbrowser/123?pmid=17054236) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17054236>

**Overactive Bladder: the Importance of New Guidance **

The recent expansion of the range of treatments available for OAB and
stress urinary incontinence makes it especially important that
physicians become aware of the differential diagnosis of these
conditions - the questions they need to ask, and the investigations
which will help determine the most appropriate course of action.

[Kirby
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Kirby+M"%5BAuthor%5D),
et al Overactive bladder: The importance of new guidance. [Int J Clin
Pract.](javascript:AL_get(this, 'jour', 'Int J Clin Pract.');) 2006
Oct;60(10):1263-71

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16981970>

and

Medscape CME

<http://www.medscape.com/viewarticle/547698>

Preventing Eating Disorders in College-Age Women

Anorexia nervosa, bulimia, and binge eating occur in about 2 to 4
percent of adolescent and young adult women. The incidence of these
disorders peaks at 16 to 20 years of age, which corresponds with the
time young women enter college. High school and college students
commonly use unhealthy weight regulation and have body image concerns
that predispose them to eating disorders. In addition, 35 to 45 percent
of adolescent girls state that they are too fat, have difficulties with
weight control, and want to lose weight. Persons with eating disorders
tend to have low self-esteem, shame, and other psychological problems.
Laxative abuse and self-induced vomiting can cause significant adverse
physical conditions. Identifiable risk factors for eating disorders
include excessive weight and body shape concerns. Using this
information, prevention programs are being developed to reduce the
incidence of eating disorders. Taylor and associates evaluated an
Internet-based psychological intervention program aimed at preventing
eating disorders in at-risk young women.

The authors conclude that an Internet-based cognitive behavior program
can significantly reduce weight and body shape concerns among
college-age women at risk of eating disorders. They note that these
programs also may reduce the onset of eating disorders in some high-risk
groups.

Taylor CB, et al. Prevention of eating disorders in at-risk college-age
women. Arch Gen Psychiatry August 2006;63:881-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16894064>

**Techniques for pelvic surgery in subfertility**

From these limited data there is no evidence of benefit or disadvantage
of tubal surgery versus no treatment or alternative treatments. Likewise
there is no evidence of advantage or disadvantage of using microsurgery
over standard techniques; laparoscopic approach over laparotomy; the use
of CO2 laser; or electrocoagulation over thermocoagulation. Randomised
controlled trials should be undertaken to determine the role of tubal
surgery versus no treatment or alternative treatments. Randomised
controlled trials should be undertaken to determine the role at tubal
surgery of magnification, laparoscopic approach, the use of lasers or
electrocoagulation.

Ahmad G, Watson A, Vandekerckhove P, Lilford R. Techniques for pelvic
surgery in subfertility. Cochrane Database of Systematic Reviews 2006,
Issue 2. Art. No.: CD000221. DOI: 10.1002/14651858.CD000221.pub3.

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

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

**Why do disparities in infant mortality continue to persist between
AIAN and white infants?**

[OBJECTIVES:]{.underline} To describe changes in infant mortality rates,
including birthweight-specific rates and rates by age at death and
cause.

[METHODS:]{.underline} We analyzed US linked birth/infant-death data for
1989-1991 and 1998-2000 for American Indians/Alaska Native (AIAN) and
White singleton infants at \> or =20 weeks\' gestation born to US
residents. We calculated birthweight-specific infant mortality rates
(deaths in each birthweight category per 1000 live births in that
category), and overall and cause-specific infant mortality rates (deaths
per 100000 live births) in infancy (0-364 days) and in the neonatal
(0-27 days) and postneonatal (28-364 days) periods.

[RESULTS:]{.underline} Birthweight-specific infant mortality rates
declined among AIAN and White infants across all birthweight categories,
but AIAN infants generally had higher birthweight-specific infant
mortality rates. Infant mortality rates declined for both groups, yet in
1998-2000, AIAN infants were still 1.7 times more likely to die than
White infants. Most of the disparity was because of elevated
post-neonatal mortality, especially from sudden infant death syndrome,
accidents, and pneumonia and influenza.

[CONCLUSIONS:]{.underline} Although birthweight-specific infant
mortality rates and infant mortality rates declined among both AIAN and
White infants, disparities in infant mortality persist. Preventable
causes of infant mortality identified in this analysis should be
targeted to reduce excess deaths among AIAN communities.

Tomashek KM et al. Infant Mortality Trends and Differences Between
American Indian/Alaska Native Infants and White Infants in the United
States, 1989-1991 and 1998-2000 December 2006, Vol 96, No. 12 American
Journal of Public Health

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17077400>

#### [Editorial comment:]{.underline} Judy Thierry, MCH Coordinator, HQE

**Infant Mortality Trends and Differences Between AI/AN Infants and
White Infants**

**1989-1991 and 1998-2000 **

Kay Tomashek and her CDC colleagues present AIAN infant mortality trends
and differences emphasizing birthweight-specific infant mortality rates.
This national picture uses three year aggregate data drawn from the NCHS
Vital Statistics in (1989-1991) and again in (1998-2000).[^1] Given the
contribution of SIDS to elevated post neonatal AIAN elevated infant
mortality it is important to consider several key studies and national
interventions that occurred in the early to mid 1990's between these two
data sets. Key contributions include: New Zealand and other
international studies on SIDS; further study and on SIDS in Seattle King
County by Spiers and Guntheroth on the supine sleep position[^2]; roll
out of the AAP and NICHD guidelines on infant sleep position and the
"Back to Sleep" campaign; and the prospective case control study
conducted by the IHS, NICHD and CDC (1994-1997) entitled the "Aberdeen
Area Tribal Chairman\'s Health Board (AATCHB) Infant Mortality study"
"Mi Cinca kin towani ewaktonji kte sni" "I will never forget my child".

The APHA December 2006 publication of the analysis demonstrates downward
trends in AIAN birthweight-specific infant mortality rates (albeit not
enough) and helps us to further clarify the populations at risk in this
complex issue, an issue that will require further elaboration using the
triple risk factor model.[^3] A list of key partners includes: Tribal
Epidemiology Centers (local surveillance) linked with Perinatal Infant
and Child Mortality Review teams (local review), Community Health
Representatives and public health nurse outreach (culturally-based
outreach); including the Healthy Start Project model of home
interventions and case management and other intensive maternal support
programs. Tomashek discusses perinatal tobacco exposure. It is cited
among the 33 references that are essential reading and reference when
discussing AIAN birth and infant death data. Maternal risk factors and
family risk factors will be further elucidated with an AIAN specific
point-in-time PRAMS soon to be underway. Funding of comprehensive
campaigns to address tobacco exposure such as the AATCHB Smoke Free
Homes Campaign should be priority. Timely access to care, quality of
care, care of the maternal/fetal unit through a planned and regionalized
and risk stratified manner remain fundamental to infant survival and
maternal wellbeing.

Single years have too few deaths to report any significance. In some
reports you will note 5 and 6 year aggregates to obtain sufficient
numbers in the 'cells'. For this analysis 3 year aggregates were used.

2 Guntheroth, W. G., Spiers, P. S., Sleeping prone and the risk of
sudden infant death syndrome, JAMA, Vol. 267 No. 17, May 6, 1992 cited
December 4, 2006

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=1564777>

3 A triple-risk model for the pathogenesis of SIDS - intersection of
three overlapping factors:

\(1\) a vulnerable infant;

\(2\) a critical developmental period in homeostatic control, and

\(3\) an exogenous stressor(s).
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=8038282>

[Filiano
JJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Filiano+JJ"%5BAuthor%5D),
[Kinney
HC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Kinney+HC"%5BAuthor%5D).
A perspective on neuropathologic findings in victims of the sudden
infant death syndrome: the triple-risk model. [Biol
Neonate.](javascript:AL_get(this, 'jour', 'Biol Neonate.');) 1994;65
(3-4):194-7.

**US Adults Prefer Comprehensive Teaching of Sex Education in Public
Schools**

CONCLUSIONS: Our results indicate that US adults, regardless of
political ideology, favor a more balanced approach to sex education
compared with the abstinence-only programs funded by the federal
government. In summary, abstinence-only programs, while a priority of
the federal government, are supported by neither a majority of the
public nor the scientific community

[Bleakley
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Bleakley+A"%5BAuthor%5D),
[Hennessy
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Hennessy+M"%5BAuthor%5D),
[Fishbein
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Fishbein+M"%5BAuthor%5D).
Public opinion on sex education in US schools. [Arch Pediatr Adolesc
Med.](javascript:AL_get(this, 'jour', 'Arch Pediatr Adolesc Med.');)
2006 Nov;160(11):1151-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17088519>

**Supersize This: Large entree portions may constitute an \"obesigenic\"
influence**

CONCLUSIONS: Large entree portions may constitute an \"obesigenic\"
environmental influence for preschool-aged children by producing
excessive intake at meals. Children with satiety deficits may be most
susceptible to large portions. Allowing children to select their own
portion size may circumvent the effects of exposure to large portions on
children\'s eating.

[Orlet Fisher
J](http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Orlet+Fisher+J"%5BAuthor%5D),
et al Children\'s bite size and intake of an entree are greater with
large portions than with age-appropriate or self-selected portions. [Am
J Clin Nutr.](javascript:AL_get(this, 'jour', 'Am J Clin Nutr.');) 2003
May;77(5):1164-70.

<http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=12716667&dopt=Abstract>

#### [Editorial comment:]{.underline}

**Target childhood obesity in preschool years**

At the annual meeting of the American College of Nutrition, Leann Birch,
Ph.D., noted efforts to prevent childhood obesity should start before
children enter school. If we wait until kids start school, we miss our
best chance to prevent obesity. Dr. Birch would argue that it's going to
be much easier to put kids on the right path in the first place than it
is to try to change a lot of bad habits when you start at age 6, 7, or
8.

Other resources from the same group include

Am. J. Clin. Nutr. 2003;78:215-20

Pediatrics 1994;93:271-7

**Perspectives on Confidential Care for Adolescent Girls**

RESULTS Mothers see themselves as their daughters' primary protectors
against daughters' poor reproductive outcomes. Many believe that
confidential care promotes risky behavior and undermines mothers'
efforts to protect girls. Mothers endorse facilitating gynecologic care
and entering alliances with physicians but see the need for care as
arising only after girls' sexual debut. Unfortunately, maternal
awareness of sexual activity is low. Adolescent girls express
considerable discomfort around reproductive health care and negotiating
maternal involvement, and they fear breaches in confidentiality.

CONCLUSIONS A lack of trust in health care clinicians and the mother's
gatekeeper role are key barriers to girls' transition to reproductive
care. Consistently including a confidential component to health care
visits in early adolescence, with preparation for both mothers and
daughters, may reduce the distrust and discomfort.

McKee MD et al Perspectives on Confidential Care for Adolescent Girls.
*Annals of Family Medicine* 4:519-526 (2006)
<http://www.annfammed.org/cgi/content/full/4/6/519>

### 

### **61% of SIDS cases among smokers were attributable to maternal smoking** 

### We investigated the effect of maternal smoking during pregnancy on the relative risk of sudden infant death syndrome (SIDS) by linking data from Georgia birth and death certificates from 1997 to 2000. We estimated the effect of misclassifying smokers as non-smokers and the effect of being misclassified on SIDS rates, and we calculated the fraction of cases caused by exposure. Of all SIDS cases, 21% were attributable to maternal smoking; among smokers, 61% of SIDS cases were attributable to maternal smoking. Maternal smoking during pregnancy is associated with a significantly increased risk of SIDS.

### Shah T; Sullivan K; Carter J. Sudden infant death syndrome and reported maternal smoking during pregnancy. [Am J Public Health.  2006; 96(10):1757-9](http://www.medscape.com/medline/publicationbrowser/123?pmid=17008569)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17008569>

**Parental genes do what\'s best for baby**

A molecular \'battle of the sexes\' long considered the major driving
force in a baby\'s development is being challenged by a new genetic
theory of parental teamwork.

This novel coadaptation theory for the evolution of genomic imprinting
is consistent with results of recent studies on epigenetic effects, and
it provides a testable hypothesis for the origin of previously
unexplained major imprinting patterns across different taxa. In
conjunction with existing hypotheses, our results suggest that
imprinting may have evolved due to different selective pressures at
different loci.

[Wolf
JB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Wolf+JB"%5BAuthor%5D),
[Hager
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Hager+R"%5BAuthor%5D).
A Maternal-Offspring Coadaptation Theory for the Evolution of Genomic
Imprinting. [PLoS Biol.](javascript:AL_get(this, 'jour', 'PLoS Biol.');)
2006 Nov 14;4(12):e380

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17105351>

**Prevention of Unintentional Childhood Injuries (also see Patient
Education)**

Injuries are the leading cause of death in children and teenagers in the
United States. The leading causes of unintentional injury vary by age
and include drowning, poisoning, suffocation, fires, burns, falls, and
motor vehicle, bicycle, and pedestrian-related crashes. Most injuries
are preventable by modifying the child\'s environment (e.g., use of
stair gates) and having parents engage in safety practices (e.g.,
keeping matches or lighters out of reach of children). Effective injury
prevention methods include the use of childproof caps on medications and
household poisons, age-appropriate restraints in motor vehicles (i.e.,
car seats, booster seats, seat belts), bicycle helmets, and a four-sided
fence with a locked gate around residential swimming pools. Am Fam
Physician 2006;74:1864-9, 1870

<http://lyris.aafp.org/t/770281/16249464/512878/0/>

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

Firearm Safety in Homes with Adolescents

Approximately one third of U.S. households with children and adolescents
contain firearms. Despite recommendations to keep these firearms stored
unloaded and locked, a significant number of households store them
loaded or unlocked, substantially increasing the risk that children or
adolescents will accidentally or intentionally use a firearm to cause
injury. Parents tend to assume that older children will act more
responsibly, and studies have evaluated safe firearm storage according
to the age of the children in the home. However, no studies have
addressed individually the issues of storing firearms unloaded and of
storing them in a locked place. Johnson and associates evaluated these
individual safety issues in households with children or adolescents.

The authors conclude that parents of adolescents are less likely to
store their firearms safely compared with parents of younger children.
They add that these results are worrying because a significant number of
firearm injuries occur in the adolescent age group. The authors suggest
that firearm prevention programs focus on parents with adolescent
children to improve safety practices.

Johnson RM, et al. Are household firearms stored less safely in homes
with adolescents? Analysis of a national random sample of parents. Arch
Pediatr Adolesc Med August 2006;160:788-92.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16894076>

**Breast Cancers Within 1 Year of a Normal Screening Mammogram: How Are
They Found?**

RESULTS Women with interval cancers were twice as likely to have a
personal history of breast cancer (30.1%) as women with screen-detected
cancers (13.6%). Among women with interval cancers, one half of the
invasive tumors (49.5%) were discovered when women initiated a health
care visit because of a breast concern, and 16.8% were discovered when a
clinician found an area of concern while conducting a routine clinical
breast examination. Having a lump and both a personal and a family
history of breast cancer was the most common reason why women initiated
a health care visit (44%) (P \<.01).

CONCLUSIONS Women with interval cancers are most likely to initiate a
visit to a primary care clinician when they have 2 or more breast
concerns. These concerns are most likely to include having a lump and a
personal and/or family history of breast cancer. Women at highest risk
for breast cancer may need closer surveillance by their primary care
clinicians and may benefit from a strong educational message to come for
a visit as soon as they find a lump.

Carney PA et al Discovery of Breast Cancers Within 1 Year of a Normal
Screening Mammogram: How Are They Found? *Annals of Family Medicine*
4:512-518 (2006)

<http://www.annfammed.org/cgi/content/full/4/6/512>

**Diabetic complications in 40 or older with undiagnosed DM is similar
to diagnosed DM**

An estimated 4.9 million adults in the United States have undiagnosed
diabetes. Because the average patient has no symptoms for up to 12
years, one in five will develop diabetic retinopathy before seeking
medical care. Other common complications of diabetes are peripheral
sensory neuropathy and nephropathy. It is uncertain how many patients
with undiagnosed diabetes are affected. Koopman and colleagues estimated
the prevalence of neuropathy and nephropathy in patients with
undiagnosed diabetes using data from the most recent U.S. National
Health and Nutrition Examination Survey (NHANES).

The authors conclude that the prevalence of nephropathy and peripheral
neuropathy in patients 40 years or older with undiagnosed diabetes is
similar to that in patients who are already diagnosed with diabetes.
This information adds to the evidence that preclinical diabetes is
associated with significant morbidity. These findings may indicate the
need for a reexamination of current policies on screening asymptomatic
patients at high risk of diabetes.

Koopman RJ, et al. Evidence of nephropathy and peripheral neuropathy in
U.S. adults with undiagnosed diabetes. Ann Fam Med September/October
2006;4:427-32.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17003143>

**Statins Should Be a Part of Preventive Management in Stroke
Patients **

CONCLUSIONS: In patients with recent stroke or TIA and without known
coronary heart disease, 80 mg of atorvastatin per day reduced the
overall incidence of strokes and of cardiovascular events, despite a
small increase in the incidence of hemorrhagic stroke.

[Amarenco
P](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Amarenco+P"%5BAuthor%5D),
et al High-dose atorvastatin after stroke or transient ischemic attack.
[N Engl J Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2006
Aug 10;355(6):549-59

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16899775>

**Herniated Disk Improves With Either Surgical or Nonsurgical
Treatment **

CONCLUSIONS: Patients with persistent sciatica from lumbar disk
herniation improved in both operated and usual care groups. Those who
chose operative intervention reported greater improvements than patients
who elected nonoperative care. However, nonrandomized comparisons of
self-reported outcomes are subject to potential confounding and must be
interpreted cautiously.

[Weinstein
JN](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Weinstein+JN"%5BAuthor%5D),
et al Surgical vs nonoperative treatment for lumbar disk herniation: the
Spine Patient Outcomes Research Trial (SPORT) observational cohort.
[JAMA.](javascript:AL_get(this, 'jour', 'JAMA.');) 2006 Nov
22;296(20):2451-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17119141>

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

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

**Treatment With Selective Serotonin Reuptake Inhibitors During
Pregnancy**

ABSTRACT: Depression is a common condition among women of reproductive
age, and selective serotonin reuptake inhibitors (SSRIs) are frequently
used for the treatment of depression. However, recent reports regarding
SSRI use during pregnancy have raised concerns about fetal cardiac
defects, newborn persistent pulmonary hypertension, and other negative
effects. The potential risks associated with SSRI use throughout
pregnancy must be considered in the context of the risk of relapse of
depression if maintenance treatment is discontinued. The American
College of Obstetricians and Gynecologists' Committee on Obstetric
Practice recommends that treatment with all SSRIs or selective
norepinephrine reuptake inhibitors or both during pregnancy be
individualized and paroxetine use among pregnant women or women planning
to become pregnant be avoided, if possible.

Treatment with selective serotonin reuptake inhibitors during pregnancy.
ACOG Committee Opinion No. 354. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2006;108:1601--3.bstet Gynecol
2006;108:1597--99.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17138801>

**Routine Cancer Screening**

ABSTRACT: Obstetrician--gynecologists serve as primary care physicians
for many women. Because the obstetrician--gynecologist may be the only
physician providing routine care, clinicians should be able to provide
recommendations for routine cancer screenings, including those for
nongynecologic cancers. This document summarizes recommendations of the
American College of Obstetricians and Gynecologists for routine cancer
screening for the average-risk American woman. The
obstetrician--gynecologist should discuss both benefits and limitations
of screening tests with the patient.

Routine cancer screening. ACOG Committee Opinion No. 356. American
College of Obstetricians and Gynecologists. Obstet Gynecol
2006;108:1611--13.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17138803>

**Primary and Preventive Care: Periodic Assessments**

ABSTRACT: [Periodic
assessments](http://www.acog.org/publications/pdfs/co357PeriodicAssessment.pdf)
offer an excellent opportunity for obstetricians and gynecologists to
provide preventive screening, evaluation, and counseling. This Committee
Opinion provides the recommendations of the American College of
Obstetricians and Gynecologists' Committee on Gynecologic Practice for
routine assessments in primary and preventive care for women based on
age and risk factors.

Primary and preventive care: periodic assessments. ACOG Committee
Opinion No. 357. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2006;108:1615--22.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17138804>

**Innovative Practice: Ethical Guidelines**

ABSTRACT: Innovations in medical practice are critical to the
advancement of medicine. Good clinicians constantly adapt and modify
their clinical approaches in ways they believe will benefit patients.
Innovative practice frequently is approached very differently from
formal research, which is governed by distinct ethical and regulatory
frameworks. Although opinions differ on the distinction between research
and innovative practice, the production of generalizable knowledge is
one defining characteristic of research. Physicians considering
innovative practice must disclose to patients the purpose, benefits, and
risks of the proposed treatment, including risks not quantified but
plausible. They should attempt an innovative procedure only when
familiar with and skilled in its basic components. A clinician should
share results, positive or negative, with colleagues and, when feasible,
teach successful techniques and procedures to other physicians.
Practitioners should be wary of adopting innovative procedures or
diagnostic tests on the basis of promotions and marketing when the value
of the procedures or tests has not been proved. A practitioner should
move an innovative practice into formal research if the innovation
represents a significant departure from standard practice, if the
innovation carries unknown or potentially significant risks, or if the
practitioner's goal is to use data from the innovation to produce
generalizable knowledge. If there is any question whether innovative
practices should be formalized as research, clinicians should seek
advice from the relevant institutional review board.

Innovative practice: ethical guidelines. ACOG Committee Opinion No. 352.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2006;108:1589--95

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17138799>

**Vaginal Agenesis: Diagnosis, Management, and Routine Care**

ABSTRACT: Vaginal agenesis occurs in 1 of every 4,000.10,000 females.
The most common cause of vaginal agenesis is congenital absence of the
uterus and vagina, which also is referred to as mullerian aplasia,
mullerian agenesis, or Mayer.Rokitansky.Kuster.Hauser syndrome. The
condition usually can be successfully managed nonsurgically with the use
of successive dilators if it is correctly diagnosed and the patient is
sufficiently motivated. Besides correct diagnosis, effective management
also includes evaluation for associated congenital renal or other
anomalies and careful psychologic preparation of the patient before any
treatment or intervention. If surgery is preferred, a number of
approaches are available; the most common is the Abbe.McIndoe operation.
Women who have a history of mullerian agenesis and have created a
functional vagina require routine gynecologic care and can be considered
in a similar category to that of women without a cervix and thus annual
cytologic screening for cancer may be considered unnecessary in this
population.

Vaginal agenesis: diagnosis, management, and routine care. ACOG
Committee Opinion No. 355. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2006;108:1605--9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17138802>

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

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

Levothyroxine Reduces Preterm Birth in Euthyroid Women

**Clinical Question:** Does treatment with levothyroxine improve birth
outcomes for pregnant euthyroid women who test positive for thyroid
peroxidase antibodies?

**Setting:**

**Study Design:** Randomized controlled trial (double-blinded)

**Synopsis:** White women receiving care in an academic obstetric clinic
in Italy were screened for thyroid peroxidase (TPO) antibodies, free
thyroxine (FT4), and thyroid-stimulating hormone (TSH) levels. Of the
1,074 women tested, 45 were excluded from the study because of overt
hypothyroidism or hyperthyroidism; 984 completed the study. The 115
women who were positive for TPO antibodies and had normal FT4 and TSH
levels were randomized to treatment with levothyroxine or placebo.
Treatment allocation was concealed and treatment began within one week
of the initial visit for prenatal care. Medication dosing for women
taking active treatment was calculated according to body weight and TSH
level, and was a mean of 50 mcg. The participating women and the
physicians providing obstetric care were blinded to treatment
assignment.

Treated women had a significant reduction in spontaneous abortion (4
versus 14 percent; number needed to treat \[NNT\] = 10). Preterm births
also were reduced in the treated group (7 versus 22 percent; NNT = 6;
95% confidence interval, 3 to 22).

Treated women had rates of spontaneous abortion and preterm birth
similar to the 869 women who screened negative for TPO antibodies. In
this population, in which 11 percent of women had a positive screen
result, the number needed to screen to prevent one preterm birth would
be 56, and the number needed to screen to prevent one miscarriage would
be 93 (assuming that all women positive for TPO antibodies would have
equally positive results with treatment).

This study may have been confounded by the women in the control group,
who were younger on average than those in the treatment group; this may
have influenced the rate of miscarriages. Also of note is that the study
was conducted in Italy where iodization of salt is not compulsory.
Iodine deficiency in this population may have reduced the functional
reserve needed for the physiologic increase in thyroid hormone
production during pregnancy.

**Bottom Line:** In this study, levothyroxine treatment of euthyroid
women who tested positive for TPO antibodies significantly decreased
spontaneous abortions and preterm births. Screening may be indicated for
populations of pregnant women with a high incidence of autoimmune
thyroid disease. Further studies in various populations are needed.

**(Level of evidence: 1b)**

Study Reference**:** Negro R, et al. Levothyroxine treatment in
euthyroid pregnant women with autoimmune thyroid disease: effects on
obstetrical complications. J Clin Endocrinol Metab July 2006;91:2587-91.

###### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16621910**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16621910)

**\*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.

Opioids for Management of Breakthrough Pain in Cancer Patients

Cochrane for Clinicians: Putting Evidence into Practice

[Clinical Scenario]{.underline}

A 74-year-old man uses long-acting opioids for chest wall pain
associated with lung cancer. He experiences breakthrough pain in the
evenings and would like advice about the best way to treat it.

[Clinical Question]{.underline}

What evidence is there for the use of rapid-acting opioids in the
management of breakthrough cancer pain?

[Evidence-Based Answer]{.underline}

Oral transmucosal fentanyl citrate (OTFC \[Actiq\]), a rapid-acting
opioid, has been shown to be an effective treatment for breakthrough
cancer pain. Other opioids, including immediate-release oral morphine
(MSIR), also may be effective; however, evidence comparing these agents
with OTFC is lacking.

[Practice Pointers]{.underline}

Cancer pain comes in many forms and often is undertreated.2 When the
pain fails to respond to acetaminophen or nonsteroidal anti-inflammatory
drugs, or otherwise becomes intractable, opioids often are recommended.3
Usually, short-acting opioids are used as needed. When the pain persists
throughout the day, short-acting opioids are replaced with longer-acting
opioids two or three times daily to provide 24-hour relief.

Even after daily opioid dosing has been established, physicians may be
called upon to treat worsening pain. In some patients, worsening pain
control is a sign of worsening disease and may warrant a thorough
reevaluation of the underlying causes. Opioid tolerance is another
possible reason for increased medication requirements. However,
increased pain (e.g., constipation and abdominal pain) also can be an
adverse effect of opioids, and physicians must be careful not to
misinterpret these symptoms.

In contrast, breakthrough pain usually is episodic and self-limited. It
often recurs at certain times of the day or in response to particular
triggers. When breakthrough pain occurs as a result of end-of-dose
failure it can be prevented by increasing the frequency of opioid
dosing-for example, administering sustained-release morphine every eight
hours instead of every 12.4 In situations where breakthrough pain is
more difficult to manage, patients often are given rapid-acting opioids
such as OTFC or immediate-release morphine to take as needed in addition
to their regular doses of longer-acting opioids.

The Cochrane reviewers assessed the evidence for the benefit of
additional doses of shorter-acting opioids for breakthrough pain in
patients who take long-acting opioids for chronic cancer pain. They
found only a few well-designed studies, all of which involved the use of
OTFC, an opioid with extremely rapid onset of pain relief that is taken
in the form of orally dissolving lozenges.

Only one study compared the effectiveness of OTFC with another opioid.5
This double-blind crossover study involved 134 patients who already
managed their breakthrough pain with immediate-release morphine, which
has a slightly slower onset of action than OTFC. During the
intervention, patients tended to have more effective relief of
breakthrough pain and a more rapid onset of relief with OTFC than with
immediate-release morphine. Sixty-four of the 93 patients who completed
the study said they would like to continue using OTFC for their
breakthrough pain. These results suggest that select cancer patients
might prefer OTFC over immediate-release morphine.

A secondary objective of the review was to find evidence supporting the
expert opinion of the European Association of Palliative Care (EAPC)
that short-acting opioids for breakthrough cancer pain should be given
in proportion to the amount of long-acting opioid being taken by the
patient.6 In the four studies reviewed, the optimal safe and effective
dose of short-acting opioid varied greatly from patient to patient.
Thus, contrary to the EAPC\'s recommendations, the reviewers conclude
that the optimal dose of opioids for breakthrough cancer pain is best
determined through trial and error.

Rapid-acting oral opioids can cause a variety of adverse effects,
including respiratory arrest in patients who have not previously used
opioids. Although short-acting opioids with a less immediate onset of
action (e.g., oxycodone \[Roxicodone\], codeine) have not been well
studied as treatments for breakthrough cancer pain, clinical experience
suggests that they are less likely than rapid-acting opioids to cause
respiratory suppression when used for episodic pain in patients with no
previous opioid use or a relatively low background exposure to
long-acting opioids. However, the evidence in this Cochrane review
indicates that OTFC, a rapid-acting opioid, is reasonably safe and
effective for the treatment of breakthrough cancer pain in patients
already taking long-acting opioids for cancer pain. In most studies, the
rapid-acting opioids were introduced at low dosages and titrated upward
gradually to reduce the risk of adverse effects.

REFERENCES

1\. Zeppetella G, Ribeiro MD. Opioids for the management of breakthrough
(episodic) pain in cancer patients. Cochrane Database Syst Rev
2006;(1):CD004311.

2\. Bernabei R, Gambassi G, Lapane K, Landi F, Gatsonis C, Dunlop R, et
al. Management of pain in elderly patients with cancer. SAGE Study
Group. Systematic Assessment of Geriatric Drug Use via Epidemiology
\[Published correction appears in JAMA 1999;281:136\]. JAMA 1998;
279:1877-82.

3\. Carr DB, Goudas LC, Balk EM, Bloch R, Ioannidis JP, Lau J. Evidence
report on the treatment of pain in cancer patients. J Natl Cancer Inst
Monogr 2004;32:23-31.

4\. Ventafridda V, Saita L, Barletta L, Sbanotto A, De Conno F. Clinical
observations on controlled-release morphine in cancer pain. J Pain
Symptom Manage 1989;4:124-9.

5\. Coluzzi PH, Schwartzberg L, Conroy JD, Charapata S, Gay M, Busch MA,
et al. Breakthrough cancer pain: a randomized trial comparing oral
transmucosal fentanyl citrate (OTFC) and morphine sulfate immediate
release (MSIR). Pain 2001;91:123-30.

6\. Hanks GW, Conno F, Cherny N, Hanna M, Kalso E, McQuay HJ, et al.,
for the Expert Working Group of the Research Network of the European
Association for Palliative Care. Morphine and alternative opioids in
cancer pain: the EAPC recommendations. Br J Cancer 2001;84:587-93

<http://www.aafp.org/afp/20061201/cochrane.html> or
[http://www.cochrane.org](http://www.cochrane.org/)

#### Agency for Healthcare Research and Quality (AHRQ) {#agency-for-healthcare-research-and-quality-ahrq .Style-Heading-4-+-Arial-14-pt-Underline}

**Maternal psychological distress and infrequent use of seat belts are
associated with children\'s low use of motor vehicle restraints**

<http://www.ahrq.gov/research/oct06/1006RA6.htm>

**Less than half of parents infected with HIV tell their children about
the diagnosis**

<http://www.ahrq.gov/research/oct06/1006RA16.htm>

#### Ask a Librarian Diane Cooper, M.S.L.S. / NIH {#ask-a-librarian-diane-cooper-m.s.l.s.-nih .Style-Heading-4-+-Arial-14-pt-Underline}

**Want to keep up with evidence-based medicine?**

Got time to read 50,000 articles? No? Then take a look at Evidence-Based
Medicine. From the editorial offices of the British Medical Journal,
this journal provides information gleaned from over 100 journals.
Published 6 times a year, the most important and valid research articles
are presented. For example, here are two current articles that may be of
interest.

Physical exertion during pregnancy

1\. Physical exertion at work during pregnancy did not increase risk of
preterm delivery or fetal growth restriction. (Evidence-Based Medicine
2006; 11: 156). This prospective cohort study included 1,908 women over
16 years of age who were 24-29 weeks pregnant and stood long hours each
week, lifted heavy objects 13 times or more each week, worked nights or
worked greater than 46 hour weeks.

Continuous dose vs. 28 day OCs

2\. Review: 6 RCTs show similar efficacy and safety for continuous
dosing and 28 day combination contraceptive pills. (Evidence-Based
Medicine 2006; 11: 53). Randomized controlled trials compared continuous
or extended combination oral contraceptives with the traditional dosing
(21 days of pills) in women of reproductive age.

To find Evidence-Based Medicine on the HSR Library website, click ONLINE
JOURNALS found on the left panel of the homepage. Next click "E" to get
to all journals starting with "E" and scan down to the journal.

Would you like to have regular updates in your special interest from
Evidence-Based Medicine and other journals you select and have complete
control over your updates? Email me for an easy "Go By" for this. And as
always, if you need any information help, just email me at
cooperd@mail.nih.gov

##### 

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

## Flu season and Breastfeeding CDR Julie Warren, RPh, Pharmacist, PIMC\*

When a breastfeeding mom gets the flu there are many medications that
can help and are safe to use. General guidelines are:

-   Keep breastfeeding. The baby has already been exposed. A
    breastfeeding mom's immunity system will make antibodies that fight
    the infection, protecting both the mom and her baby.

-   Take the medicine right after nursing or before baby's longest sleep
    time.

-   Watch baby for effects from the medicines that you take.

-   Don't choose medicines that have a variety of ingredients.

-   Use "regular strength" instead of "extra strength","maximum
    strength", or

"long acting."

-   Follow the directions on the label. Don't take more than what is
    recommended**.**

```{=html}
<!-- -->
```
-   Take the lowest dose recommended.

# If mom has:

#  *A fever ... headache ... or feel achy all over, try:*

# Acetaminophen (TylenolR and many other brands)

-   Ibuprofen (Advil^R^, Motrin^R^, etc.)

-   Naproxen (Aleve^R^, etc.)

-   Do not use aspirin.

***A stuffy nose use:***

-   [Best]{.underline}: sodium chloride nasal spray

-   Phenylephrine nasal spray (Neo-Synephrine^R^ , etc.)

-   Oxymetazoline nasal spray (Afrin^R^ and others)

-   Pseudoephedrine oral tablets (Sudafed^R^ and many other brands)

Moms may notice a decrease in breast milk production if they take
Sudafed for

extended periods.

# *Sneezing, hay fever symptoms ... her allergies are acting up, consider:*

-   Diphenhydramine (Benadryl^R^ and many other brands)

-   Brompheniramine + pseudoephedrine (Bromfed^R^, Rondec^R^ syrup,
    etc.)

-   Triprolidine + pseudoephedrine (Actifed^R^ and other brands)

-   Chlorpheniramine (Coricidin^R^ and many other brands)

-   Dexbrompheniramine + pseudoephedrine (Drixoral^R^ and others)

-   Loratadine (Claritin^R^, Alavert^R^, others)

-   Cromolyn sodium nasal spray (Nasalcrom^R^)

***A sore throat ... even after a cup of hot tea, use:***

-   Warm to hot salt water gargles (don't swallow it!)

-   Throat sprays (Cepacol^R^ Maximum Strength Sore Throat Spray,
    others)

-   Throat lozenges (Sucrets^R^ Regular Strength, Halls^R^ Mentho-Lyptus
    Drops)

-   Don't use phenol and hexylresorcinol.

***A cough, try:***

-   Guaifenesin with or without Dextromethorphan (Robitussin^R^,
    Robitussin DM^R^ and

other brands with the same ingredients)

For more information about more drugs:
<http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT>

The link is also listed on the I.H.S. MCH Breastfeeding web page, in the
Medication section.

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

I.H.S. MCH Breastfeeding web page: Home

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

\*Chair, I.H.S. MCH Breastfeeding Web Page Medication Section.

**Other Breast feeding items**

#### Breast-Feeding Offers Resilience Against Psychosocial Stress in Children {#breast-feeding-offers-resilience-against-psychosocial-stress-in-children-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Breast feeding is associated with resilience against the psychosocial stress linked with parental divorce/separation. This could be because breast feeding is a marker of exposures related to maternal characteristics and parent-child interaction. {#conclusions-breast-feeding-is-associated-with-resilience-against-the-psychosocial-stress-linked-with-parental-divorceseparation.-this-could-be-because-breast-feeding-is-a-marker-of-exposures-related-to-maternal-characteristics-and-parent-child-interaction. .Style-Heading-4-+-Arial-14-pt-Underline}

[Montgomery
SM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Montgomery+SM"%5BAuthor%5D)
et al Breast feeding and resilience against psychosocial stress. [Arch
Dis Child.](javascript:AL_get(this, 'jour', 'Arch Dis Child.');) 2006
Dec;91(12):990-4

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16887859>

**More Evidence Showing Breastfeeding Protects Against Type 2 Diabetes**

CONCLUSION: Breastfeeding in infancy is associated with a reduced risk
of type 2 diabetes, with marginally lower insulin concentrations in
later life, and with lower blood glucose and serum insulin
concentrations in infancy.

Owen, CG et al. Does breastfeeding influence risk of type 2 diabetes in
later life? A quantitative analysis of published evidence. [Am J Clin
Nutr.](javascript:AL_get(this, 'jour', 'Am J Clin Nutr.');) 2006
Nov;84(5):1043-54

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17093156>

#### 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}

#### November highlights include: {#november-highlights-include .Style-Heading-4-+-Arial-14-pt-Underline}

-Regular Cola Intake Reduces Bone Mineral Density in Women

-Perinatal depression evidence based care

-Magnesium sulfate tocolysis: time to quit

-'No touch' hysteroscopy much better tolerated

-Hot water bottles do work: Active Warming Cuts Pelvic Pain in
Pre-hospital Setting

-Early adolescents worry more as they age. . . .

-Health Behaviors among American Indian/Alaska Native Women, 1998--2000
BRFSS

-Please Get Umbilical Cord Blood Gas and Acid-Base Analysis When
Possible

-No Stirrups Preferred for Pelvic Examinations

-Want to keep up with evidence-based medicine?

-It is official, breastfeeding counts

-EC: Did not affect incidence of either pregnancy or STIs

-Telehealth Opportunity: Do you need nutrition services at your site?

-Anthropology in the clinic: the problem of cultural competency and how
to fix it

-The rest of the story RE: 'bizarre' and 'atypia' in the same
sentence...hmmm....

-What Women Want

-Prevalence of diabetes: Diagnosed Diabetes Among AI/AN Aged \<35 Years

-Preoperative Evaluation

-Assessment of Adult Health Literacy

-Be Prepared: The Boy Scout motto...er...the Maternity Care Provider
motto, too

-Causes of Type 2 Diabetes: Old and New Understandings

-IHS Consent Form 509 for an HIV Antibody Test is Hereby Cancelled

-Gestational Diabetes Linked to High Prevalence of Periodontal Disease

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/06NovOL.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/06NovOL.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocuments06novol.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-7 .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-8 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Improving the Health Care Response to Domestic Violence in AI/AN
Communities**

Conference Dates: March 16th - 17th 2007

Pre-Conference Institute: March 15, 2007

San Francisco, CA

Conference Registration
<http://www.fvpfhealthconference.org/end_landing.htm>

The institute is open to anyone, whether they are with our project or
not.

Pre-Conference Institute
<http://www.fvpfhealthconference.org/institutes.htm>

Hope to see you all there!

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

Moderate Alcohol Consumption May Be Beneficial to Older Women

Studies have shown that alcohol consumption in middle-aged women carries
risks and benefits. Notable risks include an association between higher
alcohol use and cancer and an increased risk of fractures; benefits
include a decrease in the 10-year mortality rate and improvement in
psychological well-being. However, these benefits apply only to moderate
drinking; they are attenuated in heavier drinkers. The risks and
benefits of moderate alcohol consumption in women 70 years and older are
not known. Despite the lack of current studies specific to older women
and alcohol consumption, this age group often is advised to drink fewer
than one to two drinks a day, an amount that defines moderate drinking.
To address the need for more data, Byles and colleagues reported on the
relationship between alcohol consumption, mental and physical status,
and mortality in women 70 years and older.

The authors conclude that even though there are no studies that
recommend alcohol use, this one indicates that it may be safe and
beneficial for women with moderate alcohol intake to continue drinking
at that level.

Byles J, et al. A drink to healthy aging: the association between older
women\'s use of alcohol and their health-related quality of life. J Am
Geriatr Soc September 2006;54:1341-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16970640>

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

**Bone Loss With Use of Depot Medroxyprogesterone Acetate Slows After 2
Years**

Contrary to its \"black box\" warning, depot medroxyprogesterone acetate
(DMPA) used for longer than 2 years does not substantially increase the
risk of osteoporosis. Based on these findings, the recommendation to
have bone density monitored with long-term use probably is not
warranted, since most BMD is lost within the first two years, and that
loss is generally not sufficient to pose an immediate risk for fracture.

CONCLUSION(S): Depot MPA-related BMD loss is substantial but occurs
mostly during the first 2 years of DMPA use. Therefore, longer use may
not substantially increase the risk of osteoporosis. The prolonged
recovery time suggests the need to consider timing of use in relation to
menopause or other factors that may impede bone remodeling.

[Clark
MK](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Clark+MK"%5BAuthor%5D),
et al Bone mineral density loss and recovery during 48 months in
first-time users of depot medroxyprogesterone acetate. [Fertil
Steril.](javascript:AL_get(this, 'jour', 'Fertil Steril.');) 2006
Nov;86(5):1466-74.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16996507>

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

#### Few young pregnant women know about safety and effectiveness of intrauterine devices {#few-young-pregnant-women-know-about-safety-and-effectiveness-of-intrauterine-devices-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Young women choosing contraception after a pregnancy would benefit from counseling about the relative safety and effectiveness of IUDs, allowing them to make fully informed contraceptive decisions. LEVEL OF EVIDENCE: II-2. {#conclusion-young-women-choosing-contraception-after-a-pregnancy-would-benefit-from-counseling-about-the-relative-safety-and-effectiveness-of-iuds-allowing-them-to-make-fully-informed-contraceptive-decisions.-level-of-evidence-ii-2. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Stanwood NL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Stanwood+NL"%5BAuthor%5D), [Bradley KA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Bradley+KA"%5BAuthor%5D). Young Pregnant Women\'s Knowledge of Modern Intrauterine Devices. [Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006 Dec;108(6):1417-22 [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17138775&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17138775&dopt=Abstract) {#stanwood-nl-bradley-ka.-young-pregnant-womens-knowledge-of-modern-intrauterine-devices.-obstet-gynecol.-2006-dec10861417-22-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids17138775doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Pregnancy Rates Unchanged by Easy Access to Emergency Contraception {#pregnancy-rates-unchanged-by-easy-access-to-emergency-contraception-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: This intensive strategy to enhance access to emergency contraceptive pills substantially increased use of the method and had no adverse impact on risk of sexually transmitted infections. However, it did not show benefit in decreasing pregnancy rates. LEVEL OF EVIDENCE: II-1. {#conclusion-this-intensive-strategy-to-enhance-access-to-emergency-contraceptive-pills-substantially-increased-use-of-the-method-and-had-no-adverse-impact-on-risk-of-sexually-transmitted-infections.-however-it-did-not-show-benefit-in-decreasing-pregnancy-rates.-level-of-evidence-ii-1. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Raymond EG](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Raymond+EG"%5BAuthor%5D), et al Impact of increased access to emergency contraceptive pills: a randomized controlled trial. [Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006 Nov;108(5):1098-106. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17077230&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17077230&dopt=Abstract) {#raymond-eg-et-al-impact-of-increased-access-to-emergency-contraceptive-pills-a-randomized-controlled-trial.-obstet-gynecol.-2006-nov10851098-106.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids17077230doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

####  Scientific accuracy of materials for abstinence-until-marriage education program {#scientific-accuracy-of-materials-for-abstinence-until-marriage-education-program .Style-Heading-4-+-Arial-14-pt-Underline}

Abstinence Education: Efforts to Assess the Accuracy and Effectiveness
of Federally Funded Programs describes the U.S. Department of Health and
Human Services\' (DHHS\') efforts to assess the scientific accuracy of
materials used in abstinence-until-marriage education programs and the
efforts of DHHS, states, and researchers to assess the effectiveness of
such programs. The report, produced by the Government Accountability
Office, presents results in brief and background information. Discussion
topics include limitations of federal and state efforts to assess the
scientific accuracy of materials used in abstinence-until-marriage
education programs, limits to the conclusions drawn from efforts to
assess the programs\' effectiveness, conclusions, and recommendations
for executive action, agency comments, and evaluation.

In addition, the results of efforts that meet the criteria of a
scientifically valid assessment have varied and two key studies funded
by HHS that meet these criteria have not yet been completed.

A description of how DHHS selected a contractor for the
abstinence-until-marriage technical assistance contract, which was
awarded in September 2002, is included.
<http://www.gao.gov/new.items/d0787.pdf>

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

#### Oral Contraceptive Use: Small Increased Risk for Premenopausal Breast Cancer {#oral-contraceptive-use-small-increased-risk-for-premenopausal-breast-cancer-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Use of OCs is associated with an increased risk of premenopausal breast cancer, especially with use before first full-term pregnancy in parous women. {#conclusion-use-of-ocs-is-associated-with-an-increased-risk-of-premenopausal-breast-cancer-especially-with-use-before-first-full-term-pregnancy-in-parous-women. .Style-Heading-4-+-Arial-14-pt-Underline}

[Kahlenborn
C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Kahlenborn+C"%5BAuthor%5D),
et al Oral contraceptive use as a risk factor for premenopausal breast
cancer: a meta-analysis. [Mayo Clin
Proc.](javascript:AL_get(this, 'jour', 'Mayo Clin Proc.');) 2006
Oct;81(10):1290-302

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17036554>

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

**The IHS Breastfeeding Home Page is live!**

The following announcement is from Judy Thierry: The new Breast feeding
page is formatted as the other MCH pages for your convenience. Here is
how the pages are organized:

**Center column:** Title, Easy Guide PDF and the Lactation Support
Program circular is available on the MCH web site / Breastfeeding page
<http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm>  

We are also developing a Tool Kit for work sites across the ITU --
coming to you in early 2007!

**Right column**: 9 sub pages addressing:

1.  Breastfeeding Benefits -- baby, mom, family, community, - AAP
    guidelines link

```{=html}
<!-- -->
```
1.  Going back to work or school

2.  Dad's and family page

3.  Medications: prescribed and OTC and recreational

4.  BF, DM AND OBESITY -- article

5.  Breastfeeding FAQ's -- latch, position, hunger cues, colostrum,
    supply, after birth cramping, breast engorgement, nipple care,
    supplements, frequency

6.  Twenty-two annotated links -- videos of latch, feeding in
    emergencies, case scenarios, La Leche, USDA...

7.  Policy and position description examples, print materials, staff
    contacts -- Navajo and Alaska.

8.  Breastfeeding forum -- list serve subscribe:
      <http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=82&startrow=1>

**Left column**: Site map, Up-To-Date, other IHS MCH health topics

We look forward to your comments and feedback additional links or topics
you would like to see.  We would like to hear what you are doing locally
and send pictures of dads to Suzan Murphy for posting if you would
like.   <Suzan.Murphy@ihs.gov>

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

**Q. Is an informed consent necessary for all x-rays in pregnant
women?**

A. No, not on routine diagnostic studies. High dose procedures are
treated case by case.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/XrayConsent11506.doc>

**Q. Are there any Cochrane Reviews about problems with Ortho Evra or
Nuva Ring?**

#1

RE: a Cochrane Review of the Ortho Evra issues

This particular topic wouldn't actually show up in the Cochrane database
for many years because Cochrane only deals with randomized controlled
trials.

While there has been greater publicity of the complications with the
patch, it is not known whether women using Ortho Evra are at a greater
risk of experiencing these serious adverse events.

What is now known is that the patch provides about 60% more estrogen
than a standard 35 ug pill and that in general, increased estrogen
exposure may increase the risk of blood clots. The new bolded warning
specifically states that women who use Ortho Evra are exposed to about
60 percent more total estrogen in their blood than if they were taking a
typical birth control pill containing 35 micrograms of estrogen.

However, the maximal blood level of estrogen (peak blood levels) is
about 25% lower with Ortho Evra than with typical birth control pills.
While the estrogen level with the patch remains constant for one week
until the patch is removed, the peak blood levels with a daily birth
control pill rapidly declines to levels that are lower than on the
Orthro Evra.

## FDA Updates Labeling for Ortho Evra Contraceptive Patch (see FDA full text below)

<http://www.fda.gov/bbs/topics/news/2005/NEW01262.html>

**FDA: Questions and Answers\
Ortho Evra (norelgestromin/ethinyl estradiol**)

<http://www.fda.gov/cder/drug/infopage/orthoevra/qa.htm>

**Ortho Evra product site**

<http://www.orthoevra.com/>

#2

RE: A Cochrane Review of the Nuva Ring?

Ditto above about a whether a Cochrane Review exists on this topic.

On the other hand, here haven't been any increased reports of untoward
effects for the Nuva Ring. The NuvaRing delivers 15 mcg ethinyl
estradiol and 120 mcg of etonogestrel daily and is worn intravaginally
for three weeks of each four-week cycle.

**UpToDate**

**Ethinyl estradiol and etonogestrel: Drug information**

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=drug_a_k/161047&type=A&selectedTitle=1~6>

**Patient Education: Nuva Ring**

<http://www.mckinley.uiuc.edu/handouts/nuvaring/nuvaring.htm>

## FDA Updates Labeling for Ortho Evra Contraceptive Patch

The Food and Drug Administration today approved updated labeling for the
Ortho Evra contraceptive patch to warn healthcare providers and patients
that this product exposes women to higher levels of estrogen than most
birth control pills. Ortho Evra was the first skin patch approved for
birth control.

It is a weekly prescription patch that releases ethinyl estradiol (an
estrogen hormone) and norelgestromin (a progestin hormone) through the
skin into the blood stream. FDA advises women to talk to their doctor or
healthcare provider about whether the patch is the right method of birth
control for them.

Furthermore, women taking or considering using this product should work
with their health care providers to balance the potential risks related
to increased estrogen exposure against the risk of pregnancy if they do
not follow the daily regimen associated with typical birth control
pills. Because Ortho Evra is a patch that is changed once a week, it
decreases the chance associated with typical birth control pills that a
woman might miss one or more daily doses.

The addition of this new warning is a result of FDA\'s and the
manufacturer\'s analysis directly comparing the levels for estrogen and
progestin hormones in users of Ortho Evra with those in a typical birth
control pill.

The new bolded warning specifically states that women who use Ortho Evra
are exposed to about 60 percent more total estrogen in their blood than
if they were taking a typical birth control pill containing 35
micrograms of estrogen. However, the maximal blood level of estrogen
(peak blood levels) is about 25% lower with Ortho Evra than with typical
birth control pills. While the estrogen level with the patch remains
constant for one week until the patch is removed, the peak blood levels
with a daily birth control pill rapidly declines to levels that are
lower than on the Orthro Evra.

FDA is continuing to monitor safety reports for the Ortho Evra patch.
The manufacturer, Ortho McNeil Pharmaceuticals is conducting additional
studies to compare the risk of developing serious blood clots in women
using Ortho Evra to the risk in women using typical birth control pills
that contain 35 micrograms of estrogen.

The new labeling information is available along with additional
information for healthcare providers and consumers online at:
[www.fda.gov/cder/drug/infopage/orthoevra/default.htm](http://www.fda.gov/cder/drug/infopage/orthoevra/default.htm)

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

**December 2006**

-Diagnosis and management of bronchiolitis.

-Lower respiratory tract infections among American Indian and Alaska
Native children and the general population of U.S. Children

-Does in-home water service reduce the risk of infectious disease?

-Home-visiting intervention to improve child care among American Indian
adolescent mothers: a randomized trial

-Forty years in partnership: the American Academy of Pediatrics and the
Indian Health Service

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

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

**Exam Code and Health Factor Manual**

The Office of Information Technology is pleased to present the first
version of the Exam Code and Health Factor manual.\
This manual includes listings and definitions of currently available
health factors and exam codes as well as a listing of inactivated exam
codes and recommendations for conversion to CPT/ICD9/procedure codes.\
New health factor and exam codes include: activity level, occupation,
health literacy, and fall risk.\
This manual reflects the changes in the release of AUM patch 7.1

Contact Chris Lamer [Chris.Lamer@ihs.gov]{.underline}

Self-study Course in Epidemiology Now Available Through CDC Web Site

The Centers for Disease Control and Prevention\'s (CDC\'s) introductory
self-study course, Principles of Epidemiology in Public Health Practice,
3rd ed., is now available online. The course is designed for public
health professionals at the state and local levels who are or expect to
be responsible for outbreak investigations or public health
surveillance.

The course provides an introduction to applied epidemiology and
biostatistics. Continuing education credits are offered. The course is
available at no charge at <http://www2a.cdc.gov/phtnonline>.

A printed copy of the course can be ordered from the Public Health
Foundation at [http://bookstore.phf.org](http://bookstore.phf.org/)
(telephone: 877-252-1200)

**Patent Wellness Handout**

Good day, the Patent Wellness Handout was released in September 2006 as
part of the Health Summary package v2.0 patch 15.

The implementation and use of the PWH is currently being considered as
an element of the FY 2007 Director\'s Performance Contract; therefor, we
want to make sure that is provides the functionality that you need and
the information patients want. To do so, we will be performing two
tasks: the first is to assess focus groups of patients through the HPDP
and DPTP throughout IHS and the second is to request your feedback as
clinicians. 

Please complete the following short assessment (answer all or some of
the questions) and return to me (<chris.lamer@ihs.gov>) no later than
Wednesday, December 20, 2006. Your comments will be used to revise the
application. 

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

1\] Have you used the PWH?  (yes or no)

 a\] If no, are you familiar with it? (yes or no)

 b\] If yes, did you print out the form? (yes or no)

  i\] If no, who printed the form? (patient registration, nurse,
pharmacist, provider, other)

c\] If yes, when did you print the form? (before clinic visit, during
visit, after visit, in pharmacy, other-describe)

2\] What do you like about the PWH?

3\] What do you dislike about the PWH?

4\] What fields would you like to see added to the PHW? (things like
patient labs, vital signs, screenings, etc)

5\] What fields would you like to have removed (if any)? \[none, BP,
weight, medications, immunizations due, allergies)

6\] What functionality would make this a better tool? (automatic
printing, ability to create different kinds of handouts, other -
describe)

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

Thank you very much for completing the assessment. Please return this
form to Chris Lamer by e-mail, fax, or mail before Wednesday, December
20th, 2006:

<chris.lamer@ihs.gov>

Fax: (828) 497-5343

Address: Chris Lamer; 1 Hospital Road; Cherokee, NC 29719

Description of the Patient Wellness Handout:

The Patient Wellness Handout (PWH) is a tool that provides patients with
access to some of the information in their medical record. It pulls in
selected components of the patient\'s medical record from the RPMS
database and provides a brief description about this information
including: immunizations due, weight, blood pressure, allergies, and
current medications. The PWH can be generated by data registration,
clinicians, pharmacists, or anyone else who has normal access to the
patient\'s medical record. The first version of the PWH was released on
September 1, 2006 as a mandatory install to all IHS service units. 

This tool is designed to address the Institute of Medicine\'s (IOM)
rules of patient centered care and empower patients to improve their
health and satisfaction with medical services. In combination with
patient education, the patient medical handout attempts to provide the
tools a patient requires to improve collaboration with providers and to
assist them in make appropriate health care decisions. It is widely
accepted that health information, education, and the delivery of
preventive services improve patient\'s health care and facilitate
communication between healthcare providers and patients. This can result
in improved patient outcomes.

#### International Health Update Claire Wendland, Madison, WI {#international-health-update-claire-wendland-madison-wi .Style-Heading-4-+-Arial-14-pt-Underline}

**A nurse, a doctor, and an epidemiologist were standing by the
river......**

Most of us have heard this anecdote: a nurse, a doctor, and an
epidemiologist are standing at a river's edge when they notice body
after body floating by. The doctor and nurse jump in, fish out everyone
they can, and begin resuscitating the victims. The epidemiologist runs
upstream instead, hollering over her shoulder, "I'm going to see who's
pushing them in!"

In recent years, scholars from public health and related fields have
increasingly proposed upstream or "structural" interventions into
serious problems of public health, as opposed to the traditional
education or behavior change interventions. The word "structural" in
this sense refers to the social, political and economic structures that
make individuals more vulnerable to disease and violence. The logic of
such proposals is that, for instance, it makes little sense to combat
diabetes by teaching individuals about healthy eating in a poor rural
community if the only place to buy food for miles around is a
gas-station convenience store specializing in Cheetos, and subsidized
corn syrup production means that soda is cheaper than clean water.

Though much epidemiologic and social science literature explores the
structural determinants of poor health, few structural intervention
trials have been conducted. In fact, controversy over whether such
trials are worthwhile (or ethical) is substantial. A recent trial of
microfinance initiatives and their effects on intimate partner violence
(IPV) and HIV seroconversion rates provides us a rare opportunity to
examine the effects of a structural intervention -- though with mixed
results.

Paul Pronyk and colleagues from the University of the Witwatersrand
noted that poverty, lack of economic opportunities, and gender
inequalities combine in rural South Africa to allow high levels of both
HIV infection and IPV in women. Projects addressing violence and HIV
through education alone have met with little success. Would improved
economic opportunities for women do better? Pronyk's team randomized
eight villages in Limpopo province to intervention -- establishment of a
microfinance program combined with a participatory empowerment
curriculum -- or a comparison group. Over 400 of the poorest women in
intervention villages received one or more small loans averaging \$165
to support business initiatives; as a loan condition, they also attended
training sessions on gender empowerment, relationships, communication,
HIV and domestic violence. The researchers assessed the impact of the
intervention not only on the women themselves, but also on young people
living in loan recipients' households and on randomly selected
villagers. In the intervention villages, reports of intimate partner
violence declined dramatically (adjusted RR 0.45, 95% CI 0.23-0.91).
Intervention villagers also reported improved household communication,
especially on matters of sex and sexuality, and improvement in the total
value of household assets -- though not food security or other measures
of wealth. Several other attitudinal measures of empowerment trended
toward positive change, but none met criteria for statistical
significance. In addition, young people in intervention villages showed
no difference in HIV seroconversion and rates of unprotected sex with
someone other than a spouse. (Loan recipients themselves were not asked
these questions. At a mean age of 41, the authors imply they were
considered too old to discuss such matters!)

Though the study did not demonstrate the effectiveness of microfinance
for HIV prevention, it is the first to show that microfinance is
effective in reducing intimate partner violence. (Research in South Asia
demonstrated initial increases in IPV with the initiation of
microfinance, perhaps related to threats to male control of household
resources, followed by a later decline.) It also demonstrates that a
relatively small structural intervention can have relatively quick
effects at the community level.

Pronyk PM, Hargreaves JR, Kim JC et al. Effect of a structural
intervention for the prevention of intimate-partner violence and HIV in
rural South Africa: a cluster randomized trial. Lancet 368:1973-83, 2006

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17141704>

(Full text available online at
[www.thelancet.com](http://www.thelancet.com/) requires free
registration, though)

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

**2007 Folic Acid Campaign Materials Released**

The Folic Acid Now! campaign offers an online media tool kit and
consumer materials that community programs can customize and use during
National Folic Acid Awareness Week (January 8-14, 2007). The campaign is
sponsored by the March of Dimes and the National Alliance for Hispanic
Health and managed by the National Folic Acid Council (NCFA), a project
of the National Healthy Mothers, Healthy Babies Coalition. The tool kit
contains a media outreach worksheet and outreach activity ideas,
including activities for a Hispanic community. A fact sheet and local
press release (in English and Spanish) are also provided. Consumer
materials, including bookmarks, brochures, and stickers (in English and

Spanish) are also available for use in sharing the folic acid message.

Materials may be downloaded from the NCFA Web site, or ordered
free-of-charge.
[[http://www.folicacidinfo.org/campaign]{.underline}](http://www.folicacidinfo.org/campaign)

**Three new programs proven to improve behavioral and mental health in
youth**

Three new program summaries that focus on child and adolescent behavior
and mental health were recently added to RAND\'s Promising Practices
Network Web site:

**1.) The Social Decision Making/Problem Solving Program**

helps children and adolescents in grades K-8 acquire social and
decision-making skills and apply them to real situations. The program
seeks to develop children\'s and adolescents\' self-esteem,
self-control, and social-awareness skills, as well as skills for coping
with stress and emotions.

Evaluation results show that participants experienced improved
socialization and also had better emotional and behavioral self-control,
even when exposed to distressing situations.
[[http://www.promisingpractices.net/program.asp?programid=154]{.underline}](http://www.promisingpractices.net/program.asp?programid=154)

**2.) The Coping Cat Program**

is a cognitive-behavioral therapy intervention that helps children and
adolescents ages 8-17 recognize and analyze anxious feelings and develop
strategies to cope with anxiety-provoking situations. The program uses
several behavioral training strategies, including cognitive
restructuring, simulation, real-life exposure, and relaxation training.
Participants reported improved coping skills and reductions in anxiety,
fear, and depression. Parents also reported improved behavioral, social,
and health outcomes for their children.

[[http://www.promisingpractices.net/program.asp?programid=153]{.underline}](http://www.promisingpractices.net/program.asp?programid=153)

**3.) The Reaching Educators, Children, and Parents Program**

is a comprehensive school-based skills-training program designed for
young children who experience both internalizing problem behaviors
(withdrawn, anxious, and depressed behaviors) and externalizing problem
behaviors (aggressive, oppositional, and impulsive behaviors). The
program\'s primary goals are to reduce psychological problems and to
prevent more serious problems among children who are not receiving
formal mental health services. Results show that participants generally
experienced decreases in both internalizing and externalizing problem
behaviors, although results varied depending on who reported the
behaviors: parent, teacher, peer, or the participating child.
[[http://www.promisingpractices.net/program.asp?programid=155]{.underline}](http://www.promisingpractices.net/program.asp?programid=155)

**2006 Edition of Women's Health Data Book Released**

Women\'s Health USA 2006, the fifth edition of the data book, presents a
profile of women\'s health at the national level from a variety of data
sources. The data book, developed by the Health Resources and Services
Administration\'s Office of Women\'s Health, includes information and
data on population characteristics, health status, and health services
utilization. New topics in the 2006 edition include life expectancy,
postpartum depression, food security, and smoking during pregnancy.

Racial and ethnic disparities and gender differences in women\'s health
are also highlighted. The data book is intended to be a concise
reference for policymakers and program managers at the federal, state,
and local levels to identify and clarify issues affecting the health of
women. It is available at
[[http://www.mchb.hrsa.gov/whusa_06/index.htm]{.underline}](http://www.mchb.hrsa.gov/whusa_06/index.htm)

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

#### A boy has been born in Chile with a fetus in his stomach {#a-boy-has-been-born-in-chile-with-a-fetus-in-his-stomach .Style-Heading-4-+-Arial-14-pt-Underline}

SANTIAGO, Chile (Nov. 24) \-- A boy has been born in Chile with a fetus
in his stomach in what doctors said was a rare case of \"fetus in fetu\"
in which one twin becomes trapped inside another during pregnancy and
continues to grow inside it.

Doctors carried out a scan on the boy\'s mother shortly before she gave
birth on November 15 in the southern city of Temuco and noticed the
4-inch-long fetus inside the boy\'s abdomen.

It had limbs and a partially developed spinal cord but no head and stood
no chance of survival, doctors said.

After the birth, doctors operated and removed the fetus from the boy\'s
stomach. The boy, who has not been named, was recovering at Temuco\'s
Hernan Henriquez hospital.

It\'s very rare,\" said Maria Angelica Belmar, head of the hospital\'s
neonatal wing, speaking of fetus in fetu cases. It occurs in only one in
every 500,000 live births,\" she told Reuters, adding that the number of
cases recorded worldwide was fewer than 90.

Before you explain the embryology of this case to us, please answer this
one simple question:

#### Which reputable medical resource was this story taken from?  {#which-reputable-medical-resource-was-this-story-taken-from .Style-Heading-4-+-Arial-14-pt-Underline}

#### National Enquirer  {#national-enquirer .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

#### Stay tuned till next month to find out. {#stay-tuned-till-next-month-to-find-out. .Style-Heading-4-+-Arial-14-pt-Underline}

#### (or just peruse your personal subscription to National Enquirer in the meantime) {#or-just-peruse-your-personal-subscription-to-national-enquirer-in-the-meantime .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

######### Female Genital Cutting: Epidemiology, Consequences, and Female Empowerment as a Means of Cultural Change

[http://www.medscape.com/viewarticle/546497?sssdmh=dm1.225677&src=0_tp_nl_0#](http://www.medscape.com/viewarticle/546497?sssdmh=dm1.225677&src=0_tp_nl_0)

######### 

**Recurrent Pregnancy Loss**

<http://www.medscape.com/viewprogram/5293?src=mp>

**Evaluation and Treatment of Overactive Bladder**

<http://www.medscape.com/viewprogram/5899?src=sr>

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

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

######### 

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

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

**Clinical Discussion Board Index, Medscape**

Hundreds of ongoing clinical discussions available

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

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

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

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

**Menopause Management**

#### Estradiol less than 5 yrs, estriol, or vaginal estrogens not associated with breast cancer {#estradiol-less-than-5-yrs-estriol-or-vaginal-estrogens-not-associated-with-breast-cancer-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Estradiol for 5 years or more, either orally or transdermally, means 2-3 extra cases of breast cancer per 1,000 women who are followed for 10 years. Oral estradiol use for less than 5 years, oral estriol, or vaginal estrogens were not associated with a risk of breast cancer. LEVEL OF EVIDENCE: II-2. {#conclusion-estradiol-for-5-years-or-more-either-orally-or-transdermally-means-2-3-extra-cases-of-breast-cancer-per-1000-women-who-are-followed-for-10-years.-oral-estradiol-use-for-less-than-5-years-oral-estriol-or-vaginal-estrogens-were-not-associated-with-a-risk-of-breast-cancer.-level-of-evidence-ii-2. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Lyytinen H](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Lyytinen+H"%5BAuthor%5D) et al Breast cancer risk in postmenopausal women using estrogen-only therapy. [Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006 Dec;108(6):1354-60. {#lyytinen-h-et-al-breast-cancer-risk-in-postmenopausal-women-using-estrogen-only-therapy.-obstet-gynecol.-2006-dec10861354-60. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17138766&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17138766&dopt=Abstract) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids17138766doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [Collins J](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Collins+J"%5BAuthor%5D). Hormones and breast cancer: should practice be changed? [Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006 Dec;108(6):1352-3. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17138765&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17138765&dopt=Abstract) {#collins-j.-hormones-and-breast-cancer-should-practice-be-changed-obstet-gynecol.-2006-dec10861352-3.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids17138765doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Midwives Corner**, **Lisa Allee, CNM, Chinle**

**Start 'Em Young for Future Success and Maybe No One Will Be Left
Behind**

This month I digress.\
I have no peer juried article, I don't even have a URL link. This
month's topic is in honor of my mom. I visited her for Thanksgiving and
we read an article in the Sunday New York Times Magazine called "Still
Left Behind" about the No Child Left Behind Act. My mom worked for 20+
years as a reading specialist in a junior high school and has continued
her work for literacy in retirement. She has always admonished me and my
sisters to read to our children every day starting at birth and for
years we had the grandma-books-of-the-month delivery service. She was
excited about this article because besides restating the previously
known facts that school success is proportional to income, the author
presented research delving into why this is. Some researchers have found
a link between a child's school success and his/her vocabulary at age
three---middle to upper income children often have 1000+ words at that
age versus lower income children have ½ to ¼ that amount---and that the
number of words a child has at age three is directly related to the
mother's/parents' vocabulary. Another researcher found that not only did
the parents' vocabulary matter, but the way the parents speak to the
children plays a very important role. Parents of successful children
(mid to upper income generally) used a higher proportion of
encouragements, while parents of less successful children (generally
lower income) used a much higher proportion of discouragements when
speaking to their children. So, I was profoundly struck by the
possibility that we as midwives, nurse practitioners, obstetricians, and
pediatricians could have an influence on parents and, thus, their
children by pointing out three rules:

1)  Follow Grandma Allee's rule of reading to your child every day
    starting at birth.

2)  Improve your vocabulary and use your new words with your child.

3)  Make sure at the end of every day that you have said more
    encouraging things to your child than discouraging things.

I did this with a couple expecting their second child the other day and
it took about a minute and they said thank you for the information! It
can fit into a busy clinic!!

Happy Holidays and Happy Reading!

(If you want to read the article it is Still Left Behind in the November
26, 2006 Sunday New York Times Magazine.) <Lisa.Allee@ihs.gov>

<http://www.nytimes.com/pages/magazine/index.html?adxnnl=1&adxnnlx=1165467769-TvXMoHTM4MvgdiqsiuPe2g>

**Navajo News Tomekia Strickland, Chinle**

**GYN Spotlight: Endometrial ablation**

Pre-menopausal dysfunctional uterine bleeding unrelated to malignancy
continues to be a significant problem for women wrought with social
embarrassment, disruption of daily activities, and morbidity associated
with anemia. Not only is it a challenging condition for the patient but
dysfunctional uterine bleeding usually requires lengthy and frequent
outpatient visits for appropriate evaluation and management. Many times,
patients have suffered for years with the condition and often present
discouraged after a series of failed hormonal regimens. Hysterectomy,
the only procedure that is 100% effective in eliminating abnormal
uterine bleeding, is often less acceptable to Native American women than
other populations, both for cultural reasons and because of a general
reluctance to undergo major surgery. Thus endometrial ablation has risen
as an ideal treatment option for women who have completed child bearing,
failed conservative management, and desire uterine conservation.

The Department of Gynecology at Chinle Service Unit is now offering
endometrial ablation to appropriate candidates, as are some other I.H.S.
sites. There are several global endometrial ablation techniques that
have become available nationally over the past few years. Global
endometrial ablation refers to a series of FDA approved newer generation
technologies that do not require an operative hysteroscope. These
include Thermachoice (hot liquid filled balloon), hydrothermal ablation
(circulating hot water), Novasure (bipolar desiccation), Her Option
(cryoablation)and Microwave ablation. This is in contrast to the
standard technique which uses monopolar energy via a rollerball, roller
barrel, or resectoscope requiring operative hysteroscopy. There is also
increased risk of uterine perforation and fluid overload with the
standard techniques. We have started using the Novasure system which is
a global ablative technique that utilizes a three dimensional bipolar
gold mesh that when inserted conforms to the shape of the uterine
cavity. The average ablation time for Novasure® is 90 seconds.\*It also
has the advantage of not requiring hormonal pretreatment to thin the
endometrial lining. When

used correctly, the global ablative techniques are considered safe,
effective, fast, simple to perform, painless and cost effective to both
physician and patient. Many of these procedures can also be performed as
office based procedures.

Like the standard technique, global ablation techniques are considered
successful not so much according to amenorrhea rates, but by reduction
in menstrual flow. Hypomenorrhea correlates with high rates of
subjective patient satisfaction usually greater than 80-90%. The
amenorrhea rates for some of the devices are as follows: Thermachoice
14% at 12-24 months; Microwave 38% at 3 years; and Novasure 51% at 1
year.

In conclusion, global endometrial ablation will most likely continue to
become an increasingly popular and primary minimally invasive surgical
treatment option for women who have completed childbearing and continue
to suffer for abnormal uterine bleeding despite medical therapy. Like
all medical and surgical interventions, care must be taken to evaluate
each patient carefully and individualize their treatment plan
accordingly. "Endometrial Ablation" by UpToDate
[www.uptodate.com](http://www.uptodate.com/) provides a detailed
discussion on the indications, contraindications and safety profiles for
each ablative procedure. If you would like more information about our
exciting but still new experience with Novasure, please feel free to
contact me at <tomekia.strickland@ihs.gov>

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

**Nurses Corner, Sandra Haldane, HQE**

**Nurses less satisfied than physicians or nurse managers: Perceptions
of teamwork** **on** **L/D**

Caregiver role influences perceptions of teamwork. Overall, physicians
and nurse managers were much more satisfied than nurses with the
collaboration they experienced. For example, anesthesiologists had
higher scale scores than certified registered nurse anesthetists for
five of the six teamwork climate items. Most (80 percent) L&D staff felt
it was easy for personnel in their unit to ask questions. However, only
55 percent found it easy to speak up if they perceived a problem with
patient care, and only half felt that conflicts were appropriately
resolved. The study was supported in part by the Agency for Healthcare
Research and Quality (HS11544).

<http://www.ahrq.gov/research/oct06/1006RA2.htm>

**Nurses play on important role in its detection and can reduce
depressive symptoms**

CONCLUSION: Results from this study suggest that nursing care and
problem solving training may be use confidently in the primary care
setting by nurses for women with postpartum depressive symptoms.
PRACTICE IMPLICATION: Nurses play on important role in its detection and
can reduce depressive symptoms. Public health nurses are equipped with
care paths addressing specific health needs of depressed women in the
primary care setting. Our finding indicate that these two programs of
study can converge with meaningful results, and perhaps future research
could address these points in a theoretical framework.

Tezel A; Gözüm S Comparison of effects of nursing care to problem
solving training on levels of depressive symptoms in post partum women.
[Patient Educ Couns.  2006;
63(1-2):64-73](http://www.medscape.com/medline/publicationbrowser/123?pmid=16448799) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16448799>

**For Neonatal Nurses- Primer on Antenatal Testing: 2 Parts: Tests of
Fetal Well-Being / PTL**

A number of new antenatal testing tools are being used in obstetric
practice to evaluate the clinical picture of the fetus in utero. Results
of these tests may prompt transfer to a tertiary facility for delivery
or further antenatal monitoring. Part 2 of this 2-part series will
describe antenatal testing methods used to determine fetal well-being,
as well as highlight the emerging developments in the field of fetal
surveillance. The ability to interpret antenatal testing results may
help the neonatal team triage to assure bed availability, and predict
and provide appropriate staffing for new admissions, and is an important
foundation for subsequent neonatal risks and clinical care.

[Wyatt
SN](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Wyatt+SN"%5BAuthor%5D),
[Rhoads
SJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Rhoads+SJ"%5BAuthor%5D).
A primer on antenatal testing for neonatal nurses: part 2: tests of
fetal well-being. [Adv Neonatal
Care.](javascript:AL_get(this, 'jour', 'Adv Neonatal Care.');) 2006
Oct;6(5):228-41

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17045944>

and

[Wyatt
SN](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Wyatt+SN"%5BAuthor%5D),
[Rhoads
SJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Rhoads+SJ"%5BAuthor%5D).
A primer on antenatal testing for neonatal nurses: part 1. Tests used to
predict preterm labor. [Adv Neonatal
Care.](javascript:AL_get(this, 'jour', 'Adv Neonatal Care.');) 2006
Aug;6(4):175-80

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16890130>

**6th Annual SUMMER INSTITUTE ON EVIDENCE-BASED PRACTICE '07**

Theme:  "Quality and Safety"

July 12-14, 2007

Pre Conferences July 11

Crowne Plaza Riverwalk Hotel, San Antonio, Texas

>  

The Institute prepares healthcare providers from multiple disciplines
for an increasing role in evidence-based practice to improve healthcare.
National leaders present the latest in evidence-based quality
improvement. Be part of a leading national conference on evidence-based
quality improvement!

For online brochure, after January 1 visit our
website: [www.acestar.uthscsa.edu](http://www.acestar.uthscsa.edu/)

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

**HPV Information for Clinicians**

This 36-page brochure discusses the transmission, prevention, detection
and clinical management of human papillomavirus.

This brochure covers the natural history, risk factors, transmission,
prevention and management of HPV infection and associated conditions,
including new technologies and guidelines for the prevention, screening
and management of cervical cancer. It has been tested with providers
across a range of specialties and primary practice settings.

In the coming weeks, \[CDC\] will also be posting four sets of
counseling messages, developed to facilitate provider-patient
communication about HPV and associated diseases. These will include
messages for

\(1\) prospective vaccine recipients,

\(2\) women receiving the HPV DNA test with Pap for cervical cancer
screening,

\(3\) women with a high-risk HPV DNA test result, and

\(4\) patients with genital warts.

The clinician brochure with counseling-message inserts should be
available for print ordering in early 2007, though they will not be
available in bulk. We have provided PDF and high-resolution options
online for those who wish to print and reproduce the brochure on their
own. As always, we encourage you to share these materials with
interested colleagues and providers in the field.

<http://www.cdc.gov/std/HPV/hpv-clinicians-brochure.htm>

It can also be accessed from our HPV page at
[www.cdc.gov/std/hpv](http://www.cdc.gov/std/hpv)

Finally, for those interested, you can now register for email
notifications whenever updates are made to CDC\'s HPV page. To do this,
click on the new link at the top of our HPV page
[www.cdc.gov/std/hpv](http://forumx.forum.cdc.gov:8080/www.cdc.gov/std/hpv)
called \"Email updates.\"

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

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

**Reduction in Teen Pregnancies**

The preliminary numbers from 2005 from the CDC show a 2% reduction in
teenage pregnancies down to its lowest recorded level in 65 years. The
biggest decline was in the ages 15-17 year group. Here in Oklahoma, we
were the 8th highest state in the nation for teen births ages 15-19 in
2002. Like all other states, we as women's health providers have to work
hard at encouraging young women to delay sexual activity as well as
taking steps to prevent becoming pregnant. ACOG recently released a
statement that a 13 month supply of OCPs showed a greater likelihood of
continuation and use and would be very beneficial in the continued
reduction of teen pregnancies. In fact, it is estimated that for every
dollar invested in teen pregnancy prevention programs, at least \$2.65
were saved in direct medical and social service costs (The National
Campaign to Prevent Teen Pregnancy. Not Just Another Single Issue: Teen
Pregnancy's Link to Other Social Issues, 2002).

State of the State' Health, 2005, Oklahoma State Board of Health

<http://www.health.state.ok.us/board/state05/SOSH05.pdf#page=14>

NCHS Health E Stats -- Births-Preliminary Data for 2005

<http://www.cdc.gov/nchs/products/pubs/pubd/hestats/prelimbirths05/prelimbirths05.htm>

ACOG Statement 13 month Supply of OCPS leads to more consistent use

<http://www.acog.com/from_home/publications/press_releases/nr11-01-06-2.cfm>

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

**Significant bone loss: Both low molecular weight heparin and
unfractionated heparin**

CONCLUSION: In this study, the incidence of clinically significant bone
loss (\> or = 10%) in the femur in women who received thromboprophylaxis
in pregnancy is approximately 2% to 2.5% and appears to be similar,
regardless of whether the patient receives low molecular weight heparin
therapy or unfractionated heparin therapy.

### Casele H et al Bone density changes in women who receive thromboprophylaxis in pregnancy. [Am J Obstet Gynecol.  2006; 195(4):1109-13](http://www.medscape.com/medline/publicationbrowser/123?pmid=17000242) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17000242>

**Updated Position Statement for Calcium Intake in Postmenopausal
Women**

CONCLUSIONS: The most definitive role for calcium in peri- and
postmenopausal women is in bone health, but, like most nutrients,
calcium has beneficial effects in many body systems. Based on the
available evidence, there is strong support for the importance of
ensuring adequate calcium intake in all women, particularly those in
peri- or postmenopause.

[North American Menopause
Society](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="North+American+Menopause+Society"%5BCorporate+Author%5D).
The role of calcium in peri- and postmenopausal women: 2006 position
statement of the North American Menopause Society.
[Menopause.](javascript:AL_get(this, 'jour', 'Menopause.');) 2006
Nov-Dec;13(6):862-77

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17106282>

**Teriparatide alone is less cost-effective than alendronate alone for
the treatment of women with severe osteoporosis**

Teriparatide is a promising new agent for the treatment of osteoporosis
(loss of bone mass density). The drug increases bone density and reduces
fractures in women with severe osteoporosis (those with low bone mass
and preexisting fractures) by directly stimulating new bone formation.
Yet therapy with teriparatide alone is more expensive and produces a
smaller increase in quality-adjusted life years (QALYs) than therapy
with alendronate, the U.S. market leader in osteoporosis medications.
Sequential teriparatide/alendronate therapy appears expensive; however,
it could become more cost-effective in certain circumstances.

Researchers analyzed data from three osteoporosis fracture trials to
compare the cost per QALY for usual care (calcium or vitamin D
supplementation) with that of three medication strategies for the
first-line treatment of high-risk osteoporotic women (postmenopausal
white women with low bone density and vertebral fracture). The three
medication strategies included 5 years of alendronate therapy, 2 years
of teriparatide therapy, and 2 years of teriparatide therapy followed by
5 years of alendronate therapy (sequential teriparatide/alendronate).

Compared with usual care, the cost of alendronate treatment was \$11,600
per QALY. Teriparatide alone was less cost-effective than alendronate at
\$172,300 per QALY, even if its efficacy lasted 15 years after
treatment. The cost of sequential teriparatide/alendronate therapy was
\$156,500 per QALY compared with alendronate alone. This sequential
therapy was less cost-effective than alendronate, even if fractures were
eliminated during the alendronate phase. However, it would become
cost-effective (less than \$50,000 per QALY) if the price of
teriparatide decreased 60 percent, if used in elderly women with severe
osteoporosis, or if 6 months of teriparatide therapy had comparable
efficacy to 2 years of treatment. The study was supported in part by the
Agency for Healthcare Research and Quality (T32 HS00028).

<http://www.ahrq.gov/research/oct06/1006RA7.htm>

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

#### Preventing Injuries in School-age Children and Teenagers {#preventing-injuries-in-school-age-children-and-teenagers-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20061201/1870ph.html**](http://www.aafp.org/afp/20061201/1870ph.html) {#httpwww.aafp.orgafp200612011870ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Lactose Intolerance: What You Should Know {#lactose-intolerance-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20061201/1923ph.html**](http://www.aafp.org/afp/20061201/1923ph.html) {#httpwww.aafp.orgafp200612011923ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Myths and Facts About Food Allergies {#myths-and-facts-about-food-allergies-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20061201/1919ph.html**](http://www.aafp.org/afp/20061201/1919ph.html) {#httpwww.aafp.orgafp200612011919ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Amniocentesis procedure-related loss risk of approximately 1 in 1600,
not prior 1 in 200**

Women undergoing amniocentesis were 1.1 times more likely to have a
spontaneous loss

RESULTS: The spontaneous fetal loss rate less than 24 weeks of gestation
in the study group was 1.0% and was not statistically different from the
background 0.94% rate seen in the control group (P=.74, 95% confidence
interval -0.26%, 0.49%). The procedure-related loss rate after
amniocentesis was 0.06% (1.0% minus the background rate of 0.94%). Women
undergoing amniocentesis were 1.1 times more likely to have a
spontaneous loss (95% confidence interval 0.7-1.5). CONCLUSION: The
procedure-related fetal loss rate after midtrimester amniocentesis
performed on patients in a contemporary prospective clinical trial was
0.06%. There was no significant difference in loss rates between those
undergoing amniocentesis and those not undergoing amniocentesis. LEVEL
OF EVIDENCE: II-2.

[Eddleman
KA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Eddleman+KA"%5BAuthor%5D)
et al Pregnancy loss rates after midtrimester amniocentesis. [Obstet
Gynecol.  2006;
108(5):1067-72](http://www.medscape.com/medline/publicationbrowser/123?pmid=17077226)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17077226>

**Second twins: 97 cesarean deliveries (NNT) prevent a single serious
morbidity or mortality**

OBJECTIVE: Patients are given options with regard to the mode of
delivery with increasing frequency. The manner in which obstetricians
frame the risk/benefit information can have dramatic impact on the
ultimate decision made by the patient. STUDY DESIGN: Recently published
epidemiologic data reported increased morbidity and mortality to the
second twin on the basis of mode of delivery. In this analysis, the
findings of the epidemiologic studies were translated from odds ratio
into the number of cesarean deliveries that would be required to prevent
an adverse outcome for the second twin. RESULTS: For gestations of \> or
= 36 weeks, 97 cesarean deliveries would need to be performed to prevent
a single serious morbidity or mortality in a second twin. This number is
within the range needed to prevent uterine rupture associated with trial
of labor following cesarean delivery (556) or morbidity related to
vaginal breech delivery (167). CONCLUSION: Number needed to treat may be
more useful than odds risk assessment in patient counseling.

[Meyer
MC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Meyer+MC"%5BAuthor%5D)
Translating data to dialogue: how to discuss mode of delivery with your
patient with twins. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Oct;195(4):899-906

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16626605>

**Iron / folate supplementation: Not replaced by a
multiple-micronutrient supplement**

AUTHORS\' CONCLUSIONS: The evidence provided in this review is
insufficient to suggest replacement of iron and folate supplementation
with a multiple-micronutrient supplement. A reduction in the number of
low birthweight and small-for-gestational-age babies and maternal
anaemia has been found with a multiple-micronutrient supplement against
supplementation with two or less micronutrients or none or a placebo,
but analyses revealed no added benefit of multiple-micronutrient
supplements compared with iron folic acid supplementation. These results
are limited by the small number of studies available. There is also
insufficient evidence to identify adverse effects and to say that excess
multiple-micronutrient supplementation during pregnancy is harmful to
the mother or the fetus. Further research is needed to find out the
beneficial maternal or fetal effects and to assess the risk of excess
supplementation and potential adverse interactions between the
micronutrients.

Haider BA; Bhutta ZA Multiple-micronutrient supplementation for women
during pregnancy.

[Cochrane Database Syst Rev.  2006;
(4):CD004905](http://www.medscape.com/medline/publicationbrowser/123?pmid=17054223) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17054223>

**Treatment of periodontitis does not alter PTB, low birth weight, or
fetal growth restriction**

CONCLUSIONS: Treatment of periodontitis in pregnant women improves
periodontal disease and is safe but does not significantly alter rates
of preterm birth, low birth weight, or fetal growth restriction.

### Michalowicz BS et al Treatment of periodontal disease and the risk of preterm birth. [N Engl J Med.  2006; 355(18):1885-94](http://www.medscape.com/medline/publicationbrowser/123?pmid=17079762) (ISSN: 1533-4406)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17079762>

**Preterm babies have an increased risk of asthma compared with term
babies**

CONCLUSIONS: The weight of evidence shows that preterm babies have an
increased risk of asthma compared with term babies. CLINICAL
IMPLICATIONS: Recognition of prematurity as a determinant of asthma
emphasizes the importance of active treatment of physiologic airflow
obstruction and a need for special preventive measures against known
environmental determinants of asthma in preterm babies.

Jaakkola JJ et al Preterm delivery and asthma: a systematic review and
meta-analysis. [J Allergy Clin Immunol.  2006;
118(4):823-30](http://www.medscape.com/medline/publicationbrowser/123?pmid=17030233)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17030233>

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

#### Ongoing Discussion - You still can join in

**Causes of Type 2 Diabetes: Old and New Understandings**

**Moderator: Ann Bullock M.D.**

In 2002, the International Diabetes Federation determined that the
medical literature supports 4 etiologies of type 2 diabetes:

\--Genetics

\--Fetal Origins

\--Lifestyle

\--Stress

**We will explore these issues**

-   Diabetes prevention programs focus on lifestyle modification---what
    might these programs look like if lifestyle is only one factor?

-   What else can be learned from the DPP (Diabetes Prevention Program)?

-   Pregnancy and early life risk factors

-   What are the particular roots of the diabetes and obesity epidemics
    in Indian Country

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

Subscribe to the Primary Care listserv

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

Unsubscribe from the Primary Care listserv

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

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

**STD Corner - Lori de Ravello, National IHS STD Program**

**Less than half of parents infected with HIV tell their children about
the diagnosis**

Parents are reluctant to disclose their HIV infection to their children,
primarily because they fear the emotional impact. As a result, fewer
than half (44 percent) of children are aware of their parent\'s HIV
infection, according to a new study supported in part by the Agency for
Healthcare Research and Quality (HS08578 and T32 HS00046).

Researchers interviewed 274 parents from the HIV Cost and Services
Utilization Study, a nationally representative sample of HIV-infected
adults receiving care for HIV. HIV-infected parents reported that 44
percent of their children ages 5 to 17 years old were aware of their
parent\'s HIV status. Another 14 percent of children were unaware of
their parent\'s HIV status, but knew their parent had a serious illness.
In 28 percent of households with more than one child, some, but not all,
children knew their parent\'s HIV status. Parents had discussed the
possibility that HIV or AIDS might lead to the parent\'s death with 90
percent of children who knew about their HIV infection.

Parents did not disclose their HIV status to their children primarily
due to worry about the emotional consequences of disclosure for the
child (67 percent), worry that the child would tell other people (36
percent), and not knowing how to tell their child (28 percent). Many
parents also feared that their children would reject them or lose
respect for them. Certain parents were less likely to disclose their HIV
infection than others. These included those who contracted HIV through
heterosexual intercourse (rather than homosexual intercourse or
intravenous drug use), those with higher CD4 cell counts (indicative of
greater disease progression), those who were more socially isolated, and
those with younger children. According to the parents, 11 percent of
children who were aware of their parent\'s HIV infection worried they
could catch HIV from their parent, 5 percent had experienced other
children not wanting to play with them, and 9 percent had been teased or
beaten up.

Corona R, et al Do children know their parent\'s HIV status? Parental
reports of child awareness in a nationally representative sample May
2006 Ambulatory Pediatrics 6(3), pp. 138-144.

<http://www.ahrq.gov/research/oct06/1006RA16.htm>

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

#### Barbara Stillwater Alaska State Diabetes Program  {#barbara-stillwater-alaska-state-diabetes-program .Style-Heading-4-+-Arial-14-pt-Underline}

**Three Years Later, Participants in the Diabetes Prevention Study Still
Benefiting**\
Lifestyle intervention has lasting benefits in those at risk of
diabetes. The effects of lifestyle intervention on diabetes risk do not
disappear after active counseling has stopped, a new follow-up of the
Finnish Diabetes Prevention Study shows. Three years after the end of
the study, those in the intervention group still had a reduced incidence
of type 2 diabetes compared with the control

INTERPRETATION: Lifestyle intervention in people at high risk for type 2
diabetes resulted in sustained lifestyle changes and a reduction in
diabetes incidence, which remained after the individual lifestyle
counseling was stopped.

[Lindstrom
J](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Lindstrom+J"%5BAuthor%5D)
et al Sustained reduction in the incidence of type 2 diabetes by
lifestyle intervention: follow-up of the Finnish Diabetes Prevention
Study. [Lancet.](javascript:AL_get(this, 'jour', 'Lancet.');) 2006 Nov
11;368(9548):1673-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17098085>

**Stopping the Clock on Diabetes in Women: Strategies for Prevention and
Treatment Across the Lifespan**

Diabetes in Women: Women\'s Health Seminar Series, Web cast

The National Institutes of Health (NIH), Office of Research on Women's
Health (ORWH) and the National Institute of Diabetes and Digestive and
Kidney Diseases (NIDDK) as part of the Women\'s Health Seminar Series is
sponsoring a seminar on women and diabetes. Four leading experts will
share information on an overview of women and diabetes, preventing
cardiovascular complications of diabetes, women and diabetes, diabetes
self-management, and preventing diabetes in women with and without a
history of gestational diabetes. Griffin P. Rodgers, M.D., M.A.C.P.,
Acting Director of NIDDK, will make the opening remarks. To learn more,
call 301-402-1770. <http://videocast.nih.gov/PastEvents.asp?c=11>

**Multiparity Increase Risk for Type 2 Diabetes**

Women with five or more live births are at increased risk of developing
type 2 diabetes mellitus. This appears to be the case, even after
adjusting for obesity and socioeconomic factors.

There were 754 incident cases of type 2 diabetes during follow-up. Type
2 diabetes incidence rates were highest among the grandmultiparous, at
23 cases/1,000 person-years and lowest among women with one to two live
births, at 11 cases/1,000 person-years.

The researchers acknowledge that the bulk of diabetes risk was due to
obesity and lower socioeconomic status. However, after adjusting for
these recognized risk factors as well as clinical status, inflammatory
markers and lifestyle factors, grandmultiparity remained a risk factor
for type 2 diabetes.

Whether the link between high parity and diabetes is biological or due
to lifestyle is unknown. The investigators conclude that the CONCLUSION:
Breastfeeding in infancy is associated with a reduced risk of type 2
diabetes, with marginally lower insulin concentrations in later life,
and with lower blood glucose and serum insulin concentrations in
infancy, weight gain measures, lifestyle factors and changes in
socioeconomic status. CONCLUSIONS: Grandmultiparity is predictive of
future risk of diabetes after adjustment for confounders.

[Nicholson
WK](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Nicholson+WK"%5BAuthor%5D)
et al Parity and risk of type 2 diabetes: the Atherosclerosis Risk in
Communities Study. [Diabetes
Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');) 2006
Nov;29(11):2349-54

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17065666>

**New Study Weighs Benefits of Exercise, Diets**\
While exercise and weight loss are equally effective ways to lose
weight, exercising helps to maintain muscles. These data provide
evidence that muscle mass and absolute physical work capacity decrease
in response to 12 months of CR, but not in response to a similar weight
loss induced by exercise. These findings suggest that during
exercise-induced weight loss, the body adapts to maintain or even
enhance physical performance capacity. Key words: diet, training, energy
deficit, cardiovascular.

[Weiss
EP](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Weiss+EP"%5BAuthor%5D),
et al Lower extremity muscle size and strength and aerobic capacity
decrease with caloric restriction but not with exercise-induced weight
loss. [J Appl
Physiol.](javascript:AL_get(this, 'jour', 'J Appl Physiol.');) 2006 Nov
9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17095635>

**Low-Carb Diets Reduce Coronary Disease Risk in Women**\
A study suggesting that low-carbohydrate diets do not increase the risk
for coronary artery disease in women may help to allay fears that people
who eat higher amounts of protein and fat, while cutting back on
carbohydrates, are not trading hopes of a slimmer waistline for
increased coronary disease risk. CONCLUSIONS: Our findings suggest that
diets lower in carbohydrate and higher in protein and fat are not
associated with increased risk of coronary heart disease in women. When
vegetable sources of fat and protein are chosen, these diets may
moderately reduce the risk of coronary heart disease.

[Halton
TL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Halton+TL"%5BAuthor%5D),
et al Low-carbohydrate-diet score and the risk of coronary heart disease
in women. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2006 Nov
9;355(19):1991-2002.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17093250>

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

**22nd Annual Midwinter Indian Health OB/PEDS Conference**

-   For providers caring for Native women and children

-   January 26-28, 2007

-   Telluride, CO

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

**TeenScreen Conference: Second Annual**

-   March 14 and 15, 2007

-   Washington D.C.

-   Contact <TSConference@childpsych.columbia.edu>

**2nd** **International Meeting on Indigenous Child Health**

-   April 20-22, 2007

-   Montreal, Quebec, Canada

-   Solutions, not Problems

-   Joint meeting of IHS, AAP-CONACH, First Nations and several other
    stakeholders

-   <http://www.aap.org/nach/2InternationalMeeting.htm>

**2007 Indian Health MCH and Women's Health National Conference**

-   August 15 -17, 2007

-   Albuquerque, NM

-   THE place to be for anyone involved in care of AI/AN women, children

-   Internationally recognized speakers

-   Save the dates. Details to follow

-   Want a topic discussed? Contact <nmurphy@scf.cc>

# What's new on the ITU MCH web pages? {#whats-new-on-the-itu-mch-web-pages .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

**Diabetes: Understandings About the Causes of Type 2 - Old / New**

<http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#diabetes>

There are several upcoming **Conferences**

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

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

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

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

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

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

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

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

#### The November 2006 OB/GYN CCC Corner is available at: {#the-november-2006-obgyn-ccc-corner-is-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1106.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1106.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn1106.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

####  Abstract of the Month page 5 {#abstract-of-the-month-page-5-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Regular Cola Intake Reduces Bone Mineral Density in Women

#### From your colleagues page 8 {#from-your-colleagues-page-8 .Style-Heading-4-+-Arial-14-pt-Underline}

Carolyn Aoyama

-Learn Quick Health Data Online with us                         
                                                     

-New Women's Health Work Group Forming: Looking for interested
volunteers

Burt Attico

Remembering Bill Carlile

Scott Giberson

#### Funding Opportunity: Alcohol Abuse and HIV/AIDS {#funding-opportunity-alcohol-abuse-and-hivaids .Style-Heading-4-+-Arial-14-pt-Underline}

Wanda Jones

Hyperemesis gravidum can be devastating to women

Brenda Neufeld

#### Fish Intake, Contaminants, and Human Health {#fish-intake-contaminants-and-human-health .Style-Heading-4-+-Arial-14-pt-Underline}

Chuck North

Interested in a New England winter experience? Here is a great TDY

Ron Pust

At Highest Risk: Birthing in the Andes

Judy Thierry

-AI/AN Candidates in college are encouraged to apply -- deadline 15
December 2006

-SIDS: Train the Trainer Sessions available

-Archived METH Web cast available 

-Perinatal oral health screening: Provider response and interface with
oral health care

**Dawn Wyllie**

#### -Perinatal depression evidence based care {#perinatal-depression-evidence-based-care .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Many other Depression resources  {#many-other-depression-resources .Style-Heading-4-+-Arial-14-pt-Underline}

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

##### Obstetrics page 14

-Magnesium sulfate tocolysis: time to quit

-Uterine rupture cannot be predicted with any combinations of clinical
factors

-Drugs for treatment of very high blood pressure during pregnancy:
Dealer's choice

-VBAC is safer than repeat cesarean delivery if patient has had a prior
vaginal delivery

-Sphincter injuries: Overlap repair lower risks for fecal urgency and
anal incontinence

and more....

**Gynecology page 19**

-'No touch' hysteroscopy much better tolerated

-Hot water bottles do work: Active Warming Cuts Pelvic Pain in
Pre-hospital Setting 

-Early catheter removal post-op: Early ambulation and early discharge

## -Abnormal Uterine Bleeding: A Management Algorithm: Evidenced-Based Clinical Medicine

-Suppressive Therapy for Recurrent Bacterial Vaginosis Reduces
Recurrences

and more....

**Child Health page 21**

-Early adolescents worry more as they age. . . .

-Overweight Adolescent Girls Have Increased Mortality Risk

-Adolescent overweight and obesity: Effect of maternal smoking during
pregnancy

-Public Cost of Adolescent Childbearing- By the Numbers

-Dietary calcium intervention in adolescent mothers increases bone
mineralization

and more....

**Chronic Illness and Disease page 23**

-Health Behaviors among American Indian/Alaska Native Women, 1998--2000
BRFSS

-Raloxifene did not significantly affect the risk of CHD

-Rifampin Has Improved Adherence, Less Toxicity Than Isoniazid for
Latent Tuberculosis 

-Prophylactic Surgery Reduces Ovarian Cancer Risk

-Seasonal Affective Disorder

and more....

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

American College of Obstetricians and Gynecologists page 28

-Umbilical Cord Blood Gas and Acid-Base Analysis

-Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a
Vital Sign

-Overweight Adolescent: Prevention, Treatment, and Obstetric--
Gynecologic Implications

-Breast Concerns in the Adolescent

-Using Preimplantation Embryos for Research

##### American Family Physician

No Stirrups Preferred for Pelvic Examinations

**Agency for Healthcare Research and Quality**

-Over 1 million U.S. babies are delivered by Cesarean delivery

-Bone protection shifted to nonestrogen anti-osteoporosis medicine after
WHI

**Ask a Librarian**

Want to keep up with evidence-based medicine?

**Breastfeeding**

-It is official, breastfeeding counts

#### -Breast-Feeding Protects Against Obesity in Children of Diabetic, Overweight Mothers {#breast-feeding-protects-against-obesity-in-children-of-diabetic-overweight-mothers .Style-Heading-4-+-Arial-14-pt-Underline}

-Herbal Medicines in Pregnancy and Lactation

-Infants Born During Who Were Ever Breastfed, by Race / Ethnicity of
Mother

**CCC Corner Digest**

\-[Routine HIV Screening in 13- 64 year olds: Scott
Giberson](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_AOM.cfm)

\-[40 years in partnership: American Academy of Pediatrics and Indian
Health](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Coll.cfm)

\-[Can a 29% Cesarean Delivery Rate Possibly Be
Justified?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_HT.cfm#ob)

\-[Out with Clomid? Here come the Aromatase inhibitors for ovulation
induction](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_HT.cfm#gyn)

\-[Fetal injury at cesarean delivery: Indication and type of uterine
incision](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_HT.cfm#child)

\-[Aspirin to Prevent Heart Attack and Stroke: What's the Right Dose?
160
mg/day](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_HT.cfm#chrIll)

\-[Postcoital Bleeding and Cervical Cancer Risk only
1/220](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#afp)

\-[Amnioinfusion Does Not Prevent Meconium Aspiration
Syndrome](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#acog)

\-[Exercise and Pregnancy; Preclampsia Drugs; Calcium
Supplementation](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#AskLib)

\-[Do you have breastfeeding questions? The new IHS Breast feeding site
has the
answers](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#breast)

\-[Ortho Evra Patch Linked to Risk for Venous
Thromboembolism](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#fp)

\-[New Breastfeeding Web Page for the Indian Health
System](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#webSite)

\-[Maternal survival worldwide: consensus and
controversies](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#ih)

\-[The words 'bizarre' and 'atypia' in the same pathology report
sentence...hmmm....](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#mmtour)

\-[External Fetal Monitors - Can you kick the
habit?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#MidWives)

\-[Asthma in
Pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#okie)

\-[Fracture risk among First Nations
people](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#oste)

\-[A.) Fetal Lung Maturity B.) Blood test for pre-eclampsia? C.)  Fish
oil for the
brain](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#periPicks)

\-[Causes of Type 2 Diabetes: Old and New
Understandings](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#pcf)

\-[Prevalence of HPV Infection among Men: A Systematic Review of the
Literature](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#std)

\-[No improvement in fetal outcome, increased maternal morbidity: Who
pays for
this?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#stillW)

\-[Special Care Clinic -- Phoenix Indian Medical
Center](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#new)

\-[Heard about prenatal and postpartum care? Here is something on
Internatal
Care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_Feat.cfm#new)

**Domestic Violence**

-Measuring Intimate Partner Violence Victimization and Perpetration

-CDC Reports Prevalence of Dating Violence in High School Students

**Elder Care News**

-Diagnosis of Acute Abdominal Pain in Older Patients

-Indian Health Service History Project

**Family Planning**

-Maximizing access to EC not affect incidence of either pregnancy or
STIs

-EC: Progesterone receptor modulator CDB-2914 as effective as
levonorgestrel

-Monophasic oral contraceptives preferred over biphasic for
contraception

#### -One year\'s supply of OCPs: Higher continuation, improved screening, and lowered costs {#one-years-supply-of-ocps-higher-continuation-improved-screening-and-lowered-costs .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

-Check out our new IHS STD website

-New web site focuses on the history and legacy of maternal child health

**Frequently asked questions**

Is an informed consent necessary for all x-rays in pregnant women?

**Indian Child Health Notes**

-Tall Girls: When being tall was a disease - how culture shapes and
defines medical care

-Viral gastroenteritis in AI/AN children - do we have more than everyone
else? Surprising findings

-Prevalence of mental health disease in AI/AN children

**Information Technology**

-Telehealth Opportunity: Do you need nutrition services at your site?

-AHRQ Launches Electronic Preventive Services Selector Tool for Primary
Care Clinicians

International Health

-Anthropology in the clinic: the problem of cultural competency and how
to fix it

-Cesarean Delivery: Both Overused and Underused in Developing Countries

-Risk of formula feeding to infants in sub-Saharan Africa: Need for
alternative strategies

#### MCH Alert

-Child Health USA 2005 Released

#### Medical Mystery Tour

#### The words 'bizarre' and 'atypia' in the same pathology report sentence...hmmm.... {#the-words-bizarre-and-atypia-in-the-same-pathology-report-sentencehmmm. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

**Menopause Management**

-High-Dose Gabapentin Equal to Estrogen for Hot Flashes: POEM

-Hormone Therapy in Postmenopausal and Perimenopausal Women

-Alendronate May Be Best Choice for Postmenopausal Osteoporosis

#### -Estrogen only trial WHI: Significantly lower rates of any arthroplasty {#estrogen-only-trial-whi-significantly-lower-rates-of-any-arthroplasty .Style-Heading-4-+-Arial-14-pt-Underline}

-Progestin in HRT Linked to Hearing Loss in Postmenopausal Women

and more....

**Midwives Corner**

-What Women Want

-Delayed cord clamping: Benefits in settings with high levels of
neonatal anemia

**Navajo News**

-Prevalence of diabetes: Diagnosed Diabetes Among AI/AN Aged \<35 Years

-Great, low-cost, fun CME opportunity

**Nurses Corner**

#### -Exclusively for Nurses: IHS has a Biomedical Librarian / Informationist dedicated to I/T/U {#exclusively-for-nurses-ihs-has-a-biomedical-librarian-informationist-dedicated-to-itu .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Executive Nurse Fellows Program, Robert Wood Johnson {#executive-nurse-fellows-program-robert-wood-johnson .Style-Heading-4-+-Arial-14-pt-Underline}

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

-Measuring HIV Risk in the U.S. Population Aged 15-44

-HPV and HPV Vaccine: Information for Healthcare (Revised)

**Oklahoma Perspective**

Preoperative Evaluation

Osteoporosis

Potassium Citrate Beneficial for Osteopenia

Patient Education

#### -November is National Diabetes Month: Focus on gestational diabetes (GDM) {#november-is-national-diabetes-month-focus-on-gestational-diabetes-gdm .Style-Heading-4-+-Arial-14-pt-Underline}

#### -It\'s Never Too Early to Prevent Diabetes: Tip Sheets for Women and Health Care Providers {#its-never-too-early-to-prevent-diabetes-tip-sheets-for-women-and-health-care-providers .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Be Prepared: The Boy Scout motto...er...the Maternity Care Provider
motto, too

-Adverse neonatal outcomes associated with antenatal dexamethasone vs
betamethasone

-Metformin Exposure During First Trimester Seen Safe for Fetus

-Predicting glyburide failure is difficult, not associated with adverse
pregnancy outcomes

-The current pregnancy loss rate after amniocentesis is closer to 1 in
1,600

-Treatment of periodontitis: Is it a case of association does not imply
causation ?

and more....

Primary Care Discussion Forum

Causes of Type 2 Diabetes: Old and New Understandings

STD Corner

-IHS Consent Form for an HIV Antibody Test is Hereby Cancelled

-Check out our new IHS STD website

-Adapting condoms to community values in Native American communities:
Snag bags

-Barriers to condom purchasing: Effects of product positioning on
reactions to condoms

#### -Interventions for Molluscum Contagiosum: Cochrane Briefs {#interventions-for-molluscum-contagiosum-cochrane-briefs .Style-Heading-4-+-Arial-14-pt-Underline}

and more....

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

-Gestational Diabetes Linked to High Prevalence of Periodontal Disease

-Physical activity before pregnancy or during pregnancy reduces
gestational diabetes

-Mothers with type 2 diabetes during pregnancy can transmit risk factors
to their children

-Does coffee reduce the risk of type 2 diabetes in individuals with
impaired glucose?

-Every kilogram of weight loss resulted in 16% reduction of diabetes
risk

and more....

###### Save the Dates: Upcoming events of interest page 58

#### What's new on the ITU MCH web pages page 59

-What medications, foods, and beverages irritate the bladder?

\-[CDC Compendium of Domestic Violence Assessment
Tools](http://www.ihs.gov/MedicalPrograms/MCH/V/DV01.cfm#Compendium)

\-[Compendium of State Laws](http://www.ucsf.edu/hivcntr/) Impacting HIV
Screening and Treatment

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

The past CCC Corners are archived at:

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12/10/06

[^1]: Single years have too few deaths to report any significance. In
    some reports you will note 5 and 6 year aggregates to obtain
    sufficient numbers in the 'cells'. For this analysis 3 year
    aggregates were used.

[^2]: Guntheroth, W. G., Spiers, P. S., Sleeping prone and the risk of
    sudden infant death syndrome, JAMA, Vol. 267 No. 17, May 6, 1992
    cited December 4,
    2006<http://jama.ama-assn.org/cgi/content/abstract/267/17/2359?ijkey=b3b5d2208410c6629f489a51c5f84ab6b9c0dbca&keytype2=tf_ipsecsha>

[^3]: A triple-risk model for the pathogenesis of SIDS - intersection of
    three overlapping factors: (1) a vulnerable infant; (2) a critical
    developmental period in homeostatic control, and (3) an exogenous
    stressor(s). cited December 4
    <http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=8038282>
    [Filiano
    JJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Filiano+JJ"%5BAuthor%5D),
    [Kinney
    HC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Kinney+HC"%5BAuthor%5D).
    A perspective on neuropathologic findings in victims of the sudden
    infant death syndrome: the triple-risk model. [Biol
    Neonate.](javascript:AL_get(this, 'jour', 'Biol Neonate.');) 1994;65
    (3-4):194-7.