New Features this month

Indian Child Health Notes -- Steve Holve, Pediatric Chief Clinical
Consultant

Perinatology Picks -- George Gilson, Maternal Fetal Medicine

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

OB/GYN Chief Clinical Consultant's Corner

Volume 3, No. 8, August 2005

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

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

**Open access can work for any type of practice. It is the wave of the
future**

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

**Sandy Haldane:**

-New IHS Women's Health and Advanced Practice Nurse Consultants

#### -Public health approach to suicide prevention in an American Indian Tribal Nation {#public-health-approach-to-suicide-prevention-in-an-american-indian-tribal-nation .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Healthy Native Communities Fellowship accepting applications for 2006 {#healthy-native-communities-fellowship-accepting-applications-for-2006 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Cardiovascular Disease: The Kaw Nation and other minority populations  {#cardiovascular-disease-the-kaw-nation-and-other-minority-populations .Style-Heading-4-+-Arial-14-pt-Underline}

**Ruth Lagerberg:** Fetal cardiac echogenic foci on routine obstetric
sonogram

**Sheila Mahoney:** Cord clamping: early versus delayed

Chuck North: **Advances in Indian Health, 6^th^ Annual**

#### Miles Rudd: Relative value of physical exam of the breast as a screening tool {#miles-rudd-relative-value-of-physical-exam-of-the-breast-as-a-screening-tool .Style-Heading-4-+-Arial-14-pt-Underline}

#### Jennifer Retsinas: Uterine fibroids: uterine artery embolization {#jennifer-retsinas-uterine-fibroids-uterine-artery-embolization .Style-Heading-4-+-Arial-14-pt-Underline}

#### Phil Smith: New Outreach: Updated educational materials about the Prescription Drug Benefit {#phil-smith-new-outreach-updated-educational-materials-about-the-prescription-drug-benefit .Style-Heading-4-+-Arial-14-pt-Underline}

Judy Thierry:

-Many girls are at a literal standstill

-Trends and Regional Differences: Latest available

-Great resource: MCH Alert

-"Weaving WIC into Our Traditional Families"

-Child Protection Handbook 2004, IHS/BIA

**Carol Treat:** Brochure/support for sugar substitute and gestational
DM

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

##### Obstetrics: page 12

-Trial of Labor After Cesarean: Evidence based guidelines

-Time of birth and risk of neonatal death: 12-16% increase in mortality
at night

-Parietal peritoneum closure during cesarean delivery decreases
adhesions

-Aerobic training increases exercise capacity, overcoming negative
effects of pregnancy

-Pre-pregnancy obesity: Increasing excess risk of fetal death with
advancing gestation

-Screening asymptomatic, low-risk pregnant women for hepatitis C virus
not cost effective

And more....

**Gynecology: page 15**

-Ovarian conservation benefits survival in women when undergoing
hysterectomy

-Hysterectomy Associated With Earlier Onset of Menopause

-One in ten adult women perceives urinary incontinence to be barrier to
exercise

-Reclosure of the disrupted laparotomy wound is safe and successful in
over 80%

### -Cervical cytology screening and evaluation - Clinical Expert Series

And more....

**Child Health: page 16**

-AAP Releases Report on Excessive Sleepiness in Adolescents

\-[High-Grade Cervical Lesions Progress in Adolescents at Similar Rate
as in Adults\
](http://mp.medscape.com/cgi-bin1/DM/y/hq120G875W0Dzc0Gk8W0EZ)-Reducing
the Risk of SIDS Through Community Partnerships: Editorial

-Fetal Alcohol Spectrum Disorders

-Foreign Body Ingestion in Children

And more....

**Chronic Illness and Disease: page 17**

-Guidelines for Improving Vaccination Rates Among High-Risk Adults, CDC

-Bariatric Surgery Resolves Comorbid Conditions

-Tobacco Cessation: Kicking the Habit in Alaska

-Existing coronary heart disease is undiagnosed in half of women who
have a first heart attack

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

#### Features: page 17 {#features-page-17 .Style-Heading-4-+-Arial-14-pt-Underline}

#### American Family Physician {#american-family-physician .Style-Heading-4-+-Arial-14-pt-Underline}

-Aspirin Prevents Stroke, but Not Cardiovascular Disease, in Women

-Intensive Diet-Behavior-Physical Activity Program for Obesity in
Children

-NSAIDs Alone or with Opioids as Therapy for Cancer Pain: Cochrane for
Clinicians

-Health Literacy: The Gap Between Physicians and Patients

American College of Obstetricians and Gynecologists

-Management of Endometrial Cancer ACOG Practice Bulletin

-Health Care for Homeless Women

-Two Major Women\'s Health Groups Call Attention to a Leading
Reproductive Cancer

**Agency for Healthcare Research and Quality**

-Despite revised guidelines, most OB/GYNs over-screen low-risk women for
cervical cancer

-Physician supply increases in States with caps on malpractice: greatest
impact in rural areas

-Women respond differently to medications than men, should be proactive
about medication use

-Efforts to help improve care for underserved patients: address
communication and respect

**Ask a Librarian**

The Known and the Unknown - Clinical Evidence Summarized

**Breastfeeding**

#### Fentanyl During Labor May Impede Establishment of Breastfeeding {#fentanyl-during-labor-may-impede-establishment-of-breastfeeding .Style-Heading-4-+-Arial-14-pt-Underline}

**Case Managers Corner (R.N.)**

Stress and verbal abuse in nursing

**CCC Corner, Last month's Digest**

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

-USPSTF recommends that clinicians screen all pregnant women for HIV

-Simple Educational Handouts -- Kat Franklin, Sante Fe

-Elective Repeat Cesarean Delivery May Negatively Affect Neonatal
Outcomes

-Benzocaine spray does not offer effective pain control during per
endometrial biopsy

-OCPs are more effective than placebo for relieving dysmenorrhea in
adolescents

-Death rates for CVD are higher among AI/AN than other U.S. groups

-Pregnancy and Depression: What Women Need to Know

-What is an RN Case Manager?

-2 positive blood cultures found in a postpartum patient with a fever

-Benefits of low-fat dairy products on weight loss

-What Makes a Drug Over the Counter (OTC)? The case of Plan B

-Active management of the third stage of labor among American Indian
women

-Racial / Ethnic Disparities in Infant Mortality: No significant
improvement in AI / AN

-Use the talk / sing test during exercise during pregnancy

-Here is a good web based calcium screening tool

-Can chlamydia be stopped?

**Domestic Violence**

Developing Leaders in Violence Prevention -- Travel funding available

**Cultural Competency for Non-Native Advocates: Ending Violence Against
Native Women Training**

The 2006 PREVENT Institute:  Developing Leaders in Violence Prevention

**Elder Care News**

Toward optimal screening strategies for older women: Should cost matter
the most?

**Family Planning**

[Over-The-Counter Sales of Emergency Contraception Do Not Increase
Unsafe Sex](http://mp.medscape.com/cgi-bin1/DM/y/hq120G875W0Dzc0GlAH0EU)

**Frequently asked questions**

Q. Is there any help or assistance with infertility through the Indian
Health System?

**Indian Child Health Notes**

-Pediatric sleep apnea - you know more than you think

-Sleepy teenagers - they are not just slugs, they\'re victims of biology

-TB in AI/AN is down, but not out

**Information Technology**

-VHA Pharmacy Benefits Management (PBM) Strategic Healthcare Group page

-Free Online CME from Thomson Healthcare

International Health

-Increase the interdisciplinary and transdisciplinary focus in primary
health care research

-Unite For Sight\'s 3rd Annual International Health Conference

#### MCH Alert

New edition of the Women's Health Data Book Released

#### Medical Mystery Tour

Follow-up 2 positive blood cultures found in a postpartum patient with a
fever: The answer

#### Medscape

######### Eating Disorders and Body Image Distress in Women at Midlife - CME

**Menopause Management**

USPSTF Hormone Therapy for the Prevention of Chronic Conditions in
Postmenopausal Women

**Midwives Corner**

-Please help us build the Midwives Indian Health Patient Education
Resources page

-Women and Health Care: A National Profile

**Navajo News**

Is the patch more dangerous than the pill?

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

Publications and Materials -- Many Women's Health Topics

**Oklahoma Perspective**

Who do you contact in Oklahoma for MCH issues?

Osteoporosis

Ultralow-Dose Estradiol and BMD in Postmenopausal Women

Patient Education

-Brochure/support for sugar substitute and gestational DM

-What to Do If Your Child Swallows Something**?**

Perinatology Picks

#### -Glyburide for gestational diabetes in a large managed care organization  {#glyburide-for-gestational-diabetes-in-a-large-managed-care-organization .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Overweight and obese in gestational diabetes: the impact on pregnancy outcome {#overweight-and-obese-in-gestational-diabetes-the-impact-on-pregnancy-outcome .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Glargine use in pregnancy? {#glargine-use-in-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

Primary Care Discussion Forum

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

STD Corner

-Condom effectiveness for prevention of *Chlamydia trachomatis*
infection

-The percentage of male teens who reported ever having sexual
intercourse

-Prenatal screening and treatment needed to identify women with
asymptomatic chlamydia

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

-Women the stronger gender? Men more carbohydrate intolerant / less
physical endurance

-Teen Inactivity Leads to Obesity for Girls

-Relationship of Obesity and Fitness Level to Cardiovascular Risk and
Diabetes 

-New CERTs Program Brief on Women\'s Health Is Available

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

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

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

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

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

**Open access can work for any type of practice. It is the wave of the
future**

OBJECTIVE: Appointment delays impede access to primary health care. By
reducing appointment delays, open access (OA) scheduling may improve
access to and the quality of primary health care. The objective of this
pilot study was to assess the potential impact of OA on practice and
patient outcomes by using pilot-study data from 4 North Carolina primary
care practices.

METHODS: We conducted an interrupted time-series pilot study of 4 North
Carolina primary care practices (2 family medicine and 2 pediatric
practices) participating in a quality-improvement (QI) collaborative
from May 2001 to May 2002. The year-long collaborative comprised 25
practices and consisted of three 2-day meetings led by expert faculty,
monthly data feedback, and monthly conference calls. Our main outcome
measures were appointment delays, appointment no-shows, patient
satisfaction, continuity of care, and staff satisfaction during the
12-month study period. RESULTS: Providers in all 4 practices
successfully implemented OA. On average, providers reduced their delay
to the third available preventive care appointment from 36 to 4 days.
No-show rates declined (first quarter \[Q1\] rate: 16%; fourth quarter
\[Q4\] rate: 11%; no-show reduction: 5% \[95% confidence interval: 1%,
10%\]), and overall patient satisfaction improved (Q1: 45% rated overall
visit quality as excellent; Q4: 61% rated overall visit quality as
excellent; change in satisfaction: 16% \[95% confidence interval: 0.2%,
30%\]). Continuity of care followed a similar pattern of improvement,
but the change was not statistically significant. Staff satisfaction
neither improved nor declined.

CONCLUSIONS: This pilot study suggests that primary care practices can
implement OA successfully by using QI-collaborative methods. These
results provide preliminary evidence that OA may improve practice and
patient outcomes in primary care. These analyses should be repeated in
larger groups of practices with longer follow-up.

[Bundy
DG](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Bundy+DG"%5BAuthor%5D),
et al Open access in primary care: results of a North Carolina pilot
project. Pediatrics. 2005 Jul;116(1):82-7.

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

Actually 'Open Access' to care is more than a wave of the future. "Open
Access' techniques are used successfully in many Indian Health sites
right now and 'Open access' techniques should be used throughout the
entire Indian Health system. There is extensive experience with 'Open
access' techniques at ANMC dating to the mid and late 1990's,
particularly at Southcentral Foundation. njm

Here a few comments by the author per MD Consult:

"Open access scheduling, intended to reduce or eliminate delays when
patients need to see a doctor, is a practical, effective way to
streamline medical practices while reducing patient frustration,
according to results of the above small study. \"You spend a 20-minute
visit with a patient, and you may spend the first few minutes of it sort
of picking up the pieces from the effects your wait has on that
patient,\" said study leader Dr David Bundy, a pediatrician at the
University of North Carolina-Chapel Hill Medical School. \"They\'ve been
waiting in the waiting room for 45 minutes, and then waiting in the
patient room for 10 more minutes. You walk in the room and apologize for
being late, you make explanations for why the system runs slow. Minutes
of the visit are churned up just trying to apologize for the way the
system works.\"\
\
Another impetus for considering open access involves delays in actually
getting an appointment, Dr Bundy said. Patient complaints and
frustration run high when they can\'t get an appointment to see a doctor
until two months after they call. \"Most other businesses do not operate
on a similar model,\" he said. \"If you imagine getting your oil changed
where you call and they say, \'Well, come in two months.\' I mean,
you\'d hang up the phone right away and call somebody else. So patients
have already waited so long to get to their appointment---they may have
waited six or eight weeks---and then once six or eight weeks has gone
by, then to have to sit in a lobby for another hour-and-a-half for the
visit to actually take place, there\'s a lot of patient frustration that
is usually built up by the time the patient is ready to be seen in the
room.\"\
\
Delays in scheduling can cause other problems. \"Practices that have
really long delays frequently have high no-show rates,\" Dr Bundy said.
\"Because a person who made an appointment eight weeks ago has often
forgotten, or their plans have changed. They just don\'t have the same
investment that they did when they picked up the phone eight weeks ago.
So as a result of the high no-show rate, practices respond by doing
several things. Sometimes they\'ll call the patient the day before,
which is now generating even more work.\" Many practices, anticipating a
no-show rate of 25 to 30 percent, double book their schedule, Dr Bundy
said.\
\
\"You\'re sort of drifting farther and farther into this parallel
universe where the actual schedule doesn\'t really bear that much of a
relationship to what happens on a given day any more,\" he said.
\"Because now you\'re basically scheduling appointments for patients
who, six weeks from now when that day rolls around, you\'re going to
suddenly assume are not going to come any more. So you\'re scheduling
more patients into that slot.

\"Eventually,\" he said, \"practices are just looking for a way out, a
way to turn the system upside-down and say, \'Hey, wait a minute. A
hundred patients called today. We\'re going to see those 100 patients on
the same day, it\'s just that the day we\'re going to see them is six
weeks from now. \... Why can\'t we just see them today, by working down
this backlog that we\'ve built up?\'\"\
\
To adopt open access, the practices employed such techniques as
balancing appointment supply with patient demand, standardizing
appointment lengths and making more efficient use of rooms and
equipment. In some cases, such as wellness or child care instruction,
group visits are appropriate and several patients can be handled at the
same time, Dr Bundy said.\
\
For simple follow-ups, such as notifying a patient about lab results,
many practices are now calling or e-mailing instead of having the
patient come in to the office. Continuity of care, and putting as much
content into visits as possible, also reduces the need for repeat
appointments.\
\
\"These are pretty general principles, and you can pretty rapidly start
to think of ways they can be applied in all sorts of different
practices,\" he said. The results are noteworthy. On average, according
to the study, providers reduced their delay to the third available
preventive care appointment from 36 days in the first quarter to 4 days
in the fourth quarter. During this period, the no-show rate declined
from 16 percent to 11 percent and overall patient satisfaction improved
from 45 percent to 61 percent.\
\
Reducing the backlog is a key to making open access work. \"It can
definitely be done,\" Dr Bundy said. \"There is a growing track record
of practices that have accomplished this, including large systems of
practices. For example, in the VA system, the veterans system, they
undertook an enormous collaborative, trying to improve. They had a big
problem in particular with their specialty clinics, having very long
delays for appointments. \... The data is out there, and they\'ve made
significant improvements for delays in appointments for the VA
system.\"\
\
Practices large and small have been able to implement open access, Dr
Bundy said. \"The biggest key is just having the commitment on the part
of the staff,\" he said. \"That\'s not just the providers, but down to
the appointment schedulers or the practice manager.\"\
\
This can also extend to senior leadership---from the person who oversees
a health system to the person in charge of a group of practices---having
\"the commitment that this is an important thing to do,\" he said. \"One
of the take-away messages is that this takes a lot of work on the front
end.\
\"Getting rid of the backlog is a great example. It takes extra work to
do that, extra work beyond what you are doing currently on an everyday
basis,\" Dr Bundy said. \"But that\'s a temporary increase in your work,
because once the backlog has been reduced, we\'re still seeing our same
hundred patients a day as a group. We\'re just seeing the hundred
patients who called in today or yesterday, instead of the hundred
patients who called in six weeks ago.\"\
\
Addressing a backlog can be intimidating. \"They have to get over that
hump,\" he said. \"They have to make an extra effort at the beginning.\"
But it is possible. \"The two biggest components are the commitment and
the know-how, or the tools,\" Dr Bundy said. \"That\'s where this
collaborative work comes in, to give practices the practical, specific
tools, ideas, changes, etcetera, that they need to make to their system
in order to implement open access.\"\
\
The nuts and bolts of open access---the how-to---is being shared among
practices that are part of a larger group. Right now, the practices
changing to open access are the \"motivated, ahead of the bell curve\"
groups, Dr Bundy said. He hopes that as practices successfully implement
open access, they will be able to share what they did with other
practices, reducing the learning curve.\
\
\"It\'s such a foreign notion to think that the clinic is providing you
a service and that you, the patient, should decide when you want to
receive that service,\" he said. Since reducing the backlog is a gradual
process, the first hint of change is subtle, like appointments dropping
from six weeks in the future to a month. But when the backlog is gone,
patients love the change. \"This is something that would attract
patients to a practice,\" Dr Bundy said.\
\
Open access can work for any type of practice, Dr. Bundy said. It should
be the wave of the future. \"Once some critical mass of practices has
achieved this, then it\'s just going to become the standard. You can\'t
compete any more if you have a six-week wait for an appointment when an
adjacent practice which is equally good will see (a patient) today,\" he
said.

**Other resources**

[**Institute for Health Care
Improvement**](http://home.mdconsult.com/website/view?st=&URL=http://www.ihi.org)

[http://www.ihi.org](http://www.ihi.org/)

[**Center for Children\'s Healthcare
Improvement**](http://home.mdconsult.com/website/view?st=&URL=http://www.childhealthimprovement.org)

[http://www.childhealthimprovement.org](http://www.childhealthimprovement.org/)

**The Dartmouth \"green book\" offers practical tools and templates**

<http://cms.dartmouth.edu/access.htm>

[Murray
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Murray+M"%5BAuthor%5D),
[Bodenheimer
T](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Bodenheimer+T"%5BAuthor%5D),
[Rittenhouse
D](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Rittenhouse+D"%5BAuthor%5D),
[Grumbach
K](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Grumbach+K"%5BAuthor%5D).
Improving timely access to primary care: case studies of the advanced
access model. JAMA. 2003 Feb 26;289(8):1042-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12597761&query_hl=3>

[Pierdon
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Pierdon+S"%5BAuthor%5D),
et al Implementing advanced access in a group practice network. Fam
Pract Manag. 2004 May;11(5):35-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15162609&query_hl=1>

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

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

**New IHS Women's Health Consultant and Advanced Practice Nurse
Consultant**

Please help me welcome CAPT Carolyn Aoyama to IHS Headquarters, Division
of Nursing.

As the IHS Women's Health Consultant Carolyn will represent the IHS on
matters of women's health, providing leadership and technical assistance
on program development, implementation, evaluation, and policy.  As the
Advanced Practice Nurse Consultant, Carolyn will provide leadership and
technical expertise on matters pertaining to policy and standards of
practice as they pertain to Nurse Practitioners, Certified Nurse
Midwives, and Certified Registered Nurse Anesthetists.  Carolyn received
her BSN from the University of WI, her MPH from Johns Hopkins and is
also a Certified Nurse Midwife.  Carolyn began her nursing career in IHS
as a PHN at Ft. Defiance.  Carolyn has worked as a CNM in the inner city
of Baltimore and Phoenix and as the Maternal Child Health Consultant for
the State of Alaska's Department of Health and Social Services. 
Subsequently she worked as an EIS Officer with the CDC, a Public Health
Advisor in the Perinatal Care Program of HRSA's Bureau of Primary Health
Care (BPHC), Nurse Consultant for Mental Health/Substance Abuse Service
(HRSA/BPHC/Division of Community and Migrant Health), a Community Health
Center Project Officer with HRSA/BPHC, and most recently as a Nurse
Consultant with HRSA/Bureau of Health Professions/Division of Nursing. 
Carolyn can be reached at 301-443-1028 or in Suite 300 of the Reyes
Building.

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

#### Public health approach to suicide prevention in an American Indian Tribal Nation {#public-health-approach-to-suicide-prevention-in-an-american-indian-tribal-nation-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Data from this community-based approach document a remarkable downward trend-measured by both magnitude and temporal trends in the specifically targeted age cohorts-in suicidal acts. The sequential decrease in age-specific rates of suicide attempts and gestures is indicative of the program\'s success. {#conclusions-data-from-this-community-based-approach-document-a-remarkable-downward-trend-measured-by-both-magnitude-and-temporal-trends-in-the-specifically-targeted-age-cohorts-in-suicidal-acts.-the-sequential-decrease-in-age-specific-rates-of-suicide-attempts-and-gestures-is-indicative-of-the-programs-success. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**May PA**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="May+PA"%5BAuthor%5D) et al Outcome evaluation of a public health approach to suicide prevention in an American Indian Tribal Nation. Am J Public Health. 2005 Jul;95(7):1238-44. {#may-pa-et-al-outcome-evaluation-of-a-public-health-approach-to-suicide-prevention-in-an-american-indian-tribal-nation.-am-j-public-health.-2005-jul9571238-44. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15933239&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15933239&dopt=Abstract) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids15933239doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Healthy Native Communities Fellowship accepting applications for 2006 {#healthy-native-communities-fellowship-accepting-applications-for-2006-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Designed to build the capacity for effective health promotion practices at the local level by increasing the knowledge, skills, and capacities of Tribal, IHS, and Urban Indian health workers and leaders. Deadline September 1, 2005 [**http://www.ihs.gov/hpdp**](http://www.ihs.gov/hpdp) {#designed-to-build-the-capacity-for-effective-health-promotion-practices-at-the-local-level-by-increasing-the-knowledge-skills-and-capacities-of-tribal-ihs-and-urban-indian-health-workers-and-leaders.-deadline-september-1-2005-httpwww.ihs.govhpdp .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Cardiovascular Disease: The Kaw Nation and other minority populations  {#cardiovascular-disease-the-kaw-nation-and-other-minority-populations-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Cordelia Clapp: Minority Nurse Magazine [**http://www.minoritynurse.com/features/health/05-03-05e.html**](http://www.minoritynurse.com/features/health/05-03-05e.html) {#cordelia-clapp-minority-nurse-magazine-httpwww.minoritynurse.comfeatureshealth05-03-05e.html .Style-Heading-4-+-Arial-14-pt-Underline}

#### Ruth Lagerberg, CNM, formerly ANMC {#ruth-lagerberg-cnm-formerly-anmc .Style-Heading-4-+-Arial-14-pt-Underline}

**Fetal cardiac echogenic foci on routine obstetric sonogram**

What is your recommendation for follow-up for the finding of fetal
cardiac echogenic foci on routine ob sono?  Level II looking for other
markers of trisomy 21 or fetal cardiac Doppler or no f/u necessary?  I
am working at a community health center north of NYC - the nearest
perinatologist is over an hour away and many of our patients have
limited resources, including transportation difficulties.  Level II
sonos are available locally.  Our back-up OBs differ on their opinion of
f/u.  I did a lit search, but the literature differs on recommendations
as well.

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

As luck would have it, the Indian Health system has two resources to
offer on these issues. There is a helpful FAQ, plus a free CEU /CME
module

**Q. What is the significance 2^nd^ trimester of ultrasound (US) markers
for Down syndrome?**

A. If US markers are negative, then decrease the risk by serum testing
in \~1/2.

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

**Prenatal Genetic Screening -- Serum and Ultrasound - CEU /CME module**

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

**Sheila F. Mahoney CNM, NIH**

**Cord clamping: Early versus delayed**

Referring to the benefits of delayed cord clamping cited in June's
OB/GYN & Pediatrics CCC Corner\*:

I would like to refer readers to another study which showed benefits of
delayed cord clamping in preterm neonates -

CONCLUSION: The research design is feasible. The immediate benefit of
improved blood pressure was confirmed and other findings deserve
consideration for further study.

[Mercer JS, McGrath MM, Hensman A, Silver H, Oh
W.](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=13679933&query_hl=6)
Immediate and delayed cord clamping in infants born between 24 and 32
weeks: a pilot randomized controlled trial. J Perinatol. 2003
Sep;23(6):466-72.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=13679933&query_hl=6>

.....and to an excellent review of this topic which concluded that there
were benefits of delayed cord clamping in both preterm and full term
neonates.

CONCLUSION: For both term and preterm infants, few, if any, risks were
associated with delayed cord clamping. Longitudinal studies of infants
with immediate and delayed cord clamping are needed.

[Mercer
JS.](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11783688&query_hl=6)
Current best evidence: a review of the literature on umbilical cord
clamping.\
J Midwifery Womens Health. 2001 Nov-Dec;46(6):402-14. Review.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11783688&query_hl=6>

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

At this time the comments above are best applied to pre-term delivery as
the weight of evidence favors early cord clamping in term delivery.

There are two main approaches to term third stage management

Expectant management --- Expectant or physiologic management consists of
delivery of the placenta without the use of uterotonic agents, cord
clamping, or cord traction.\
\
Active management --- Active management generally consists of early cord
clamping, controlled cord traction, and administration of a uterotonic
agent.

A classic study randomly assigned 1795 women to expectant or active
third stage labor management. Actively managed patients

-received 5 IU of oxytocin and 0.5 mg of ergometrine upon delivery of
the fetal anterior shoulder

-followed by controlled cord traction.

Almost all women allocated to active management actually received it,
while just under one-half of those allocated to physiological management
received no intervention. The active management group had a
significantly lower incidence of postpartum hemorrhage (6 versus 18
percent) and a shorter median duration of the third stage (5 versus 15
minutes).

A Cochrane review of five studies comparing active versus expectant
management of the third stage of labor. Expectant management of the
third stage of labour involves allowing the placenta to deliver
spontaneously or aiding by gravity or nipple stimulation. Active
management involves administration of a prophylactic oxytocic before
delivery of the placenta, and usually early cord clamping and cutting,
and controlled cord traction of the umbilical cord.

Cochrane found that active management was associated with reduced risks
of: maternal blood loss (weighted mean difference -79.33 mL, 95 percent
CI -94.29 to -64.37); postpartum hemorrhage of more than 500 mL
(relative risk 0.38, 95 percent CI 0.32 to 0.46); and prolonged third
stage of labor (weighted mean difference -9.77 minutes, 95 percent CI
-10.00 to -9.53). Active management was defined as administration of a
prophylactic oxytocic before delivery of the placenta; typically with
early cord clamping and cutting and controlled traction of the umbilical
cord. The authors concluded that \"active management should be the
routine management of choice for women expecting to deliver a baby by
vaginal delivery in a maternity hospital.

Active management of labor is the most common standard of care for term
patients, plus there is recent data from Indian Country to support
active management of term third stage of labor in Indian Health.
<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0705_Feat.cfm#navajo>

**Resources**

Prendiville WJ; Elbourne D; McDonald S Active versus expectant
management in the third stage of labour. Cochrane Database Syst Rev
2000;(3):CD000007.

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

Prendiville WJ; Harding JE; Elbourne DR; Stirrat GM The Bristol third
stage trial: active versus physiological management of third stage of
labour. BMJ 1988 Nov 19;297(6659):1295-300.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=3144366&query_hl=12>

Rabe H, et al. Early versus delayed umbilical cord clamping in preterm
infants. Cochrane Database Syst Rev 2004;(3):CD003248

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15495045&query_hl=6]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15495045&query_hl=6)

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

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

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

May 2-6, 2006

Albuquerque, NM

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

Save the dates brochure

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Advancesflyer2006.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Advancesflyer2006.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocumentsadvancesflyer2006.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Miles Rudd, Warm Springs, OR {#miles-rudd-warm-springs-or .Style-Heading-4-+-Arial-14-pt-Underline}

#### Relative value of physical exam of the breast as a screening tool {#relative-value-of-physical-exam-of-the-breast-as-a-screening-tool .Style-Heading-4-+-Arial-14-pt-Underline}

#### Miles Rudd at Warm Springs, OR raised the issue of the relative value of physical exam of the breast exam in cancer screening. {#miles-rudd-at-warm-springs-or-raised-the-issue-of-the-relative-value-of-physical-exam-of-the-breast-exam-in-cancer-screening. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Here are some brief bulleted points for Dr. Eve Espey's presentation on Breast Cancer at the 2005 IHS / ACOG Obstetric, Neonatal and Gynecologic Care Postgraduate Course. More complete discussion below. {#here-are-some-brief-bulleted-points-for-dr.-eve-espeys-presentation-on-breast-cancer-at-the-2005-ihs-acog-obstetric-neonatal-and-gynecologic-care-postgraduate-course.-more-complete-discussion-below. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [Breast self exam (BSE) Canadian Task Force on Prevention\*]{.underline} {#breast-self-exam-bse-canadian-task-force-on-prevention .Style-Heading-4-+-Arial-14-pt-Underline}

#### Fair evidence of no benefit  {#fair-evidence-of-no-benefit .Style-Heading-4-+-Arial-14-pt-Underline}

#### Good evidence of harm  {#good-evidence-of-harm .Style-Heading-4-+-Arial-14-pt-Underline}

#### Overall fair evidence that routine teaching of BSE should be excluded from the annual exam {#overall-fair-evidence-that-routine-teaching-of-bse-should-be-excluded-from-the-annual-exam .Style-Heading-4-+-Arial-14-pt-Underline}

#### D recommendation {#d-recommendation .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [USPSTF: 2002, Should we recommend BSE?]{.underline} {#uspstf-2002-should-we-recommend-bse .Style-Heading-4-+-Arial-14-pt-Underline}

#### BSE: insufficient evidence to recommend for or against {#bse-insufficient-evidence-to-recommend-for-or-against .Style-Heading-4-+-Arial-14-pt-Underline}

#### "I" recommendation {#i-recommendation .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [Studies evaluating BSE]{.underline} {#studies-evaluating-bse .Style-Heading-4-+-Arial-14-pt-Underline}

#### 2 RCTs, 1 quasi RCT, 3 case-control studies {#rcts-1-quasi-rct-3-case-control-studies .Style-Heading-4-+-Arial-14-pt-Underline}

#### No difference in breast cancer mortality {#no-difference-in-breast-cancer-mortality .Style-Heading-4-+-Arial-14-pt-Underline}

#### No difference in stage of cancer at diagnosis {#no-difference-in-stage-of-cancer-at-diagnosis .Style-Heading-4-+-Arial-14-pt-Underline}

#### More provider visits: 8% vs. 4% {#more-provider-visits-8-vs.-4 .Style-Heading-4-+-Arial-14-pt-Underline}

#### More benign biopsies {#more-benign-biopsies .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [ACOG Practice Bulletin: Breast cancer screening, April, 2003]{.underline}  {#acog-practice-bulletin-breast-cancer-screening-april-2003 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Despite a lack of definitive data for or against breast self-examination, breast self-examination has the potential to detect palpable breast cancer and can be recommended. {#despite-a-lack-of-definitive-data-for-or-against-breast-self-examination-breast-self-examination-has-the-potential-to-detect-palpable-breast-cancer-and-can-be-recommended. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [Costs of BSE]{.underline} {#costs-of-bse .Style-Heading-4-+-Arial-14-pt-Underline}

#### \$700 per competent frequent self-examiner {#per-competent-frequent-self-examiner .Style-Heading-4-+-Arial-14-pt-Underline}

#### Opportunity cost: limited time for counseling {#opportunity-cost-limited-time-for-counseling .Style-Heading-4-+-Arial-14-pt-Underline}

#### Anxiety, worry, depression {#anxiety-worry-depression .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [Summary]{.underline} {#summary .Style-Heading-4-+-Arial-14-pt-Underline}

#### Take down your shower card for BSE {#take-down-your-shower-card-for-bse .Style-Heading-4-+-Arial-14-pt-Underline}

#### Encourage mammography {#encourage-mammography .Style-Heading-4-+-Arial-14-pt-Underline}

#### Work up palpable masses {#work-up-palpable-masses .Style-Heading-4-+-Arial-14-pt-Underline}

#### Don't worry quite so much... {#dont-worry-quite-so-much .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The data shows that the foundation of any breast cancer screening effort is a comprehensive mammography based program. The history and physical examination are an important adjuncts to screening, but should not delay, or become barriers to mammography. An equally important public health systems 'process' is a robust follow-up system. The RPMS Women's Health Program, or other tracking system software packages, can be critical to maintaining adequate screening follow up.  {#the-data-shows-that-the-foundation-of-any-breast-cancer-screening-effort-is-a-comprehensive-mammography-based-program.-the-history-and-physical-examination-are-an-important-adjuncts-to-screening-but-should-not-delay-or-become-barriers-to-mammography.-an-equally-important-public-health-systems-process-is-a-robust-follow-up-system.-the-rpms-womens-health-program-or-other-tracking-system-software-packages-can-be-critical-to-maintaining-adequate-screening-follow-up. .Style-Heading-4-+-Arial-14-pt-Underline}

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

What is the Indian Health Manual suggested approach? National
benchmarks?

The Indian Health Manual suggested approach is based on mammography and
is compatible with national benchmarks. The article referenced below is
a good summary of the national benchmarks, though is not entirely
internally consistent. The first part of the article articulates the
limitations of the data on clinical breast exam (CBE). The second part
(their 'Recommendations') is essentially a primer on performing the
extensive Mammacare exam.

Though Mammacare has been shown to find more lesions during the lengthy
exam, the increased detection of non-malignant lesions does not improve
breast cancer outcomes.

[Saslow
D](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Saslow+D"%5BAuthor%5D),
et al Clinical breast examination: practical recommendations for
optimizing performance and reporting. CA Cancer J Clin. 2004
Nov-Dec;54(6):327-44\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15537576&query_hl=2>

#### The above are just a few of Dr. Espey's many helpful points. The whole presentation is here: [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/BreastCa2005.ppt**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/BreastCa2005.ppt) {#the-above-are-just-a-few-of-dr.-espeys-many-helpful-points.-the-whole-presentation-is-here-httpwww.ihs.govmedicalprogramsmchmdocumentsbreastca2005.ppt .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Please also see the Reference Text Chapter from the Postgraduate Course {#please-also-see-the-reference-text-chapter-from-the-postgraduate-course .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/medicalprograms/MCH/M/MCHdownloads/Chap_P.pdf?page=2**](http://www.ihs.gov/medicalprograms/MCH/M/MCHdownloads/Chap_P.pdf?page=2) {#httpwww.ihs.govmedicalprogramsmchmmchdownloadschap_p.pdfpage2 .Style-Heading-4-+-Arial-14-pt-Underline}

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

IHS Manual Part 3 -- Chapter 13.11F1

"Resources for screening mammography should be identified for patients
at increased risk for breast cancer as based upon age as well as other
personal and familial risk factors."

<http://www.ihs.gov/PublicInfo/Publications/IHSManual/Part3/pt3chapt13/pt3chpt13.htm>

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

IHS Women's Health Breast Cancer web page

<http://www.ihs.gov/MedicalPrograms/MCH/W/WHcancer.asp#breast>

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

#### \*USPSTF and Canadian TFPHC Rating of evaluations {#uspstf-and-canadian-tfphc-rating-of-evaluations .Style-Heading-4-+-Arial-14-pt-Underline}

#### A: Strong recommendation to include the service  {#a-strong-recommendation-to-include-the-service .Style-Heading-4-+-Arial-14-pt-Underline}

#### B: Recommendation to include the service  {#b-recommendation-to-include-the-service .Style-Heading-4-+-Arial-14-pt-Underline}

#### C: No recommendation either for or against {#c-no-recommendation-either-for-or-against .Style-Heading-4-+-Arial-14-pt-Underline}

#### D: Recommendation against routine provision of the service  {#d-recommendation-against-routine-provision-of-the-service .Style-Heading-4-+-Arial-14-pt-Underline}

#### I: Evidence insufficient  {#i-evidence-insufficient .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Jennifer Retsinas, ANMC {#jennifer-retsinas-anmc .Style-Heading-4-+-Arial-14-pt-Underline}

#### Uterine fibroids: uterine artery embolization versus abdominal hysterectomy {#uterine-fibroids-uterine-artery-embolization-versus-abdominal-hysterectomy .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Compared with hysterectomy, UAE is safe and effective for treatment of bleeding fibroids, necessitates a shorter hospital stay, and results in fewer major complications {#conclusion-compared-with-hysterectomy-uae-is-safe-and-effective-for-treatment-of-bleeding-fibroids-necessitates-a-shorter-hospital-stay-and-results-in-fewer-major-complications .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**Pinto I**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Pinto+I"%5BAuthor%5D), et al Uterine fibroids: uterine artery embolization versus abdominal hysterectomy for treatment\--a prospective, randomized, and controlled clinical trial. Radiology. 2003 Feb;226(2):425-31. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12563136&query_hl=6**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12563136&query_hl=6) {#pinto-i-et-al-uterine-fibroids-uterine-artery-embolization-versus-abdominal-hysterectomy-for-treatment--a-prospective-randomized-and-controlled-clinical-trial.-radiology.-2003-feb2262425-31.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids12563136query_hl6 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### New Outreach: Updated educational materials about the Prescription Drug Benefit {#new-outreach-updated-educational-materials-about-the-prescription-drug-benefit .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.cms.hhs.gov/medicarereform/factsheets.asp**](http://www.cms.hhs.gov/medicarereform/factsheets.asp) {#httpwww.cms.hhs.govmedicarereformfactsheets.asp .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Many girls are at a literal standstill**

Decline in physical activity plays key role in weight gain among
adolescent girls

<http://www.nih.gov/news/pr/jul2005/nhlbi-13.htm>

**Trends and Regional Differences: Latest available**

It has come to my attention that some of you do not have the latest
Trends and Regional Differences publications produced by our Statistics
Branch. Please contact Lindy with your name address and we can mail them
to you. Archived 1999 and prior year PDF's of tables and graphics are
available at this link.
<http://www.ihs.gov/PublicInfo/Publications/index.asp>

**Great resource: MCH Alert**

If you have not subscribed to this list serve the link is below at the
end of the email and here as well.

To subscribe to MCH Alert, send an e-mail message to
<MCHAlert-request@list.ncemch.org>

with SUBSCRIBE in the subject line. You do not need to enter any text in
the body of the message.

**"Weaving WIC into Our Traditional Families"**

National Indian and Native American Coalition August 27-30, 2005 Tempe,
Arizona

[[http://www.itcaonline.com/event008/eventreg.html]{.underline}](http://www.itcaonline.com/event008/eventreg.html)

**Child Protection Handbook 2004, IHS/BIA**

IHS Office of Behavioral Health - BIA funded the development of a CD ROM

[[http://www.ccan.ouhsc.edu/nativeamerican.asp]{.underline}](http://www.ccan.ouhsc.edu/nativeamerican.asp)
or
[[http://www.ccan.ouhsc.edu/CPT.htm]{.underline}](http://www.ccan.ouhsc.edu/CPT.htm)

**Tribes and Tribal Organizations for Tobacco Prevention and Control
Grant**

Procurement and Grants Office, HHS:  Center for Disease Control and
Prevention\
<http://www.fedgrants.gov/Applicants/HHS/CDC/PGO/CDC-RFA-AA066/listing.html>

**Carol Treat, Nutritionist, ANMC**

**Brochure/support for sugar substitute and gestational DM**

[[http://www.ific.org/publications/brochures/upload/gestationaldiabetes.pdf]{.underline}](http://www.ific.org/publications/brochures/upload/gestationaldiabetes.pdf)

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

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

**Trial of Labor After Cesarean: Evidence based guidelines**

The American Academy of Family Physicians Commission on Clinical
Policies and Research convened a panel to systematically review the
available evidence on trial of labor after cesarean (TOLAC) using the
Agency for Healthcare Research and Quality \"Evidence Report on Vaginal
Birth After Cesarean (VBAC).\" The panel's objective was to provide an
evidence-based clinical practice guideline for pregnant women and their
families, maternity care professionals, facilities, and policy makers
who care about trial of labor and maternity care for a woman with one
previous cesarean. The recommendations are as follows:

**Recommendation 1:** Women with 1 previous cesarean delivery with a low
transverse incision are candidates for and should be offered a trial of
labor (TOL). (Level A)

**Recommendation 2:** Patients desiring TOLAC should be counseled that
their chance for a successful vaginal birth after cesarean (VBAC) is
influenced by the following: (Level B)

**Positive factors (increased likelihood of successful VBAC)**

Maternal age \<40 years

Previous vaginal delivery (particularly previous successful VBAC)

Favorable cervical factors

Presence of spontaneous labor

Non-recurrent indication that was present for previous cesarean delivery
(CD)

**Negative factors (decreased likelihood of successful VBAC)**

Increased number of previous CDs

Gestational age \>40 weeks

Birthweight \>4,000 g

Induction or augmentation of labor

**Recommendation 3:** Prostaglandins should not be used for cervical
ripening or induction, as their use is associated with higher rates of
uterine rupture and decreased rates of successful vaginal delivery.
(Level B)

**Recommendation 4:** TOLAC should not be restricted only to facilities
with available surgical teams present throughout labor, because there is
no evidence that these additional resources result in improved outcomes.
(Level C) At the same time, it is clinically appropriate that a
management plan for uterine rupture and other potential emergencies
requiring rapid cesarean section should be documented for each woman
undergoing TOLAC. (Level C)

**Recommendation 5:** Maternity care professionals need to explore all
the issues that may affect a woman's decision, including issues such as
recovery time and safety. (Level C) No evidence-based recommendation can
be made regarding the best way to present the risks and benefits of
TOLAC to patients.

[Borgmeyer
C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Borgmeyer+C"%5BAuthor%5D);
[American Academy of Family
Physicians](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="American+Academy+of+Family+Physicians"%5BCorporate+Author%5D).Guideline
showcases AAFP\'s commitment to evidence-based, patient-centered care -
Trial of Labor After Cesarean (TOLAC), Formerly Trial of Labor Versus
Elective Repeat Cesarean Section for the Woman With a Previous Cesarean
Section. *Annals of Family Medicine* 3:378-380 (2005)

<http://www.annfammed.org/cgi/data/3/4/378/DC1/1>

or

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16046579&dopt=Abstract>

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

This document is helpful as it more strictly applies the available
scientific literature, rather than relying as heavily on tort liability
as a premise. The Indian Health system has had extensive discussions
about emergency vaginal delivery in rural settings. As symptomatic
uterine rupture is a relatively rare event, it is highly recommended
that each center offering vaginal delivery have periodic drills on
various other emergency delivery scenarios to assure that the whole
labor and delivery system is capable of a timely response.

**Other Resources**

**Vaginal Birth After Cesarean (VBAC), AHRQ, Evidence Report/Technology
Assessment: Number 71** <http://www.ahrq.gov/clinic/epcsums/vbacsum.htm>

[**VBAC: Is There Such a Thing as Low
Risk?**](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/NewMexico.ppt)

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

[**Emergency Delivery Simulations: How to Develop
Teamwork**](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/Talk.ppt)

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

[Leeman
L](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Leeman+L"%5BAuthor%5D),
[Leeman
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Leeman+R"%5BAuthor%5D).
Do all hospitals need cesarean delivery capability? An outcomes study of
maternity care in a rural hospital without on-site cesarean capability.
J Fam Pract. 2002 Feb;51(2):129-34.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=11978210&dopt=Abstract>

Leeman, L, Leman, R. A Native American Community with a 7% Cesarean
Delivery Rate: Does Case Mix, Ethnicity, or Labor Management Explain the
Low Rate? *Annals of Family Medicine* 1:36-43 (2003)
<http://www.annfammed.org/cgi/content/full/1/1/36>

Vaginal birth after previous cesarean delivery. ACOG Practice Bulletin
No. 54. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2004;104:203--12.

**ACOG non-members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15229039&query_hl=5>

**ACOG Members**

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

**Other Obstetric Hot Topics**

**Time of birth and risk of neonatal death: 12-16% increase in mortality
at night**

[Conclusion:]{.underline} Identifying the causal factors and reducing
the increased burden of mortality for infants born at night should be a
major priority for perinatal medicine. Level of Evidence: III.

\* After adjusting for the adequacy of prenatal care, complications of
pregnancy, gender, and birthweight, mortality for infants born during
early night and those born during late night increased by 12% and 16%,
respectively, compared with mortality for infants born during the day.

\* There was an increase in mortality for both VLBW infants and non-VLBW
infants born during early and late night.

\* Mortality was significantly elevated for singletons born during early
and late night. For multiples, mortality was elevated only for infants
born during early night.

\* During early night there was a significant increase in the mortality
of infants delivered vaginally but not in the mortality of infants
delivered by cesarean. During late night, the situation was reversed:
there was a marked increase in the mortality of infants delivered by
cesarean but only a weak increase among infants delivered vaginally.

\* After adjusting for differences in risk across time, there was no
significant elevation in mortality for infants born in primary care
hospitals. In hospitals with intermediate intensive care, infants born
during early or late night had elevated mortality. In hospitals
providing community and regional intensive care, mortality was elevated
only for infants born during late night.

Gould JB, Qin C, Chavez G. 2005. Time of birth and the risk of neonatal
death. Obstetrics & Gynecology 106(2):352-358.
[[http://www.greenjournal.org/cgi/content/abstract/106/2/352]{.underline}](http://www.greenjournal.org/cgi/content/abstract/106/2/352)
or

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16055587&dopt=Abstract>

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

There have been several studies of European births during the 1990s
reported increased mortality for infants born at night, yet no reports
have been published about neonatal mortality by hour of birth in the
United States. The article describes a study to determine whether the
time of birth influenced the risk of neonatal death for infants born in
California. This study provides Level III evidence that infants born at
night have a 12-16% increase in mortality and it needs be confirmed with
larger prospective trials before major health care shifts are
considered.

In the meantime, considering the implications of the evidence to date,
facilities in the Indian Health system should carefully investigate
their local data and consider reevaluating their diurnal staffing
patterns.

**Parietal peritoneum closure during cesarean delivery decreases
adhesions**

Conclusion: Parietal peritoneal closure at primary cesarean delivery was
associated with significantly fewer dense and filmy adhesions. The
practice of nonclosure of the parietal peritoneum at cesarean delivery
should be questioned. Level of Evidence: II-2.\
[Lyell
DJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Lyell+DJ"%5BAuthor%5D)
et al Peritoneal closure at primary cesarean delivery and adhesions.
Obstet Gynecol. 2005 Aug;106(2):275-80.,

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16055575&dopt=Abstract>

**Aerobic training increases exercise capacity, overcoming negative
effects of pregnancy**

Conclusion: Aerobic training in overweight pregnant women substantially
increases submaximal exercise capacity, overcoming the otherwise
negative effects of pregnancy in this regard. Additional studies are
required to evaluate its effect on major clinical outcomes. LEVEL OF
EVIDENCE: I. [Santos
IA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Santos+IA"%5BAuthor%5D),
et al Aerobic Exercise and Submaximal Functional Capacity in Overweight
Pregnant Women: A Randomized Trial. Obstet Gynecol. 2005
Aug;106(2):243-249\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16055571&dopt=Abstract>

**Prepregnancy obesity: Increasing excess risk of fetal death with
advancing gestation**

Conclusion: Prepregnancy obesity was associated with an increasing
excess risk of fetal death with advancing gestation, and placental
dysfunction may be a possible contributing factor. Level of Evidence:
II-2. [Nohr
EA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Nohr+EA"%5BAuthor%5D)
et al Prepregnancy Obesity and Fetal Death: A Study Within the Danish
National Birth Cohort. Obstet Gynecol. 2005 Aug;106(2):250-259.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16055572&dopt=Abstract>

**Interpregnancy intervals \< 12 months \> 59 months associated adverse
perinatal outcomes**

Conclusion: In Latin America, interpregnancy intervals shorter than 12
months and longer than 59 months are independently associated with
increased risk of adverse perinatal outcomes. These data suggest that
spacing pregnancies appropriately could prevent perinatal deaths and
other adverse perinatal outcomes in the developing world. Level of
Evidence: II-2.

[Conde-Agudelo
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Conde-Agudelo+A"%5BAuthor%5D)
et al Effect of the Interpregnancy Interval on Perinatal Outcomes in
Latin America. Obstet Gynecol. 2005 Aug;106(2):359-366.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16055588&dopt=Abstract>

**Study finds that screening asymptomatic, low-risk pregnant women for
hepatitis C virus is not cost effective**
<http://www.ahrq.gov/research/jul05/0705RA16.htm>

**Simple blood test may predict deadly pregnancy complications**

CONCLUSION: Our results indicate that HLA-G levels in plasma from women
who subsequently develop PE are lower than control patients, as early as
the first trimester. This suggests that determination of circulating
HLA-G protein concentration may be useful as an early predictor for the
development of PE. [Yie
SM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Yie+SM"%5BAuthor%5D),
[Taylor
RN](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Taylor+RN"%5BAuthor%5D),
[Librach
C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Librach+C"%5BAuthor%5D).Low
plasma HLA-G protein concentrations in early gestation indicate the
development of preeclampsia later in pregnancy. Am J Obstet Gynecol.
2005 Jul;193(1):204-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16021080&query_hl=3>

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

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

**Ovarian conservation benefits survival in women when undergoing
hysterectomy**

Conclusion: Ovarian conservation until at least age 65 benefits
long-term survival for women at average risk of ovarian cancer when
undergoing hysterectomy for benign disease. Level III\
[Parker
WH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Parker+WH"%5BAuthor%5D)
et al Ovarian Conservation at the Time of Hysterectomy for Benign
Disease. Obstet Gynecol. 2005 Aug;106(2):219-226.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16055568&dopt=Abstract>

Editorial- [Olive
DL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Olive+DL"%5BAuthor%5D).
Et al Dogma, skepsis, and the analytic method: the role of prophylactic
oophorectomy at the time of hysterectomy. Obstet Gynecol. 2005
Aug;106(2):214-5.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16055566&dopt=Abstract>

**Hysterectomy Associated With Earlier Onset of Menopause**

CONCLUSIONS: Hysterectomy is associated with an earlier onset of
menopause. Hysterectomy with unilateral oophorectomy is associated with
an even earlier onset of the menopause in this study. [Farquhar
CM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Farquhar+CM"%5BAuthor%5D),
et al The association of hysterectomy and menopause: a prospective
cohort study. BJOG. 2005 Jul;112(7):956-62.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15957999&query_hl=25>

**One in ten adult women perceives urinary incontinence to be barrier to
exercise**

Conclusion: Urinary incontinence is perceived as a barrier to exercise,
particularly by women with more severe leakage. Level of Evidence: II-3.
[Nygaard
I](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Nygaard+I"%5BAuthor%5D),
et al Is Urinary Incontinence a Barrier to Exercise in Women? Obstet
Gynecol. 2005 Aug;106(2):307-314.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16055580&dopt=Abstract>

**Reclosure of the disrupted laparotomy wound is safe and successful in
over 80%**

Conclusion: Reclosure of disrupted laparotomy wounds was successful in
over 80% of patients. Failed reclosure resulted in no life-threatening
complications. Reclosure of disrupted laparotomy wounds is safe and
decreases healing times.

[Wechter
ME](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Wechter+ME"%5BAuthor%5D),
et al Reclosure of the Disrupted Laparotomy Wound: A Systematic Review.
Obstet Gynecol. 2005 Aug;106(2):376-383.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16055590&dopt=Abstract>

### **Cervical cytology screening and evaluation - Clinical Expert Series**

In this article, I will explain how I have incorporated some of the new
guidelines into my practice, how the use of the human papillomavirus DNA
(HPV-DNA) test can help us manage patients, and how I approach minimally
abnormal cytology and biopsy (CIN1).

[Noller
KL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Noller+KL"%5BAuthor%5D).Cervical
cytology screening and evaluation. Obstet Gynecol. 2005
Aug;106(2):391-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16055593&dopt=Abstract>

**Diagnosis and Management of Uncomplicated Urinary Tract Infections**

<http://www.aafp.org/afp/20050801/451.html>

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

AAP Releases Report on Excessive Sleepiness in Adolescents

Inadequate sleep has become a widespread problem for adolescents.
Physicians have an important role in identifying adolescent patients at
risk for inadequate sleep and in providing counseling and support to
help manage sleep-related symptoms.

Common causes of sleepiness in adolescents include normal changes that
occur during the transition into adolescence (e.g., varying sleep/wake
times, relaxed parental control of bedtimes, changing school start
times). Many adolescents also have part-time jobs that cut into their
sleep time. Studies have shown that the biological system that regulates
circadian rhythms may change during adolescence, creating a later timing
of sleep. Because of these changes, adolescents get less sleep than they
did as children. Insomnia, narcolepsy, idiopathic hypersomnia, restless
legs syndrome, and numerous medications are also common causes of
inadequate sleep in adolescents.

Lack of sleep can affect adolescents\' cognitive function, concentration
and attention, alertness, and ability to perform in school. Studies have
shown that many adolescents who have sleep disorders also have symptoms
of attention-deficit/hyperactivity disorder. Adolescents with clinical
mood disorders, especially severe depression, report higher incidences
of sleep disturbance. Sleepiness is also the leading cause of motor
vehicle crashes among drivers 16 to 29 years of age.

The AAP concludes that physicians should recognize the significant
problem of sleepiness among their adolescent patients. Physicians need
to ask questions about sleep patterns, how much sleep their adolescent
patients are getting, and if they are having any sleep-related symptoms.
A sleep history should focus on the following points:

• Bedtime problems

• Excessive daytime sleepiness

• Awakenings during the night

• Regularity and duration of sleep

• Sleep-disordered breathing (e.g., loud snoring)

AAP recommends educating adolescent patients about their sleep needs and
the detrimental effects of sleep loss on performance and health.

Based on a meta-analysis, June 2005 issue of *Pediatrics*.
<http://www.aafp.org/afp/20050715/practice.html>

[**High-Grade Cervical Lesions Progress in Adolescents at Similar Rate
as in Adults\
**](http://mp.medscape.com/cgi-bin1/DM/y/hq120G875W0Dzc0Gk8W0EZ)CONCLUSION:
Adolescents with LSIL and HSIL cytology are at significant risk for
progression to high-grade cervical abnormalities. The rate of
development of high-grade cervical abnormalities in adolescents is
similar to adults. Adolescents with cytologic abnormalities mandate
close follow-up. LEVEL OF EVIDENCE: II-3.\
[Wright
JD](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Wright+JD"%5BAuthor%5D),
et al Cervical dysplasia in adolescents. Obstet Gynecol. 2005
Jul;106(1):115-20.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15994625&dopt=Abstract>

**Reducing the Risk of SIDS Through Community Partnerships: Editorial**

<http://www.aafp.org/afp/20050715/editorials.html>

**Fetal Alcohol Spectrum Disorders**

<http://www.aafp.org/afp/20050715/279.html>

**Rural hospitals appear to deliver care similar to non-rural hospitals
for many common pediatric conditions**
<http://www.ahrq.gov/research/jun05/0605RA16.htm#head16>

**Nurses can take steps to prevent pediatric medication errors
associated with dosing and administration**
<http://www.ahrq.gov/research/jun05/0605RA17.htm#head17>

**Foreign Body Ingestion in Children (also see Patient Education)**

<http://www.aafp.org/afp/20050715/287.html>

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

Guidelines for Improving Vaccination Rates Among High-Risk Adults, CDC

The Task Force on Community Preventive Services of the Centers for
Disease Control and Prevention (CDC) has issued an evidence-based review
of interventions to improve influenza, pneumococcal polysaccharide, and
hepatitis B vaccination coverage among high-risk adults younger than 65
years. The recommendations were based on a systematic review. *Morbidity
and Mortality Weekly Report* April 1, 2005
<http://www.cdc.gov/mmwr/PDF/rr/rr5405.pdf>

**Bariatric Surgery Resolves Comorbid Conditions**

Preventive measures carry the highest hope for managing obesity at the
lowest cost. Meanwhile, this review shows that bariatric surgery is far
more effective in treating obesity than diet, exercise, or pharmacologic
management. Because of the high rate of morbidity and increased
mortality associated with epidemic levels of obesity, a cost-benefit
analysis is likely to favor surgical intervention. For those who are not
candidates for bariatric surgery, recommendations for conventional
weight loss goals are 10 percent of body weight. Patients should be told
that a 10-kg (22-lb) weight loss results in multiple health benefits,
including decreased angina, lower blood pressure, and lower lipid and
blood sugar levels. The results, however, will not be nearly as dramatic
as those cited here.

[CONCLUSIONS:]{.underline} Effective weight loss was achieved in
morbidly obese patients after undergoing bariatric surgery. A
substantial majority of patients with diabetes, hyperlipidemia,
hypertension, and obstructive sleep apnea experienced complete
resolution or improvement.\
[Buchwald
H](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Buchwald+H"%5BAuthor%5D),
et al Bariatric surgery: a systematic review and meta-analysis. JAMA.
2004 Oct 13;292(14):1724-37.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15479938&query_hl=8>

**Tobacco Cessation: Kicking the Habit in Alaska**

Part 5 of a 5-Part Series - July 15, 2005 State of Alaska: Section of
Epidemiology

<http://www.epi.alaska.gov/bulletins/docs/rr2005_01.pdf>

**Existing coronary heart disease is undiagnosed in half of women who
have a first heart attack**
[[http://www.ahrq.gov/research/jun05/0605RA10.htm#head10]{.underline}](http://www.ahrq.gov/research/jun05/0605RA10.htm#head10)

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

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

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

Aspirin Prevents Stroke, but Not Cardiovascular Disease, in Women

[Clinical Question:]{.underline} Does aspirin prevent cardiovascular
disease in women?

###### **[Bottom Line:]{.underline}** Aspirin reduces the risk of stroke and transient ischemic attack in women, but does not reduce the risk of myocardial infarction or cardiovascular death. The reduction in strokes over 10 years (NNT = 444) must be balanced against an increase in serious gastrointestinal bleeding (NNH = 553). No change regarding all-cause mortality was seen in this large, long study. 

###### (Level of Evidence: 1b) [**http://www.aafp.org/afp/20050801/tips/9.html**](http://www.aafp.org/afp/20050801/tips/9.html)

Intensive Diet-Behavior-Physical Activity Program for Obesity in
Children

[Clinical Question]{.underline}: Can a specific program of diet and
exercise result in sustained weight loss in children?

[Bottom Line:]{.underline} An intensive three-month program of dietary
counseling, a hypocaloric diet, and structured exercise can cause weight
loss in children that is sustained over one year. More important, the
program seemed to increase the amount of exercise the children
performed, and this increase was sustained after the intervention was
discontinued. (

Level of Evidence: 2b) <http://www.aafp.org/afp/20050801/tips/7.html>

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

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

**Other AFP**

NSAIDs Alone or with Opioids as Therapy for Cancer Pain: Cochrane for
Clinicians

Clinical Scenario

A 70-year-old woman is diagnosed with malignant melanoma that has
metastasized to the liver and lungs. She has begun to experience
abdominal pain, which you attribute to the liver metastases. She wants
to know what you recommend for pain management.

Clinical Question

What is the most effective therapy for the management of cancer pain?

Evidence-Based Answer

Short-term trials indicate that cancer pain can be reduced with the use
of nonsteroidal anti-inflammatory drugs (NSAIDs) as initial monotherapy.
NSAIDs combined with opioids can result in slight short-term improvement
in pain compared with either agent alone. Long-term efficacy and safety
of NSAIDs for cancer pain have not been established.

<http://www.aafp.org/afp/20050801/cochrane.html#c1>

**Health Literacy: The Gap Between Physicians and Patients**

<http://www.aafp.org/afp/20050801/463.html>

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

**Management of Endometrial Cancer**

ACOG Practice Bulletin NUMBER 65, AUGUST 2005

**Summary of Recommendations and Conclusions**

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

-   Most women with endometrial cancer should undergo systematic
    surgical staging, including pelvic washings, bilateral pelvic and
    paraaortic lymphadenectomy, and complete resection of all disease.
    Exceptions to this include young or perimenopausal women with grade
    1 endometrioid adenocarcinoma associated with atypical endometrial
    hyperplasia and those at increased risk of mortality secondary to
    comorbidities.

-   Women with atypical endometrial hyperplasia and endometrial cancer
    who desire to maintain their fertility may be treated with progestin
    therapy. Following therapy they should undergo serial complete
    intrauterine evaluation approximately every 3 months to document
    response. Hysterectomy should be recommended for women who do not
    desire future fertility.

-   Patients with surgical stage I disease may be counseled that
    postoperative radiation therapy can reduce the risk of local
    recurrence, but the cost and toxicity should be balanced with the
    evidence that it does not improve survival or reduce distant
    metastasis.

-   For those women who have not received radiation therapy, pelvic
    examinations every 3--4 months for 2--3 years, then twice yearly
    following surgical treatment of endometrial cancer are recommended
    for detection and treatment of recurrent disease.

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

-   Women who cannot undergo systematic surgical staging because of
    comorbidities may be candidates for vaginal hysterectomy.

-   Only a physical examination and a chest radiograph are required for
    preoperative staging of the usual (type I endometrioid grade 1)
    histology, clinical stage I patient. All other preoperative testing
    should be directed toward optimizing the surgical outcome.

Management of endometrial cancer. ACOG Practice Bulletin No. 65.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2005;106:413--25

Non-ACOG Members

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16055605&query_hl=4>

ACOG Members

<http://www.acog.org/publications/educational_bulletins/pb065.cfm>

**Health Care for Homeless Women**

Homelessness is a considerable social and health problem in the United
States with far-reaching effects on the health of homeless women.
Homeless women are at higher risk for injury and illness and are less
likely to obtain needed health care than women who are not homeless. It
is critical to undertake efforts to prevent homelessness. Until this can
be accomplished, community-based services targeted specifically to this
population that provide both health care and support services are
essential. Health care providers can help address the needs of the
homeless by identifying their own patients who may be homeless, treating
their health problems, offering preventive care, and working with the
community to improve the full range of resources available to these
individuals.

Health Care for Homeless Women. ACOG Committee Opinion No. 312. American
College of Obstetricians and Gynecologists. Obstet Gynecol
2005;106:429--34.

Non-ACOG Members

<http://www.ncbi.nih.gov/entrez/query.fcgi>

ACOG Members

<http://www.acog.org/publications/committee_opinions/co312.cfm>

**Two Major Women\'s Health Groups Call Attention to a Leading
Reproductive Cancer**

The American College of Obstetricians and Gynecologists (ACOG) and the
Society of Gynecologic Oncologists (SGO) today issued guidance to
physicians for diagnosing, managing, and treating endometrial cancer,
the most common female genital tract malignancy. In the US, more than
40,000 women will be diagnosed with endometrial cancer this year; it is
the fourth most common cancer in women, behind lung, breast, and colon
cancer. Approximately 7,310 women die annually from the disease. Because
it is the most common cancer of the female reproductive system, nearly
all ob-gyns will encounter the disease sometime in their career.

Written in partnership with the SGO, the new ACOG Practice Bulletin,
\"Management of Endometrial Cancer,\" provides information on the
epidemiology, the cause(s) and effects of the disease, and the
management strategies, that will allow ob-gyns to identify women at
increased risk, help diagnose cases early, and recommend treatment
options. The document also outlines instances in which patients may
benefit from referral to a gynecologic oncologist.

\"This important collaboration between ACOG and SGO is another step we
have taken together to improve care for women with gynecologic
cancers,\" says James W. Orr, Jr, MD, ACOG Fellow and immediate past
president of SGO. \"The comprehensive guidance offered for the
management of women with endometrial cancer will contribute to improving
patient outcomes.\"

The most common cause of endometrial cancer is an excess of estrogen
unopposed by progestogen; it is more common in women who take estrogen
therapy alone, without a progestin hormone, after menopause. Women who
take combination birth control pills (estrogen plus progestin) appear to
have a lower risk. Women are at a higher risk of endometrial cancer if
they:

-   Do not ovulate regularly and often miss periods

-   Began menstruating before age 12

-   Have never been pregnant

-   Have a history of infertility

-   Are 50 or more pounds overweight

-   Have endometrial hyperplasia (abnormal thickening of the
    endometrium)

-   Have late menopause (on average, around age 51)

It is important to identify women at risk for endometrial cancer in
order to provide them with counseling and appropriate screening. In
addition, women with anovulatory disorders or problems with ovulation
should be counseled about their long-term risk of endometrial cancer,
and ways they can prevent or reduce their risk of the disease.

There is no standard screening test to detect endometrial cancer and
routine screening is not recommended because of the lack of an
appropriate, cost-effective, and acceptable test that reduces mortality.
Fortunately, most women (90%) with endometrial cancer develop
symptomatic vaginal bleeding or discharge that leads to an early
diagnosis and results in an increased opportunity for cure, notes ACOG.
Other symptoms include pelvic pressure or discomfort. A biopsy is the
accepted first step in evaluating a patient with abnormal uterine
bleeding or if endometrial cancer is suspected.

According to ACOG, most women with endometrial cancer should undergo
complete systematic surgical staging to help determine appropriate
management. Surgery is the most common treatment for women with
endometrial cancer. In the unusual instance when a patient is deemed an
exceptionally poor surgical candidate, radiation treatments alone may be
considered in an attempt to treat the uterine disease. Women with
atypical endometrial hyperplasia or very small endometrial cancer who
want to maintain their fertility may be treated with progestin therapy.

ACOG also recommends that to detect any recurrent disease, patients
should undergo pelvic exams every three to four months for two to three
years, then twice a year, after surgical treatment of the cancer.
<http://www.acog.org/from_home/publications/press_releases/nr08-01-05-3.cfm>

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

**Despite revised guidelines, most obstetrician/gynecologists continue
to over-screen low-risk women for cervical cancer**
<http://www.ahrq.gov/research/jun05/0605RA12.htm#head12>

**Physician supply increases in States with caps on malpractice lawsuit
awards, with the greatest impact in rural areas**
<http://www.ahrq.gov/research/jun05/0605RA1.htm>

**Women respond differently to medications than men and should be
proactive about their medication use**
<http://www.ahrq.gov/research/jun05/0605RA11.htm#head11>

**Efforts to help physicians improve care for underserved patients
should address issues of communication and respect**
<http://www.ahrq.gov/research/jul05/0705RA19.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}

**The Known and the Unknown - Clinical Evidence Summarized**

A new resource offering the best available evidence on the effects of
common clinical interventions is now available online. **Clinical
Evidence** summarizes what is known -- and not known -- on over 200
medical conditions and over 2,000 treatments seen in primary and
hospital care. **Clinical Evidence** is based on thorough searches and
appraisal of the literature. It is neither a textbook of medicine nor a
set of guidelines. Instead it describes the best available evidence from
systematic reviews, randomized control trials, and observational
studies. Here are some reasons **Clinical Evidence** may be useful to
you:

-   You start with a question -- **Clinical Evidence** does too

-   Evidence is presented in clear and easy-to-read summaries

-   New and updated topics are added monthly

-   Includes information on benefits, harms and outcomes which will help
    you with you treatment decisions

-   Saves you time and effort

    To access **Clinical Evidence** go to:
    [http://hsrl.nihlibrary.nih.gov](http://hsrl.nihlibrary.nih.gov/)

    Click on **Research Tools** \> **Databases** \> **Clinical
    Evidence**

##### 

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

#### Fentanyl During Labor May Impede Establishment of Breastfeeding {#fentanyl-during-labor-may-impede-establishment-of-breastfeeding-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: A dose-response relationship between fentanyl and artificial feeding has not been reported elsewhere. When well-established determinants of infant feeding are accounted for, intrapartum fentanyl may impede establishment of breastfeeding, particularly at higher doses {#conclusions-a-dose-response-relationship-between-fentanyl-and-artificial-feeding-has-not-been-reported-elsewhere.-when-well-established-determinants-of-infant-feeding-are-accounted-for-intrapartum-fentanyl-may-impede-establishment-of-breastfeeding-particularly-at-higher-doses .Style-Heading-4-+-Arial-14-pt-Underline}

[Jordan
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Jordan+S"%5BAuthor%5D),
et al The impact of intrapartum analgesia on infant feeding.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15957994&query_hl=21>

**Case Manager's Corner (R.N.)\***

**Stress and verbal abuse in nursing**

RESULTS: Respondents reported that the most frequent source of abuse was
nurses (27%), followed by patients\' families (25%), doctors (22%),
patients (17%), residents (4%), other (3%) and interns (2%). Of those
who selected a nurse as the most frequent source, staff nurses were
reported to be the most frequent nursing source (80%) followed by nurse
managers (20%). CONCLUSIONS: Verbal abuse in nursing is quite costly to
the individual nurses, the hospitals and the patients. Nurses who
regularly experience verbal abuse may be more stressed, may feel less
satisfied with their jobs, may miss more work and may provide a
substandard quality of care to patients.

[Rowe
MM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Rowe+MM"%5BAuthor%5D),
[Sherlock
H](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Sherlock+H"%5BAuthor%5D).
Stress and verbal abuse in nursing: do burned out nurses eat their
young? J Nurs Manag. 2005 May;13(3):242-8\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15819837&query_hl=23>

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

This is an important article that should serve to remind us that there
is no role for verbal abuse in the health care setting. As over ½ of the
sources of the verbal abuse are fellow health care workers, this problem
can be remedied with improved communication with our colleagues.

\*In lieu of a Case Manager submission, Reynaldo Espera, from ANMC Labor
and Delivery submitted the above

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

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

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

-USPSTF recommends that clinicians screen all pregnant women for HIV

-Simple Educational Handouts -- Kat Franklin, Sante Fe

-Elective Repeat Cesarean Delivery May Negatively Affect Neonatal
Outcomes

-Benzocaine spray does not offer effective pain control during per
endometrial biopsy

-OCPs are more effective than placebo for relieving dysmenorrhea in
adolescents

-Death rates for CVD are higher among AI/AN than other U.S. groups

-Pregnancy and Depression: What Women Need to Know

-What is an RN Case Manager?

-2 positive blood cultures found in a postpartum patient with a fever

-Benefits of low-fat dairy products on weight loss

-What Makes a Drug Over the Counter (OTC)? The case of Plan B

-Active management of the third stage of labor among American Indian
women

-Racial / Ethnic Disparities in Infant Mortality: No significant
improvement in AI / AN

-Use the talk / sing test during exercise during pregnancy

-Here is a good web based calcium screening tool

-Can chlamydia be stopped?

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05JulyOL.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05JulyOL.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocuments05julyol.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

**Developing Leaders in Violence Prevention -- Travel funding
available**

Please forward to any group that may be interested, including tribal
organizations. Program fees and accommodation costs are borne by the
Institute. Travel stipends are available for teams that may not be able
to afford travel. You can contact the institute for further information.
<Theresa.Cullen@IHS.GOV>

Cultural Competency for Non-Native Advocates and Ending Violence Against
Native Women Training Institute

##### September 24-30, 2005, Rapid City, SD

##### Sacred Circle National Resource Center to End Violence Against Native Women will hold two sessions at the Holiday Inn Rushmore Plaza.  Cultural Competency for Non-Native Advocates will address the realities for Native women and strategies for inclusion and recruitment of Native women by Non-Native programs on September 24 to 26.  The Ending Violence Against Native Women Training Institute will address colonization and violence against women, dynamics of battering, federal laws including the Violence Against Women Act, coordinating a tribal community response and prioritizing women's safety and offender accountability.  For more information, please call 1-877-733-7623. [**Theresa.Cullen@IHS.GOV**](mailto:Theresa.Cullen@IHS.GOV)

**The 2006 PREVENT Institute:  Developing Leaders in Violence
Prevention**

An intensive training experience for advanced multi-organizational teams
working to prevent violence before it starts.  This training is
different than our Workshop in length, intensity, content, application
process and types of teams selected.  Please go to
[*www.PREVENT.unc.edu*](../www.PREVENT.unc.edu) for more information on
both programs.

The **PREVENT** Institute builds skills to:\
- Enhance leadership for violence prevention and social change\
- Plan, implement, evaluate and sustain evidence-based prevention
efforts\
- Communicate effectively with policy makers, media and others\
- Develop partnerships and extend networks\
Visit
[http://www.prevent.unc.edu/education/institute.htm](http://www.prevent.unc.edu/)
for Institute information

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

**Toward optimal screening strategies for older women: Should cost
matter the most?**

CONCLUSIONS: If all women receive idealized treatment, the benefits of
mammography beyond age 79 are too low relative to their costs to justify
continued screening. However, if treatment is not ideal, extending
screening beyond age 79 could be considered, especially for women in the
top 25% of life expectancy for their age.

[Mandelblatt
JS](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Mandelblatt+JS"%5BAuthor%5D),
et al Toward optimal screening strategies for older women. J Gen Intern
Med. 2005 Jun;20(6):487-96.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15987322&query_hl=1>

**[Comment:]{.underline} Burt Attico, M.D. Retired USPHS**

This is a long paper, but its general theme is based on averages and
costs. The rates of cancer in women are generally stated as 1 in 8, but
that is actually the risk at age 85. This paper argues that screening is
expensive, and, as the population \"grays,\" this will amount to
increased costs for the health system, with the potential life
expectancy really not being increased significantly when breast cancer
is diagnosed. This is the reason for the testing frequency then dropping
when the patient gets older.

I am concerned about ethical issues with this type of cost reasoning,
where economics becomes one of the major factors in deciding whether a
health \"benefit\" is offered or not. I am going to present this to one
of my friends who serves on two local Ethics Committees.

This is a treatise based on \"evidence-based medicine,\" in which the
authors distort the recommended guidelines for doing breast CA
screening, and then say that you should probably totally forget
screening after age 79, since screening and treatment are dramatically
increasing the costs of Medical care (Medicare costs) for the number of
years that are saved when compared to life expectancy. 

Old people cost too much. That\'s a very crude way of saying it, but
I\'ve essentially distilled it; I got lost in their math.  They start by
saying that breast CA is mainly a disease of old-age, that incidence
goes up after 50, that the death rate is higher after age 65, but that
you should figure life expectancy when deciding whether or not to do
screening. They advocate screening [biennially]{.underline}, although
the present standard is [annually]{.underline}, and have their cost
model figured on biennial screening.\
\
I even went back and looked up the ACOG Clinical Practice Bulletins to
make sure.  This article definitely [conflicts]{.underline}, and puts a
**\$\$\$-cost** sign on the life and the health of older women.  I feel
that its implications are basically **unethical**, since the implication
is that these elders owe society a cost debt and should therefore pay
that debt by dying - sooner rather than later, regardless of their
health, regardless of whether they have something that is treatable or
not.  I think we might possibly discuss the issue (screening in elders)
the next time we meet (if ever).  Again, crude, but that was my
interpretation of this \$\$\$ laden article.

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

[**Over-The-Counter Sales of Emergency Contraception Do Not Increase
Unsafe
Sex**](http://mp.medscape.com/cgi-bin1/DM/y/hq120G875W0Dzc0GlAH0EU)

CONCLUSION: The awareness and use of EC were low in our study
population. They were not ready for more liberal delivery of ECPs as
less than 50% of women supported these new delivery modes and their
knowledge on ECPs use was inadequate.

[Wan
RS](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Wan+RS"%5BAuthor%5D),
[Lo
SS](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Lo+SS"%5BAuthor%5D).Are
women ready for more liberal delivery of emergency contraceptive pills?
Contraception. 2005 Jun;71(6):432-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15914132&query_hl=27>

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

**Q. Is there any help or assistance with infertility through the Indian
Health System?**

A. Yes, basic infertility services are provided in the ITU system.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Infertility81105.doc>

**Indian Child Health Notes**

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

-Pediatric sleep apnea - you know more than you think

-Sleepy teenagers - they are not just slugs, they\'re victims of biology

-TB in AI/AN is down, but not out

[[http://www.ihs.gov/MedicalPrograms/MCH/C/documents/ICHN805.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/C/documents/ICHN805.doc)

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

**VHA Pharmacy Benefits Management (PBM) Strategic Healthcare Group
page**

Many electronic resources about medication available

<http://www.vapbm.org/PBM/menu.asp>

**Free Online CME from Thomson Healthcare**

All specialties

[www.freecme.com](http://www.freecme.com/)

OB/GYN

<http://www.freecme.com/gcourses1.php?specialty_id=41&specialty_name=OB/GYN>

or go to the many posted Online CME sites on the Indian Health MCH site

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN02.cfm#top>

or Indian Health's own Perinatology Corner

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

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

**Increase the interdisciplinary and transdisciplinary focus in primary
health care research**

The \"Transdisciplinary Understanding and Training on Research - Primary
Health Care (TUTOR-PHC)\" program is accepting applications for its 2006
class of students. Program objectives are to build a critical mass of
skilled, independent researchers through both student and faculty
development; and to increase the interdisciplinary and transdisciplinary
focus in primary health care research.

APPLICANTS

-Any student/practicing professional regardless of home discipline with
an interest in primary health care research -Academic levels: Masters,
PhD, Post-doctoral fellow, mid-career clinicians

\- Deadline for application submission is October 31, 2005

FELLOWSHIPS AND OTHER BENEFITS

\- Strategic Training Fellowships ranging from \$17 850 to \$47 250 per
year depending on academic level and health professional status

\- Accredited as one full graduate course through The University of
Western Ontario

\- Trainees receive the distinction of \"CIHR Strategic Training
Fellow\"

\- Physicians receive up to 123 MAINPRO-M1 credits

CURRICULUM

The curriculum spans one year (May 2006-April 2007) and includes:

\- A three-day symposium held in May each year

\- On-line lab/discussion groups (total of 12 weeks)

\- On-line workshops (total of 6 weeks) and

\- Mentoring of students by established primary care researchers

Website:
[[www.uwo.ca/fammed/csfm/tutor-phc]{.underline}](../www.uwo.ca/fammed/csfm/tutor-phc)
e-mail: <tutor@uwo.ca>

Phone: 519-661-2111 x22089 Leslie Meredith, program coordinator

**Unite For Sight\'s 3rd Annual International Health Conference**

\"Empowering Communities to Bridge Health Divides\"\
When: April 1-2, 2006\
Where: Yale University, New Haven, Connecticut\
Theme: \"Empowering Communities to Bridge Health Divides\"\
Who should attend?  Anyone interested in medicine, health education,
health promotion, public health, international health, international
service, or eye care\
Conference Goal: To empower conference attendees to identify health
needs and to develop solutions to improve access to care for the
medically underserved\
<http://www.uniteforsight.org/2006_annual_conference.php>\
Early Bird Registration Rate: \$25 student rate; \$30 for all others\
How to Submit Abstract**:**
<http://www.uniteforsight.org/2006_conference_posters.php>

ABSTRACT SUBMISSION DEADLINE: AUGUST 15

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

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

**New edition of the Women's Health Data Book Released**

Women\'s Health USA 2005, the fourth 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 this edition include
household composition, maternity leave, contraception, and adolescent
pregnancy. The data book also highlights racial and ethnic disparities
and gender differences in women\'s health. 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.
[[http://mchb.hrsa.gov/whusa_05/index.htm]{.underline}](http://mchb.hrsa.gov/whusa_05/index.htm)

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

**Follow-up 2 positive blood cultures found in a postpartum patient with
a fever**

#### A little refresher from last issue {#a-little-refresher-from-last-issue .Style-Heading-4-+-Arial-14-pt-Underline}

-This 22 year old G1 P0 presented in active labor at 40 weeks gestation
after a benign prenatal course that was significant only for a positive
perineum and rectal culture for beta streptococcus group B screen at 36
weeks and a weight gain of over 50 pounds with a normal glucose
challenge test.

-The patient had a normal spontaneous delivery over a large 4th degree
laceration. There was also an extensive left perineal laceration with
avulsion. The patient had a standard repair of the 4th degree laceration
and a right vulvar skin flap closure of the left perineal laceration in
the delivery room. What followed was an unremarkable post partum course.
The patient remained afebrile throughout with an intact perineal repair
and had a normal bowel movement prior to discharge.

-The patient returned on postpartum day #5 with a temperature of 101.9
degrees F, a tender uterus with an intact perineum, and a WBC of 13.3K.
The patient was re-hospitalized for endometritis and treated with
metronidazole and ampicillin / sulbactam. The patient defervesced and
was discharged home again on post partum day #8. The patient was called
back into the hospital within hours of leaving when it was noted that 2
of her blood cultures had become positive.
<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0705_Feat.cfm#mmtour>

**The blood cultures positive with what organism? What was the source?**

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

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

#### The preliminary findings of gram negative rods isolated in both anaerobic bottles were called STAT to the provider. Subsequent identification revealed fusobacterium mortiferum in both bottles. {#the-preliminary-findings-of-gram-negative-rods-isolated-in-both-anaerobic-bottles-were-called-stat-to-the-provider.-subsequent-identification-revealed-fusobacterium-mortiferum-in-both-bottles. .Style-Heading-4-+-Arial-14-pt-Underline}

Anaerobes account for 2 to 5 percent of blood culture isolates from
patients with clinically significant bacteremia, but the rate is
decreasing reflecting the frequent use of anti-anaerobic antibiotics.
The most common blood culture isolates among anaerobes are the B.
fragilis group, which account for 60 to 80 percent. A review of the
suspected portal of entry for 855 episodes of bacteremia involving
anaerobes indicated an intraabdominal source in 52 percent, the female
genital tract in 20 percent, the lower respiratory tract in 6 percent,
the upper respiratory tract in 5 percent, and soft tissue infections in
8 percent.

#### Fusobacterium is one of the anaerobic bacteria species often involved in a variety of infections of the oral cavity and adjacent structures, including serious infections with suppurative (septic) thrombophlebitis of the jugular vein.  {#fusobacterium-is-one-of-the-anaerobic-bacteria-species-often-involved-in-a-variety-of-infections-of-the-oral-cavity-and-adjacent-structures-including-serious-infections-with-suppurative-septic-thrombophlebitis-of-the-jugular-vein. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### On the other hand, fusobacterium sp. are detected in amniotic fluid in preterm labor more commonly than other anaerobes. Fusobacterium burrow through amnion tissue rapidly and sometimes are present in amnion tissue in large numbers as if penetrating between the amnion epithelial cells. Large numbers of fusobacterium have been identified in Wharton's jelly. This suggests a peculiar propensity for these microorganisms to penetrate amnion tissue, which also covers the umbilical cord. Fusobacterium produce a variety of toxins, some of which are extraordinarily potent in stimulating cytokine formation in mononuclear phagocytes. In the setting of premature rupture of membranes it has been hypothesized that fusobacterium penetrate the fetal membranes after the tissues are exposed to these microorganisms in the cervical /vaginal fluid.  {#on-the-other-hand-fusobacterium-sp.-are-detected-in-amniotic-fluid-in-preterm-labor-more-commonly-than-other-anaerobes.-fusobacterium-burrow-through-amnion-tissue-rapidly-and-sometimes-are-present-in-amnion-tissue-in-large-numbers-as-if-penetrating-between-the-amnion-epithelial-cells.-large-numbers-of-fusobacterium-have-been-identified-in-whartons-jelly.-this-suggests-a-peculiar-propensity-for-these-microorganisms-to-penetrate-amnion-tissue-which-also-covers-the-umbilical-cord.-fusobacterium-produce-a-variety-of-toxins-some-of-which-are-extraordinarily-potent-in-stimulating-cytokine-formation-in-mononuclear-phagocytes.-in-the-setting-of-premature-rupture-of-membranes-it-has-been-hypothesized-that-fusobacterium-penetrate-the-fetal-membranes-after-the-tissues-are-exposed-to-these-microorganisms-in-the-cervical-vaginal-fluid. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The rest of the story {#the-rest-of-the-story .Style-Heading-4-+-Arial-14-pt-Underline}

The patient was treated with IV ampillin /sulbactam plus metronidazole
intravenously and discharged on oral metronidazole and amoxicillin /
clavulanate within 2 days of the positive blood cultures.

The patient initially did well as an outpatient, but had to be
re-admitted with a fever and a breakdown of her labial repair six days
later. The admission examination revealed that the 4^th^ degree
laceration also developed a small fistula. The patient was initially
treated with a broad spectrum anaerobic regimen IV, and subsequently
underwent debridement and a rectovaginal fistula repair 2 days later.

Though the source can not be known with complete certainty, due the
mixed microbiology of the genital system, it appears the source was the
perineal and 4^th^ degree lacerations, and not endomyometritis as
suspected with the patient's first postpartum admission.

The rectovaginal fistula repair was well healed 8 weeks later.

Here is more information on fusobacterium infections

[**Anaerobic bacterial
infections**](http://www.uptodateonline.com/application/topic/topicText.asp?file=bact_inf/34691&type=A&selectedTitle=2~13#top)

<http://www.uptodateonline.com/application/topic.asp?file=bact_inf/34691&type=A&selectedTitle=2~13>

[**Suppurative (septic)
thrombophlebitis**](http://www.uptodateonline.com/application/topic/topicText.asp?file=bact_inf/26863#top)

<http://www.uptodateonline.com/application/topic.asp?file=bact_inf/26863>

Have a case you would like to discuss in the Medical Mystery Tour?
Please contact <nmurphy@scf.cc>

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

######### Eating Disorders and Body Image Distress in Women at Midlife - CME

<http://www.medscape.com/viewprogram/4302?src=mp>

######### 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**

U.S. Preventive Services Task Force

Hormone Therapy for the Prevention of Chronic Conditions in
Postmenopausal Women

Summary of Recommendations

The USPSTF recommends against routine use of combined estrogen and
progestin for the prevention of chronic conditions in postmenopausal
women.

**D recommendation**.

The USPSTF found good evidence that the use of combined estrogen and
progestin results in both benefits and harms. Benefits include reduced
risk for fracture (good evidence) and colorectal cancer (fair evidence).
Combined estrogen and progestin has no beneficial effect on coronary
heart disease (CHD) and may even pose an increased risk (good evidence).
Other harms include increased risk for breast cancer (good evidence),
venous thromboembolism (good evidence), stroke (fair evidence),
cholecystitis (fair evidence), dementia (fair evidence), and lower
global cognitive function (fair evidence). Because of insufficient
evidence, the USPSTF could not assess the effects of combined estrogen
and progestin on the incidence of ovarian cancer, mortality from breast
cancer or coronary heart disease, or all-cause mortality. The USPSTF
concluded that the harmful effects of combined estrogen and progestin
are likely to exceed the chronic disease prevention benefits in most
women.

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

**D recommendation**.

The USPSTF found good evidence that the use of unopposed estrogen
results in both benefits and harms. The benefits include reduced risk
for fracture (good evidence). Harms include increased risk for venous
thromboembolism (fair evidence), stroke (fair evidence), dementia (fair
evidence), and lowered global cognitive functioning (fair evidence).
There is fair evidence that unopposed estrogen has no beneficial effect
on coronary heart disease. Because of insufficient evidence, the USPSTF
could not assess the effects of unopposed estrogen on the incidence of
breast cancer, ovarian cancer, or colorectal cancer, as well as breast
cancer mortality or all-cause mortality. The USPSTF concluded that the
harmful effects of unopposed estrogen are likely to exceed the chronic
disease prevention benefits in most women.

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

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

**Midwives Corner**: **Judy Whitecrane, Phoenix**

**Please help us build the Midwives Indian Health Patient Education
Resources page**

Do you have any good ideas about links to offer to your colleagues?

Send them to <nmurphy@scf.cc>

Here is what the Indian Health Patient Education Resources page has so
far:

CIR - Indian Health Patient Education Resources page

<http://www.ihs.gov/medicalprograms/CIR/index.cfm?module=cir_patient_education>

SIMPLE PATIENT EDUCATION HANDOUTS

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

Here is wide variety of MCH oriented Patient Education Resources

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

Each Perinatology Corner Module has topic specific Patient Education

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

Here is one example from the Perinatology module: Diabetes in Pregnancy.

<http://www.ihs.gov/MedicalPrograms/MCH/M/DP11.asp#patEdu>

(The patient education resources are usually on the 'Other Online
Resources' page of each module)

Consumer Health -- Features Easy to Read Resources

<http://www.ihs.gov/MedicalPrograms/consumer-health/>

**Women and Health Care: A National Profile**

A new national survey of women on their health finds that a substantial
percentage of women cannot afford to go to the doctor or get
prescriptions filled. Although a majority of women are in good health
and satisfied with their health care, many have health problems and do
not get adequate levels of preventive care. The report also examines
women's health status, health care costs, insurance, access to care,
prevention, and their role in family health care.

Women and Health Care: A National Profile is a nationally representative
telephone survey of 2,766 women ages 18 and older. A shorter companion
survey of 507 men was conducted for comparison purposes.
<http://www.kff.org/womenshealth/whp070705pkg.cfm>

**Navajo News Jean Howe, Chinle**

**Is the patch more dangerous than the pill?**

"*More fatalities than expected occur from birth control patch*"

On July 15^th^, an Associated Press article with this alarming title was
published in one of our local newspapers, The Gallup Independent. It
reported that there was a three-fold increased risk of death with
contraceptive patch use, as compared to oral hormonal contraceptive use,
based on cases reported to the FDA. They cite the following risks:

  --------------------------------------- -------------------- ----------
  Risk group                              Risk of non-fatal    Risk of
                                          blood clot           death

  Non-smokers, \<35 years old, on oral    1-3 in 10,000        1 in
  contraceptive pills                                          200,000

  Non-smokers, \<35 years old, using      12 in 10,000         3 in
  contraceptive patch                                          200,000
  --------------------------------------- -------------------- ----------

The article also states that 2 blood clots occurred in the 3,300 patch
users who participated in clinical trials prior to FDA approval.

The article is quite dramatic, including several touching vignettes of
young women who died unexpectedly while using the patch. It offers other
death rates for comparison, but only in a somewhat confusing table, and
not in the text itself. (These include a death rate of 28 per 100,000
per year for pill users under 35 who smoke, 143 per 100,000 for pill
users 35-44 years old who smoke, 10 per 100,000 for women at 20+ weeks
gestation, and 100 per 100,000 for motorcycle riders.) The article does
not state a risk for non-fatal blood clots associated with pregnancy.

This inflammatory article is another example of non-evidence based data
being presented to the public in a sensational manner. The FDA reports
are collected to look for unanticipated adverse outcomes associated with
medication use that were not identified in studies conducted prior to
FDA approval. Their collection is important but the information must be
interpreted with caution. Importantly, the AP article apparently bases
its risk calculations on a denominator of 800,000 patch users in 2004.
Ortho states that the actual number of patch users was closer to
2,000,000 in 2004; clearly that would change the risk calculations
dramatically.

This is a perplexing situation. Women's health providers wouldn't want
to ignore potentially important safety information about the patch. But
it is not clear that these spontaneously generated FDA reports actually
represent important new safety information. It is our duty as providers
to provide our patients with the best evidence-based information
available and protect them from media hysteria. The available data shows
that hormonal contraception does pose a slightly increased risk of blood
clots, regardless of route (pill, patch, or vaginal ring). This risk is
much less than the risk associated with pregnancy. For women who find it
difficult to use other methods reliably, the contraceptive patch remains
an excellent method of birth control. If anything this article
illustrates the need to encourage smoking cessation in all hormonal
contraception users under 35 and work with smokers 35 and over both to
find acceptable alternative methods of birth control and to quit
smoking.

**Resources**

FDA -- Home page

<http://www.fda.gov/default.htm>

FDA APPROVES FIRST HORMONAL CONTRACEPTIVE SKIN PATCH

<http://www.fda.gov/bbs/topics/ANSWERS/2001/ANS01119.html>

FDA and Johnson & Johnson Warn Public About Counterfeit Contraceptive
Patches Sold Through Foreign Internet Site

<http://www.fda.gov/bbs/topics/NEWS/2004/NEW01017.html>

Ortho Evra: Othro - McNeil

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

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

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

**Publications and Materials -- Many Women's Health Topics**

#### Link below to recent publications and other materials related to women\'s health, including fact sheets, recommendations, reports, disease trends, program strategies, and more. Click on a link below to get information on the Web by health topic or to get selected documents by fax. Supplies are limited and subject to change and availability. [**http://www.cdc.gov/od/spotlight/nwhw/pubs.htm**](http://www.cdc.gov/od/spotlight/nwhw/pubs.htm) {#link-below-to-recent-publications-and-other-materials-related-to-womens-health-including-fact-sheets-recommendations-reports-disease-trends-program-strategies-and-more.-click-on-a-link-below-to-get-information-on-the-web-by-health-topic-or-to-get-selected-documents-by-fax.-supplies-are-limited-and-subject-to-change-and-availability.-httpwww.cdc.govodspotlightnwhwpubs.htm .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-31 .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}

**Who do you contact in Oklahoma for MCH issues?**

Two contacts are Dr. George Chiarchiaro in the Area Office and Greggory
Woitte at Tahlequah. George is the MCH Coordinator and has a helpful
website with many resources

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHC07.cfm#top>

Greggory Woitte at Tahlequah is available at
<Greggory.Woitte@mail.ihs.gov>

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

**Ultralow-Dose Estradiol and BMD in Postmenopausal Women**

CONCLUSION: Postmenopausal treatment with low-dose, unopposed estradiol
increased bone mineral density and decreased markers of bone turnover
without causing endometrial hyperplasia. Ettinger B, et al. Effects of
ultralow-dose transdermal estradiol on bone mineral density: a
randomized clinical trial. Obstet Gynecol September 2004;104:443-51

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15339752&query_hl=18>

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

**Brochure/support for sugar substitute and gestational DM**

[[http://www.ific.org/publications/brochures/upload/gestationaldiabetes.pdf]{.underline}](http://www.ific.org/publications/brochures/upload/gestationaldiabetes.pdf)

**What to Do If Your Child Swallows Something?**

<http://www.aafp.org/afp/20050715/292ph.html>

#### Perinatology Picks George Gilson, Maternal Fetal Medicine, ANMC {#perinatology-picks-george-gilson-maternal-fetal-medicine-anmc .Style-Heading-4-+-Arial-14-pt-Underline}

#### Glyburide for gestational diabetes in a large managed care organization  {#glyburide-for-gestational-diabetes-in-a-large-managed-care-organization-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### RESULTS: In 1999 through 2000, 268 women had GDM diagnosed and were treated with insulin; in 2001 through 2002, 316 women had GDM diagnosed of which 236 (75%) received glyburide..... {#results-in-1999-through-2000-268-women-had-gdm-diagnosed-and-were-treated-with-insulin-in-2001-through-2002-316-women-had-gdm-diagnosed-of-which-236-75-received-glyburide.. .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: In a large managed care organization, glyburide was at least as effective as insulin in achieving glycemic control and similar birth weights in women with GDM who failed diet therapy. The increased risk of preeclampsia and phototherapy in the glyburide group warrant further study {#conclusion-in-a-large-managed-care-organization-glyburide-was-at-least-as-effective-as-insulin-in-achieving-glycemic-control-and-similar-birth-weights-in-women-with-gdm-who-failed-diet-therapy.-the-increased-risk-of-preeclampsia-and-phototherapy-in-the-glyburide-group-warrant-further-study .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**Jacobson GF**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Jacobson+GF"%5BAuthor%5D) et al Comparison of glyburide and insulin for the management of gestational diabetes in a large managed care organization. Am J Obstet Gynecol. 2005 Jul;193(1):118-24. {#jacobson-gf-et-al-comparison-of-glyburide-and-insulin-for-the-management-of-gestational-diabetes-in-a-large-managed-care-organization.-am-j-obstet-gynecol.-2005-jul1931118-24. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16021069&query_hl=1**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16021069&query_hl=1) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16021069query_hl1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Overweight and obese in gestational diabetes: the impact on pregnancy outcome {#overweight-and-obese-in-gestational-diabetes-the-impact-on-pregnancy-outcome-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### RESULTS: Four thousand and one women were enrolled. Obese women who achieved targeted levels of glycemic control had comparable pregnancy outcomes to normal weight and overweight women only when they were treated with insulin..... {#results-four-thousand-and-one-women-were-enrolled.-obese-women-who-achieved-targeted-levels-of-glycemic-control-had-comparable-pregnancy-outcomes-to-normal-weight-and-overweight-women-only-when-they-were-treated-with-insulin.. .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: In obese women with BMI \> or =30 with GDM, achievement of targeted levels of glycemic control was associated with enhanced outcome only in women treated with insulin. {#conclusion-in-obese-women-with-bmi-or-30-with-gdm-achievement-of-targeted-levels-of-glycemic-control-was-associated-with-enhanced-outcome-only-in-women-treated-with-insulin. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**Langer O**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Langer+O"%5BAuthor%5D) et al Overweight and obese in gestational diabetes: the impact on pregnancy outcome. Am J Obstet Gynecol. 2005 Jun;192(6):1768-76. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15970805&query_hl=3**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15970805&query_hl=3) {#langer-o-et-al-overweight-and-obese-in-gestational-diabetes-the-impact-on-pregnancy-outcome.-am-j-obstet-gynecol.-2005-jun19261768-76.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15970805query_hl3 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Glargine use in pregnancy? {#glargine-use-in-pregnancy-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### As Dr. Gilson has raised the issue of diabetes in pregnancy, here is a question that was posed to the Area Diabetes Program Director: {#as-dr.-gilson-has-raised-the-issue-of-diabetes-in-pregnancy-here-is-a-question-that-was-posed-to-the-area-diabetes-program-director .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### "There seems to be frequent discussion about glargine being best for type I diabetics (as their basal insulinization), but not for type 2 DM. Type 2 diabetics are often hyperinsulinemic - especially when pregnant. This comes up most frequently in pre-existing type 2 pregnant diabetics who have used glargine previously. I most frequently recommend switching them to NPH and lispro for the pregnancy.  {#there-seems-to-be-frequent-discussion-about-glargine-being-best-for-type-i-diabetics-as-their-basal-insulinization-but-not-for-type-2-dm.-type-2-diabetics-are-often-hyperinsulinemic---especially-when-pregnant.-this-comes-up-most-frequently-in-pre-existing-type-2-pregnant-diabetics-who-have-used-glargine-previously.-i-most-frequently-recommend-switching-them-to-nph-and-lispro-for-the-pregnancy. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Will you corroborate that philosophy, or am I just \"behind the times\". {#will-you-corroborate-that-philosophy-or-am-i-just-behind-the-times. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Response from the Alaska Area Diabetes Program Director: {#response-from-the-alaska-area-diabetes-program-director .Style-Heading-4-+-Arial-14-pt-Underline}

Glargine is being used extensively in type 2 diabetes.  The ANMC
pharmacy, however, has it restricted to type 1 patients at the present
time.  This is in part due to the cost concerns of glargine compared to
NPH.  We are working with pharmacy to develop a protocol which, after
approval by P & T, will allow us to use glargine in type 2 patient more
liberally. We do have around 60 type 2 diabetics on glargine at the
present time.  A recent article in Diabetes Care by Riddle looked at
night time NPH and glargine\*.  There was not great convincing evidence
that glargine was significantly better than NPH in type 2 patients;
however, there were less hypoglycemic episodes with the glargine group. 
Both groups had similar improvement in their A1c levels.  The main
advantage of glargine over NPH is it can be given any time of the day,
which makes it much more \"user friendly\" for patients.  It is no
longer necessary to only give in the evening. 

I had to do a little research to answer your second question.  And you
are not \"behind the times\", rather in line with what most
endocrinologists would recommend:

So, I had the opportunity to talk with an endocrinologist who has
in-depth knowledge of glargine last night and he helped answer your
question. 

Neither the analog insulins (lispro and aspart) nor glargine are FDA
approved for pregnancy.  Despite this, aspart and lispro are used in
pumps and for nutritional dosing during pregnancy without problems.  The
issue with glargine is its binding to IGF1 receptors: glargine has a 7X
greater affinity for IGF1 than other insulin(s).  This raises concerns
of increased risk of possible birth defects. 

Studies in rats and (I believe) rabbits have not shown evidence of
glargine related birth defects but (needless to say) there are no human
studies.  Therefore most endocrinologists would not recommend glargine
during pregnancy.  The endocrinologist I spoke with felt that this was,
in part, due to concerns of a baby born with a birth defect whose mother
has used glargine during her pregnancy.  The endocrinologist recommended
either changing the patient to NPH during the pregnancy or transitioning
the patient to a pump in the pre or post conception state.

**[CCC Comment:]{.underline}**

Until further data is available, regimens that include short and
intermediate acting insulin(s) are recommended for those Indian Health
patients using insulin as their hypoglycemic agent during pregnancy.

Here is the resource discussed above, as well as the Diabetes in
Pregnancy Guidelines posted on the MCH web page:

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

\*[Riddle
MC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Riddle+MC"%5BAuthor%5D),
et Al The treat-to-target trial: randomized addition of glargine or
human NPH insulin to oral therapy of type 2 diabetic patients. Diabetes
Care. 2003 Nov;26(11):3080-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14578243&query_hl=5>

[Riddle
MC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Riddle+MC"%5BAuthor%5D).
Timely initiation of basal insulin. Am J Med. 2004 Feb 2;116 Suppl
3A:3S-9S.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15013454&query_hl=5>

[Janka
HU](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Janka+HU"%5BAuthor%5D),
[Plewe
G](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Plewe+G"%5BAuthor%5D),
[Riddle
MC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Riddle+MC"%5BAuthor%5D),
et al Comparison of basal insulin added to oral agents versus
twice-daily premixed insulin as initial insulin therapy for type 2
diabetes. Diabetes Care. 2005 Feb;28(2):254-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15677775&query_hl=5>

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

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

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

Moderator: Chuck North\
-Are you comfortable using narcotics to treat chronic pain?\
-Is there abuse of prescription controlled medications in your
community?\
-What controls should health professionals have in place to regulate the
use of controlled substances? \
-Do you use pain contracts?  Are they useful?\
-What services are available to serve your chronic pain patients in
addition to primary care? \
-Are you successful in obtaining mental health services for your
patients?

**Other issues**\
-Describe your level of comfort based on your experience.\
-What are the most popular drugs?  Are narcotics, benzodiazepines or
stimulants most popular? \
-Are particular brand names valued more than others? \
-Do you know the local \"street value\" of prescription pills?\
-Would you like to consult with a psychiatrist yourself about some of
your patients?

This discussion is ongoing now so you can still jump in. The captured
discussion so far and a number of excellent resources available from
this discussion available here

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

(please scroll down to "Narcotics for......" in alphabetical order)

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

Subscribe to the Primary Care listserv

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

Unsubscribe from the Primary Care listserv

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

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

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

**Condom effectiveness for prevention of *Chlamydia trachomatis*
infection**

**Background/objectives:** A growing body of evidence is increasingly
demonstrating the effectiveness of condoms for sexually transmitted
infection (STI) prevention. The purpose of the present analysis was to
provide a disease specific estimate for the effectiveness of condoms in
preventing *Chlamydia trachomatis* infection while controlling for known
exposure to infection.

**Methods:** Condom effectiveness for *C trachomatis* was estimated
using a medical record database from a public sexually transmitted
disease clinic (n = 1455). Clients were classified as having known
exposure to *C trachomatis* if they presented to the clinic as a contact
to an infected partner.

**Results:** Among clients with known exposure, 13.3% of consistent
condom users were diagnosed with *C trachomatis* infection compared to
34.4% of inconsistent condom users (adjusted odds ratio = 0.10; 95% CI:
0.01 to 0.83). Among clients with unknown exposure, there was no
observed protective effect of condoms.

**Conclusions:** This study provides further evidence that condoms are
effective in preventing *C trachomatis* infection by reporting a disease
specific estimate and restricting analyses to individuals with known
exposure.

M Niccolai, A Rowhani-Rahbar, H Jenkins, S Green, and D W Dunne. Condom
effectiveness for prevention of *Chlamydia trachomatis* infection Sex
Transm Infect 81: 323-325          

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16061540&query_hl=1>

![](media/image2.png){width="5.873611111111111in"
height="3.563888888888889in"}

The percentage of male teens who reported ever having sexual intercourse
decreased significantly for both younger (aged 15\--17 years) and older
(aged 18\--19 years) teens from 1995 to 2002. Among females, the
percentage who reported ever having sexual intercourse declined
significantly for those aged 15\--17 years.
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5430a7.htm>

Additional information is available at
<http://www.cdc.gov/nchs/nsfg.htm>

**Other News on STIs**

**Prenatal screening and treatment are needed to identify pregnant women
with asymptomatic chlamydial infections**
<http://www.ahrq.gov/research/jul05/0705RA15.htm>

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

**Women the stronger gender? Men more carbohydrate intolerant / less
physical endurance**

CONCLUSIONS: Severely obese men were more carbohydrate-intolerant and
sustained less physical endurance than was predicted according to
standards in comparison with obese women. The cycle ergometer data
indicated that male gender was associated with less physical fitness.\
[Dolfing
JG](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Dolfing+JG"%5BAuthor%5D),
et al Different cycle ergometer outcomes in severely obese men and women
without documented cardiopulmonary morbidities before bariatric surgery.
Chest. 2005 Jul;128(1):256-62.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16002944&query_hl=2>

**Teen Inactivity Leads to Obesity for Girls**

Decreasing physical activity during adolescence seems to play a major
role in weight gain among girls as they transition from children to
women.  Inactive girls gained an average of 10 pounds to 15 pounds more
than girls who were active between the ages of 9 and 19.The number of
calories consumed increased marginally and did not appear to be
associated with the weight gain.

INTERPRETATION: Changes in activity levels of US girls during
adolescence significantly affected changes in BMI and adiposity. Thus,
preventing the steep decline in activity during adolescence is an
important method to reduce obesity.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16039332&query_hl=6>

**Cardiovascular Fitness Inversely Linked to Risk of Metabolic
Syndrome**

CONCLUSIONS: Low cardiorespiratory fitness is a strong and independent
predictor of incident metabolic syndrome in women and men. Clinicians
should consider the potential benefits of greater cardiorespiratory
fitness in the primary prevention of metabolic syndrome, particularly
among patients who have already begun to cluster metabolic syndrome
components.

[Lamonte
MJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Lamonte+MJ"%5BAuthor%5D),
et al Cardiorespiratory Fitness Is Inversely Associated With the
Incidence of Metabolic Syndrome. A Prospective Study of Men and Women.
Circulation. 2005 Jul 11;

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16009797&dopt=Abstract>

**Relationship of Obesity and Fitness Level to Cardiovascular Risk and
Diabetes **

CONCLUSIONS: Among women undergoing coronary angiography for suspected
ischemia, higher self-reported physical fitness scores were
independently associated with fewer CAD risk factors, less angiographic
CAD, and lower risk for adverse CV events. Measures of obesity were not
independently associated with these outcomes.

[Wessel
TR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Wessel+TR"%5BAuthor%5D),
et al Relationship of physical fitness vs body mass index with coronary
artery disease and cardiovascular events in women. JAMA. 2004 Sep
8;292(10):1179-87.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15353530&query_hl=9>

**New CERTs Program Brief on Women\'s Health Is Available**

AHRQ released a new program brief on women\'s health from its Centers
for Education and Research on Therapeutics (CERTs) program. The program
brief highlights risks and benefits identified in CERTs studies of
medical therapies in women such as the association between
cholesterol-lowering drugs and hip fractures, as well as heart rhythms
and the menstrual cycle, and antibiotic resistance and urinary tract
infections. It also addresses current treatment information for
physicians and their patients on the use of hormone therapy and
prescription drug use by pregnant women.
<http://www.ahrq.gov/clinic/certswomen.htm> or e-mail
<ahrqpubs@ahrq.gov>

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

#### Treatment and Management of HIV Infection in the United States {#treatment-and-management-of-hiv-infection-in-the-united-states .Style-Heading-4-+-Arial-14-pt-Underline}

#### September 15-18, 2005 {#september-15-18-2005 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Atlanta, Georgia {#atlanta-georgia .Style-Heading-4-+-Arial-14-pt-Underline}

#### 16.5 Credits, Univ. of California @ San Francisco / VA Administration {#credits-univ.-of-california-san-francisco-va-administration .Style-Heading-4-+-Arial-14-pt-Underline}

#### First domestic conference of its kind. Mark your calendar {#first-domestic-conference-of-its-kind.-mark-your-calendar .Style-Heading-4-+-Arial-14-pt-Underline}

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

**National Indian Health Board: Youth and Tradition - Our Greatest
Resources**

-   October 16-19, 2005

-   Phoenix, AZ

-   Distinguished presenters and informative workshops

-   <http://www.nihb.org/staticpages/index.php?page=200403301344379533>

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

-   May 2-6, 2006

-   Albuquerque, NM

-   Save the dates brochure

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

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

-   May 3--6, 2006

-   Anchorage, Alaska

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

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

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

-   May 6-10, 2006

-   Washington, DC

-   Save the dates brochure

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

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

**Q. Is there any help or assistance with infertility through the Indian
Health System?**

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Infertility81105.doc>

**[Prescription
Opioids:](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/2005prescropoidsgoodbadugly.ppt)
Good, bad, and ugly, Sidney Schnoll MD PHD**

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/2005prescropoidsgoodbadugly.ppt>

**Eve Espey M.D. - [Breast Cancer
Screening](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/BreastCa2005.ppt)**

**2005 IHS/ACOG Obstetric, Neonatal and Gynecologic Care Postgraduate
Course**

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/BreastCa2005.ppt>

There are several upcoming **Conferences**

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

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

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

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

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

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

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

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

The **July 2005 OB/GYN CCC Corner** is available at:\
<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0705.cfm>

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

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

USPSTF recommends that clinicians screen all pregnant women for HIV

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

### **Katherine Palatianos:** Brachial plexus injury: Permanent in 1 of every 10,000 deliveries

**Terry Cullen:** Native Peoples of North America HIV/AIDS Conference

#### Kat Franklin: Simple Patient Education Handouts {#kat-franklin-simple-patient-education-handouts .Style-Heading-4-+-Arial-14-pt-Underline}

#### Sandy Haldane: Science and Leadership: Women With Heart Disease {#sandy-haldane-science-and-leadership-women-with-heart-disease .Style-Heading-4-+-Arial-14-pt-Underline}

**Steve Holve:** July 2005 Indian Child Health Notes

**Harvey Huddleston:** Interested in part-time or locums tenens

**Phil Smith:** Encouraging Onsite Mammography: New mammography
standards for HSP

**Roy Teramoto:** HPV and Cervical Cancer: An Update on Prevention
Strategies

**Judy Thierry:**

-Useful atlas for injury causes of AIAN morbidity and mortality when
citing stats

#### -Ribavirin pregnancy registry - seeking enrollment Hepatitis C {#ribavirin-pregnancy-registry---seeking-enrollment-hepatitis-c .Style-Heading-4-+-Arial-14-pt-Underline}

-Rural/Frontier Women\'s Health Coordinating Centers (RFCCs) RFP is Out

-RFP for SIDS Training and Outreach in the AI/AN Communities

#### -Mean length stay for delivery hospitalization among AI/AN {#mean-length-stay-for-delivery-hospitalization-among-aian .Style-Heading-4-+-Arial-14-pt-Underline}

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

##### Obstetrics: page 10

-Treatment of GDM reduces perinatal morbidity, may improve
health-related quality of life

-Elective Repeat Cesarean Delivery May Negatively Affect Neonatal
Outcomes

-Indomethacin tocolysis not associated with increased risk of adverse
neonatal outcomes

-Diabetic Retinopathy Occurs in Pre-Diabetes: Implications in GDM

-No benefit to hospitalization in women with arrested preterm labor and
intact membranes

...and more

**Gynecology: page 13**

-High Intake of Calcium, Vitamin D May Reduce the Risk of Premenstrual
Syndrome

-Pediatric Torsed Ovaries May Be More Salvageable Than Previously
Reported

-Benzocaine spray does not offer effective pain control during per
endometrial biopsy

-US exam of the perineum after childbirth improves diagnosis of anal
sphincter tears

-Short-term results of the TVT procedure encouraging, but long-term is
disappointing

...and more

**Child Health: page 14**

-OCPs more effective than placebo treatment for relieving dysmenorrhea
in adolescents

-How to get your child off the couch? Evidence based physical activity
for youth

-Children's adaptation to a fat reduced diet

-Adolescent Pregnancy: Current Trends and Issues: American Academy of
Pediatrics

-Suicide Prevention among AI/AN Adolescents Evaluated: Public Health
Approach

...and more

**Chronic Illness and Disease: page 15**

-Death rates for CVD are higher among AI/AN than other U.S. groups
(AHRQ)

-Each Pound of Weight Lost May Reduce Knee Load per Step Fourfold

-Most parents want to quit smoking but they need assistance. Learn how
to help

-European study confirms red meat link with bowel cancer

-Self-Monitoring in Type 2 Diabetes Not on Insulin: A waste of money?

...and more

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

#### Features: page 17 {#features-page-17-1 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician

-Three Days of Ciprofloxacin Better for Uncomplicated UTI

-Gonorrhea

-Low-Molecular-Weight Heparin for Initial Treatment of Venous
Thromboembolism

-Follow-up After Surgically Treated Breast Cancer

American College of Obstetricians and Gynecologists

-Hemoglobinopathies in Pregnancy

-Pregnancy and Depression: What Women Need to Know

**Agency for Healthcare Research and Quality**

-Breast cancer risk and the effects of tamoxifen prophylaxis among women
in primary care

-Acupuncture appears promising for the treatment of depression during
pregnancy

**Ask a Librarian**

A new quick and easy way to find best clinical articles: PubMed Clinical
Queries

**Breastfeeding**

-1st week of life critical window for ingestion of maternal \"diabetic\"
breast milk

-Medication Use During Pregnancy and Breastfeeding

-Breastfeeding may be associated with a reduced risk of atherosclerosis

**Case Manager's Corner**

What is an RN Case Manager?

**CCC Corner Digest**

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

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

-Slight delay in umbilical cord clamping better for preterm infants

-Transdermal contraceptive promising for reducing bleeding and delaying
menses

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

-Women with pregnancy induced HTN: Increased risk for metabolic syndrome
later

-Urinary Incontinence in Women: Practice Bulletin NUMBER 63, JUNE 2005

-AskUs Live! Available to all Indian Health Staff

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

-Follow-up: Answer to the May Mystery Question

-Screening for Genital Herpes: USPSTF

-West Nile Virus in Women

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

-Screening for Gonorrhea: USPSTF Recommendation Statement

-Any new solutions to Nausea and Vomiting in Pregnancy?\
-New Perinatology Corner Free CEU / CME Module

**Domestic Violence**

#### Women who declined survey regarding DV at risk for adverse pregnancy outcome {#women-who-declined-survey-regarding-dv-at-risk-for-adverse-pregnancy-outcome .Style-Heading-4-+-Arial-14-pt-Underline}

#### Juvenile Justice Issues - Coordinating Council - Key Programs Advancing Youth {#juvenile-justice-issues---coordinating-council---key-programs-advancing-youth .Style-Heading-4-+-Arial-14-pt-Underline}

**Elder Care News**

-2nd Annual Alzheimer\'s Disease and Dementia Update Conference 

-Secondary Prevention of Coronary Heart Disease in Elderly Patients

-Nursing Guide to Prevention / Management of Falls in Patients in
Long-term Care Settings

-2005 ASCP Foundation Interdisciplinary GeroPsych/Behavioral Disorders
Traineeship

-Prevention of Falls in Older Patients

**Family Planning**

Low-dose oral contraceptives increase cardiovascular disease risk

**Frequently asked questions**

-Do you know of any good links to simple patient education?

-What are some good paper based women's resources for Advanced Practice
Nurses?

**Information Technology**

Computer-assisted cognitive therapy effectively treats depression: RCT

International Health

#### Medical Investigations of Homicides of Prisoners of War in Iraq and Afghanistan

Association between subsidized housing and children's nutritional status

#### MCH Alert

Health Care Insurance (SCHIP) Improves racial / ethnic health
disparities

#### Medical Mystery Tour

2 positive blood cultures found in a postpartum patient with a fever

#### Medscape

######### Mammography: Is Early Detection Really the Best Form of Prevention?

**Menopause Management**

-Benefits of low-fat dairy products on weight loss

-Testosterone Patch Helps Surgically Menopausal With Hypoactive Sexual
Desire: RCT

-SSRIs Ineffective for the Management of Hot Flashes

-Hormone replacement therapy plummeted after findings from the WHI trial
(AHRQ)

**Midwives Corner**

-USPSTF Issues Revised Guidelines for Routing Gonorrhea Screening

-What Makes a Drug Over the Counter (OTC)? The case of Plan B

-The Nursing Mothers Herbal

-Current Resources for Evidence-Based Practice

-National Indian Health Board Conference - Oct. 16-19, 2005, Phoenix

**Navajo News**

-Active management of the third stage of labor among American Indian
women

-Annual Navajo Area Women's Health Provider Meeting

-Upcoming ALSO Course in Shiprock

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

Racial / Ethnic Disparities in Infant Mortality: No significant
improvement in AI / AN

**Oklahoma Perspective**

Patient should be capable of talking or singing during exercise during
pregnancy

Osteoporosis

-Here is a good web based calcium screening tool

-Benefits and limitations of quantitative heel ultrasound in screening
for osteoporosis

Patient Education

-Simple Patient Education Handouts

-Endometriosis, from WebMD Health

-Guide to Endometriosis- [**More Printable Patient
FAQ\'s**](http://www.medscape.com/pages/editorial/public/index/faq)

Primary Care Discussion Forum

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

STD Corner

-Can chlamydia be stopped?

**-Chlamydia trachomatis infection in a colposcopy unit**

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

Waist Circumference Can Exclude Insulin Resistance and Identify Those At
Greatest Risk

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

#### What's new on the ITU MCH web pages page 32

The past CCC Corners are archived at:

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

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

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

or 907 729 3154 (with voicemail)

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

8/14/05