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OB/GYN Chief Clinical Consultant's Corner

Volume 5, No. 7, August 2007

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

#### Abstract of the Month page 6 {#abstract-of-the-month-page-6 .Style-Heading-4-+-Arial-14-pt-Underline}

**Within the Hidden Epidemic: STDs** **and HIV/AIDS Among AI/AN**

#### From your colleagues page 8 {#from-your-colleagues-page-8 .Style-Heading-4-+-Arial-14-pt-Underline}

**Scott Giberson**

# -Rapid HIV testing in emergency departments

-Treating Antiretroviral-Experienced Patients: Case-based CME Program\
-Stop the Silence

**James Holsinger Jr, Surgeon General Nominee**

Physician professionalism for a new century

**Favian Kennedy**

-How long does it take Nicotine to reach your brain after inhaling ?

-Northern Plains Tobacco Prevention Project: Spring Newsletter available
online

**Roberta Ward, Anchorage**

All you need to know about food safety during pregnancy, FDA

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

##### Obstetrics page 10

-VBAC: Labor induction outcome dependent on history of vaginal delivery
and cervix

-New Recommendation for Varicella Vaccine: Prenatal Assessment and
Postpartum Vaccination

-Postpartum Labial Adhesions

-Administration of cefazolin prior to skin incision is superior to
cefazolin at cord clamping

-Simulation-based, hands-on training can identify recurring errors in
emergencies

and others....

**Gynecology page 14**

-LEEP doubles risk of preterm delivery: Patients need to be informed

-Treatment of bleeding irregularities induced by progestin only
contraceptives: Effective

-Clinic management of early pregnancy failure: Safe, cost-effective

-Short-term superiority of effectiveness of transobturator tape reported

-Women in their 50s: fecal incontinence not associated with parity or
mode of delivery

and others....

**Child Health page 17**

-Physical Activity Alone May Not Reduce Obesity in Children

-Obese Young Adults Face High Diabetes Risk

-Increased risk of autism: associated with parental age and obstetric
conditions

-Physician Prompting Improves Asthma Preventive Care

-Child adiposity at 3 years: New recommendations for gestational weight
gain required?

and others....

**Chronic Illness and Disease page 18**

-Teratogenicity of SSRIs\--serious concern or much ado about little?

-American Native Suicide

-Depression: Deadlier in the Spring

-Rosiglitazone: seeking a balanced perspective

-How much does exercise help in weight loss?

and others....

#### Features page 21 {#features-page-21 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-Management of Herpes in Pregnancy

-Management of Adnexal Masses

-Sterilization of Women, Including Those With Mental Disabilities

-The Role of Cystourethroscopy in the Generalist Obstetrician
Gynecologist Practice

-Adoption

and others....

##### American Family Physician

-Screening for Breast Cancer: Current Recommendations and Future
Directions

-ACS Recommendations on MRI and Mammography for Breast Cancer Screening

-Ginger: An Overview

-CDC Changes Treatment Guidelines for Gonorrhea

-Headache (Chronic Tension-Type)

and others....

**Agency for Healthcare Research and Quality**

-Use of high-risk medications by pregnant women is not uncommon

-GI complaints in young women of low to normal weight may indicate
eating disorders

-Contribution of mammography and therapy to reducing breast cancer
deaths from 1975 to 2000

-PEDS with more knowledge of identifying and managing child abuse more
likely to identify abuse

-Oncologists communicate differently with breast cancer patients: age,
race, education, income

and others....

**Ask a Librarian**

*Scopus*™: A New Database

**Breastfeeding**

-My newborn likes the bottle better: What to do when

-New IHS Breast feeding Family Support web page: Have pictures to share?

-Cup feeding not be recommended over bottle feeding as a supplement to
breastfeeding

-Despite the benefits of early breastfeeding, many women find it
unexpectedly difficult and painful

**CCC Corner Digest**

-A new management category: 'First Trimester GDM'

-Control over schedule: Most important predictor of staff work-life
balance / burnout

-Placental problems with previous caesarean delivery: Abruptio, previa

-Discharge 24 Hours After Vaginal Hysterectomy Safe, Acceptable

-Guidelines for School-Based STD Screening in Indian Country

-Malabsorption of Oral Antibiotics in Pregnancy after Gastric Bypass
Surgery

-Seeking and Giving Consultation

-Long-Term Breastfeeding among Native American Women

-The failure to protect Indigenous women from sexual violence in the USA

-Reasons for unprotected intercourse

-What are the Unnecessary Tests?

-Improve HIV screening in pregnancy? Preliminary GPRA Related Results

-Social context of maternal deaths and morbidity

-Improve the system - Improve the care: Underpinnings

-Which Indian Health facilities lead the U.S. in national benchmarks?

-Earlier hormone therapy closer to menopause tended to have reduced CHD
risk

-Adjustable Urethral Slings: Hope for Patients with Complex Incontinence

-Personal Digital Assistants: Practical Advice for Nurses in 2007

-Placental cultures and histology poor predictors of infectious amniotic
fluid

-Electronic Health Record (EHR) Implementation: Worth the effort?

-Fluoroquinolones No Longer Recommended for Gonococcal Infections

-High rate of DM among indigenous people ?not due to thrifty gene

-Women's Early Drinking Problems More Likely to Escape Diagnosis

**Domestic Violence**

-IHS-ACF DV Project: Conference CD

-Family Violence Prevention Funds Screen to End Abuse Video

-Perceptions of Adult Patients' History of Child Abuse

-Study finds connection between teenage violence and domestic violence

-SANE: Is there a center near you?

and others....

**Elder Care News**

-Reporting Medical Conditions That May Affect Driving Competency: AAN
Guidelines

-Elderly patients with low health literacy receive little tangible
support for their health care needs

**Family Planning**

#### -Waiting until the menses to start hormonal contraceptives: Needless Obstacle  {#waiting-until-the-menses-to-start-hormonal-contraceptives-needless-obstacle .Style-Heading-4-+-Arial-14-pt-Underline}

-One In Four with Unplanned Pregnancy Experience Gaps In BCM Or Do Not
Use A Method

#### -Little variation in the frequency of reported symptoms among oral contraceptive pills {#little-variation-in-the-frequency-of-reported-symptoms-among-oral-contraceptive-pills .Style-Heading-4-+-Arial-14-pt-Underline}

#### -FDA Approves Contraceptive for Continuous Use {#fda-approves-contraceptive-for-continuous-use .Style-Heading-4-+-Arial-14-pt-Underline}

-Implanon and bone mineral density

and others....

**Featured Website**

-Contraception Online

-Last Special Issue on Methamphetamine in Indian Country: Now online

-Wrong link for National Sexual Violence Resource Center

**Frequently asked questions**

-Can oral or sublingual misoprostol be used for postpartum hemorrhage?

-How should you greet your patients?

-How can I better counsel my patient to adhere to therapy?

-Should patients use sweat lodges during pregnancy?

-What is recommended about peyote use in pregnancy

**Indian Child Health Notes**

-Lactose intolerance in infants, children, and adolescents.

-Influenza activity, 2006-7

-Inhalant abuse

-Fatal Injuries Among Children by Race and Ethnicity

**Information Technology**

-Integrated case management software application release

-iCare Training

International Health

-Maternal survival redux: a view from Malawi - Failure of justice

-Malarial drugs in early pregnancy

-Malaria Preventive Therapy Useful for Pregnant Women Despite Resistance

-Multivitamins should be considered for all pregnant women in developing
countries

#### MCH Alert

-Who needs liquor stores when parents will do?

-Home visiting associated with decreased infant death

-Resident fathers' prenatal behaviors, pregnancy intentions and
involvement with infants

-Office based motivational interviewing to prevent overweight in
children

-Association between confidential services and parent adolescent
**communiciation**

and others....

#### MCH Headlines

-Taking a harder line on blood transfusions

-Are you interested in the bigger picture of Indian Health care? Join a
listserv

-Do you know your state\'s teen-driving-laws?

-Program for At-Risk Infants and Mothers Recognized

-Adolescent Pregnancy Prevention Knowledge Path

and others....

#### Medical Mystery Tour

#### Nausea and Vomiting in Pregnancy {#nausea-and-vomiting-in-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

######### -Public Health Impact of HPV Vaccination: Aligning Policy With Science

######### -Premenstrual Dysphoric Disorder: A New Treatment Paradigm

-Hormone Therapy Safer in Younger Women? A Best Evidence Review

**Menopause Management**

-Hormone Replacement Therapy Linked to Ovarian Cancer 

-Menopause Linked to Elevated Fasting Plasma Glucose Levels in
Nondiabetic Women

-Exercise Plus Isoflavones May Improve Body Composition in
Postmenopausal Women

-Relation of Cortisol Levels and BMD Among Premenopausal Women With
Depression 

-New Guidelines Issued for Treatment of Vaginal Atrophy: NAMS

and others....

**Midwives Corner**

-Midwifery's approach to pre-labor SROM supported by professional
organization's journal

-Let it pulse---the cord that is

-Upright position during the first stage of labor did not contribute
towards a shorten labor

-Cesarean rate can be reduced by health workers in analyzing and
modifying their practice

-Midwives' perspectives improves risk assessment in early pregnancy

and others....

**Navajo News**

The evolution of management of Actinomyces on a Pap report

**Nurses Corner**

#### -Health Care Without Harm: Nurses Take Action {#health-care-without-harm-nurses-take-action .Style-Heading-4-+-Arial-14-pt-Underline}

#### -A Complementary Approach to Pain Management {#a-complementary-approach-to-pain-management .Style-Heading-4-+-Arial-14-pt-Underline}

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

-One Test. Two Lives Campaign

-Human Papillomavirus: HPV Information for Clinicians

**Oklahoma Perspective**

Preconception Health of Women Delivering Live-Born Infants --- Oklahoma,
2000--2003

Osteoporosis

-Dietary calcium is better than supplements at protecting bone health

-Calcium, Vitamin D supplements may help prevent weight gain in
postmenopausal women

-Down to the Bone: Issues in the Maintenance and Evaluation of Bone
Health: CME

Patient Education

#### Heavy Periods (Menorrhagia) {#heavy-periods-menorrhagia .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Anemia in Pregnancy Briefly: The Common to the Unusual -- including IV
therapy

-Contingent sequential screening is the most cost-effective form of Down
syndrome

-Aspirin during pregnancy could reduce risk of pre-eclampsia

-Abnormal Doppler is the best predictor of adverse perinatal outcome in
IUGR

-Changes in prepregnancy BMI between the first and second pregnancies
and risk of LGA

and others....

Primary Care Discussion Forum

Chronic Renal Disease: How is Primary Care Effected? Andy Narva,
September 1^st^

STD Corner

-Updated Screening for Chlamydial Infection Recommendations, USPSTF

#### -Sexually active women benefit from HPV vaccine {#sexually-active-women-benefit-from-hpv-vaccine .Style-Heading-4-+-Arial-14-pt-Underline}

#### -HPV vaccine against human papillomavirus to prevent anogenital diseases {#hpv-vaccine-against-human-papillomavirus-to-prevent-anogenital-diseases .Style-Heading-4-+-Arial-14-pt-Underline}

-Vulvar Vaccinia Infection After Sexual Contact with a Military Smallpox
Vaccinee

#### -A Series on Adolescence Sexual Activity {#a-series-on-adolescence-sexual-activity .Style-Heading-4-+-Arial-14-pt-Underline}

and others....

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

-(How) can we prevent type 2 diabetes?

-Prenatal Omega 3 Fatty Acid Consumption Improves Infant Problem Solving

-More Women than Men Having Mid-Life Stroke

#### -Diabetes Reduces Life Expectancy by 8 Years {#diabetes-reduces-life-expectancy-by-8-years .Style-Heading-4-+-Arial-14-pt-Underline}

#### -GDM represents a significant risk factor for future DM development regardless of ethnicity {#gdm-represents-a-significant-risk-factor-for-future-dm-development-regardless-of-ethnicity .Style-Heading-4-+-Arial-14-pt-Underline}

and others....

**Women's Health Headlines**

-Why do Native American women have the poorest 5-year survival rate for
breast cancer?

-Motivational Interviewing training and Promoting Motivational
Incentives: NIDA

-Aiming Higher: Results from a State Scorecard on Health System
Performance

-Women\'s emotional health and wellness materials

-Native American Rehabilitation Association: Children, Youth & Family
Services Director

###### Save the Dates: Upcoming events of interest page 74

#### What's new on the ITU MCH web pages page 74

-Should patients use sweat lodges during pregnancy?

-New Breast feeding Family Support web page: Have pictures to share?

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

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

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

**Within the Hidden Epidemic: Sexually Transmitted Diseases and HIV/AIDS
Among American Indians and Alaska Natives.**

OBJECTIVES: To review the epidemiology, research, and prevention
programs for sexually transmitted diseases in American Indians and
Alaska Natives (AI/ANs).

STUDY DESIGN: We reviewed the current national and regional trends in
sexually transmitted diseases (STDs) for AI/ANs from 1998-2004,
peer-reviewed studies from January 1996, through May 2006, and reports,
unpublished documents, and electronic resources addressing AI/AN STD
prevention and control.

RESULTS: STD prevalence among AI/ANs remains high. For example, the case
rate of C. trachomatis in the North Central Plains AI/AN populations is
6 times the overall US rate. Trends for C. trachomatis also show
sustained increases. Little research exists on STDs for this population,
and most is focused on HIV/AIDS. Fear of compromised confidentiality,
cultural taboos, and complex financial and service relationships inhibit
effective surveillance, prevention, and management.

CONCLUSIONS: Recommendations for STD control in this population include
improved local surveillance and incorporation of existing frameworks of
health and healing into prevention and intervention efforts. Research
defining the parameters of cultural context and social epidemiology of
STDs is necessary.

[Kaufman
CE](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Kaufman CE"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Shelby
L](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Shelby L"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Mosure
DJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Mosure DJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Marrazzo
J](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Marrazzo J"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Wong
D](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Wong D"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[de Ravello
L](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="de Ravello L"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Rushing
SC](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Rushing SC"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Warren-Mears
V](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Warren-Mears V"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Neel
L](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Neel L"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Jumping Eagle
S](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Jumping Eagle S"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Tulloch
S](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Tulloch S"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Romero
F](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Romero F"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Patrick
S](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Patrick S"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Cheek
JE](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Cheek JE"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus);
[for the Task force on STD Prevention and Control Among American Indians
and Alaska
Natives](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="for the Task force on STD Prevention and Control Among American Indians and Alaska Natives"%5BCorporate Author%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).

Within the Hidden Epidemic: Sexually Transmitted Diseases and HIV/AIDS
Among American Indians and Alaska Natives. Sex Transm Dis. 2007 May 25;

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17538516>

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

**Other AI/AN specific HIV resources:**

**The need for historically grounded HIV/AIDS prevention research among
Native Americans**

This is a brief report that summarizes the need for historically
grounded HIV prevention research among Native Americans living in the
United States. It illustrates the intersection of culture and history,
showing that ethnic groups can respond to historical traumatic events
for generations, often to the detriment of individual and collective
health. Journal of the Association of Nurses in AIDS Care. 18(2):15-7,
2007 Mar-Apr.

**American Indian Women, HIV/AIDS, and Health Disparity**

Data are presented regarding the prevalence of HIV/AIDS among American
Indian women. Health disparities found among American Indians are
discussed and biological, economic, social, and behavioral risk factors
associated with HIV are detailed. Recommendations are suggested to
alleviate the spread of HIV among American Indian women and, in the
process, to diminish a culture of treatment malpractice and a weakening
of treatment ethics, racism, and genderism. 

Substance Use & Misuse, Volume 42 Issue 4 2007  p.  741 - 752

**The IHS National STD Program: A great resource**

You will recognize many of the author's names in the abstract above from
the IHS Division of Epidemiology and Disease Prevention and the IHS
National STD Program. Don't hesitate to utilize the expertise the IHS
National STD Program has to offer on HIV prevention and control. Below
is some background on the IHS National STD Program.

**National IHS HIV/AIDS Consultant**

Scott Giberson is another great resource. Scott is the National IHS
HIV/AIDS Consultant in the Office of Clinical and Preventive Services,
HQE and a regular contributor to the CCCC. <Scott.Giberson@ihs.gov>

**Background**

**IHS National STD Program MISSION / GOALS**\
The mission of the IHS National STD Program, in partnership with
American Indian/Alaska Native people, is to raise their physical,
mental, social, and spiritual health to the highest level possible
through prevention and reduction of sexually transmitted diseases.\
\
Our goals are to:

-   Raise awareness of STDs as a high priority health issue.

-   Support partnerships and collaborations with state STD programs,
    IHS, tribal, urban Indian (I/T/U), and other public health agencies.

-   Support improvement of I/T/U, state, and local STD programs for
    AI/AN.

-   Increase access to up-to-date STD training for clinicians and public
    health practitioners.

-   Support and strengthen surveillance systems to monitor STD trends.

-   Promote STD research and identify effective interventions for
    reducing STD morbidity.

-   Support STD outbreak response efforts.

-   Support integration of STD/HIV/AIDS, and hepatitis prevention and
    control activities.

**ABOUT US: IHS National STD Program**\
Sexually transmitted diseases (STDs) are a significant public health
problem in the United States and remain largely unrecognized as a
serious public health threat. Each year there are an estimated 19
million new STD infections. STDs cause harmful and often irreversible
complications, including chronic pelvic pain, infertility, cancer, poor
pregnancy and fetal outcomes, and even death. They are also expensive to
society as a whole, with direct medical costs as high as \$15.5 billion
in a single year.\
\
Although widespread across the U.S. in all populations, the STD epidemic
disproportionately affects certain racial and ethnic groups. Such
disparities in STD rates are complex to understand, but may be rooted in
a number of social factors such as poverty, inadequate access to health
care, lack of education, social inequality, and cultural influences. One
group adversely affected by STDs is the American Indian and Alaskan
Native (AI/AN) population.\
\
Since 1994, CDC has collaborated with the IHS Division of Epidemiology
and Disease Prevention by providing staff, funds, and technical
assistance to address the STD prevention needs of AI/AN. This
relationship has been and continues to be critical for the development
of STD prevention capacity in Indian Country. In recent years, the staff
and budget of the IHS National STD Program have grown dramatically.
Today, the program is staffed by three CDC assignees, one IHS
administrative staff, and two contractors.

**STAFF: IHS National STD Program**\
**Scott Tulloch**![](media/image2.jpeg){width="1.4583333333333333in"
height="1.3125in"}Scott Tulloch is a Public Health Advisor with the CDC
assigned to the IHS National STD Program since March 2006. Scott has a
variety of public health interests including interventions in
corrections, outbreak response, and community capacity building.
<scott.tulloch@ihs.gov>\
\
**Lori de Ravello, MPH**
![](media/image3.jpeg){width="1.4583333333333333in" height="1.09375in"}\
Lori de Ravello is a Public Health Advisor with CDC assigned to the IHS
National STD Program. Lori is a regular contributor to the CCCC's STD
Corner <lori.deravello@ihs.gov>

**IHS National STD Program**

<http://www.ihs.gov/medicalprograms/epi/index.cfm?module=health_issues&option=std&cat=sub_0>

**IHS Division of Epidemiology and Disease Prevention**

<http://www.ihs.gov/medicalprograms/epi/index.cfm>

**References:**

**American Indian Women, HIV/AIDS, and Health Disparity**

Vernon IS. American Indian Women, HIV/AIDS, and Health Disparity
Substance Use & Misuse, Volume 42 Issue 4 2007  p.  741 - 752

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17558961>

**The need for historically grounded HIV/AIDS prevention research among
Native Americans**

Lowe J Research brief: the need for historically grounded HIV/AIDS
prevention research among Native Americans. \[Review\] Journal of the
Association of Nurses in AIDS Care. 18(2):15-7, 2007 Mar-Apr.
<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17403492>

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

#### Scott Giberson, HQE {#scott-giberson-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**American Indian / Alaska Native (AI/AN) population has the shortest
timeline HIV to AIDS**

The American Indian / Alaska Native (AI/AN) population has the 3rd
highest rate of HIV/AIDS, the shortest timeline between diagnosis and
death and the highest percentage of 'late' diagnosis (determined by
progression of disease at time of diagnosis) of any race/ethnic group.

This suggests the critical preventive component of missed screening
opportunities. Reports of the percentage of AI/AN tested for HIV range
anywhere from below 50% to roughly 75%. Given the risk factors and
population vulnerabilities, it is imperative we screen individuals at
every opportunity. The impact of screening early and often is easily
justifiable as treatment and care is available. Screening also serves as
a preventive measure since it is estimated that over half of newly
infected individuals acquire HIV from those unaware of their status.

With the revised CDC testing guidelines, states are changing
requirements and attempting to adjust policy to effectively implement
more broad-based screening efforts. The IHS supports these CDC
recommendations and have removed any potential barriers (at the Agency
level) to increase screening efforts. It is a responsibility that each
of us attempts to take on the role of an advocate, supporter,
facilitator, or provider of prevention and care, to include advocacy for
HIV screening.

More information can be found at [www.aids.gov](http://www.aids.gov/)
and / or
[www.ihs.gov/medicalprograms/hivaids/](http://www.ihs.gov/medicalprograms/hivaids/) 

# 

# Rapid HIV testing in emergency departments\--three U.S. sites, January 2005-March 2006

Approximately one fourth of the estimated 1 million persons living with
human immunodeficiency virus (HIV) in the United States are unaware that
they are infected with HIV and at risk for transmitting the virus to
others. In April 2003, CDC announced a new initiative, Advancing HIV
Prevention: New Strategies for a Changing Epidemic, aimed at reducing
barriers to early diagnosis of HIV infection and increasing access of
persons infected with HIV to medical care and prevention services. A
priority strategy of this initiative is to make HIV testing a routine
part of medical care. In April 2004, HIV testing was implemented in one
emergency department (ED) in Los Angeles, California, and one in New
York, New York, to determine the feasibility and acceptability of
offering rapid HIV testing as a routine part of health care in EDs. In
January 2005, an ED in Oakland, California, also began offering HIV
testing routinely. This report summarizes the preliminary results of
integrating rapid HIV testing into the health-care services routinely
offered in the three EDs during January 2005-March 2006. Those results
indicated that, of 9,365 persons tested, 97 (1.0%) ED patients had newly
diagnosed HIV infection, and 85 (88%) of those 97 were linked after
diagnosis to HIV care and treatment. EDs should consider integrating
rapid HIV testing into their routine medical services to identify
patients who are unaware that they are infected with HIV and link them
to health and prevention services.

Centers for Disease Control and Prevention (CDC).

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5624a2.htm>

**Treating Antiretroviral-Experienced Patients: Case-based CME
Program**\
This CME program, presented by The Johns Hopkins University School of
Medicine, provides clinicians with the latest information regarding the
management of patients living with HIV who have persistent viral levels
despite initial therapy.  This educational activity focuses on the
effectiveness of antiretroviral (ARV) therapy using newer treatments and
an optimized background regimen that has the potential to achieve
maximal viral suppression and immunologic improvement in a significant
proportion of ARV-experienced patients, preventing or delaying the
development of additional virologic resistance and AIDS-related events. 
This free CME program is intended for physicians and other clinicians
who actively manage patients with HIV and AIDS.\
<http://www.hivcases.org/>

**Stop the Silence**

The Red Talon project media campaign, "Stop the Silence"
[www.stopthesilence.org](../../../../../../../../%5C%5Cwww.stopthesilence.org)
also offers posters, Public Service Announcements and an "Advocacy Kit",
which contains information about AI/AN STD rates, the social and
economic impact of STDs on tribal communities, and steps that can be
taken by tribal councils to improve school-based, clinic-based, and
community-based prevention efforts. Attached is one of their posters.
More information about this project and these materials will soon be
posted on the IHS HIV/AIDS website under the "Toolkit" tab (left column)
at
<http://www.ihs.gov/MedicalPrograms/hivaids/index.cfm?module=toolkit#top>

**James Holsinger Jr, Surgeon General Nominee**

**Physician professionalism for a new century (**The latest publication
by the SG nominee)

During the past 50 years, physicians have become increasingly
dissatisfied with certain aspects of their profession. Dissatisfaction
has intensified with the advent of managed care in the late 20th
century, the medical liability crisis, and the growing divergence
between the professional and personal expectations placed upon
physicians and their practical ability to meet these expectations. These
and other factors have encroached on physician autonomy, the formerly
ascendant professional value within medicine. As the underlying values
and practical realities of the broader American health care system have
changed, the professional values and practices of physicians have failed
to adapt correspondingly, resulting in a \"professionalism gap\" that
contributes to physician dissatisfaction. To improve the outlook and
efficacy of modern American physicians, the profession must adopt a new
values framework that conforms to today\'s health care system. This
means foregoing the 20th century\'s preferred \"independent physician\"
model in favor of a new professional structure based on teamwork and
collaboration. Convincing established physicians to embrace such a model
will be difficult, but opportunities exist for significant progress
among a new generation of physicians accustomed to the realities of
managed care, flexible practice models, and health information
technology. The teaching of clinical anatomy, given its incorporation of
student collaboration at the earliest stages of medical education,
offers a prime opportunity to introduce this generation to a
reinvigorated code of professionalism that should reduce physician
dissatisfaction and benefit society

[Holsinger
JW](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Holsinger JW"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Beaton
B](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Beaton B"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Physician professionalism for a new century. [Clin
Anat.](javascript:AL_get(this, 'jour', 'Clin Anat.');) 2006
Jul;19(5):473-9

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16506233>

**Favian Kennedy, Rapid City, SD**

**HOW long does it take Nicotine to reach your brain after inhaling ?**

Check out the web site below:

v       Tobacco facts - classroom discussions

v       Sites for teens (see Resources)

v       Smoke Free Homes -- campaign materials -- contact Favian for
details 

v       Community resources - Smoking Cessation resources links for
people who want to quit

smoking and using chew 

v       Clinical treatment guidelines for health professionals  

v       Field community survey tool -  American Indian Adult Tobacco
Survey (AI-ATS).

§       Provides tribal specific smoking rate estimates for national,
state, regional, and Healthy

People 2010 benchmarks comparison.

§       Looks attitudes, behaviors, and beliefs related to tobacco use
among tribal members  

§       Data for setting health priorities and policies

Answer: 7 seconds.** ** <http://www.worthit.org/>

**Northern Plains Tobacco Prevention Project: Spring Newsletter
available online**

We are currently promoting smoke-free policies among our consortium
member tribes. Two of our tribes are currently considering policies so
we want to provide as much support to those local coalitions who are
doing all of the leg work. We are also trying to encourage direct
service healthcare providers to increase their education of basic
environmental asthma trigger identification and mitigation. See link
below to Issue #7

<http://www.aatchb.org/nptpp/Resources/publications.html>

Favian Kennedy, MSW

Program Director

Northern Plains Tobacco Prevention Project Aberdeen Area Tribal
Chairmen\'s Health Board 1770 Rand Road Rapid City, SD 57702

\(605\) 721- 1922 ext 112

\(605\) 721-1932 (fax)

**Roberta Ward, Anchorage**

**All you need to know about food safety during pregnancy, FDA**

The At-a-Glance Food Safety Brochure at the link below would be a good
brochure to include in your New OB education materials.

<http://www.cfsan.fda.gov/~pregnant/ataglanc.html>

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

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

**VBAC: Labor induction outcome dependent on history of vaginal delivery
and cervix**

OBJECTIVE: To compare pregnancy outcomes in women with one prior
low-transverse cesarean delivery after induction of labor with pregnancy
outcomes after spontaneous labor. METHODS: This study is an analysis of
women with one prior low-transverse cesarean and a singleton gestation
who underwent a trial of labor and who were enrolled in a 4-year
prospective observational study. Pregnancy outcomes were evaluated
according to whether a woman underwent spontaneous labor or labor
induction

RESULTS: Among the 11,778 women studied, vaginal delivery was less
likely after induction of labor both in women without and with a prior
vaginal delivery (51% versus 65%, P\<.001; and 83% versus 88%, P\<.001).
An increased risk of uterine rupture after labor induction was found
only in women with no prior vaginal delivery (1.5% versus 0.8%, P=.02;
and 0.6% versus 0.4%, P=.42). Blood transfusion, venous thromboembolism,
and hysterectomy were also more common with induction among women
without a prior vaginal delivery. No measure of perinatal morbidity was
associated with labor induction. An unfavorable cervix at labor
induction was not associated with any adverse outcomes except an
increased risk of cesarean delivery. CONCLUSION: Induction of labor in
the study population is associated with an increased risk of cesarean
delivery in all women with an unfavorable cervix, a statistically
significant, albeit clinically small, increase in maternal morbidity in
women with no prior vaginal delivery, and no appreciable increase in
perinatal morbidity. LEVEL OF EVIDENCE: II.

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

**VBAC: The pendulum is swinging back**

After peaking in 1996, the vaginal birth after cesarean delivery (VBAC)
rate has steadily declined to 13% in 2004. This decline has been
accompanied by a number of articles that have questioned whether a trial
of labor is equally suitable for all women with a prior low-transverse
cesarean delivery. Correspondingly, investigators have tried to identify
factors predictive of a lower chance of a successful trail of labor as
well as a greater chance of uterine rupture, and thereby identify the
specific women for whom a trial of labor is less safe and appropriate.

In contrast to the declining rate of VBAC, the rate of labor induction
has been steadily increasing, more than doubling over the last decade to
a frequency of more than 20%. Thus, the effect of induced versus
spontaneous labor in women attempting VBAC is of particular interest.
Initial reports suggested that women who underwent labor induction were
no more likely than their spontaneously laboring counterparts to have a
cesarean delivery or a uterine rupture. More recent studies, however,
have challenged both conclusions, showing a higher rate of both cesarean
delivery and uterine rupture among women undergoing labor induction with
a prior cesarean delivery.

The 2001 Lydon-Rochelle et al in the NEJM raised questions about a
possible higher rate of uterine rupture during induction of labor after
previous cesarean delivery and temporally was related with a further
erosion of the VBAC rate. The current prospective observation study
above further illuminates the weakness of the Lydon-Rochelle et al
article which was based on ICD 9 codes alone, a method known for
ascertainment bias.

Women who desire a VBAC and are confronted with the decision to undergo
labor induction can be counseled that their risk for most serious
adverse outcomes is not significantly increased, the adverse outcomes
that are increased have a small attributable risk associated with
induction, and that even this small attributable risk appears limited to
women without a prior vaginal birth.

[Grobman
WA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Grobman+WA"%5BAuthor%5D),
et al Outcomes of induction of labor after one prior cesarean. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Feb;109(2 Pt 1):262-9.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17267822]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17267822)

**Other Cesarean Delivery Resources:**

**Elective cesarean increases risk of respiratory morbidity after 37
completed weeks**

CONCLUSION: Delivery by elective caesarean section was shown to increase
the risk of respiratory morbidity in all studies eligible for inclusion.
The magnitude of this relative risk seemed to depend on gestational age
even in deliveries after 37 completed weeks of gestation.

Hansen AK et al Elective caesarean section and respiratory morbidity in
the term and near-term neonate. [Acta Obstet Gynecol Scand.  2007;
86(4):389-94](http://www.medscape.com/medline/publicationbrowser/123?pmid=17486457)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17486457>

**Decision aids help women with previous cesarean section: May reduce
cesarean rate**

CONCLUSIONS: Decision aids can help women who have had a previous
caesarean section to decide on mode of delivery in a subsequent
pregnancy. The decision analysis approach might substantially affect
national rates of caesarean section.

[Montgomery
AA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Montgomery AA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Two decision aids for mode of delivery among women with previous
caesarean section: randomised controlled trial.
[BMJ.](javascript:AL_get(this, 'jour', 'BMJ.');) 2007 Jun
23;334(7607):1305

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17540908>

**Who will succeed with a trial of labor after VBAC?**

RESULTS: Seven-thousand six hundred sixty women were available for
analysis. The prediction model is based on a multivariable logistic
regression, including the variables of maternal age, body mass index,
ethnicity, prior vaginal delivery, the occurrence of a VBAC, and a
potentially recurrent indication for the cesarean delivery. After
analyzing the model with cross-validation techniques, it was found to be
both accurate and discriminating.

CONCLUSION: A predictive nomogram, which incorporates six variables
easily ascertainable at the first prenatal visit, has been developed
that allows the determination of a patient-specific chance for
successful VBAC for those women who undertake trial of labor. LEVEL OF
EVIDENCE: II.

Grobman WA et al Development of a nomogram for prediction of vaginal
birth after cesarean delivery. [Obstet Gynecol.  2007;
109(4):806-12](http://www.medscape.com/medline/publicationbrowser/123?pmid=17400840) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17400840>

**Postcesarean delivery adhesions associated with delayed delivery of
infant**

CONCLUSION: A high percentage of cesarean deliveries result in adhesive
disease, which delays repeat cesarean delivery of the fetus. The
potential for adhesive disease should be included in counseling
regarding primary elective cesarean births.

[Morales
KJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Morales KJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Postcesarean delivery adhesions associated with delayed delivery
of infant [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
May;196(5):461

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17466702>

**New CDC / ACIP Recommendation for Varicella Vaccination in Women**

#### Prenatal Assessment and Postpartum Vaccination 

Prenatal assessment of women for evidence of varicella immunity is
recommended. Birth before 1980 is not considered evidence of immunity
for pregnant women because of potential severe consequences of varicella
infection during pregnancy, including infection of the fetus. Upon
completion or termination of their pregnancies, women who do not have
evidence of varicella immunity should receive the first dose of vaccine
before discharge from the health-care facility. The second dose should
be administered 4\--8 weeks later, which coincides with the postpartum
visit (6\--8 weeks after delivery). For women who gave birth, the second
dose should be administered at the postpartum visit. Women should be
counseled to avoid conception for 1 month after each dose of varicella
vaccine. Health-care settings in which completion or termination of
pregnancy occurs should use standing orders to ensure the administration
of varicella vaccine to women without evidence of immunity. ..."

# Prevention of Varicella: Recommendations of the Advisory Committee on Immunization Practices (ACIP) [**http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5604a1.htm?s_cid=rr5604a1_e**](http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5604a1.htm?s_cid=rr5604a1_e)

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

**Update the clinical guidelines at your hospital to include the above
recommendations**

Please add prenatal screening and postpartum vaccination as per CDC /
ACIP

**Postpartum Labial Adhesions**

Background: Labial adhesions are common in young girls and menopausal
women. Topical estrogen is the first line of therapy for these
adhesions. Based on a systematic literature review, postpartum labial
adhesions are uncommon in clinical practice. They are not painful but
can prevent patients from resuming normal sexual activity. Topical
estrogen therapy is an ineffective treatment option for adhesions in
this setting. Surgical division under local anesthesia is usually
effective.

Case: A 29-year-old women presented at 6 weeks after an uncomplicated
vacuum-assisted delivery for a routine postpartum evaluation.
Examination revealed a 5-mm labial adhesion connecting her left and
right labia minora. Division under local anesthetic resulted in a
complete recovery within 3 days.

Conclusion: Postpartum labial adhesions can usually be surgically
divided under local anesthetic with complete and rapid recovery.

Seehusen, DA, Earwood, JS. Postpartum Labial Adhesions Journal of the
American Board of Family Medicine 20 (4): 408-410 (2007)

<http://www.jabfm.org/cgi/content/abstract/20/4/408?etoc>

**Administration of cefazolin prior to skin incision is superior to
cefazolin at cord clamping**

CONCLUSION: Administration of prophylactic cefazolin 15-60 minutes prior
to incision prior to skin incision resulted in a decrease in both
endomyometritis and total postcesarean infectious morbidity, compared
with administration at the time of cord clamping. This dosing did not
result in increased neonatal septic workups or complications.

[Sullivan
SA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Sullivan SA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Administration of cefazolin prior to skin incision is superior to
cefazolin at cord clamping in preventing postcesarean infectious
morbidity: a randomized, controlled trial. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
May;196(5):455.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17466699>

**Simulation-based, hands-on training can identify recurring errors in
emergencies**

CONCLUSION: A curricular unit based on simulation of obstetric
emergencies can identify pitfalls of management in labor and delivery
rooms that need to be addressed.

[Maslovitz
S](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Maslovitz S"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract)
et al Recurrent obstetric management mistakes identified by simulation.
[Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');)
2007 Jun;109(6):1295-300.

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17540800&dopt=Abstract>

Dystocia in Nulliparous Women (ALSO Serialization)

Dystocia is common in nulliparous women and is responsible for more than
50 percent of primary cesarean deliveries. Because cesarean delivery
rates continue to rise, physicians providing maternity care should be
skilled in the diagnosis, management, and prevention of dystocia. If
labor is not progressing, inadequate uterine contractions, fetal
malposition, or cephalopelvic disproportion may be the cause. Before
resorting to operative delivery for arrested labor, physicians should
ensure that the patient has had adequate uterine contractions for four
hours, using oxytocin infusion for augmentation as needed. For
nulliparous women, high-dose oxytocin-infusion protocols for labor
augmentation decrease the time to delivery compared with low-dose
protocols without causing adverse outcomes. The second stage of labor
can be permitted to continue for longer than traditional time limits if
fetal monitoring is reassuring and there is progress in descent.
Prevention of dystocia includes encouraging the use of trained labor
support companions, deferring hospital admission until the active phase
of labor when possible, avoiding elective labor induction before 41
weeks\' gestation, and using epidural analgesia judiciously. Am Fam
Physician 2007;75:1671-8.

[**http://www.aafp.org/afp/20070601/1671.html**](http://www.aafp.org/afp/20070601/1671.html)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17329511>

**Postterm pregnancy: No difference - Induction versus serial antenatal
fetal monitoring**

CONCLUSION: No differences were found between the induced and monitored
groups regarding neonatal morbidity or mode of delivery, and the
outcomes were generally good.

Heimstad R; et al Induction of labor or serial antenatal fetal
monitoring in postterm pregnancy: a randomized controlled trial. [Obstet
Gynecol.  2007;
109(3):609-17](http://www.medscape.com/medline/publicationbrowser/123?pmid=17329511)

**Uterine compression sutures effective: Outcome of subsequent pregnancy
is reassuring**

CONCLUSION: Uterine compression sutures for severe postpartum hemorrhage
may obviate the need for hysterectomy and appear not to jeopardize
subsequent pregnancy. LEVEL OF EVIDENCE: III.

[Baskett
TF](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Baskett TF"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract).
Uterine compression sutures for postpartum hemorrhage: efficacy,
morbidity, and subsequent pregnancy. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Jul;110(1):68-71

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17601898&dopt=Abstract>

**Usefulness of Knowledge of Occiput Posterior Position Prior to Labor
is Limited**

CONCLUSION: Two thirds of OP positions at delivery after induction of
labor occur due to a mal-rotation in labor from a non-OP position.
Ultrasonography is an easy method of assessing fetal head position
before induction of labor. In clinical practice, its usefulness is
limited by the fact that, contrary to conventional teaching, OP position
before induction of labor does not appear to be associated with an
increased risk of cesarean delivery. LEVEL OF EVIDENCE: II.

Peregrine E; O\'Brien P; Jauniaux E Impact on delivery outcome of
ultrasonographic fetal head position prior to induction of labor.
[Obstet Gynecol.  2007;
109(3):618-25](http://www.medscape.com/medline/publicationbrowser/123?pmid=17329512) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17329512>

**HSV-1 appears more readily transmissible to the neonate than HSV-2**

CONCLUSION: Our results suggest that maternal HSV-1 antibody offers
little, if any, protection against neonatal HSV-2 infection. During
reactivation, HSV-1 appears more readily transmissible to the neonate
than HSV-2, a concerning finding given the rising frequency of genital
HSV-1 infection.

[Brown
EL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Brown EL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Effect of maternal herpes simplex virus (HSV) serostatus and HSV
type on risk of neonatal herpes. [Acta Obstet Gynecol
Scand.](javascript:AL_get(this, 'jour', 'Acta Obstet Gynecol Scand.');)
2007;86(5):523-9

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17464578>

**Women with previous episode of chorioamnionitis have a twofold risk of
recurrence**

CONCLUSION: Women delivering vaginally who were diagnosed with
chorioamnionitis during their first pregnancy are at increased risk for
chorioamnionitis in a subsequent pregnancy. This supports the concept
that there may be a predisposition to chorioamnionitis that should be
further investigated. LEVEL OF EVIDENCE: II-2.

[Laibl
VR](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Laibl VR"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Recurrence of clinical chorioamnionitis in subsequent pregnancies.
[Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');)
2006 Dec;108(6):1493-7

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17138785>

**Active Management of the Third Stage of Labor**

AUTHORS\' CONCLUSIONS: Prophylactic intramuscular or intravenous
injections of ergot alkaloids are effective in reducing blood loss and
postpartum hemorrhage, but adverse effects include vomiting, elevation
of blood pressure and pain after birth requiring analgesia, particularly
with the intravenous route of administration.

Liabsuetrakul T et al Prophylactic use of ergot alkaloids in the third
stage of labour.[Cochrane Database Syst Rev.  2007;
(2):CD005456](http://www.medscape.com/medline/publicationbrowser/123?pmid=17443592)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17443592>

**Nephrolithiasis requiring hospital admission increases risk of preterm
delivery**

CONCLUSION: Although the incidence of nephrolithiasis requiring hospital
admission during pregnancy is relatively low, these women have an
increased risk of preterm delivery. This has potential implications for
counseling of pregnant women with kidney stones requiring hospital
admission. Additionally, it may prompt definitive treatment of small,
asymptomatic stones in women during reproductive years.

Swartz MA et al Admission for nephrolithiasis in pregnancy and risk of
adverse birth outcomes. [Obstet Gynecol.  2007;
109(5):1099-104](http://www.medscape.com/medline/publicationbrowser/123?pmid=17470589) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17470589>

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

**LEEP doubles risk of preterm delivery: Patients need to be informed**

CONCLUSION: Our study showed an almost 2-fold increase in the risk of
preterm delivery after LEEP treatment. Thus, women in their reproductive
age should be informed about the increased risk of preterm delivery, if
treated with LEEP.

[Nøhr
B](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Nøhr B"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Loop electrosurgical excision of the cervix and the subsequent
risk of preterm delivery. [Acta Obstet Gynecol
Scand.](javascript:AL_get(this, 'jour', 'Acta Obstet Gynecol Scand.');)
2007;86(5):596-603

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17464590>

**Treatment of bleeding irregularities induced by progestin only
contraceptives: Effective**

AUTHORS\' CONCLUSIONS: Some women may benefit from the interventions
described, particularly with cessation of an ongoing bleeding episode.
Several regimens offer promise in regulating bleeding, but findings need
to be reproduced in larger scale trials. Intermittent treatment with an
agent may help some women to continue the use of a progestin-only
contraceptive. The results of this review do not support routine
clinical use of any of the regimens included in the trials, particularly
for long-term effect.

Abdel-Aleem H et al Treatment of vaginal bleeding irregularities induced
by progestin only contraceptives.[Cochrane Database Syst Rev.  2007;
(2):CD003449](http://www.medscape.com/medline/publicationbrowser/123?pmid=17443526)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17443526>

**Clinic management of early pregnancy failure: Safe, cost-effective**

Early pregnancy failure and induced abortion are often managed
differently, even though safe uterine evacuation is the goal in both.
Early pregnancy failure is commonly treated by curettage in operating
room settings in anesthetized patients. Induced abortion is most
commonly managed by office vacuum aspiration in awake or sedated
patients. Medical evidence does not support routine operating room
management of early pregnancy failure. The University of Michigan
initiated office uterine evacuations for early pregnancy failure
treatment. Patients previously went to the operating room. These changes
required faculty, staff, and resident education. Our efforts blurred the
lines between spontaneous and induced abortion management, improved
patient care and better utilized hospital resources

[Harris
LH](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Harris LH"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et a; Surgical management of early pregnancy failure: history, politics,
and safe, cost-effective care [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
May;196(5):445.e1-5

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17466695>

**Short-term superiority of effectiveness of transobturator tape**
**reported**

AUTHOR\'S CONCLUSIONS: The evidence for short-term superiority of
effectiveness of transobturator and retropubic tape procedures (TOT) is
currently limited. Bladder injuries and voiding difficulties are lower,
but the risk of vaginal erosions and groin pain is higher with TVTO/TOT.
Methodologically sound and sufficiently powered RCTs with long-term
follow up are needed, and the results of continuing trials are

Latthe PM et al Transobturator and retropubic tape procedures in stress
urinary incontinence: a systematic review and meta-analysis of
effectiveness and complications.

[BJOG.  2007;
114(5):522-31](http://www.medscape.com/medline/publicationbrowser/123?pmid=17362484) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17362484>

**Women in their 50s: fecal incontinence not associated with parity or
mode of delivery**

CONCLUSION: In our population of women in their 50s, fecal incontinence
was not associated with either parity or mode of delivery. LEVEL OF
EVIDENCE: III.

[Fritel
X](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Fritel X"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
et al Mode of Delivery and Fecal Incontinence at Midlife: A Study of
2,640 Women in the Gazel Cohort. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Jul;110(1):31-38

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17601893&dopt=Abstract>

**Hysterectomy or levonorgestrel-releasing intrauterine system on sexual
functioning**

RESULTS: Among women treated by hysterectomy, sexual satisfaction
increased and sexual problems decreased. Among LNG-IUS users,
satisfaction with partner decreased. In addition to treatment modality
(P = 0.02), estrogen therapy (P = 0.01), smoking (P = 0.001), night
sweats (P = 0.03), vaginal dryness (P = 0.04), hot flushes (P = 0.01),
and having someone to ask for advice (P = 0.03) and to share worries (P
= 0.01) explained changes in sexual functioning. CONCLUSIONS: Among
women with menorrhagia, hysterectomy improves sexual functioning,
whereas LNG-IUS does not have such a positive effect.

Halmesmäki K et al The effect of hysterectomy or
levonorgestrel-releasing intrauterine system on sexual functioning among
women with menorrhagia: a 5-year randomised controlled trial. [BJOG.
 2007;
114(5):563-8](http://www.medscape.com/medline/publicationbrowser/123?pmid=17439564) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17439564>

**Radiotherapy for stage I endometrial cancer reduces local disease: May
extend survival**

AUTHORS\' CONCLUSIONS: Patients with stage I endometrial carcinoma have
different risks of local and distant recurrence depending on the
presence of risk factors including stage 1c, grade 3, lymphovascular
space invasion and age. Though external beam pelvic radiotherapy reduced
locoregional recurrence by 72%, there is no evidence to suggest that it
reduced the risk of death. In patients with multiple high risk factors,
including stage 1c and grade 3, there was a trend towards a survival
benefit and adjuvant external beam radiotherapy may be justified. For
patients with only one risk factor, grade 3 or stage 1c, no definite
conclusion can be made and data from ongoing studies ( ASTEC; Lukka) are
awaited. External beam radiotherapy carries a risk of toxicity and
should be avoided in stage 1 endometrial cancer patients with no high
risk factors

Kong A et al Adjuvant radiotherapy for stage I endometrial cancer.
[Cochrane Database Syst Rev. 2007;
(2):CD003916](http://www.medscape.com/medline/publicationbrowser/123?pmid=17443533) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17443533>

**Daily record of severity of problems: Screening instrument for
premenstrual syndrome**

CONCLUSION: The DRSP administered on the first day of menses is an
acceptable screening instrument to identify women who may have PMS.

Borenstein JE et al Using the daily record of severity of problems as a
screening instrument for premenstrual syndrome. [Obstet Gynecol.  2007;
109(5):1068-75](http://www.medscape.com/medline/publicationbrowser/123?pmid=17470584) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17470584>

**New cervical cancer test increases the detection rate of abnormal
cells**

CONCLUSION: The ThinPrep Imager detects 1.29 more cases of histological
high grade squamous disease per 1000 women screened than conventional
cytology, with cervical intraepithelial neoplasia grade 1 as the
threshold for referral to colposcopy. More imager read slides than
conventional slides were satisfactory for examination and more contained
low grade cytological abnormalities.

[Davey
E](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Davey E"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Accuracy of reading liquid based cytology slides using the
ThinPrep Imager compared with conventional cytology: prospective study.
[BMJ.](javascript:AL_get(this, 'jour', 'BMJ.');) 2007 Jun 29;

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17604301>

**Higher circulating CRP concentrations in women who developed ovarian
cancer**

CONCLUSION: Higher circulating CRP concentrations in women who
subsequently developed ovarian cancer support the hypothesized role of
chronic inflammation in ovarian carcinogenesis. LEVEL OF EVIDENCE: II.

McSorley MA et al C-reactive protein concentrations and subsequent
ovarian cancer risk. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Apr;109(4):933-41

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17400857>

**Pain relief in hysterosalpingography**

AUTHORS\' CONCLUSIONS: There is little evidence of benefit in terms of
pain relief of any of the interventions considered in this study during
or immediately after HSG. However, there is limited evidence of pain
reduction 30 minutes after the procedure. Further RCTs should consider
the role of non steroidal antiinflammatories (NSAIDs) and intrauterine
anaesthetic during HSG.

Ahmad G; Duffy J; Watson AJ Pain relief in hysterosalpingography.
[Cochrane Database Syst Rev.  2007;
(2):CD006106](http://www.medscape.com/medline/publicationbrowser/123?pmid=17443612) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17443612>

**Treatment of Menorrhagia**

Menorrhagia is defined as excessive uterine bleeding occurring at
regular intervals or prolonged uterine bleeding lasting more than seven
days. The classic definition of menorrhagia (i.e., greater than 80 mL of
blood loss per cycle) is rarely used clinically. Women describe the loss
or reduction of daily activities as more important than the actual
volume of bleeding. Routine testing of all women with menorrhagia for
inherited coagulation disorders is unnecessary. Saline infusion
sonohysteroscopy detects intracavitary abnormalities such as endometrial
polyps or uterine leiomyoma and is less expensive and invasive than
hysteroscopy. Endometrial biopsy is effective for diagnosing
precancerous lesions and adenocarcinoma but not for intracavitary
lesions. Except for continuous progestin, medical therapies are limited.
The levonorgestrel-releasing intrauterine device is an effective therapy
for women who want to preserve fertility and avoid surgery. Surgical
therapies include endometrial ablation methods that preserve the uterus;
and hysterectomy, which results in high satisfaction rates but with
potential surgical morbidity. Overall, hysterectomy and endometrial
ablation result in the greatest satisfaction rates if future
childbearing is not desired. Treatment of menorrhagia results in
substantial improvement in quality of life. Am Fam Physician
2007;75:1813-9,1820. <http://www.aafp.org/afp/20070615/1813.html>

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

**Physical Activity Alone May Not Reduce Obesity in Children**

Conclusion: The authors conclude that this program to increase physical
activity resulted in improvement in motor skills of children four to
five years of age but had no demonstrable impact on obesity. They
suggest that the program may have provided inadequate levels of physical
activity to produce a measurable effect, and that several factors may
need to be addressed simultaneously to impact body mass index. They
suggest that future intervention programs for obesity in early childhood
should incorporate attention to diet, more behavioral approaches, and
greater involvement of parents.

Reilly JJ, et al. Physical activity to prevent obesity in young
children: cluster randomised controlled trial. BMJ November 18,
2006;333:1041-3.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17028105>

**Obese Young Adults Face High Diabetes Risk**

People who are obese at age 18 will more likely than not develop type 2
diabetes at some point.

CONCLUSIONS: Cardiometabolic abnormalities are present in nearly 68% of
young, healthy, Asian-Indian adolescents and even among those with
normal weight. Insulin resistance is associated with individual
cardiometabolic factors, and plasma insulin showed association with
clustering of some variables

[Ramachandran
A](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Ramachandran A"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
Insulin resistance and clustering of cardiometabolic risk factors in
urban teenagers in southern India. [Diabetes
Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');) 2007
Jul;30(7):1828-33.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17416794>

**Increased risk of autism: associated with parental age and obstetric
conditions**

CONCLUSIONS: Evidence to suggest that parental age and obstetric
conditions are associated with an increased risk of autism and autism
spectrum disorders is accumulating. Although not proven as independent
risk factors for autism, these variables should be examined in future
studies that use large, population-based birth cohorts with precise
assessments of exposures and potential confounders.

Kolevzon A et al Prenatal and perinatal risk factors for autism: a
review and integration of findings. [Arch Pediatr Adolesc Med.  2007;
161(4):326-33](http://www.medscape.com/medline/publicationbrowser/123?pmid=17404128)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17404128>

**Physician Prompting Improves Asthma Preventive Care**

Conclusion: The authors conclude that use of a physician prompt that
includes severity of the disease and care guidelines at an office visit
can improve the delivery of preventive asthma care. They add that
because urban children have the highest risk of asthma morbidity, this
intervention has the potential to reduce morbidity in this population.

Halterman JS, et al. Improved preventive care for asthma. A randomized
trial of clinician prompting in pediatric offices. Arch Pediatr Adolesc
Med October 2006;160:1018-25.

<http://www.aafp.org/afp/20070615/tips/6.html>

**Child adiposity at 3 years: New recommendations for gestational weight
gain required?**

RESULTS: Greater weight gain was associated with higher child body mass
index z-score (0.13 units per 5 kg \[95% CI, 0.08, 0.19\]), sum of
subscapular and triceps skinfold thicknesses (0.26 mm \[95% CI, 0.02,
0.51\]), and systolic blood pressure (0.60 mm Hg \[95% CI, 0.06,
1.13\]).

CONCLUSION: New recommendations for gestational weight gain may be
required in this era of epidemic obesity.

Oken E et al Gestational weight gain and child adiposity at age 3 years.
[Am J Obstet Gynecol. 2007;
196(4):322.e1-8](http://www.medscape.com/medline/publicationbrowser/123?pmid=17403405)** **

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17403405>

**Outcome of infants with an Apgar score of zero at 10 minutes is almost
universally poor**

Results: death or severe disability occurred in 8 of 9 infants.
Combining the results of metaanalysis of published data with our results
of 94 infants, 88 infants (94%) either died or were handicapped
severely; 2 infants (2%) were handicapped moderately, and 1 infant (1%)
was handicapped mildly. For 3 infants (3%), the long-term outcome could
not be determined.

CONCLUSION: The outcome of infants with an Apgar score of zero at 10
minutes is almost universally poor.

[Harrington
DJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Harrington DJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al The long-term outcome in surviving infants with Apgar zero at 10
minutes: a systematic review of the literature and hospital-based cohort

[Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
May;196(5):463

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17466703>

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

**Teratogenicity of SSRIs\--serious concern or much ado about little?**

Researchers from Boston University's Slone Epidemiology Center have
found that certain selective serotonin reuptake inhibitors (SSRIs)
antidepressants do not appear to increase the risk for most kinds of
birth defects. CONCLUSIONS: Our findings do not show that there are
significantly increased risks of craniosynostosis, omphalocele, or heart
defects associated with SSRI use overall. They suggest that individual
SSRIs may confer increased risks for some specific defects, but it
should be recognized that the specific defects implicated are rare and
the absolute risks are small.

[Louik
C](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Louik C"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al First-trimester use of selective serotonin-reuptake inhibitors and
the risk of birth defects. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2007 Jun
28;356(26):2675-83

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17596601>

**Maternal use of SSRIs was not associated with significantly increased
risks**

CONCLUSIONS: Maternal use of SSRIs during early pregnancy was not
associated with significantly increased risks of congenital heart
defects or of most other categories of birth defects. Associations were
observed between SSRI use and three types of birth defects, but the
absolute risks were small, and these observations require confirmation
by other studies

[Alwan
S](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Alwan S"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
et al Use of selective serotonin-reuptake inhibitors in pregnancy and
the risk of birth defects. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2007 Jun
28;356(26):2684-92

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17596602&dopt=Abstract>

**Editorial**

**Teratogenicity of SSRIs\--serious concern or much ado about little?**

".....Patients and physicians alike would prefer it if there were clear
lines separating \"risk\" and \"no risk\" and if all studies gave
consistent results pointing in the same direction. Unfortunately, this
is often not the case, and the data to inform potential risks of SSRIs
are no exception. The two reports in this issue of the Journal, together
with other available information, do suggest that any increased risks of
these malformations in association with the use of SSRIs are likely to
be small in terms of absolute risks. "

[Greene
MF](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Greene MF"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract).
Teratogenicity of SSRIs\--serious concern or much ado about little? [N
Engl J Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2007 Jun
28;356(26):2732-3.\
<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17596609&dopt=Abstract>

**Two Other Depression Related Resources:**

**American Native Suicide**

Following the Depression theme in the last issue, I wanted to look at
suicide, the tragic outcome of acute untreated depression. You don't
have to look far to realize that while Alaska's suicide rate is far
worse that the national, Alaska Native Suicide is three times as high
here as non-native! This issue explores why this is so, and more
importantly what is needed to turn this around. I have included one
website for help in dealing with suicidal behavior in general -- because
this is prime time and the more we know, the greater our chances of
averting tragedy!

<http://consortiumlibrary.org/hsis/about/newsletters/May07.pdf>

Health Sciences Information Service Newsletter, University of Alaska,
Anchorage

**Depression: Deadlier in the Spring**

This issue is about depression, a critically important topic for this
time of year. The take-home message is that all of us need to be aware
of the symptoms of depression and alert for them in ourselves and in
those around us. Please take time to explore the excellent websites
which provide good coverage of all aspects of depression, including
research news. Depression is a very treatable medical condition! I've
seen this demonstrated in my own family.

Sally J. Bremner, Health Sciences Librarian  

<http://consortiumlibrary.org/hsis/about/newsletters/Apr07.pdf>

**Rosiglitazone: seeking a balanced perspective**

CONCLUSIONS: Rosiglitazone was associated with a significant increase in
the risk of myocardial infarction and with an increase in the risk of
death from cardiovascular causes that had borderline significance. Our
study was limited by a lack of access to original source data, which
would have enabled time-to-event analysis. Despite these limitations,
patients and providers should consider the potential for serious adverse
cardiovascular effects of treatment with rosiglitazone for type 2
diabetes

[Nissen
SE](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Nissen SE"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Wolski
K](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Wolski K"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Effect of rosiglitazone on the risk of myocardial infarction and death
from cardiovascular causes. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2007 Jun
14;356(24):2457-71.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17517853>

**[Editorial Comments:]{.underline}**

**British Analysis Does Not Confirm Rosiglitazone (Avandia) MI Risk**

After weighing all options and reviewing data from both the NEJM article
and information sent out from GlaxoSmithKline, most do not *presently*
believe it rational to have a blanket policy of taking patients off of
rosiglitazone. No other major professional entity has recommended that
up to this time. Rather, we recommend three possible options in
consultation with the patient either by phone or at an appointed clinic
visit.

-   The patient and provider may choose to continue rosiglitazone with
    careful attention to possible symptoms of either ischemia or
    congestive heart failure.

-   The patient and provider may negotiate a change in medication to
    pioglitazone if that is available on the pharmacy formulary. 15 to
    30 mg of pioglitazone is roughly equivalent to 4 mg of rosiglitazone
    and 45 mg roughly corresponds to the 8mg dose.

-   The patient and provider may choose to take the patient off
    rosiglitazone. This requires careful blood glucose monitoring for 2-
    3 months as the effect of the TZD class is not lost immediately on
    discontinuing this medicine. Titration of insulin or adding another
    agent may be necessary depending on the response to discontinuing
    the medicine.

Recall that pioglitazone is in the same family as rosiglitazone and we
have no guarantee this is not a class effect, nor do we understand the
mechanism for this yet. While pioglitazone showed some modest
cardiovascular benefits in secondary outcomes in the "PROACTIVE" study,
there was also a significant side effect of CHF in 3.3% of the
participants, not always predictable based on risk for CHF. We will
remain vigilant for follow up information on this issue.

"....Taken together, these results, although based on very small numbers
of events, certainly raise a signal of concern and indicate the need for
more reliable information about rosiglitazone's safety. But the FDA,
physicians, and patients can reasonably await the results of RECORD, a
phase III trial designed specifically to study cardiovascular outcomes.
Until the results of RECORD are in, it would be premature to over
interpret a meta-analysis that the authors and NEJM editorialists all
acknowledge contains important weaknesses.

To avoid unnecessary panic among patients, a calmer and more considered
approach to the safety of rosiglitazone is needed. Alarmist headlines
and confident declarations help nobody. ■ The Lancet..."
[http://www.medpagetoday.com/](http://broadcaster.medpagetoday.com/t?r=2&ctl=3CC4:30235F6733E4624962257E32606697C2)

**Q. How much does exercise help in weight loss?**

**A. There is a clear dose-response relationship between physical
activity and weight**

The majority of randomized, controlled trials (RCTs) show only modest
weight loss with exercise intervention alone, and slight increases in
weight loss when exercise intervention is added to dietary restriction.
In most RCTs, the energy deficit produced by the prescribed exercise is
far smaller than that usually produced by dietary restriction. In
prospective studies that prescribed high levels of exercise, enrolled
individuals achieved substantially greater weight loss--comparable to
that obtained after similar energy deficits were produced by caloric
restriction. High levels of exercise might, however, be difficult for
overweight or obese adults to achieve and sustain. RCTs examining
exercise and its effect on weight-loss maintenance demonstrated mixed
results; however, weight maintenance interventions were usually of
limited duration and long-term adherence to exercise was problematic.
Epidemiologic, cross-sectional, and prospective correlation studies
suggest an essential role for physical activity in weight-loss
maintenance, and post hoc analysis of prospective trials shows a clear
dose-response relationship between physical activity and weight
maintenance.

Evidence from existing RCTs is relatively consistent with regard to the
role of exercise in producing weight loss, either when used alone or in
combination with dietary modification. Although the majority of RCTs
show only modest weight loss with exercise alone, in most of these
studies the level of exercise prescribed was relatively low and would
have produced an energy deficit far smaller than that usually
recommended for weight loss by caloric restriction. The resulting
weight-loss findings from these studies are, therefore, consistent with
the amount of exercise prescribed. Although other studies demonstrate
that it is possible to achieve significant weight loss with high levels
of physical activity alone (when the volume of exercise prescribed is
equivalent to the energy deficit usually recommended for weight loss by
caloric restriction and energy intake is held constant), producing the
amount of activity needed is challenging given the difficulty of getting
sedentary people to achieve and consistently adhere to increased
physical activity.

Although adding physical activity to dietary modification increases
initial weight loss, only a small advantage was gained in most of the
RCTs. The daily energy deficit produced by short-term food restriction
usually greatly exceeds that produced by physical activity and thus the
contribution of additional physical activity (in the levels prescribed
in many of these studies) to negative energy balance was minimal.

RCTs that have investigated the role of physical activity in weight-loss
maintenance have reported mixed findings; however, limitations in
existing RCTs include poor adherence to the physical activity
prescribed, notable variability in the amount of exercise prescribed,
and the limited duration of the exercise interventions. Few RCTs truly
address the role of activity in weight-loss maintenance by providing a
long term, sustained-activity intervention and there is a need for
well-designed, prospective, randomized trials to assess such regimens.
Studies in which activity is measured by observation or retrospective
analysis illustrate a strong relation ship between physical activity and
success in weight-loss maintenance.

Future research should focus on the impact of physical activity on other
components of energy balance, why physical activity appears to be so
critical for successful weight maintenance, individual specific
determinants of how much activity is required for weight-loss
maintenance, and how to motivate people to achieve and sustain the
levels of activity that seem to be required for weight loss and
weight-loss maintenance.

[Catenacci
VA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Catenacci VA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Wyatt
HR](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Wyatt HR"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
The role of physical activity in producing and maintaining weight loss.
[Nat Clin Pract Endocrinol
Metab.](javascript:AL_get(this, 'jour', 'Nat Clin Pract Endocrinol Metab.');)
2007 Jul;3(7):518-29

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17581621>

and

**The Role of Physical Activity in Producing and Maintaining Weight
Loss: CME**

<http://www.medscape.com/viewarticle/557969>

**Rizatriptan was effective for the treatment of menstrual migraine**

Rizatriptan 10 mg was effective for the treatment of ICHD-II menstrual
migraine, as measured by 2-h pain relief and 24-h sustained pain relief.

[Mannix
LK](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Mannix LK"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Rizatriptan for the acute treatment of ICHD-II proposed menstrual
migraine: two prospective, randomized, placebo-controlled, double-blind
studies.
[Cephalalgia.](javascript:AL_get(this, 'jour', 'Cephalalgia.');) 2007
May;27(5):414-21

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17448179>

**Prehospital and Hospital Delays After Stroke Onset - United States,
2005-2006**

To assess prehospital delays from onset of stroke symptoms to emergency
department (ED) arrival and hospital delays from ED arrival to receipt
of brain imaging, CDC analyzed data from the four states participating
in the national stroke registry. Among the 3,795 patients who arrived at
the ED within 2 hours of symptom onset, 3,491 had data recorded
regarding the interval from ED arrival to receipt of brain imaging. A
total of 2,275 (65.2%) received imaging within 1 hour of ED arrival.
Significantly fewer women received imaging within 1 hour of ED arrival
than men (62.9% versus 67.6%, p=0.004), and fewer nonambulance patients
received imaging within 1 hour compared with patients transported by
ambulance (56.3% versus 69.2%, p=0.001). No disparities among racial
groups were observed regarding receipt of imaging within 1 hour of ED
arrival. Among those patients who arrived at the ED within 2 hours, the
median time from ED arrival to brain imaging was 0.73 hours (43.8
minutes).

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5619a3.htm>

**CDC Releases Report on Prevalence of Adult Obesity**

Obesity is linked with a higher risk of hypertension, dyslipidemia, type
2 diabetes, coronary heart disease, stroke, and some cancers. One goal
is to reduce the prevalence of obesity in adults by 15 percent. To
analyze the prevalence of obesity by state, the Centers for Disease
Control and Prevention (CDC) evaluated data from the 1995, 2000, and
2005 Behavioral Risk Factor Surveillance System surveys.

Adults with a body mass index (BMI) of 25 kg per m2 or more were
classified as as overweight, a BMI of 30 or more as obese, and a BMI of
40 or more as extremely obese. In 2005, approximately 60 percent of
adults were overweight, 24 percent were obese, and 3 percent were
extremely obese. Overall, 24.2 percent of men and 23.5 percent of women
were obese, and 17.7 percent of persons 18 to 29 years of age and 29.5
percent of persons 50 to 59 years of age were obese. The highest obesity
rate (33.9 percent) was in non-Hispanic blacks. After adjusting for age,
obesity prevalence was 15.6 percent in 1995, 19.8 percent in 2000, and
23.7 percent in 2005.

The CDC found that the prevalence of obesity increased significantly
(*P* \< .01) from 1995 to 2005 in all states. From 1995 to 2000, the
number of states with a less than 20 percent obesity rate dropped from
50 to 28 *(Figure 1).* In 2005, only four states had an obesity rate of
less than 20 percent. Seventeen states had an obesity rate of 25 percent
or more, and three of these had a rate of 30 percent or more. To reverse
this trend, an effective public health response is needed, including
programs aimed at improving environmental factors, increasing awareness,
and changing behaviors.

CDC
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5536a1.htm?s_cid=mm5536a1_e>

Practice Guideline Briefs
<http://www.aafp.org/afp/20070701/practice.html>

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

#### ACOG, American College of Obstetricians and Gynecologists {#acog-american-college-of-obstetricians-and-gynecologists .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Management of Herpes in Pregnancy: Practice Bulletin**

**Summary of Recommendations and Conclusions**

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

-   Women with active recurrent genital herpes should be offered
    suppressive viral therapy at or beyond 36 weeks of gestation.

-   Cesarean delivery is indicated in women with active genital lesions
    or prodromal symptoms, such as vulvar pain or burning at delivery,
    because these symptoms may indicate an impending outbreak.

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

-   In women with premature rupture of membranes, there is no consensus
    on the gestational age at which the risks of prematurity outweigh
    the risks of HSV.

-   Cesarean delivery is not recommended for women with a history of HSV
    infection but no active genital disease during labor.

-   Routine antepartum genital HSV cultures in asymptomatic patients
    with recurrent disease are not recommended.

-   Routine HSV screening of pregnant women is not recommended

Management of Herpes in Pregnancy. ACOG Practice Bulletin No. 82.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2007; 109:1233--48.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17569194>

**Management of Adnexal Masses: Practice Bulletin**

**Summary of Recommendations and Conclusions**

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

-   In asymptomatic women with pelvic masses, whether premenopausal or
    postmenopausal, transvaginal ultrasonography is the imaging modality
    of choice. No alternative imaging modality has demonstrated
    sufficient superiority to transvaginal ultrasonography to justify
    its routine use.

-   Specificity and positive predictive value of CA 125 level
    measurements are consistently higher in postmenopausal women
    compared with premenopausal women. Any CA 125 elevation in a
    postmenopausal woman with a pelvic mass is highly suspicious for
    malignancy.

-   Simple cysts up to 10 cm in diameter on ultrasound findings are
    almost universally benign and may safely be followed without
    intervention, even in postmenopausal patients.

-   Unilateral salpingo-oophorectomy or ovarian cystectomy in patients
    with germ cell tumors, stage I stromal tumors, tumors of low
    malignant potential, and stage IA, grade 1--2 invasive cancer who
    undergo complete surgical staging and who wish to preserve fertility
    does not apper to be associated with compromised prognosis.

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

-   Women with ovarian cancer whose care is managed by physicians who
    have advanced training and expertise in the treatment of women with
    ovarian cancer, such as gynecologic oncologists, have improved
    overall survival rates compared with those treated without such
    collaboration.

-   Most masses in pregnancy appear to have a low risk for both
    malignancy and acute complications and, thus, may be considered for
    expectant management.

Management of Adnexal Masses ACOG Practice Bulletin No. 83. American
College of Obstetricians and Gynecologists. Obstet Gynecol 2007;
110:201--14.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17601923>

**Sterilization of Women, Including Those With Mental Disabilities**

ABSTRACT: Sterilization, like any other surgical procedure, must be
carried out under the general ethical principles of respect for
autonomy, beneficence, and justice. Women requesting sterilization
should be encouraged to discuss their decision and associated issues
with their husbands or other appropriate intimate partners. The
physician who objects to a patient's request for sterilization solely as
a matter of conscience has the obligation to inform the patient that
sterilization services may be available elsewhere and should refer the
patient to another caregiver. The presence of a mental disability does
not, in itself, justify either sterilization or its denial. When a
patient's mental capacity is limited and sterilization is considered,
the physician must consult with the patient's family, agents, and other
caregivers in an effort to adopt a plan that protects what the consulted
group believes to be the patient's best interests while, at the same
time, preserving, to the maximum extent possible, the patient's
autonomy.

ACOG Committee Opinion No. 371: Sterilization of Women, Including Those
With Mental Disabilities. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Jul;110(1):217-20

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17601925>

**The Role of Cystourethroscopy in the Generalist Obstetrician
Gynecologist Practice**

ABSTRACT: Cystourethroscopy can be performed for diagnostic and a few
operative indications by obstetrician--gynecologists to help improve
patient care. Perhaps the most important indications for
cystourethroscopy are to rule out cystotomy and intravesical or
intraurethral suture or mesh placement and to verify bilateral ureteral
patency during or after certain gynecologic surgical procedures. The
granting of privileges for cystourethroscopy and other urogynecologic
procedures should be based on training, experience, and demonstrated
competence. Postgraduate education, including residency training
programs in obstetrics and gynecology and continuing medical education,
should include education in the instrumentation, technique, and
evaluation of findings of cystourethroscopy, and in the pathophysiology
of diseases of the lower urinary tract.

Although many of the pioneers of cystourethroscopy, most notably Howard
Kelly, were gynecologists, for decades the procedure has been performed
mainly by urologists. However, cystourethroscopy can be performed for
diagnostic and a few operative indications by
obstetrician--gynecologists to help improve patient care. This document
reviews the definition and indications for cystourethroscopy and
discusses the evidence and recommendations for its use in the generalist
obstetrician--gynecologist practice. situations and be prepared to
respond in a professional, ethical manner to patient requests for
information and procedures.

ACOG Committee Opinion No. 372: The Role of Cystourethroscopy in the
Generalist Obstetrician Gynecologist Practice. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Jul;110(1):221

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17601926>

**Adoption**

ABSTRACT: Obstetrician--gynecologists may find themselves at the center
of adoption issues because of their expertise in the assessment and
management of infertility, pregnancy, and childbirth. Physicians have a
responsibility to provide information about adoption to all patients
with unwanted pregnancies, to all patients with infertility concerns,
and to same-sex partners seeking information on parenting. Unless
physicians are truly expert in the field of adoption, they should guard
against advocating for a particular action. Physicians should not serve
as brokers in independent adoptions. When authorized by patients to fill
out forms for adoption agencies, physicians should do so truthfully,
with full disclosure to patients of what they intend to say.

Adoption. ACOG Committee Opinion No. 368. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2007; 109:1507--10.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17569192>

**Communication Strategies for Patient Handoffs**

ABSTRACT: Handoff communication, which includes up-to-date information
regarding patient care, treatment and service, condition, and any recent
or anticipated changes, should be interactive to allow for discussion
between the giver and receiver of patient information. It requires a
process for verification of the received information, including
read-back or other methods as appropriate.

Communication Strategies for Patient Handoffs. ACOG Committee Opinion
No. 367. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2007;109:1503--5.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17569191>

**Institutional Responsibility to Provide Legal Representation**

ABSTRACT: Hospitals, academic institutions, professional corporations,
and other health care organizations should have policies and procedures
by which alleged violations of professional behavior can be reported and
investigated. These institutions should adopt policies on legal
representation and indemnification to protect those whose
responsibilities in managing such investigations may expose them to
potentially costly legal actions. The American College of Obstetricians
and Gynecologists' Committee on Ethics supports the position of the
American Association of University Professors regarding institutional
responsibility for legal demands on faculty.

ACOG Committee Opinion No. 370: Institutional Responsibility to Provide
Legal Representation. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Jul;110(1):215-6

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17601924>

**Multifetal Pregnancy Reduction**

ABSTRACT: Counseling for treatment of infertility should include a
discussion of the risks of multifetal pregnancy, and multifetal
pregnancy reduction should be discussed with patients before the
initiation of any treatment that could increase the risk of multifetal
pregnancy. In almost all cases, it is preferable to terminate an
ovulation induction cycle or limit the number of embryos to be
transferred to prevent a situation in which fetal reduction will have to
be considered. The best interests of the patient and the future child or
children should be at the center of the risk--benefit equation. Although
no physicians need to perform fetal reductions if they believe that such
procedures are morally unacceptable, all obstetricians and gynecologists
should be aware of the medical and ethical issues in these complex
situations and be prepared to respond in a professional, ethical manner

Multifetal Pregnancy Reduction. ACOG Committee Opinion No. 369. American
College of Obstetricians and Gynecologists. Obstet Gynecol 2007;
109:1511--5.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17569193>

## AFP, American Family Physician {#afp-american-family-physician .Style-Heading-2-+-14-pt}

Screening for Breast Cancer: Current Recommendations and Future
Directions

Breast cancer is one of the most significant health concerns in the
United States. Recent reviews have questioned the value of traditional
breast cancer screening methods. Breast self-examination has been shown
not to improve cancer-specific or all-cause mortality in large studies,
but it is commonly advocated as a noninvasive screen. Patients who
choose to perform self-examination should be trained in appropriate
technique and follow-up. The contribution of the clinical breast
examination to early detection is difficult to determine, but studies
show that sensitivity is highly dependent on time taken to do the
examination. Up to 10 percent of cancers are mammographically silent but
evident on clinical breast examination. The U.S. Preventive Services
Task Force recommends mammography for women older than 40 years who are
in good health, but physicians should consider that sensitivity is lower
for younger women. Digital mammography is somewhat more sensitive in
younger women and women with dense breasts, but outcome studies are
lacking. Although magnetic resonance imaging shows promise as a
screening tool in some high-risk women, it is not currently recommended
for general screening because of high false-positive rates and cost. The
American Cancer Society recommends annual magnetic resonance imaging as
an adjunct to screening mammography in high-risk women 30 years and
older. Am Fam Physician 2007;5:1660-6

[**http://www.aafp.org/afp/20070601/1660.html**](http://www.aafp.org/afp/20070601/1660.html)

**ACS Recommendations on MRI and Mammography for Breast Cancer
Screening**

Women at high risk of developing breast cancer should receive annual
magnetic resonance imaging (MRI) as an adjunct to mammography, according
to new guidelines from the American Cancer Society (ACS).

Groups for whom MRI screening is recommended include the following:

> • Women with a *BRCA* mutation
>
> • Women with a first-degree relative who has a *BRCA* mutation

• Women with a 20 to 25 percent or greater lifetime risk for breast
cancer, based on

BRCAPRO or other risk models that depend largely on family history

• Women exposed to chest radiation between the ages of 10 and 30 years

• Women with Li-Fraumeni syndrome, and first-degree relatives of women
with this

syndrome

• Women with Cowden and Bannayan-Riley-Ruvalcaba syndromes, and
first-degree

relatives of women with these syndromes

MRI screening has been proven to detect cancer with early-stage tumors,
which are associated with better outcomes. Studies have found high
sensitivity for MRI, ranging from 71 to 100 percent versus 16 to 40
percent for mammography alone in high-risk populations. MRI also finds
smaller tumors compared with mammography, and the types of cancers found
with MRI contribute to reduced mortality rates.

Three approaches are available for identifying women with a high risk
for breast cancer: family history, genetic testing, and clinical
history. Although many women have at least one relative with breast
cancer, most of these women are not at increased risk. Only 1 to 2
percent of women have a family history suggestive of the inheritance of
an autosomal-dominant, high-penetrance gene that confers up to an 80
percent lifetime risk of breast cancer. In some families, there is also
a high risk of ovarian cancer. Family history findings that suggest the
presence of such a high-penetrance gene include two or more close
relatives (i.e., first- or second-degree) with breast or ovarian cancer;
breast cancer occurring before 50 years of age in a close relative; a
family history of breast and ovarian cancers; one or more relatives with
two cancers (breast and ovarian cancers or two independent breast
cancers); and male relatives with breast cancer.

Inherited mutations in the two breast and ovarian cancer susceptibility
genes, *BRCA1* and *BRCA2*, are present in approximately one half of
families in which an inherited risk is strongly suspected. Several
models can help physicians determine risk estimates: the Gail, Claus,
and Tyrer-Cuzick models are based on family history, and BRCAPRO and the
Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation
Algorithm (BOADICEA) estimate the likelihood of *BRCA* mutations.

Genetic testing for *BRCA* mutations usually is offered to adult members
of families with a known mutation and to women with a 10 percent or
greater likelihood of carrying such a mutation. If a woman from a family
in which a *BRCA* mutation has been identified does not have that
mutation, her breast cancer risk is no higher than it would have been if
she did not have a family history of breast cancer. However, in women
from high-risk families without a known mutation, failure to find a
mutation does not reduce risk.

[**http://caonline.amcancersoc.org/cgi/content/full/57/2/75**](http://caonline.amcancersoc.org/cgi/content/full/57/2/75)

Ginger: An Overview

Ginger *(Zingiber officinale)* is one of the more commonly used herbal
supplements. Although often consumed for culinary purposes, it is taken
by many patients to treat a variety of conditions. Ginger has been shown
to be effective for pregnancy-induced and postoperative nausea and
vomiting. There is less evidence to support its use for motion sickness
or other types of nausea and vomiting. Mixed results have been found in
limited studies of ginger for the treatment of arthritis symptoms. Am
Fam Physician 2007;75:1689-91.

[**http://www.aafp.org/afp/20070601/1689.html**](http://www.aafp.org/afp/20070601/1689.html)

CDC Changes Treatment Guidelines for Gonorrhea

Fluoroquinolones (i.e., ciprofloxacin \[Cipro\], ofloxacin \[Floxin\],
and levofloxacin \[Levaquin\]) have been used since 1993 for the
treatment of gonorrhea because of their effectiveness, availability, and
convenience as a single-dose oral therapy. However, the prevalence of
fluoroquinolone resistance in *Neisseria gonorrhoeae* has been
increasing in the United States, necessitating changes in treatment
regimens. Since 1999, increasing resistance of *N. gonorrhoeae* to
fluoroquinolones has been reported, first in Hawaii, then in California
and other Western states, then among men who have sex with men, and now
in other populations and regions. Data from 2005 and 2006 show that the
prevalence of fluoroquinolone-resistant *N. gonorrhoeae* has continued
to increase among heterosexual men and is present in all regions of the
United States.

Because fluoroquinolones are no longer recommended for the treatment of
gonorrhea, treatment options are limited. For the treatment of
uncomplicated urogenital and anorectal gonorrhea, the CDC now recommends
a single 125-mg intramuscular dose of ceftriaxone (Rocephin) or a single
400-mg oral dose of cefixime (Suprax). Alternative regimens include a
single 400-mg oral dose of cefpodoxime (Vantin) or a 1-g dose of
cefuroxime (Ceftin).

For pharyngeal gonorrhea, the CDC now recommends a single 125-mg
intramuscular dose of ceftriaxone.
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a3.htm>

Headache (Chronic Tension-Type)

What are the effects of drug treatments for chronic tension-type
headache?

beneficial

**Amitriptyline.** One systematic review and three small, short duration
randomized controlled trials (RCTs) found that amitriptyline reduced the
duration and frequency of chronic tension-type headache compared with
placebo. One RCT found that amitriptyline was more effective than
citalopram in improving headache duration, frequency, and severity.
Another RCT found comparable effectiveness between amitriptyline and
mirtazapine for the treatment of chronic tension-type headache, although
amitriptyline was associated with a less favorable adverse effect
profile. One RCT found no significant difference between amitriptyline
and cognitive behavior therapy in headache scores or frequency of
clinically important improvement after six months.

**Mirtazapine** (Only Short-term Evidence). One small RCT found that
mirtazapine reduced the duration, frequency, and intensity of chronic
tension-type headache compared with placebo. One RCT found comparable
effectiveness between mirtazapine and amitriptyline for the treatment of
chronic tension-type headache, although mirtazapine was associated with
a more favorable adverse effect profile.

unknown effectiveness

**SSRI Antidepressants.** One systematic review and one additional RCT
provided insufficient evidence about the effects of selective serotonin
reuptake inhibitors (SSRIs) on symptoms of chronic tension-type headache
compared with placebo. One systematic review found no significant
difference between SSRIs compared with amitriptyline for treatment of
chronic tension-type headache; however, more adverse effects occurred in
the amitriptyline group.

**Tricyclic Antidepressants (Other Than Amitriptyline).** We found
insufficient evidence about the effects of tricyclic antidepressants
other than amitriptyline.

likely to be ineffective or harmful

**Benzodiazepines.** Two RCTs provided insufficient evidence about the
effects of benzodiazepines compared with placebo or other treatments.
Benzodiazepines are commonly associated with adverse effects if taken
regularly.

**Botulinum Toxin.** One systematic review and one subsequent RCT
provided no evidence that botulinum toxin improved the symptoms of
chronic tension-type headache compared with placebo. However, botulinum
toxin is associated with important adverse effects.

**Regular Acute Pain Relief Medication.** We found no systematic review
or RCTs. One nonsystematic review of observational studies provided
insufficient evidence about the benefits of common analgesics in persons
with chronic tension-type headache. It found that sustained and frequent
use of some analgesics was associated with chronic headache and reduced
the effectiveness of prophylactic treatment.

What are the effects of nondrug treatments for chronic tension-type
headache?

likely to be beneficial

**Cognitive Behavior Therapy.** One systematic review and one subsequent
RCT found limited evidence that cognitive behavior therapy reduced the
symptoms of chronic tension-type headache at six months compared with
placebo. One RCT found no significant difference between cognitive
behavior therapy and amitriptyline or in headache scores or frequency of
clinically important improvement after six months. One systematic review
provided insufficient evidence to compare cognitive behavior therapy
versus relaxation or electromyographic biofeedback therapy.

uknown effectiveness

**Acupuncture.** Two systematic reviews and one subsequent RCT provided
insufficient evidence about the effects of acupuncture compared with
sham acupuncture in persons with chronic tension-type headache. A second
subsequent RCT found that low-power laser acupuncture improved headache
intensity, duration, and frequency compared with placebo.

**Indian Head Massage.** We found no systematic review or RCTs about the
effects of Indian head massage in persons with chronic tension-type
headache.

**Relaxation and Electromyographic Biofeedback.** Two systematic reviews
and one subsequent RCT provided insufficient evidence about the effects
of relaxation and electromyographic biofeedback on symptoms of chronic
tension-type headache.

[Definition]{.underline}

Chronic tension-type headache is a disorder that evolves from episodic
tension-type headache, with daily or very frequent episodes lasting
minutes to days. The 2004 International Headache Society criteria for
chronic tension-type headache includes having headaches for 15 or more
days a month (180 days per year) for at least three months; pain that is
bilateral, pressing, or tightening in quality and that is nonpulsating,
of mild or moderate intensity, and that does not worsen with routine
physical activity such as walking or climbing stairs; presence of no
more than one additional clinical feature (e.g., mild nausea,
photophobia, phonophobia); and without moderate or severe nausea or
vomiting. Chronic tension-type headache is generally regarded as a
featureless headache. Not all experts agree that mild features more
typically seen in migraine (e.g., photophobia, phonophobia) should be
included in the operational definition of chronic tension-type headache,
and it is often difficult to distinguish mild migraine headache from
tension-type headache.

Chronic tension-type headache is to be distinguished from other causes
of chronic daily headache that require different treatment strategies
(e.g., new daily persistent headache, medication overuse headache,
chronic migraine, hemicrania continua). Many persons who develop chronic
daily headache owing to chronic migraine or medication overuse also
develop mild migrainous \"background\" headaches that might be mistaken
for coincidental chronic tension-type headache. It is therefore
extremely important to take a full headache history to elicit the
individual features of the headache and to look for prodromal or
accompanying features that might indicate an alternative diagnosis.

In contrast to chronic tension-type headache, episodic tension-type
headache can last for 30 minutes to seven days and occurs for fewer than
180 days a year. The greatest obstacle to studying tension-type headache
is the lack of any single proven specific or reliable, clinical, or
biological defining characteristic of the disorder. Terms based on
assumed mechanisms (e.g., muscle contraction headache, tension headache)
are not operationally defined. Older studies that used these terms may
have included persons with many different types of headache.

[Incidence and Prevalence]{.underline}

The prevalence of chronic daily headache from a survey of the general
population in the United States was 4.1 percent; one half met the
International Headache Society criteria for chronic tension-type
headache. In a survey of 2,500 U.S. undergraduate students, the
prevalence of chronic tension-type headache was 2 percent. The
prevalence was 2.5 percent in a Danish population-based survey of 975
persons. One community-based survey in Singapore (2,096 persons from the
general population) found that the prevalence was 1.8 percent in women
and 0.9 percent in men.

[Etiology]{.underline}

Tension-type headache is more prevalent in women (65 percent of cases in
one survey). Symptoms begin before 10 years of age in 15 percent of
persons.7 There is a family history of some form of headache in 40
percent of persons with chronic tension-type headache,8 although a twin
study found that the risk of headache was similar for identical and
nonidentical twins.

[Prognosis]{.underline}

The prevalence of chronic tension-type headache declines with age.

Clinical Evidence Concise, A Publication of BMJ Publishing Group

<http://www.aafp.org/afp/20070701/bmj.html>

Exercise for Older Patients Who Are Acutely Hospitalized

Clinical Question

What are the effects of exercise interventions for patients older than
65 years who are acutely hospitalized?

Evidence-Based Answer

The effects of exercise interventions on functional outcomes are
unclear, but there is a trend toward functional improvement.
Multidisciplinary interventions that include exercise also show several
other benefits, including reduction in length of hospitalization and
hospital costs; these benefits have not been shown with exercise-only
interventions, however.

Practice Pointers

Older adults experience declines in physical strength, mobility, and
functioning during and after acute hospitalization.1 Exercise training
can improve functional outcomes in these patients.2

In this Cochrane review, the authors searched for studies evaluating the
effectiveness of inpatient exercise programs for older patients admitted
to the hospital with general medical problems. Nine studies with 4,223
total patients were included. Patients in specialized stroke, intensive
care, or rehabilitation units or those with primarily orthopedic
diagnoses were excluded. Interventions were started within three days of
admission and were compared with usual hospital care. The exercise
interventions ranged from increased physical activity to individually
tailored walking and strengthening programs.

The review found that older patients benefited from a multidisciplinary
intervention program that incorporated exercise. The benefits included a
decrease in hospital costs of about \$300 per hospital stay, an average
one-day reduction in length of hospitalization, and a 6 percent increase
in the proportion of patients discharged to home rather than to a
nursing home or other facility (number needed to treat = 16). It is
important to note that exercise-only programs did not demonstrate these
outcomes. In addition, the exercise portion of the multidisciplinary
interventions was not explained in detail, thus limiting the practical
implication of the studies. The authors conclude that the benefits may
be from the multidisciplinary effort rather than the exercise itself.

These data support including exercise in multidisciplinary programs
initiated as early as hospital admission and continuing until discharge.
Multidisciplinary programs generally include individually designed
patient exercise plans, a specialized geriatric inpatient unit, and
evaluation and treatment by physical and occupational therapists and a
physician or nurse trained as a geriatrician. Small but important
clinical outcomes can be expected with this multidisciplinary approach.
Cochrane Brief

de Morton NA, Keating JL, Jeffs K. Exercise for acutely hospitalised
older medical patients. Cochrane Database Syst Rev 2007(1):CD005955.

###### [**http://www.aafp.org/afp/20070701/cochrane.html**](http://www.aafp.org/afp/20070701/cochrane.html)

###### Evaluation of Nausea and Vomiting

A comprehensive history and physical examination can often reveal the
cause of nausea and vomiting, making further evaluation unnecessary.
Acute symptoms generally are the result of infectious, inflammatory, or
iatrogenic causes. Most infections are self-limiting and require minimal
intervention; iatrogenic causes can be resolved by removing the
offending agent. Chronic symptoms are usually a pathologic response to
any of a variety of conditions. Gastrointestinal etiologies include
obstruction, functional disorders, and organic diseases. Central nervous
system etiologies are primarily related to conditions that increase
intracranial pressure, and typically cause other neurologic signs.
Pregnancy is the most common endocrinologic cause of nausea and must be
considered in any woman of childbearing age. Numerous metabolic
abnormalities and psychiatric diagnoses also may cause nausea and
vomiting. Evaluation should first focus on detecting any emergencies or
complications that require hospitalization. Attention should then turn
to identifying the underlying cause and providing specific therapies.
When the cause cannot be determined, empiric therapy with an antiemetic
is appropriate. Initial diagnostic testing should generally be limited
to basic laboratory tests and plain radiography. Further testing, such
as upper endoscopy or computed tomography of the abdomen, should be
determined by clinical suspicion based on a complete history and
physical examination. Am Fam Physician 2007;76:76-84.

<http://www.aafp.org/afp/20070701/76.html>

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

**Use of high-risk medications by pregnant women is not uncommon**

<http://www.ahrq.gov/research/may07/0507RA19.htm>

**Gastrointestinal complaints in young women of low to normal weight may
indicate possible eating disorders**

<http://www.ahrq.gov/research/apr07/0407RA11.htm>

**Model shows contribution of mammography screening and adjuvant therapy
to reducing breast cancer deaths from 1975 to 2000**

<http://www.ahrq.gov/research/apr07/0407RA13.htm>

**Pediatricians with more knowledge of and confidence in identifying and
managing child abuse are more likely to identify abuse**

<http://www.ahrq.gov/research/may07/0507RA10.htm>

**Oncologists appear to communicate differently with breast cancer
patients depending on women\'s age, race, education, and income**

<http://www.ahrq.gov/research/apr07/0407RA12.htm>

**Clinic-based and community-based strategies can promote the use of key
preventive services by Latina women**

<http://www.ahrq.gov/research/apr07/0407RA14.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}

*Scopus*™**: A New Database**

*Scopus*™ is an interdisciplinary, bibliographic database that indexes
the contents of more than 15,000 journals in the physical sciences,
engineering, earth and environmental sciences, life and health sciences,
social sciences, psychology, business, and management. *Scopus* coverage
includes 535 open access journals, 12,850 academic journals, conference
proceedings, trade publications, 13 million patents, and more than 200
million scientific web pages. The coverage of *Scopus* is strongest from
1996 to the present and it is updated daily.

In terms of functionality, *Scopus*:

-   provides the ability to view search results and refine them to the
    most relevant hits,

-   offers an email alerting service that notifies you when a new
    publication matches your search terms, and when a new publication
    cites a selected publication,

-   presents patent search results from four patent offices,

-   includes seamless links to full-text articles and other library
    resources.

+-----------------------------------------------------------------------+
| **Search Functions**                                                  |
+-----------------------------------------------------------------------+
|   ----------------- ------------------- ----------------------------- |
|   **Function **     **Symbol/Method**   **Example**                   |
|                                                                       |
|   Freetext          Select \"All                                      |
|   searching         fields\"                                          |
|                                                                       |
|   Spelling          Use all variations  colour, color                 |
|                                                                       |
|   Phrases           use quotation       \"avian flu\"                 |
|                     marks - \" \"                                     |
|                                                                       |
|   Truncation        \*                  arter\* gives artery or       |
|                                         arteries                      |
|                                                                       |
|   Wildcard          \*                  wom\*n gives woman or women   |
|                                                                       |
|   Optional wildcard ?                   p?ediatric gives pediatric or |
|                                         paediatric                    |
|                                                                       |
|   Controlled        none                                              |
|   vocabulary                                                          |
|                                                                       |
|   Boolean           AND, OR, AND NOT    human AND NOT rat             |
|   ----------------- ------------------- ----------------------------- |
+-----------------------------------------------------------------------+

You can access *Scopus* via Research Tools
[Databases](http://nihlibrary.nih.gov/ResearchTools/default.htm?srchType=ViewDatabases)
on the green menu bar on the HSR Library webpage. For more information
about using *Scopus* email me at <cooperd@mail.nih.gov>

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

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

**What to do when: Mom says, "My newborn likes the bottle better."**

Why does it happen?

In a normal, healthy newborn, bottle preference is usually from overuse
of a bottle and/or pacifier. However, it is helpful to rule out unusual
newborn issues that can effect sucking like a short frenulum or thrush.

What is the cause?

Formula or breast milk comes out of the bottle quickly, just a little
tug. Also, the plastic nipple can rub the roof of the mouth, stimulating
the suck. It is not much work for the baby - and there is no waiting for
let down. It is easy. Breastfeeding takes more work. Often, but not
always, a baby will begin to favor the bottle and avoid breastfeeding.
Unfortunately, it is hard to know which baby will be influenced by
frequent bottles/pacifiers.

In the first couple weeks, there is probably still time for the mom's
supply to bounce back. To get mom and baby back to breastfeeding:

Assure the mom that her baby is getting enough:

Have her count diaper changes - if her baby has least 6 in 24 hours, her
baby is probably has an adequate intake.

Check her baby's weight gain -- ½ oz -- 1 oz per day, 3.5 - 7 oz per
week is normal

Tell the mom to breastfeed about 2 hours -- 8 to 12 times in 24 hours.
The baby's suck muscles and mom's milk supply will get up to speed
together and the frequency will slow down within a couple days.

Discourage the "pump and feed" method -- it has a near 100% burn out
rate.

Tell the mom to praise her baby for sucking well. The baby knows mom's
happier voice and will respond appropriately.

Recommend less use of the bottle. If the bottle can be weaned down to
once or twice a day, the mom's milk supply will probably be protected.
Less is best in the first 4-6 weeks.

Suggest that the pacifier be avoided -- and saved for difficult times
like car trips with screaming a baby or challenging moments.

If it looks like it really is a supply issue, or the "bounce back" is
not happening, consider medication. Clinical studies indicate that
metoclopromide can increase milk supply in difficult situations. For
more information, refer to Thomas Hales' text, Medications and Mother's
Milk or sources like the San Diego Breastfeeding Coalition web page,
<http://www.breastfeeding.org/articles/reglan.html>.

If the baby won't latch, refer the mom to WIC or a Lactation Consultant.
It is OK to call us for over-the-phone-ideas at 1- 877-868-9473. It is
toll-free - best times are 7 am -- 10 pm, Mountain Standard Time.

What about extra fluids?

Clinical studies have not agreed with the common practice of encouraging
fluids to increase milk supply. Unfortunately the studies were small,
each with less than 30 participants, and did not correct for climate
issues -- such as excessive heat/cold, or the typical amount of outdoor
exposure the mother experienced. So while encouraging water is a healthy
practice, excessive fluids are not necessary. A reasonable
recommendation is to keep water nearby and drink to thirst.

Please note: If it is believed that a specific (safe) beverage will
help, it probably will. Confidence is a powerful tool with parenting,
especially breastfeeding.

**References**

Dusdieker LB et al. Prolonged maternal fluid supplementation in
breast-feeding. Pediatrics,

1990 Nov;86(5):737-40.

Morse JM et al. The effect of maternal fluid intake on breast milk
supply: a pilot study.

Canadian Journal of Public Health, 1992 May-Jun;83(3):213-6.

**Other**

**New IHS Breast feeding Family Support web page: Have pictures to
share?**

When family and friends support breastfeeding,\
it makes the challenges easier.\
Your encouragement will touch a lifetime.

Tell mom that she is doing great.\
Let dad know that his patience is beautiful.\
Let the new family how proud you are of them.\
Praise grandparents/aunts/uncles/cousins/friends\
for their wonderful care and wisdom.

#### Give the new family a boost: 

-   Tackle some household chores

-   Bring a meal over

-   Change some diapers

-   Make the trip to the grocery store

-   Give the baby a bath

-   Take the new siblings to the park

-   Read a book or watch TV with the new siblings

-   Keep mom resting, bring the baby to her

If you have pictures to share, please email them to
[[suzan.murphy@ihs.gov]{.underline}](mailto:suzan.murphy@ihs.gov)

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

**Cup feeding not be recommended over bottle feeding as a supplement to
breastfeeding**

AUTHORS\' CONCLUSIONS: Cup feeding cannot be recommended over bottle
feeding as a supplement to breastfeeding because it confers no
significant benefit in maintaining breastfeeding beyond hospital
discharge and carries the unacceptable consequence of a longer stay in
hospital.

[Flint
A](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Flint A"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Cup feeding versus other forms of supplemental enteral feeding for
newborn infants unable to fully breastfeed. [Cochrane Database Syst
Rev.](javascript:AL_get(this, 'jour', 'Cochrane Database Syst Rev.');)
2007 Apr 18;(2):CD005092

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17443570>

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

**Despite the benefits of early breastfeeding, many women find it
unexpectedly difficult and painful**
<http://www.ahrq.gov/research/may07/0507RA18.htm>

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

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

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

#### June / July Highlights include: {#june-july-highlights-include .Style-Heading-4-+-Arial-14-pt-Underline}

-A new management category: 'First Trimester GDM'

-Control over schedule: Most important predictor of staff work-life
balance / burnout

-Placental problems with previous caesarean delivery: Abruptio, previa

-Discharge 24 Hours After Vaginal Hysterectomy Safe, Acceptable

-Guidelines for School-Based STD Screening in Indian Country

-Malabsorption of Oral Antibiotics in Pregnancy after Gastric Bypass
Surgery

-Seeking and Giving Consultation

-Long-Term Breastfeeding among Native American Women

-The failure to protect Indigenous women from sexual violence in the USA

-Reasons for unprotected intercourse

-What are the Unnecessary Tests?

-Improve HIV screening in pregnancy? Preliminary GPRA Related Results

-Social context of maternal deaths and morbidity

-Improve the system - Improve the care: Underpinnings

-Which Indian Health facilities lead the U.S. in national benchmarks?

-Earlier hormone therapy closer to menopause tended to have reduced CHD
risk

-Adjustable Urethral Slings: Hope for Patients with Complex Incontinence

-Personal Digital Assistants: Practical Advice for Nurses in 2007

-Placental cultures and histology poor predictors of infectious amniotic
fluid

-Electronic Health Record (EHR) Implementation: Worth the effort?

-Fluoroquinolones No Longer Recommended for Gonococcal Infections

-High rate of DM among indigenous people ?not due to thrifty gene

-Women's Early Drinking Problems More Likely to Escape Diagnosis

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_06.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_06.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocumentscccc_v5_06.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-6 .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-7 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Domestic Violence Denise Grenier, Tucson / Rachel Locker, Warm Springs {#domestic-violence-denise-grenier-tucson-rachel-locker-warm-springs .Style-Heading-4-+-Arial-14-pt-Underline}

**IHS-ACF DV Project: Conference CD**

I want to make you aware that you can obtain a copy of the National
Conference on Health and Domestic Violence Conference -- Presenter CD by
clicking on the URL:

<http://fvpfstore.stores.yahoo.net/2007-conference-presentation2008.html>

You may find the CD content helpful as you work towards improving your
DV screening, patient education and patient safety planning

Carolyn Aoyama <Carolyn.Aoyama@ihs.gov>

**Family Violence Prevention Funds Screen to End Abuse Video**

IHS-ACF DV Project: Free online DV training video and CME: The Family
Violence Prevention Funds Screen to End Abuse video is now up on
Medscape with a free 1 hour CEU. People may view the video and then take
a CME test to receive credit.

Now Available on Medscape with CME: Screen to End Abuse

 

Screen to End Abuse, a 30 minute training video produced by the Family
Violence Prevention Fund (FVPF) includes five clinical vignettes
demonstrating techniques for screening and responding to domestic
violence in primary care settings.  The FVPF partnered with Medscape, an
internet provider of educational tools for health care professionals and
students to develop the Screen to End Abuse video into a Continuing
Education activity. The free 1 hour activity includes the five
vignettes, learning objectives and statistics from Screen to End Abuse
and incorporates Pre and Post-test questions to facilitate the user's
learning experience. 

-To view the video visit: [www.medscape.com](http://www.medscape.com/)

(log in free and search: *"Domestic Violence and Your Patient\'s Health:
Asking the Right Questions"*)

**Perceptions of Adult Patients' History of Child Abuse**

The providers in our exploratory study seemed to lack awareness and
strategies about how and when to incorporate inquiry into a history of
child abuse in their clinical assessment. Contradictory discourses exist
among them about the potential significance of routine inclusion of
child abuse history in the initial and/or ongoing assessment of adult
patients. Despite the fact that primary care providers are in an ideal
position to identify and treat the physical and emotional sequelae of
early abuse, and that patients, including those with abuse histories,
favor screening about childhood physical and sexual abuse, these family
physicians expressed reluctance to enter these troubled waters.

The potential benefits of a patient\'s disclosure of a history of
childhood abuse to his or her family physician are many: A survivor
might feel relief from the burden of the secret and might finally hear
that the abuse was not his or her fault. The patient might be able to
make a connection between current emotional and physical symptoms with
past abuse and might take the opportunity to engage in counseling or
psychotherapy around these painful issues. The patient might realize
that his or her own body is not shameful and start to be able to take
better care of it and make healthier lifestyle
choices.[9](http://www.jabfm.org/cgi/content/full/20/4/417?etoc#R9%23R9)
Finally, a caring relationship with a nonabusive adult such as a family
physician may facilitate healing and speed a survivor\'s journey to
recovery.[10](http://www.jabfm.org/cgi/content/full/20/4/417?etoc#R10%23R10)
The potential for such inquiry to have a therapeutic effect deserves
further investigation.

Weinreb, L et al Perceptions of Adult Patients' History of Child Abuse
in Family Medicine Settings Journal of the American Board of Family
Medicine 20 (4): 417-419 (2007)

<http://www.jabfm.org/cgi/content/full/20/4/417?etoc>

**Study finds connection between teenage violence and domestic
violence**

Researchers tracing the development of violent behavior have found a
link between teenage violence and domestic violence.

Adolescents who engaged in violent behavior at a relatively steady rate
through their teenage years and those whose violence began in their mid
teens and increased over the years are significantly more likely to
engage in domestic violence in their mid 20s than other young adults,
according to a new University of Washington study.

\"Most people think youth violence and domestic violence are separate
problems, but this study shows that they are intertwined,\" said Todd
Herrenkohl, lead author of the study and a UW associate professor of
social work.

The study also found no independent link between an individual\'s use of
alcohol or drugs and committing domestic violence. In addition it showed
that nearly twice as many women as men said they perpetrated domestic
violence in the past year including kicking, biting or punching their
partner, threatening to hit or throw something at their partner, and
pushing, grabbing or shoving their partner.

Data from the study came from the on-going Seattle Social Development
Project which has been tracing youth development and the social and
antisocial behavior of more than 800 participants. It began when they
were in the fifth grade and continues to follow them into adulthood.

That project earlier showed four patterns of youth violence taken by
teens between the ages of 13 and 18.

-    Non-offenders, the largest group (60 percent), did not engage in
    violent behavior in adolescence.

-    Desisters (15 percent) engaged in violence early on but stopped by
    age 16.

-    Chronic offenders (16 percent) began violent behavior early and it
    persisted at a moderate level up to age 18.

-    Late increasers (9 percent) became involved with violence in mid
    adolescence with the behavior increasing up to age 18.

The new study found that individuals from the last two groups were
significantly more likely than non-offenders to have committed
moderately severe forms of domestic violence when they were 24 years
old. At that age, nearly 650 of the original students had a partner and
about 19 percent of them, or 117 individuals, reported having committed
domestic violence in the past year.

The finding that a perpetrator\'s use of alcohol is not significantly
related to domestic violence was somewhat surprising since other studies
have shown such an association. The reasons for this are unclear,
according to Herrenkohl, who speculated such a relationship may have
shown up if more severe forms of domestic violence, such as those
requiring hospitalization had been measured.

The study also showed a number of personal characteristics, partner
characteristics and neighborhood conditions that increased an
individual\'s chances of being involved in domestic violence as a young
adult. Being diagnosed with a major episode of depression or receiving
welfare were significantly related to committing domestic violence, as
were having a partner who used drugs heavily, sold drugs, had a history
of violence toward others, had an arrest record or was unemployed.

Disorganized neighborhoods where attitudes toward drug sales and
violence were favorable also increased a person\'s likelihood of
committing domestic violence.

\"Individuals who have a history of anti-social behavior may be more
likely to find a partner with a similar history and re-create what they
experienced as children. They may also be more likely to be in places in
their communities where they interact with people with the same types of
behavior,\" said Herrenkohl.

\"The take-home message from this study is that it may be possible to
prevent some forms of domestic violence by acting early to address youth
violence. Our research suggests the earlier we begin prevention programs
the better, because youth violence appears to be a precursor to other
problems including domestic violence.\"

[[http://uwnews.washington.edu/ni/article.asp?articleID=34626]{.underline}](http://uwnews.washington.edu/ni/article.asp?articleID=34626)

Co-authors of the study were Rick Kosterman, a research scientist; W.
Alex Mason, a research analyst; and J. David Hawkins, professor of
social work. All are affiliated with the UW\'s Social Development
Research Group. The paper appears in the current issue of the journal
Violence and Victims and the research was funded by the National
Institute on Drug Abuse and the National Institute of Mental Health.

**SANE: Is there a center near you?**

From the International Association of Forensic Nurses \"Beyond
Tradition, Advancing Humanity\"

Web site - US Map with state-by-state links to local sites.
[[http://www.iafn.org/registry/reghome.cfm]{.underline}](http://www.iafn.org/registry/reghome.cfm)

 

**Frequently Asked Questions:**

-Standards of Practice: Domestic Violence  [Is there any source
available for standards for care of domestic violence
victims?](http://www.iafn.org/about/aboutFAQ.cfm?nav=registry#29) 

<http://www.iafn.org/about/aboutFAQ.cfm?nav=registry#29>

-Publications on line at the following link:   

<https://www.iafn.org/store/storeHome.cfm>

-Standards of Practice: Forensic Nursing   [Where can I find Forensic
Nursing Standards of
Practice?](http://www.iafn.org/about/aboutFAQ.cfm?nav=registry#20)

<http://www.iafn.org/about/aboutFAQ.cfm?nav=registry#20>

-Website Tools: Listing Tools    [How can I make changes to our program
on line?](http://www.iafn.org/about/aboutFAQ.cfm?nav=registry#90)

<http://www.iafn.org/about/aboutFAQ.cfm?nav=registry#90>

Certification chapters committees education events jobs membership
projects publications registry (includes Canadian provinces)

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

AAN Guidelines on Reporting Medical Conditions That May Affect Driving
Competency

Driving laws for persons with medical conditions that affect cognition,
consciousness, vision, or motor skills vary from state to state.
Physicians are expected to report a patient\'s driving-related condition
to authorities if the condition might pose a safety risk, especially
when the patient does not comply with requests to be tested or stop
driving. Requiring mandatory reporting, however, may negatively affect
the patient-physician relationship. Reporting also may not result in
safety benefits to the public or the patient, who may consequently
withhold important medical information.

Poorly designed reporting laws may also expose physicians to liability
for a patient\'s driving outcomes, even when a physician has followed
all applicable laws. Most states have full legal immunity for physicians
who follow applicable laws in good faith. However, physicians in some
states (e.g., Arkansas, Georgia) may be sued for reporting a patient
with questionable driving abilities, resulting in a suggested violation
of patient-physician privilege. In other states (e.g., Michigan,
Montana), a physician who does not report a patient who appears to be a
sound driver is at risk of being sued if that patient later causes an
accident.

The American Academy of Neurology (AAN) encourages physicians to review
applicable driving laws with their patients and to discuss and document
their medical recommendations with their patients. The AAN also supports
optional reporting of persons with medical conditions that may affect
their ability to drive safety, especially for cases in which public
safety has already been compromised or when the person clearly no longer
has the skills to drive safely.

Physician immunity policies should be clarified so that physicians are
granted immunity for reporting or not reporting a patient\'s condition
when such action is taken in good faith, when the patient is reasonably
informed of his or her driving risks, and when such actions are
documented by the physician in good faith.

American Academy of Neurology
<http://www.neurology.org/content/vol68/issue15/#SPECIAL_ARTICLES>

AFP Practice Guideline Briefs
<http://www.aafp.org/afp/20070701/practice.html>

**Elderly Medicare patients with low health literacy receive little
tangible support for their health care needs**

<http://www.ahrq.gov/research/may07/0507RA20.htm>

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

#### Waiting until the menses to start hormonal contraceptives: Needless Obstacle  {#waiting-until-the-menses-to-start-hormonal-contraceptives-needless-obstacle-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Protocols that require a woman to wait until the next menses to start hormonal contraceptives are an obstacle to contraceptive initiation. Directly observed, immediate initiation of the pill improves short-term continuation  {#conclusion-protocols-that-require-a-woman-to-wait-until-the-next-menses-to-start-hormonal-contraceptives-are-an-obstacle-to-contraceptive-initiation.-directly-observed-immediate-initiation-of-the-pill-improves-short-term-continuation .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Westhoff C](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Westhoff C"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract), et al Initiation of oral contraceptives using a quick start compared with a conventional start: a randomized controlled trial. [Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007 Jun;109(6):1270-6. {#westhoff-c-et-al-initiation-of-oral-contraceptives-using-a-quick-start-compared-with-a-conventional-start-a-randomized-controlled-trial.-obstet-gynecol.-2007-jun10961270-6. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17540797&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17540797&dopt=Abstract) {#httpwww.ncbi.nlm.nih.govsitesentrezcmdretrievedbpubmedlist_uids17540797doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

**One In Four with Unplanned Pregnancy Experience Gaps In BCM Or Do Not
Use A Method**

#### Fifteen percent of U.S. women in a recent survey who were at risk of unplanned pregnancy had had a gap in contraceptive use of one or more months during the previous year, while 8% had not used any method {#fifteen-percent-of-u.s.-women-in-a-recent-survey-who-were-at-risk-of-unplanned-pregnancy-had-had-a-gap-in-contraceptive-use-of-one-or-more-months-during-the-previous-year-while-8-had-not-used-any-method .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Providers could better help women avoid unintended pregnancy by initiating regular assessments of method use difficulties, improving counseling on method choice and pregnancy risk, and identifying and assisting women at higher risk for inconsistent method use because of disadvantage, relationship characteristics or ambivalence about pregnancy prevention. In addition to providers\' efforts, broader societal commitment is critical for increasing contraceptive knowledge and expanding access to contraceptive care for all women who are at risk of having an unintended pregnancy {#conclusions-providers-could-better-help-women-avoid-unintended-pregnancy-by-initiating-regular-assessments-of-method-use-difficulties-improving-counseling-on-method-choice-and-pregnancy-risk-and-identifying-and-assisting-women-at-higher-risk-for-inconsistent-method-use-because-of-disadvantage-relationship-characteristics-or-ambivalence-about-pregnancy-prevention.-in-addition-to-providers-efforts-broader-societal-commitment-is-critical-for-increasing-contraceptive-knowledge-and-expanding-access-to-contraceptive-care-for-all-women-who-are-at-risk-of-having-an-unintended-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

#### Frost J et al Factors associated with contraceptive use and nonuse, United States, 2004. [Perspect Sex Reprod Health.](javascript:AL_get(this, 'jour', 'Perspect Sex Reprod Health.');) 2007 Jun;39(2):90-9 {#frost-j-et-al-factors-associated-with-contraceptive-use-and-nonuse-united-states-2004.-perspect-sex-reprod-health.-2007-jun39290-9 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17565622**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17565622) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17565622 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Little variation in the frequency of reported symptoms among oral contraceptive pills {#little-variation-in-the-frequency-of-reported-symptoms-among-oral-contraceptive-pills-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: In the absence of sufficient evidence-based data to support the existence of differences in the tolerance profile of low-dose combined OCPs, future well-designed randomized trials are needed to guide providers in their choice of OCPs. However, research should also assess the effectiveness of counseling on the tolerance of OCPs, an intervention that may prove to be more rewarding than basing the choice of OCPs on their theoretical properties. {#conclusion-in-the-absence-of-sufficient-evidence-based-data-to-support-the-existence-of-differences-in-the-tolerance-profile-of-low-dose-combined-ocps-future-well-designed-randomized-trials-are-needed-to-guide-providers-in-their-choice-of-ocps.-however-research-should-also-assess-the-effectiveness-of-counseling-on-the-tolerance-of-ocps-an-intervention-that-may-prove-to-be-more-rewarding-than-basing-the-choice-of-ocps-on-their-theoretical-properties. .Style-Heading-4-+-Arial-14-pt-Underline}

### Moreau, C et al Does the Type of Pill Matter? Oral Contraceptive Tolerance. [Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007 Jun;109(6):1277-85.

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17540798&dopt=Abstract>

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

#### FDA Approves Contraceptive for Continuous Use {#fda-approves-contraceptive-for-continuous-use-1 .Style-Heading-4-+-Arial-14-pt-Underline}

The Food and Drug Administration (FDA) approved Lybrel, the first
continuous use drug product for prevention of pregnancy on May 22, 2007

The new contraceptive, Lybrel, comes in a 28 day-pill pack with low-dose
combination tablets that contain 90 micrograms of a progestin,
levonorgestrel, and 20 micrograms of an estrogen, ethinyl estradiol,
which are active ingredients available in other approved oral
contraceptives. Continuous contraception works the same way as the 21
days on-seven days off cycle. It stops the body\'s monthly preparation
for pregnancy by lowering the production of hormones that make pregnancy
possible.

Other contraceptive pill regimens have placebo or pill-free intervals
lasting four to seven days that stimulate a menstrual cycle. Lybrel is
designed to be taken without the placebo or pill-free time interval.
Women who use Lybrel would not have a scheduled menstrual period, but
will most likely have unplanned, breakthrough, unscheduled bleeding or
spotting.

The safety and efficacy of Lybrel as a contraceptive method were
supported by two one-year clinical studies, enrolling more than 2,400
women, ages 18 to 49. Health care professionals and patients are advised
that when considering the use of Lybrel, the convenience of having no
scheduled menstruation should be weighed against the inconvenience of
unscheduled bleeding or spotting. The occurrence of unscheduled bleeding
decreases over time in most women who continue to take Lybrel for a full
year. In the primary clinical study, 59 percent of the women who took
Lybrel for one year had no bleeding or spotting during the last month of
the study.

Like other available oral contraceptives, Lybrel is effective for
prevention of pregnancy when used as directed. The risks of using Lybrel
are similar to the risks of other conventional oral contraceptives and
include an increased risk of blood clots, heart attacks, and strokes.
The labeling also carries a warning that cigarette smoking increases the
risk of serious cardiovascular side effects from the use of combination
estrogen and progestin-containing contraceptives. Birth control pills do
not protect against HIV infection (AIDS) or other sexually transmitted
diseases.

Because Lybrel users will eliminate their regular periods, it may be
difficult for women to recognize if they have become pregnant. Women
should take a pregnancy test if they believe they may be pregnant. Women
should also discuss contraceptive use, and the precautions and warnings
for use of the drug product, with their doctors or other health care
professional.

The approval of Lybrel concludes a comprehensive review process that
included expert advice from a meeting of an FDA\'s Reproductive Health
Drugs advisory committee and an opportunity for public comment on issues
regarding hormonal contraception.

Lybrel is manufactured by Wyeth of Philadelphia, PA.

#### [**http://www.fda.gov/bbs/topics/NEWS/2007/NEW01637.html**](http://www.fda.gov/bbs/topics/NEWS/2007/NEW01637.html) {#httpwww.fda.govbbstopicsnews2007new01637.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Implanon and bone mineral density: Two Articles {#implanon-and-bone-mineral-density-two-articles .Style-Heading-4-+-Arial-14-pt-Underline}

#### BMD during long-term use of the progestagen contraceptive implant {#bmd-during-long-term-use-of-the-progestagen-contraceptive-implant .Style-Heading-4-+-Arial-14-pt-Underline}

#### An open, prospective, comparative study was done in healthy women, aged between 18 and 40 years, to study the effects of long-term etonogestrel treatment on bone mineral density (BMD). The control group used a non-hormone-medicated intrauterine device (IUD). The BMD was measured using a dual energy X-ray absorptiometry instrument. Measurements included the lumbar spine (L(2)-L(4)), the proximal femur (femoral neck, Ward\'s triangle, trochanter) and distal radius. The period of treatment was 2 years and 44 women in the Implanon group and 29 in the IUD group provided data. Groups were comparable at baseline with respect to age, weight, body mass index, BMD and 17beta-oestradiol status. Changes from baseline in BMD in the Implanon group were not essentially different from those in the IUD group. There was no relationship between 17beta-oestradiol concentrations and changes in BMD in this study population. The results of the present study indicate that Implanon((R)) can safely be used in young women who have not yet achieved their peak bone mass. {#an-open-prospective-comparative-study-was-done-in-healthy-women-aged-between-18-and-40-years-to-study-the-effects-of-long-term-etonogestrel-treatment-on-bone-mineral-density-bmd.-the-control-group-used-a-non-hormone-medicated-intrauterine-device-iud.-the-bmd-was-measured-using-a-dual-energy-x-ray-absorptiometry-instrument.-measurements-included-the-lumbar-spine-l2-l4-the-proximal-femur-femoral-neck-wards-triangle-trochanter-and-distal-radius.-the-period-of-treatment-was-2-years-and-44-women-in-the-implanon-group-and-29-in-the-iud-group-provided-data.-groups-were-comparable-at-baseline-with-respect-to-age-weight-body-mass-index-bmd-and-17beta-oestradiol-status.-changes-from-baseline-in-bmd-in-the-implanon-group-were-not-essentially-different-from-those-in-the-iud-group.-there-was-no-relationship-between-17beta-oestradiol-concentrations-and-changes-in-bmd-in-this-study-population.-the-results-of-the-present-study-indicate-that-implanonr-can-safely-be-used-in-young-women-who-have-not-yet-achieved-their-peak-bone-mass. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Beerthuizen R](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Beerthuizen R"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), et al Bone mineral density during long-term use of the progestagen contraceptive implant Implanon compared to a non-hormonal method of contraception. [Hum Reprod.](javascript:AL_get(this, 'jour', 'Hum Reprod.');) 2000 Jan;15(1):118-22 {#beerthuizen-r-et-al-bone-mineral-density-during-long-term-use-of-the-progestagen-contraceptive-implant-implanon-compared-to-a-non-hormonal-method-of-contraception.-hum-reprod.-2000-jan151118-22 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=10611199**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=10611199) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch10611199 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### BMD with Implanon (etonorgestrel- and levonorgestrel-releasing contraceptive implants) {#bmd-with-implanon-etonorgestrel--and-levonorgestrel-releasing-contraceptive-implants .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Women of 19-43 years of age using either one of the implants showed lower BMD at 18 months of use at the midshaft of the ulna, however, without a difference at the distal radius. {#conclusions-women-of-19-43-years-of-age-using-either-one-of-the-implants-showed-lower-bmd-at-18-months-of-use-at-the-midshaft-of-the-ulna-however-without-a-difference-at-the-distal-radius. .Style-Heading-4-+-Arial-14-pt-Underline}

Bahamondes l et al A prospective study of the forearm bone density of
users of etonorgestrel- and levonorgestrel-releasing contraceptive
implants. Human Reproduction. 21(2):466-470, February 2006.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16253974>

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

#### Oral Contraceptives - Individualized Treatment \-- Optimal Results (Slides with Audio)  {#oral-contraceptives---individualized-treatment----optimal-results-slides-with-audio .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/557225**](http://www.medscape.com/viewarticle/557225) {#httpwww.medscape.comviewarticle557225 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Featured Website David Gahn, IHS MCH Portal Web Site Content
Coordinator**

**From Roberta Ward, CNM, ANMC**

In case you didn\'t know about this website: +++

A couple of good handouts from Contraception Online that you may want to
use with your patients are:

-Implantable Rod

-Extended Dosing

There are other handouts on that website also.

**Contraception Online** <http://www.contraceptiononline.org/index.cfm>

**Last Special Issue on Methamphetamine in Indian Country: Now online**

This is to let you know that the third (and last) special issue on meth
in the IHS Primary Care

Provider is now available on-line at this link below

Thanks again to everyone who contributed to this important series.

Lori de Ravello, MPH <lori.deravello@ihs.gov>

**Methamphetamine in Indian Country: Part 3**

<http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV0407.pdf>

**Wrong link for National Sexual Violence Resource Center**

[www.nsvrc.org](http://www.nsvrc.org/)  is the CORRECT link for National
Sexual Assault Resource Center

 ***NOT***    [www.ncvrc.org](http://www.ncvrc.org/) 

From Yohanah B <LeivaYohanah.Leiva@ihs.gov>

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

**Q. Can oral or sublingual misoprostol be used for postpartum
hemorrhage?**

A. Yes and both have a more rapid onset of action than rectal
adminstraion

The doses are smaller than some of the rectal doses that are being used.
The sublingual and oral doses of misoprostol mentioned below are: 400,
and 600 microg. 

Sublingual and oral doses reach a peak concentration much more rapidly,
so sublingual or oral dosing may have more of a role in the acute
management of PPH, rather the mid and long term management as with
rectal misoprostol. (The time to peak concentration (Tmax) was similar
in both the sublingual (26.0 +/- 11.5 min) and oral groups (27.5 +/-
14.8 min) and was significantly shorter than those in both vaginal
groups.)

Here are a few articles on sublingual and oral doses of misoprostol used
in postpartum hemorrhage.

**Effect of sublingual misoprostol on severe postpartum haemorrhage in a
primary health centre in Guinea-Bissau: randomised double blind clinical
trial.**

CONCLUSION: Sublingual misoprostol reduces the frequency of severe
postpartum haemorrhage.

[Høj
L](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Høj L"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Effect of sublingual misoprostol on severe postpartum haemorrhage
in a primary health centre in Guinea-Bissau: randomised double blind
clinical trial. [BMJ.](javascript:AL_get(this, 'jour', 'BMJ.');) 2005
Oct 1;331(7519):723.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16195287>

**Sublingual misoprostol versus methylergometrine for active management
of the third stage of labor**

CONCLUSION: Sublingual misoprostol appears to be as effective as
intravenous methylergometrine in the prevention of postpartum
hemorrhage. However, larger randomized studies are needed to advocate
its routine use.

[Vimala
N](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Vimala N"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Sublingual misoprostol versus methylergometrine for active
management of the third stage of labor. [Int J Gynaecol
Obstet.](javascript:AL_get(this, 'jour', 'Int J Gynaecol Obstet.');)
2004 Oct;87(1):1-5

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15464767>

**A pilot-randomized comparison of sublingual misoprostol with
syntometrine on the blood loss in third stage of labor**

CONCLUSION: The use of sublingual misoprostol or intravenous
syntometrine in spontaneous vaginal delivery resulted in a comparable
amount of blood loss. Transient side effect such as fever and shivering
which resolved within a day occurred more frequent to those who received
sublingual misoprostol.

[Lam
H](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Lam H"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al A pilot-randomized comparison of sublingual misoprostol with
syntometrine on the blood loss in third stage of labor. [Acta Obstet
Gynecol
Scand.](javascript:AL_get(this, 'jour', 'Acta Obstet Gynecol Scand.');)
2004 Jul;83(7):647-50

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15225189>

**A multicentre randomized controlled trial of oral misoprostol and i.m.
syntometrine in the management of the third stage of labour**

Oral misoprostol might be used in the management of the third stage,
especially in situations where the use of syntometrine is
contraindicated and facilities for storage and parenteral administration
of oxytocics are limited.

[Ng
PS](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Ng PS"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al A multicentre randomized controlled trial of oral misoprostol and
i.m. syntometrine in the management of the third stage of labour. [Hum
Reprod.](javascript:AL_get(this, 'jour', 'Hum Reprod.');) 2001
Jan;16(1):31-35

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11139532>

**A double-blind randomized controlled trial of oral misoprostol and
intramuscular syntometrine in the management of the third stage of
labor.**

CONCLUSION: Orally administered misoprostol at a dose of 400 mug is an
acceptable alternative in preventing post-partum blood loss, as measured
by the peri-partum change in hemoglobin level and was not associated
with an increased incidence of side effects.

[Ng
PS](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Ng PS"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al A double-blind randomized controlled trial of oral misoprostol and
intramuscular syntometrine in the management of the third stage of
labor. [Gynecol Obstet
Invest.](javascript:AL_get(this, 'jour', 'Gynecol Obstet Invest.');)
2007;63(1):55-60

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16940738>

**Oral misoprostol in preventing postpartum haemorrhage in resource-poor
communities: a randomised controlled trial**

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

[Derman
RJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Derman RJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al  Oral misoprostol in preventing postpartum haemorrhage in
resource-poor communities: a randomised controlled trial.
[Lancet.](javascript:AL_get(this, 'jour', 'Lancet.');) 2006 Oct
7;368(9543):1248-53

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17027730>

**A randomised placebo controlled trial of oral misoprostol in the third
stage of labour.**

CONCLUSIONS: Shivering has been shown in this study to be a specific
side effect of misoprostol administered orally in the puerperium. No
serious side effects were noted. Misoprostol shows promise as a method
of preventing postpartum haemorrhage. Because of the potential benefits
for childbearing women, particularly those in developing countries,
further research to determine its effects with greater certainty should
be expedited.

[Hofmeyr
GJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Hofmeyr GJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al A randomised placebo controlled trial of oral misoprostol in the
third stage of labour. [Br J Obstet
Gynaecol.](javascript:AL_get(this, 'jour', 'Br J Obstet Gynaecol.');)
1998 Sep;105(9):971-5

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=9763047>

**A double-blind placebo controlled randomised trial of misoprostol and
oxytocin in the management of the third stage of labour**

CONCLUSIONS: In low risk women oral misoprostol appears to be as
effective in minimising blood loss in the third stage of labour as
intramuscular oxytocin. Shivering was noted more frequently with
misoprostol use, but no other side effects were noted. Misoprostol has
great potential for use in the third stage of labour especially in
developing countries.

[Walley
RL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Walley RL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al  A double-blind placebo controlled randomised trial of misoprostol
and oxytocin in the management of the third stage of labour.
[BJOG.](javascript:AL_get(this, 'jour', 'BJOG.');) 2000
Sep;107(9):1111-5

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11002954>

**Pharmacokinetics of different routes of administration of
misoprostol.**

CONCLUSION: The new sublingual route of administration of misoprostol
demonstrated a great potential to be developed into a method of medical
abortion.

[Tang
OS](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Tang OS"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Pharmacokinetics of different routes of administration of
misoprostol. [Hum
Reprod.](javascript:AL_get(this, 'jour', 'Hum Reprod.');) 2002
Feb;17(2):332-6

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11821273>

**Q. How should you greet your patients?**

A. Most Patients Prefer Their Physicians to Greet Them With a Handshake
and Introduction

CONCLUSIONS: Physicians should be encouraged to shake hands with
patients but remain sensitive to nonverbal cues that might indicate
whether patients are open to this behavior. Given the diversity of
opinion regarding the use of names, coupled with national patient safety
recommendations concerning patient identification, we suggest that
physicians initially use patients\' first and last names and introduce
themselves using their own first and last names.

[Makoul
G](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Makoul G"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al An evidence-based perspective on greetings in medical encounters.
[Arch Intern Med.](javascript:AL_get(this, 'jour', 'Arch Intern Med.');)
2007 Jun 11;167(11):1172-6

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17563026>

**Q. How can I better counsel my patient to adhere to therapy?**

A. Treatment effects expressed in terms of number needed to treat (NNT)
yielded higher consent rates than did those expressed as equivalent
postponements.

[Background:]{.underline} Ways to communicate the benefits of
risk-reducing drug therapies include the number needed to treat (NNT) to
prevent adverse events, such as heart attacks or hip fractures, and
gains in disease-free life expectancy or postponement of adverse events.

[Methods:]{.underline} Respondents were randomized to a scenario with 1
of 3 outcomes after 5 years of treatment. For the drug to prevent heart
attacks, the outcomes were postponement by 2 months for all patients,
postponement by 8 months for 1 of 4 patients, or an NNT of 13 patients
to prevent 1 heart attack.For the drug to prevent hip fractures, the
outcomes were postponement by 16 days for all patients, postponement by
16 months for 3 of 100 patients, or an NNT of 57 patients to prevent 1
fracture. Study endpoints were consent to receive the intervention and
perceived ease of understanding the treatment effect.

CONCLUSIONS: Treatment effects expressed in terms of NNT yielded higher
consent rates than did those expressed as equivalent postponements. This
result suggests that the description of the anticipated outcome may
influence the patient\'s willingness to accept a recommended
intervention.

[Halvorsen
PA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Halvorsen PA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Different ways to describe the benefits of risk-reducing
treatments: a randomized trial [Ann Intern
Med.](javascript:AL_get(this, 'jour', 'Ann Intern Med.');) 2007 Jun
19;146(12):848-56

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17577004>

**Q. Should patients use sweat lodges during pregnancy?**

A. A sweat lodge that does not elevate the maternal core temperature
would be acceptable

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/SweatLodge7607.doc>

**Q. What is recommended about peyote use in pregnancy?**

A. Use of hallucinogens are not recommended in pregnancy

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Peyote7607.doc>

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

**August 2007 -- Highlights**

-Lactose intolerance in infants, children, and adolescents.

-Influenza activity, 2006-7

-Inhalant abuse

-Fatal Injuries Among Children by Race and Ethnicity

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN807.doc>

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

**Integrated case management software application release**

The IHS Office of Information Technology (OIT) is pleased to announce
the release of iCare, the next generation of RPMS Population Management
software. We would like to thank Cherokee Indian Hospital, Phoenix
Indian Medical Center, Red Lake Hospital Service Unit; Sells Service
Unit, and SouthEast Alaska Regional Health Consortium for testing this
application.

IHS Office of Information Technology initiated this population health
care software application to provide an easy-to --use tool with multiple
uses to a wide variety of providers. iCare is a Windows-based graphical
user interface (GUI) component of the IHS Resource and Patient
Management System (RPMS) that presents diverse patient data in a
user-friendly perspective.

This initial version of iCare will provide IHS providers the ability to
view patient data from an individual patient as well as a
\"population-centric\" perspective. The application will assist the user
in identifying trends in care for individuals and populations as well as
increase awareness of the services that patients need by highlighting
the status of key clinical prevention and treatment measures.

User-defined patient lists (panels) can be created, sorted and filtered
in a variety of ways to form the core functionality of iCare.
Additionally, auto-tagging\" of patients with one or more clinical
diagnoses and facilitating provider review of clinical quality of care
measures for their own patients should enable improvement in the quality
of healthcare delivery.

iCARE can be used by sites that are on RPMS-EHR as well as those that
are not on RPMS-EHR. We encourage all sites to start using this
software.

To encourage use, OIT is pleased to offer WebEx training for the new
iCare (Population Management) software application. You will be able to
participate in the training from your office or conference room and will
not be required to travel to obtain this training. For more information
on these training sessions, please visit our website:
<http://www.ihs.gov/CIO/ca/icare/index.asp> and download the training
schedule.

The new release of this software is available on the IHS Web site:
<http://www.ihs.gov/Cio/RPMS/index.cfm?module=home&option=software>

or ITSC system, cmbsyb, in the /usr/spool/uucppublic/DIST/2006cert
directory

**iCare Training**

The IHS Office of Information Technology is pleased to continue offering
WebEx training for the new iCare (Population Management) software
application. You will be able to participate in the training from the
comfort of your office or conference room and will not be required to
travel to obtain this training.

iCare is a tool with multiple uses for a wide variety of providers that
presents diverse RPMS data through an easy to use graphical user
interface (GUI).

There are two types of training offered:

1.  iCare Technical Overview

2.  iCare -- Nuts and Bolts

The target audience is [any]{.underline} provider who cares for patients
(e.g. physicians, mid-level providers, nurses, case managers, public
health personnel, pharmacists etc.)

**[NOTE:]{.underline}** **You must register for these classes.** They
are NOT limited to participants in a particular Area; they are open to
all, however, space is limited so be sure to register right away. Below
are the agendas and date/times for both classes. It is recommended that
you attend them sequentially.

[Each session is limited to 30 participants.]{.underline}  [Therefore,
if there is a group of people who would like to attend at your facility,
our recommendation is that you attend as a group and have only one
person register for the session.]{.underline}  For the group, you will
need a conference room, conference phone, computer and projector. 
Please ensure someone at your facility is responsible for taking care of
these arrangements.

Please note this is a live, internet-based training, not a recorded
session, and people will be able to ask questions and actively
participate in the class.

**[NOTE:  All training times shown above are for the Pacific Daylight
Time zone.  Please ensure you adjust the time for your particular time
zone.]{.underline}**

**[Training Schedule]{.underline}**

1.  **[iCare -- Nuts and Bolts]{.underline}**

> Target Audience -- Patient Care Providers (e.g. physicians, mid-level
> providers, nurses, case managers, public health personnel, pharmacists
> etc.)
>
> **[Agenda]{.underline}**

-   Introductions and Context

-   Set Up and Background (Server) Processes

-   Establishing and Changing User Preferences

-   Panel Creation

-   Panel Modification

-   Flags

-   Diagnostic Tags

-   National Performance Measures

-   Patient Record

-   Question and Answer Session

**[Session                          Date and Time                Reg
Password]{.underline}**

iCare Nuts and Bolts Mon 07/16/2007 12:00-14:00 PDT coyote

Tue 07/31/2007 11:00-13:00 PDT coyote

Thur 08/23/2007 09:00-11:00 PDT coyote

Mon 08/27/2007 13:30-15:30 PDT coyote

Fri 09/14/2007 10:30-12:30 PDT coyote

2.  **[The Practical Use of iCare]{.underline}**

> Target Audience -- Patient Care Providers (e.g. physicians, mid-level
> providers, nurses, case managers, public health personnel, pharmacists
> etc.)
>
> **[Agenda]{.underline}**

-   Introductions and Context

-   Scenarios

-   Tips

-   Using the Performance Measure views to improve outcomes

-   Questions and Answers

**[Session                         Date and
Time                              Reg Password]{.underline}**

The Practical Use of iCare Wed 07/18/2007 09:00-10:30 PDT coyote

Thur 08/02/2007 09:30-11:00 PDT coyote

Fri 08/24/2007 10:00-11:30 PDT coyote

Thur 08/30/2007 12:00-13:30 PDT coyote

Wed 09/19/2007 11:00-12:30 PCT coyote

**[Registration Information]{.underline}**

1.  Click this link:<https://ihs-training.webex.com/>

```{=html}
<!-- -->
```
1.  At the Search For box, type in \"iCare\" (do not type in the
    quotation marks) and click the Go button.  **NOTE:  If you do not
    see the Search For box, ensure the Training Center tab is selected
    at the top of the WebEx window, immediately under "webex."**

2.  All of the scheduled sessions will then be displayed in the window
    below.  Choose the one you want to attend and click "Registration"
    in the Status column.

3.  Enter the Registration password that is shown above that corresponds
    to the class you want to attend.

4.  Click the OK button.

5.  Complete the registration form.

6.  Click the Register button.

7.  A Registration confirmation is displayed that contains all of the
    information for the training session, including the link for the
    session and the password to enter when you are ready to attend the
    session.  Click the OK button to finish.

**[Setup (Software Install) Information:]{.underline}**

You must have the WebEx software installed on your computer prior to
attending the WebEx session.  **[You should setup the software at least
a day before the training session.]{.underline}**  You should not need
anyone such as the Site Manager to install it for you.  Below are the
instructions.

1.  Click this link:

> <https://ihs-training.webex.com/ihs-training/mywebex/default.php?Rnd0969=0.20680128403018566>

1.  On the left side of the window, click Set Up.

2.  Immediately under Set Up you will see two options:  Training
    Manager, Preferences.

3.  Click Training Manager.

4.  A message is displaying giving you information about the setup
    process. Click the Set Up button.

5.  After the software is installed, click the OK button.

**[Attending the Session:]{.underline}**

When you are ready to attend the session, connect to the WebEx session
first using the information contained in your registration confirmation
e-mail and then connect to the conference line.  The dial information
for the conference line is shown below and is also included in your
registration confirmation message.

Phone Number:  (877) 781-4791

Passcode:         135963#

Questions? Contact Cynthia Gebremariam at <Cynthia.Gebremariam@ihs.gov>

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

**Maternal survival redux: a view from Malawi - Failure of justice**

Last November this column reviewed the Lancet's recent series on
maternal survival, which assessed the progress and pitfalls of the Safe
Motherhood movement. This month I want to revisit the issue of maternal
survival from a more personal perspective. I spent the first five months
of 2007 in Blantyre, Malawi, the largest city in a country in which a
woman's lifetime chance of dying from childbirth complications is around
one in eight. While there I spent part of each week working clinically
in a busy public referral and teaching hospital, alongside many of the
nation's new nurse midwives- and doctors-in-training. During these five
months we averaged two to three maternal deaths every week in the
hospital. I also spent time out in the community, interviewing nurse
midwives at area health centers, and speaking with traditional midwives
(TBAs in the biomedical lexicon). Many health workers -- both within and
outside of the formal medical sector \-- shared their perceptions of
maternal risk in Malawi. Some thoughts based on these experiences:

-   Birth in a safe facility, attended by a skilled health worker, is
    just a start. And it doesn't necessarily equate with "birth in a
    hospital with a biomedically trained doctor or nurse midwife." Can a
    referral hospital be considered a "safe facility" if it has no
    sutures, runs out of all antibiotics except penicillin G, or has
    such poor staffing that one nurse covers a ward of eighty patients?
    Can a government health center be considered safe if there is no
    equipment to start an IV, nor any blood pressure cuff? What if the
    "skilled health worker" is demoralized and apathetic because he
    hasn't been paid in two months? What if she is a brand new intern --
    poorly trained and supervised -- who learned how to do a Cesarean
    from another intern and isn't too sure how to use oxytocin? Making
    motherhood safer won't happen simply by bringing women into the
    hospital. It is going to require detailed attention to sector-wide
    issues like supply chains, health sector funding, training and brain
    drain.

-   Infection is playing a huge role in maternal deaths, at least in
    countries with high HIV prevalence, and the role of Cesarean section
    needs to be investigated carefully in these settings. Since I first
    worked in Malawi, the pattern of maternal deaths has shifted. In
    1990, deaths from septic unsafe abortion were common, as was death
    from hemorrhage. In 2007, both of these have declined, but
    postpartum -- and especially postoperative -- infection deaths have
    skyrocketed. HIV-positive women are especially (but not exclusively)
    at risk. HIV treatment and prevention are crucial. And in this
    setting, the increased morbidity and mortality attendant upon
    surgical intervention should affect the risk/benefit analysis for
    Cesarean: the adoption of First World standards like surgical
    delivery for breech needs careful re-evaluation.

-   We should rethink \-- AGAIN \-- the question of traditional birth
    attendant training. TBA training has all but vanished from
    international funders' priorities, based on conflicting data on
    effectiveness. This despite the fact that TBAs continue to be the
    attendants at many births in the developing world; half of Malawi's
    births are outside of formal-sector health facilities. TBAs I spoke
    with in Malawi very strongly advocated for a restoration of training
    programs that they felt provided them not only with valuable
    information and skills, but perhaps even more importantly enabled
    them to forge mutually respectful connections with district health
    offices and staff at local hospitals. These proved invaluable when
    it came time to manage difficult cases together.

-   Women's empowerment is more than a buzzword. In too many families, a
    woman's value is in her capacity to bear children. In too many
    places, a girl's ability to access schooling or employment depends
    on her willingness to trade sex for the patronage of an older male.
    In too many countries, women do not make the policy decisions that
    affect their lives. When a fifteen-year-old dies after an unsafe
    abortion, when a woman who knows she has AIDS dies of postpartum
    sepsis after her third attempt in three years to bear a son,
    maternal death is not just a biomedical problem, remediable by
    technical interventions. It is a failure of justice.

    **November 2006 International Health Update**

    <http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1106_Feat.cfm#ih>

    **Other**

**Q. How about these two malarial drugs in early pregnancy?**

Mefloquine Hydrochloride

Sulfadoxine and pyrimethamine (Fansidar)

**Response from George Gilson, MFM**

The above two drugs are not known to be teratogenic to human pregnancy.
There has been 

extensive experience with their use for malaria prophylaxis in
developing countries. I will summarize what is known about each drug
below. The ReproTox website, which is an excellent resource, has all the
references. While the two drugs are not known to have adverse effects at
a specific week of pregnancy, depending on one's menstrual history it is
somewhat unsure, and it would be best to date the pregnancy with
ultrasound for the usual obstetric reasons. One may not even have been
pregnant at the time they took the drugs. 

 

Mefloquine is a quinine derivation useful for the prophylaxis of
chloroquine-resistant malaria. Several large studies involving several
thousand women have shown it not to be associated with an increased
incidence of congenital anomalies or miscarriage above that of the
general population when taken in the first trimester.

 

Sulfadoxine/pyrimethamine (Fansidar, Malarid, etc) is a combination of a
sulfonamide with a folic acid antagonist used as an antimalarial and as
treatment for toxoplasmosis (in pregnancy). While it has been noted to
be teratogenic in rodents (cleft lip/palate, embryo resorbtion) at doses
12 times the usual human dose, it has not been shown to be teratogenic
in humans. It is not recommended in pregnancy because it has been
associated with serious maternal adverse effects (severe sulfa allergy,
agranulocytosis, etc) and there are many effective alternatives.

**In this situation should one continue the pregnancy?**

Let's assume the medications were taken during the time of
organogenesis. While the information is in general reassuring that the
medications are not thought to be teratogenic, the information about the
Malarid is limited. The decision to terminate is always up to the woman;
I can\'t tell you what she should do, sorry! If one does decide to
continue the pregnancy, then I would suggest one get a fetal anatomic
survey (detailed ultrasound) at 18 weeks for reassurance

**Malaria Preventive Therapy Useful for Pregnant Women Despite
Resistance**

CONCLUSIONS: In areas in which 1 of 4 treatments with
sulfadoxine-pyrimethamine fail in children by day 14, the 2-dose IPT
with sulfadoxine-pyrimethamine regimen continues to provide substantial
benefit to HIV-negative semi-immune pregnant women. However, more
frequent dosing is required in HIV-positive women not using
cotrimoxazole prophylaxis for opportunistic infections.

[ter Kuile
FO](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="ter Kuile FO"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Effect of sulfadoxine-pyrimethamine resistance on the efficacy of
intermittent preventive therapy for malaria control during pregnancy: a
systematic review. [JAMA.](javascript:AL_get(this, 'jour', 'JAMA.');)
2007 Jun 20;297(23):2603-16

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17579229>

**Multivitamins should be considered for all pregnant women in
developing countries** CONCLUSIONS: Multivitamin supplementation reduced
the incidence of low birth weight and small-for-gestational-age births
but had no significant effects on prematurity or fetal death.
Multivitamins should be considered for all pregnant women in developing
countries

Fawzi WW et al Vitamins and perinatal outcomes among HIV-negative women
in Tanzania.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17409323>

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

**Who needs liquor stores when parents will do?**

The present study findings \"highlight the need for alcohol prevention
efforts to address . . . social sources of alcohol, particularly before
high school; a major challenge for alcohol prevention efforts.

The authors found that

\* At the beginning of 6th grade, parents and guardians were the most
common source of alcohol (32.7%), followed by another adult age 21 or
older (15.7%) and someone age 20 or younger (9.7%).

\* By the end of 8th grade, another adult age 21 or older (22.7%)
surpassed parents and guardians (18.9%) as the most prevalent source
reported.

\* Consistent users followed a pattern similar to that of the entire
sample, with social sources outstripping commercial sources.

\* Over time, student reports of taking alcohol from home or a friend\'s
home, receiving alcohol from a friend\'s parent or guardian, and
purchasing alcohol from commercial sources were lower in prevalence
compared to accessing alcohol from parents or guardians, another adult
age 21 or older, or someone age 20 or younger.

\* Among the entire sample of alcohol users, increases over time were
observed across the following sources of alcohol: another adult age 21
or older, someone age 20 or younger, took it from home, and commercial.

\* Parents as a source of alcohol use decreased over time.

\* Males were more likely than females to get alcohol from commercial
sources. Among consistent users, males were more likely than females to
get alcohol from a friend\'s parent.

\* No significant racial and ethnic differences (white adolescents vs.

African-American or Hispanic adolescents) were observed across sources
of alcohol use over time.

\"Recognizing the importance of social sources of alcohol and how social
sources change as children age offers an ideal opportunity for primary
prevention,\" the authors conclude.

Hearst MO, Fulkerson JA, Maldonado-Molina MM, et al. 2007. Who needs
liquor stores when parents will do? The importance of social sources of
alcohol among young urban teens. Preventive Medicine 44(6):471-476.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17428525>

**Home visiting associated with decreased infant death**

Infant death may be considered the \'tip of the iceberg\' in which
children of families at risk experience suboptimal care, poor health
outcomes, and the possibility of lifelong disability; some die before
their first birthday.

The authors found that

\* After controlling for race, prenatal care, maternal smoking, maternal
education, and maternal age, enrollment in greater Cincinnati\'s Every
Child Succeeds (ECS) was associated with a 60% decrease in the
likelihood of infant death.

\* The differences between black participants in ECS and black
nonparticipants tended to be much larger than the differences observed
for nonblack infants.

\* Among all the independent variables identified, adequacy of prenatal
care had the strongest association with the likelihood of infant death.

\* Black mothers enrolled in ECS before birth were more likely to
received adequate prenatal care, compared with control subjects.

\* The largest association between ECS participation and reduced infant
mortality rate was seen for black infants.

\* No influence of ECS enrollment on gestational age at birth was
observed.

The authors conclude that \"our study findings are consistent with the
findings from randomized, controlled trials and suggest that home
visiting reduces the risk of infant death.\"

Donovan EF, Ammerman RT, Besl J, et al. 2007. Intensive home visiting is
associated with decreased risk of infant death. Pediatrics 119
(6):1145-1151.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17545382>

**Resident fathers' prenatal behaviors, pregnancy intentions and
involvement with infants**

Men\'s Pregnancy Intentions and Prenatal Behaviors: What They Mean for
Fathers\' Involvement with Their Children examines how men feel about a
pregnancy (pregnancy intentions), how men act during the pregnancy
(prenatal behaviors), and the effects of these intentions and behaviors
on men\'s involvement with very young children following birth. The
research brief, published by Child Trends, draws on data from the 2001
Early Childhood Longitudinal Study \-- Birth Cohort, 9-month Resident
Father Survey, which tracks a nationally representative sample of
children from infancy to first grade. The brief includes a summary, a
discussion of the implications for policy and practice, and a
conclusion. References and statistical charts and graphs are also
included.
[[http://www.childtrends.org/Files//Child_Trends-2007_05_31_RB_Prenatal.pdf]{.underline}](http://www.childtrends.org/Files//Child_Trends-2007_05_31_RB_Prenatal.pdf)

**Office based motivational interviewing to prevent overweight in
children**

This feasibility study demonstrates that pediatricians and RDs
(registered dieticians) can be taught to use some of the tools and
techniques of MI (motivational interviewing) and that this approach is
well received by parents.

The authors found that

\* At the 6-month follow-up, there were mean decreases in BMI of 0.6
percentiles among children in the control group, 1.9 among those in the
minimal group, and 2.6 among those in the intensive group.

\* Parents in the minimal group reported a significant within-group
decrease in their child\'s intake of snacks, a change that was
significantly greater than the change reported by parents in the control
group. Parents in the intensive group reported a significant net
decrease in dining out compared with parents in the minimal group.

\* Ninety-four percent of the parents reported being very satisfied with
the pediatrician visit, and all were very satisfied with the RD visit;
94% of the parents also reported that the pediatrician and RD helped
them think about changing their family\'s eating habits.

The authors conclude that \"many challenges remain in designing and
implementing research to test the effectiveness of the MI approach in
practice settings, but practice-based research networks afford the
opportunity to conduct the additional studies needed to make the office
setting an effective site for obesity intervention.\"

Schwartz RP, Hamre R, Dietz WH, et al. 2007. Office-based motivational
interviewing to prevent childhood obesity. Archives of Pediatrics and
Adolescent Medicine 161(5):495-501

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17485627>

**Association between confidential services and parent adolescent
communiciation**

This study supports the hypothesis that availability of services is not
a barrier to adolescent-parent communication about their health.

The authors found that

\* Fifty-eight percent of the adolescents came to the clinic for
confidential services.

\* Overall, 69.5% (N=41) of the adolescents told their parents they were
coming to the clinic.

\* Less than half (43.1%, N=25) of the adolescents reported that they
would tell their parents if they were found to have a serious and
sensitive reproductive health problem (sexually transmitted infection or
pregnancy). Of those who would tell their parents, approximately half
had come in for confidential services and half for non-confidential
services.

\* In terms of adolescents\' decisions about whether to discuss their
reasons for coming to the clinic and their future communication related
to serious and sensitive reproductive health care issues with their
parents, there was no significant difference between adolescents who
came in for confidential vs. non-confidential services.

The authors suggest that further research is needed to explore health
professionals\' role in helping adolescents share information about a
serious and sensitive reproductive health problem and assisting them in
obtaining support from their parents. The authors add that interventions
need to be in place to educate parents about communication with their
adolescent and the rights of their adolescent under the minor\'s consent
laws.

Lerand SJ, Ireland M, Boutelle K. 2007. Communication with our teens:

Associations between confidential service and parent-teen communication.
Journal of Pediatric and Adolescent Gynecology 20():173-178.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17561185>

**Policy options to better serve adolescents who age out of foster
care**

Time for Reform: Aging Out and on Their Own briefly discusses the
history of permanency and federal child welfare policy, presents the
latest state-by-state data on the number of adolescents who have aged
out of foster care, and offers recommendations for public policy reforms
to decrease the number of adolescents who age out of care each year. The
report, published by the Pew Charitable Trusts, draws on findings from
focus groups conducted with adolescents who aged out or expect to age
out of foster care, research studies, and interviews to document the
adverse long-term effects that aging out of foster care has had on a
growing number of adolescents each year. The appendix contains charts
depicting the number and percentage of adolescents aging out and length
of stay by state, describes the characteristics of focus group
participants and methodology, and presents selected outcomes for
adolescents who age out of foster care (education, health, employment
and income, living arrangements, contact with the criminal justice
system). The report is intended for use by program administrators,
policymakers, and others to improve the system so that all children in
foster care achieve permanency with families, and to ensure that proper
support is in place for those who may age out of the system without a
permanent family.
[[http://www.pewtrusts.org/pdf/Aging_Out_May2007.pdf]{.underline}](http://www.pewtrusts.org/pdf/Aging_Out_May2007.pdf)

**MCH Headlines Judy Thierry HQE**

**Taking a harder line on blood transfusions**

Hospitals trying to zero in on the key factors that put patients at risk
for blood transfusions might start by looking within.

"One of the biggest risks in the U.S. of being transfused is which doors
you happen to walk through on the day of surgery," anesthesiologist
Timothy Hannon, MD, MBA, said in a recent G-2 Reports audioconference on
blood management. Even within a group of surgeons or anesthesiologists,
he said, you see considerable variation in blood use, with some ordering
quite a bit and others very little.

In fact, he told CAP TODAY, a hospital is a "quantifiable risk factor
for transfusion" for all patients, whether or not they have surgery.
That's because the hospital tends to have a "culture" for how it
approaches transfusion therapy, says Dr. Hannon, medical director of the
blood management program at St. Vincent Hospital, Indianapolis, and
president and CEO of Strategic Healthcare Group, which offers, among
other services, blood management consultation.

It has been known for some time that a restrictive transfusion strategy
may be better for adult patients than a liberal strategy. Now, a new
study has found that a restrictive strategy (hemoglobin threshold of 7
g/dL) for red-cell transfusion can decrease transfusion requirements
without increasing adverse outcomes in stable, critically ill children
(Lacroix 2007). The mounting more-may-be-less data is why some hospitals
are implementing conservative, evidence-based blood management programs.

The College of American Pathologists article below gives multiple other
successful examples from adult medicine, orthopedics, and other
disciplines.

[http://www.cap.org/apps/cap.portal?\_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&\_windowLabel=cntvwrPtlt&cntvwrPtlt%7BactionForm.contentReference%7D=cap_today%2Ffeature_stories%2F0507Transfusion.html&\_state=maximized&\_pageLabel=cntvwr](http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt{actionForm.contentReference}=cap_today%2Ffeature_stories%2F0507Transfusion.html&_state=maximized&_pageLabel=cntvwr)

Lacroix J, et al. Transfusion strategies for patients in pediatric
intensive care units. N Engl J Med. 2007;356:1609--1619

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17442904>

**Are you interested in the bigger picture of Indian Health care? Join a
listserv**

Perhaps you should join an Indian Health list serve on your topic(s) of
interest?

Centering prenatal care, breastfeeding, primary care discussion forum,
CCC newsletter ... elder care -  the linked site below has many choices
on the "available list".

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

**Do you know your state\'s teen-driving-laws?**

How does your state line up with THE FOLLOWING:

-   An extended learner period of supervised driving

-   Required hours of adult supervision during the learner period

-   Restrictions on late-night driving during initial months of
    licensure

-   Restrictions on transporting teen passengers during initial months
    of licensure

-   Seat belt requirements for drivers and passengers

-   CUT AND PAST THIS LINK INTO YOUR BROWSER\
     <http://www.allstate.com/citizenship/foundation/teen-driving/teen-driving-laws.aspx> 

VEHICLE RELATED FATALITIES BY TYPE OF VEHICLE, YEAR AND BY state

 <http://www.ite.org/crashes/index.htm>   

**Program for At-Risk Infants and Mothers Recognized**

Baby Love, a social work program for at-risk infants and mothers based
out of University of Rochester Medical Center's Strong Memorial
Hospital, has been recognized by the Healthcare Association of New York
State as one of the state's best examples of an institutional commitment
to improve the health of the surrounding community.

The Baby Love program, which was started in 1988, is a home visit
program designed to reduce infant mortality, premature births, low birth
weight rates, and foster care placement in poor inner-city
neighborhoods. The program works in close partnership with neighborhood
based health and social service providers, integrated health service
systems, county health and social service agencies, and insurers.

Teams of social workers and outreach workers work with at-risk pregnant
women and teens -- visiting their homes on a weekly basis -- to ensure
patients have access to regular health and social services and that
their homes are ready for the arrival of the newborn. The outreach teams
also help the families secure needed goods and services such as food,
clothing, and baby items. Families referred into the program are
enrolled as early in the pregnancy as possible and the home visits
continue until the child's third pediatric well care visit. The program
is currently seeking funding that would allow it to continue visits
until the child enters early childhood education.

The Baby Love program emerged from a community-wide effort to respond to
the health challenges facing inner-city families and the program is an
integral part of two community-wide initiatives -- the Rochester Early
Enhancement Program and Rochester Healthy Start. Rochester currently
ranks eleventh in the nation in the number of children living in
poverty. Low birth weight rates for city residents are twice as high as
those who live in the suburbs and the infant mortality rate is three
times higher.

Baby Love serves approximately 200 medically and psychosocially at-risk
pregnant women and teens, their newborns, and families per year and has
demonstrated that this model of direct, home-based intervention can be
highly successful. Since 2002 the Baby Love program has provided
outreach service to high-risk pregnant women for the Monroe Plan for
Medical Care, a local health management organization that primarily
serves low-income individuals and the working poor. In subsequent years
the Monroe Plan experienced a 60% drop in its neonatal intensive care
unit (NICU) admission rates. Another pilot project using Baby Love
outreach workers has reduced the disparity in NICU admission rates
between African-American and white teens.
[http://www.urmc.rochester.edu](http://www.urmc.rochester.edu/)

**Adolescent Pregnancy Prevention Knowledge Path**

The MCH Library has released a new edition of Knowledge Path: Adolescent
Pregnancy Prevention. This electronic guide presents a selection of
current, high-quality resources that measure, document, and monitor the
problem; identify risk and protective factors; and report on promising
intervention strategies. The knowledge path is intended for use by
health professionals, policymakers, researchers, and others who are
interested in tracking information on this topic. Separate sections
identify resources for families and schools.

View the path online at
<http://www.mchlibrary.info/KnowledgePaths/kp_adolpreg.html>

Knowledge paths on other maternal and child health topics are available
at <http://mchlibrary.info/KnowledgePaths/index.html>

**Dental Care for Children Tips on Preventing Cavities**

3.5 minute spot education for the public 

Video feed of Dr. Lisa Thebner providing tips on how to prevent cavities
in children.

Link is available online at:

v       Teeth are a  place holder for surrounding and next teeth

v       Cavities can actually lead to nerve damage

v       Children need assistance in learning to brush, early brushing of
gums

v       1-2 minute brushing -- parent modeling the behavior

v       Visit to Oral Health Practitioner - First tooth or by first year
-- PREVENTION

v       Cavities are contagious -- bacteria transmitted causes cavities

v       Brush after milk intake

v       No sippy-cup or bottle all-day-long -- bathing the teeth

v       Fluoride toothpaste by age 2 -3 -- 'pea size' amount

<http://video.wnbc.com/player/?id=101888> 

**Prevent cavities -- water only in the sippy cup**\
Tooth decay in young children\'s baby teeth is on the rise, a concerning
trend that signals toddlers and preschoolers are eating too much sugar,
according to a recent Centers for Disease Control and Prevention study
of dental health.\
\
Experts are concerned about the prevalence of cavities in baby teeth of
children ages 2 to 5.\
\
Cavities in that age group increased to 28 percent in 1999-2004, from 24
percent in 1988-1994, according to the report. Tooth decay in young
children had been decreasing for 40 years, but this report shows there
are new concerns likely linked to sugar intake.\
\
An easy solution? Put water in that sippy cup instead of juice or sugary
beverages, says the American Academy of Pediatric Dentistry.\
\
Revised guidelines from the AAPD say sippy cups should only be filled
with water when used at anytime other than mealtime. Sugar from
beverages other than water can cause tooth decay in young teeth.\
\
The lidded cups were created to help children transition from a bottle
to a regular cup, but they\'re used too often and too long by most
parents because they are convenient for reducing spills, AAPD experts
say.\
\
Using them at nap time, bedtime, or playtime with beverages other than
water can lead to serious cavity problems, dentists warn. Additional
research has shown that nearly one-third of toddlers with tooth decay
problems used sippy cups, the AAPD says.\
\
Tooth decay is the single most common chronic childhood disease

90 percent of all tooth decay is preventable, the AAPD says.

<http://www.aapd.org/>

**Stop Bullying Now**

"Come on, take a stand, lend a hand -- stop  bullying now"  the mantra
of the bullying campaign at this Interactive web site --  student
friendly -- material for teacher and school projects on what is
accessible and readable and interesting for kids to manage bullying in
their world and their friends, classmates and school's culture.

-   Webisodes -- scenarios with a Q&A

-   Toon Characters, teacher interactions, has you listening to dialogue

-   Acts of kindness, diverse characters

-   Gets at myths -- beyond big bullies and small victims...

-   Same gender, girl bullying, clics, peer suppression of speaking up
    and speaking out.

-   Having 'different' 'sets' of friends.

-   Parent child sharing and divulging and covering up "just great"

-   Passivity versus standing up and speaking out

-   By scenario 6 -7 the HEAT builds

-   Identifiable messages

-   Skills in altering relationships with bullies

-   Sharing, confidence building and peer to peer support.

<http://stopbullyingnow.hrsa.gov/index.asp>

**New Parent Advocacy Brief\--Preschool Services under IDEA**

The National Center for Learning Disabilites has created a new Parent
Advocacy Brief, [Preschool Services Under
IDEA](http://ga3.org/ct/y1Lcsv51OmDk/), to help parents understand their
children\'s education rights.

No two children learn at the same pace or in the same way.\
\
While the preschool years can be a time of learning and discovery for
many children, approximately eight (8) percent of all young children are
identified as having disabilities that may prevent them from reaching
developmental milestones as expected. Often times children are not
identified at birth as having a disability, but exhibit more subtle
issues between the ages of three to five, such as:

-   Speech and language delays or disorders;

-   Putting shoes or mittens on the wrong feet or hands;

-   Having difficulty remembering direction;

-   Seeming uninterested in playing early learning games or listening to
    stories;

-   Seeming mildly uncoordinated.

If you think you need to wait until your child\'s enrolled in school to
address your concerns---think again.

-   The Individual with Disabilities Education Act (IDEA) is for
    children from birth to age 21.

-   If your child is between ages 3-5, they can be evaluated for a
    developmental delay or specific learning disability (SLD) and access
    intervention services under IDEA part B section 619 for free.

For more information about the law and your preschool age child,
visit [NCLD\'s Parent Center](http://ga3.org/ct/ydLcsv51OmD9/) and
download our free Parent Advocacy Brief, [Preschool Services Under
IDEA.](http://ga3.org/ct/y1Lcsv51OmDk/)

Remember to visit [NCLD\'s Parent Center message boards and online
chats](http://ga3.org/ct/UpLcsv51OmDi/) to talk about the parenting and
education issues that matter to you.

<http://www.ncld.org/images/stories/downloads/parent_center/preschool_brief.pdf>

**Births to Cohabiting Couples at All-Time High**

Movie stars do it. Big-time athletes do it. And so do ordinary Jane(s)
and Joe(s). \"It,\" in this case, is having children outside of
marriage. The proportion of births in the United States that occur
outside of marriage has climbed dramatically over the last few decades,
and more of these births are occurring to \"cohabiting couples\" -
unmarried couples who live together.

A new research brief published by Child Trends, '[The Relationship
Context of Births Outside of Marriage: The Rise of
Cohabitation](http://ent.groundspring.org/EmailNow/pub.php?module=URLTracker&cmd=track&j=141812708&u=1357815)',
takes a closer look at trends in childbearing outside of marriage in
general, and trends within cohabiting relationships in particular. A
[news
release](http://ent.groundspring.org/EmailNow/pub.php?module=URLTracker&cmd=track&j=141812708&u=1357816)
is also available.

ABOUT THE RESEARCH SOURCES FOR THIS BRIEF

All the 2001 data on relationship status at birth in this brief were
obtained from the Early Childhood Longitudinal Study - Birth Cohort
(ECLS-B), gathered by the National Center for Education Statistics
within the U.S. Department of Education. The ECLS-B is a nationally
representative study of 10,688 children born in 2001. Unless otherwise
noted, the analyses presented in this brief refer to a sample of 10,040
children who lived with their biological

or adoptive mother at the time of the ECLS-B baseline interview, and
whose mothers provided information on their marital or cohabitation
status at the child's birth. Findings in this brief are drawn from two
papers and are supplemented by original analyses by Child Trends.

Unmarried and Living Together With Children: Births to Cohabiting
Couples at All-Time High
<http://www.childtrends.org/Files//Child_Trends-2007_05_14_RB_OutsideBirths.pdf>

[**2nd National Summit on Preconception Health and Health
Care**](http://www.marchofdimes.com/california/4947_24789.asp)

...will be held in Oakland, California on Monday October 29 through
Wednesday October 31, 2007, at the Oakland Marriott City Center, 1001
Broadway.  The Summit is being planned and hosted by the Preconception
Care Council of California, March of Dimes California Chapter, and the
California Department of Health Services, in collaboration with the
Centers for Disease Control and Prevention (CDC) and the Health
Resources and Services Administration (HRSA).  On-line registration and
links to abstract submission are available on [THE SUMMIT
WEBSITE](http://www.marchofdimes.com/california/4947_24789.asp) .

<http://www.marchofdimes.com/california/4947_24789.asp>

Please note that the deadline for abstract and proposal submission is
June 18, 2007, the deadline for early registration is September 15, 2007
and the deadline for all registration is October 15, 2007. 

**2008 National Conference of State Breastfeeding Coalitions**

January 26-28, 2008 in Arlington, VA.

The United States Breastfeeding Committee is inviting proposals for
coalitions to share their experience, expertise, and problem-solving
approaches during

75 minute breakout sessions, poster session, or at breakfast topic
tables.

To access the Call for Abstracts documents on the State Coalition
section of the USBC site:

▪ Go to
[www.usbreastfeeding.org/State-Coalitions/2008-NCSBC](http://www.usbreastfeeding.org/State-Coalitions/2008-NCSBC)

▪ Enter the UserName "StateCoalitions" and the password "USBC". These
are case-sensitive and spacing-sensitive, so enter them exactly as they
appear here.

Complete -- 2-page fillable form or download and complete.

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

#### Nausea and Vomiting in Pregnancy {#nausea-and-vomiting-in-pregnancy-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Case 1

MTB is a 24 y/o G1P0 at 10 weeks by her dates who presents to her first
prenatal visit complaining of morning sickness. Her symptoms are not
incapacitating, but she would like to feel better. She has tried various
herbal teas without much relief. Your most useful recommendation at this
initial visit would be:

a.  reassurance, small frequent intake, pyridoxine (vitamin B-6)

b.  prescribe a cholinomimetic agent (e.g., metoclopramide)

c.  prescribe a 5-HT-3 receptor inhibitor (e.g., ondansetron)

d.  clear liquid diet and bismuth subsalicylate (Pepto-Bismol)

Case 2

HB is a 30 y/o G3P2 at 9 weeks by her dates who presents for her first
prenatal visit complaining of nausea with vomiting that lasts pretty
much all day, but she is able to keep some food down. She says this has
occurred with each of her pregnancies, but this time it is especially
troublesome. She has had a small amount of spotting but no cramping. She
appears to be well hydrated. Your initial work up at this time should
include:

a.  complete metabolic panel, thyroid functions, amylase and lipase

b.  electrolytes, alanine aminotransferase, pelvic ultrasound

c.  upper abdominal ultrasound, H.pylori antigen testing, stool guiac
    testing

d.  no laboratory studies are indicated at this time

Case 3

EP is a 19 y/o G1P0 at 11 weeks by her dates who presents to the
emergency department complaining of severe nausea and vomiting. She is
wretching, appears ill, and is only able to produce a small amount of
concentrated urine that is strongly positive for ketones. Your initial
management should include:

a.  oral hydration, mental health consult

b.  intravenous hydration, admit for parenteral alimentation

c.  intravenous hydration, nasogastric tube, H2-blocker drip

d.  intravenous hydration, parenteral anti-emetics

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

#### What do you think? {#what-do-you-think .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Stay tuned for the discussion in next month's CCC Corner {#stay-tuned-for-the-discussion-in-next-months-ccc-corner .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

######### Public Health Impact of HPV Vaccination: Aligning Policy With Science

######### [**http://www.medscape.com/viewprogram/7219?sssdmh=dm1.285905&src=nlcmealert**](http://www.medscape.com/viewprogram/7219?sssdmh=dm1.285905&src=nlcmealert)

######### Premenstrual Dysphoric Disorder: A New Treatment Paradigm

<http://www.medscape.com/viewarticle/557445>

**Hormone Therapy Safer in Younger Women? A Best Evidence Review**

<http://www.medscape.com/viewprogram/7404?sssdmh=dm1.285646&src=nlcmealert>

######### 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**

**Hormone Replacement Therapy Linked to Ovarian Cancer **

The Million Women Study, a trial in the United Kingdom of postmenopausal
women, has found that those receiving hormone replacement therapy (HRT)
were, on average, 20% more likely to develop and die from ovarian cancer
than women who never received therapy. Authors say that since 1991, HRT
has resulted in some 1300 additional ovarian cancers and 1000 additional
deaths from this malignancy in the United Kingdom alone.

In the United Kingdom, ovarian cancer is the fourth most common cancer
in women, with 6700 new cases and 4600 deaths from ovarian cancer every
year. Studies of the association between use of HRT and later risk of
developing ovarian cancer are inconclusive, with some showing a
significantly increased risk for fatal and incident ovarian cancer in
users of HRT, but with most lacking statistical power.

The current study used a large cohort of women in the United Kingdom
(Million Women Study), in which about half the postmenopausal women had
used HRT, to evaluate the effect of HRT on women\'s risk of developing
and dying from ovarian cancer

[http://www.medscape.com/viewarticle/555597?sssdmh=dm1.276434&src=top10#](http://www.medscape.com/viewarticle/555597?sssdmh=dm1.276434&src=top10)

**Menopause Linked to Elevated Fasting Plasma Glucose Levels in
Nondiabetic Women**

Stepwise multivariate regression analysis showed that the independent
risk factors for elevated FPG levels were body mass index, menopause,
and triglycerides level, whereas age and low-density lipoprotein
cholesterol level did not contribute to FPG levels. CONCLUSIONS:
Menopause, but not age, is directly involved in augmented FPG levels in
nondiabetic women.

[Otsuki
M](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Otsuki M"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Menopause, but not age, is an independent risk factor for fasting
plasma glucose levels in nondiabetic women.
[Menopause.](javascript:AL_get(this, 'jour', 'Menopause.');) 2007
May-Jun;14(3 Pt 1):404-7

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17213751>

**Exercise Plus Isoflavones May Improve Body Composition in
Postmenopausal Women**

CONCLUSIONS:: Compared to an aerobic exercise program alone, 70 mg/day
of isoflavones combined with exercise may promote significant
improvements in body composition parameters that are known to influence
cardiovascular disease risk in postmenopausal women.

[Aubertin-Leheudre
M](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Aubertin-Leheudre M"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Effect of 6 months of exercise and isoflavone supplementation on
clinical cardiovascular risk factors in obese postmenopausal women: a
randomized, double-blind study.
[Menopause.](javascript:AL_get(this, 'jour', 'Menopause.');) 2007 Feb 6;

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17290158>

**Relation of Cortisol Levels and BMD Among Premenopausal Women With**
**Depression **

Major depression had important effects on BMD and bone turnover markers.
Depression should be considered among risk factors for osteoporosis in
premenopausal women.

[Altindag
O](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Altindag O"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Relation of cortisol levels and bone mineral density among
premenopausal women with major depression. [Int J Clin
Pract.](javascript:AL_get(this, 'jour', 'Int J Clin Pract.');) 2007
Mar;61(3):416-20

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17313608&>

**New Guidelines Issued for Treatment of Vaginal Atrophy: NAMS**

In general, creams may be associated with more adverse effects than ring
or tablet formulations, perhaps because there is more potential for
women to apply higher-than-recommended dosing with cream. However, a
Cochrane review reported no significant differences among the delivery
methods in terms of hyperplasia, endometrial thickness, or the
proportion of women with adverse events. The most commonly reported
adverse effects associated with vaginal estrogen therapy are vaginal
bleeding and breast pain, with nausea and perineal pain reported less
frequently.

When low-dose estrogen is administered locally for vaginal atrophy,
progestogen is generally not indicated. Data are insufficient to
recommend annual endometrial surveillance in asymptomatic women using
vaginal estrogen therapy.

Vaginal estrogen therapy should be continued as long as women continue
to have distressing symptoms. Management of vaginal atrophy is similar
for the group of women without a cancer history and for women treated
for non--hormone-dependent cancer. However, for women with a history of
hormone-dependent cancer, management recommendations are individualized
and vary based on each woman\'s preference in consultation with her
oncologist.

Specific recommendations are as follows:

-   The primary goals of vaginal atrophy management are symptom relief
    and reversal of atrophic anatomic changes.

-   For women with vaginal atrophy, first-line treatments include
    nonhormonal vaginal lubricants and moisturizers.

-   Symptomatic vaginal atrophy that does not respond to nonhormonal
    vaginal lubricants and moisturizers may require prescription
    therapy.

-   Randomized controlled trials in postmenopausal women are limited.
    However, they have demonstrated that low-dose, local, prescription
    vaginal estrogen delivery is effective and well tolerated for
    treating vaginal atrophy while limiting systemic absorption.

-   Low-dose vaginal estrogen products approved in the United States for
    treating vaginal atrophy include estradiol vaginal cream, conjugated
    estrogens vaginal cream, the estradiol vaginal ring, and the
    estradiol hemihydrate vaginal tablet. These are equally effective at
    the doses recommended in labeling, so specific choice depends on
    clinical experience and patient preference.

-   When low-dose estrogen is administered locally for vaginal atrophy,
    progestogen is generally not indicated.

-   Closer surveillance may be required for women at high risk for
    endometrial cancer, those using a higher dose of vaginal estrogen
    therapy, or those with symptoms such as spotting or breakthrough
    bleeding. Evidence is insufficient to recommend annual endometrial
    surveillance in asymptomatic women using vaginal estrogen therapy.

-   Vaginal estrogen therapy should be continued for as long as women
    have distressing symptoms.

-   For women treated for non--hormone-dependent cancer, management of
    vaginal atrophy is similar to that for women without a cancer
    history, but for those with a history of hormone-dependent cancer,
    management recommendations should be based on each woman\'s
    preference and the advice of her oncologist.

Overall, subjective improvement occurs in 80% to 90% of women treated
with local vaginal estrogen,\" the authors conclude. \"Vaginal atrophy
unresponsive to estrogen may be due to undiagnosed dermatitis/dermatosis
or vulvodynia, so treatment failure warrants future evaluation and
careful examination.

The role of local vaginal estrogen for treatment of vaginal atrophy in
postmenopausal women: 2007 position statement of The North American
Menopause Society.
[Menopause.](javascript:AL_get(this, 'jour', 'Menopause.');) 2007
May-Jun;14(3):370-1

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17489067>

**Ineffectiveness of sertraline for treatment of menopausal hot flushes:
RCT**

CONCLUSION: Treatment with sertraline did not improve hot flush
frequency or severity in generally healthy perimenopausal and
postmenopausal women, but was associated with bothersome side effects.

Grady D et al Ineffectiveness of sertraline for treatment of menopausal
hot flushes: a randomized controlled trial. [Obstet Gynecol.  2007;
109(4):823-30](http://www.medscape.com/medline/publicationbrowser/123?pmid=17400842) 

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17400842**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17400842) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17400842 .Style-Heading-4-+-Arial-14-pt-Underline}

**Hormone Therapy Safer in Younger Women? A Best Evidence Review**

<http://www.medscape.com/viewprogram/7404?sssdmh=dm1.285646&src=nlcmealert>

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

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

**Midwifery's approach to pre-labor SROM supported by professional
organization's journal**

Morwitz and Jordan present a review of the literature on pre-labor
rupture of membranes at term. Most significantly, they point out some of
the flaws in the TERMPROM study by Hannah et al. The biggest problem was
that there was no control of the number of vaginal exams, which have
been shown to be directly correlated with increased risk of infection by
Hannah et al. and others. Speculation has been made that if the number
of vaginal exams had been limited in the study pool the results may have
been different. Another problem has to do with GBS-positive management
being very different and inconsistent during the study time period as
compared to today. The authors' concluding statements support the
time-honored midwifery practice of having options in the management of
pre-labor SROM tailored to the individual patient and setting and the
integral role played by the woman herself in the decision making
process.

'Two practices supported by current research findings should be
incorporated into midwifery care of women with term PROM. The first is
to strictly limit vaginal examinations. There is considerable evidence
documenting the increased risk of perinatal infection related to digital
vaginal examination, yet little change has occurred in this aspect of
practice. Despite ACOG's recommendation that vaginal examination should
be deferred during the initial evaluation, doing a "baseline vaginal
exam" is common practice. Requiring vaginal examinations at set
intervals to prove labor progression is another entrenched habit. A
speculum examination to determine initial cervical status is sufficient
in most cases, and digital examinations should be done only when the
information is needed to make management decisions. The second practice
is to consistently provide information about the options of expectant
management and immediate induction to women with term PROM, and to
involve them in the decision-making process. This is congruent with
midwifery hallmarks and philosophy of care. In addition, it is
explicitly supported by Cochrane reviewers and the TERMPROM researchers.

In an editorial accompanying the publication of the term PROM study,
Duff stated his view that the practice of expectant management should be
abandoned. An unquestioning acceptance of this view is not justified
based on available evidence. Women should be fully informed on the risks
and benefits of induction and expectant management, and offered both
options. Midwives should strive to remain champions of a care approach
that involves women in decision making and supports the value of
nonintervention.'

Marowitz, A; Jordan, R Midwifery management of prelabor rupture of
membranes at term. J Midwifery Womens Health. 2007 May-Jun;52(3):199-206

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17467586>

**[Editorial Comment by Lisa Allee, CNM:]{.underline}**

I couldn't have said it better myself. But I will add my two cents, too.
I think the ACOG statement that induction should be started immediately
upon SROM is over interventionist, not evidence based, and disrespectful
of the inherent wisdom and intelligence of women's bodies and minds. I
encourage midwives to feel supported by our professional organization's
journal in continuing evidence-based approaches to pre-labor SROM by
offering options of induction or awaiting spontaneous labor. AND most
importantly keep your fingers out of there!!! (Really folks, the vaginal
exam does not make much difference --her cervix is what is and her labor
goes as it goes no matter if we check the cervix or not AND there are
other ways to tell how her labor is progressing---tune in and labor
sit.)

[Hannah
ME](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Hannah ME"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Induction of labor compared with expectant management for prelabor
rupture of the membranes at term. TERMPROM Study Group. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 1996 Apr
18;334(16):1005-10
<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=8598837>

[Duff
P](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Duff P"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Premature rupture of the membranes at term. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 1996 Apr
18;334(16):1053-4

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=8598845>

**Let it pulse---the cord that is**

I have previously written in this column that letting the cord pulse has
physiological benefits for the baby, mainly citing writings by Judith
Mercer, CNM. Here is another excellent article demonstrating that this
practice should be incorporated as a standard of care. Hutton and Hassan
did a meta-analysis of the literature on early vs. late cord clamping.
They found strong evidence that late cord clamping improves iron stores
in babies and helps prevent anemia in infancy. They also address
concerns that have been raised over the years about delayed cord
clamping causing neonatal problems due to polycythemia and found the
fears unfounded by the evidence.

'Although late clamping was associated with a moderate increase in blood
viscosity and increased rates of polycythemia, there was no evidence of
any significant harm as measured by the need for phototherapy to treat
jaundice or by admission to the NICU. The risk of polycythemia was not
significant when only high-quality studies were considered. In addition,
none of the polycythemic infants evaluated in this review were
symptomatic (ie, had symptoms of central nervous system,
cardiopulmonary, gastrointestinal tract, or renal impairment).

They also discuss concerns about active management of the third stage
and though their analysis did not address this because few of the
studies looked at maternal outcomes, their conclusion is as follows:

Although conclusions about maternal outcomes cannot be drawn from our
research, it is likely that delayed clamping is compatible with active
management of the third stage of labor. Uterotonic agents administered
following birth and prior to cord clamping have been shown to increase
the rate of placental transfusion and are thus likely to enhance the
effect of delayed clamping. Although this approach has not been studied,
a joint statement from the International Federation of Gynaecology and
Obstetrics and the International Confederation of Midwives on active
management of the third stage of labor already recommends that delayed
clamping be incorporated as part of the active management approach to
placental delivery. In a recent literature review, similar practice
recommendations pertaining to third-stage management were made for
providing care in resource-poor settings.

And their final conclusion:

Late clamping of the umbilical cord is a physiological and inexpensive
means of enhancing hematologic status, preventing anemia over the first
3 months of life and enriching iron stores and ferritin levels for as
long as 6 months. Although this is of particular importance for
developing countries in which anemia during infancy and childhood is
highly prevalent, it is likely to have an important impact on all
newborns, regardless of birth setting. Additional research may be
helpful in refining the timing of clamping by determining the minimum
time required to provide maximum benefit associated with placental
transfusion. Questions remain about whether the optimal time for
clamping is affected by the use of oxytocic drugs before the delivery of
the placenta or by milking of the umbilical cord. We believe that this
meta-analysis supports incorporating into clinical practice a minimum
delay of 2 minutes before clamping the umbilical cord following birth
for all full-term newborns.'

Hutton, EK; Hassan, ES Late vs early clamping of the umbilical cord in
full-term neonates: systematic review and meta-analysis of controlled
trials. JAMA 2007 Mar 21;297(11):1241-52.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17374818>

**[Editorial Comment by Lisa Allee, CNM:]{.underline}**

I have let many, many cords pulse until they are done and I can
anecdotally report that the outcomes are good. More than one baby I
expected to have a hard time came around quickly as they continued to
get oxygen from their mom and received their blood volume (Hutton and
Hassan state that this could be 25-60% of their volume!) from the
placenta. As for third stage, in the last couple years since we started
using active management of third stage\*, I have continued to let the
cord pulse at least a couple of minutes. I have found that this fits
right in with the active management as the delay in cord cutting is
during the time of placental separation and I have seen significantly
fewer postpartum hemorrhages, as predicted.

\*(At Chinle we came to a consensus that our active management of third
stage would be Pitocin 20 units in 1000ml LR at 200ml/hour after the
baby is born (frequently after the cord is clamped), gentle cord
traction, and bolus rate for the Pitocin after the placenta is born.
Each provider decides when to clamp and cut the cord.)

**Other**

**Upright position during the first stage of labor did not contribute
towards a shorten labor**

CONCLUSIONS: The upright position during the first stage of labor did
not contribute towards a shorter duration of labor; however, it proved
to be a safe and well-accepted option for the women of this study.

[Miquelutti
MA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Miquelutti MA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al [Upright position during the first stage of labor: a randomised
controlled
trial.](http://mp.medscape.com/cgi-bin1/DM/y/hBSUZ0Ou5N60Juv0IjKk0EQ)
[Acta Obstet Gynecol
Scand.](javascript:AL_get(this, 'jour', 'Acta Obstet Gynecol Scand.');)
2007;86(5):553-8

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17464583>

**Cesarean rate can be reduced by health workers in analyzing and
modifying their practice**

CONCLUSIONS: The cesarean rate can be safely reduced by interventions
that involve health workers in analyzing and modifying their practice.
Our results suggest that multifaceted strategies, based on audit and
detailed feedback, are advised to improve clinical practice and
effectively reduce cesarean section rates. Moreover, these findings
support the assumption that identification of barriers to change is a
major key to success.

Chaillet N; Dumont A Evidence-based strategies for reducing cesarean
section rates: a meta-analysis.[Birth.  2007;
34(1):53-64](http://www.medscape.com/medline/publicationbrowser/123?pmid=17324180)
 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17324180>

**Midwives' perspectives improves risk assessment in early pregnancy**

CONCLUSIONS: Replacing the routine consultation with the doctor early in
pregnancy with a planning conference had no negative impact on risk
identification. The results support that the different perspectives of
the two professions in combination are important for the safety of
surveillance and the psychosocial support expected from antenatal care.

Berglund A et al Combining the perspectives of midwives and doctors
improves risk assessment in early pregnancy. [Acta Obstet Gynecol Scand.
 2007;
86(2):177-84](http://www.medscape.com/medline/publicationbrowser/123?pmid=17378102) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17378102>

**Acupuncture better results compared to physiotherapy: Pelvic and back
pain in pregnancy**

AUTHORS\' CONCLUSIONS: All but one study had moderate to high potential
for bias, so results must be viewed cautiously. Adding
pregnancy-specific exercises, physiotherapy or acupuncture to usual
prenatal care appears to relieve back or pelvic pain more than usual
prenatal care alone, although the effects are small. We do not know if
they actually prevent pain from starting in the first place. Water
gymnastics appear to help women stay at work. Acupuncture shows better
results compared to physiotherapy.

[Pennick
VE](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Pennick VE"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Interventions for preventing and treating pelvic and back pain in
pregnancy. [Cochrane Database Syst
Rev.](javascript:AL_get(this, 'jour', 'Cochrane Database Syst Rev.');)
2007 Apr 18;(2):CD001139.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17443503>

**12-week group training effective in preventing lumbopelvic pain in
pregnancy**

CONCLUSIONS: A 12-week specially designed training program during
pregnancy was effective in preventing lumbopelvic pain in pregnancy.

Mørkved S et al Does group training during pregnancy prevent lumbopelvic
pain? A randomized clinical trial. [Acta Obstet Gynecol Scand.  2007;
86(3):276-82](http://www.medscape.com/medline/publicationbrowser/123?pmid=17364300)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17364300>

**Interpregnancy intervals longer than 5 years associated with
preeclampsia and dysotcia**

Overall, long interpregnancy intervals, possibly longer than 5 years,
are independently associated with an increased risk of preeclampsia.
There is emerging evidence that women with long interpregnancy intervals
are at increased risk for labor dystocia and that short intervals are
associated with increased risks of uterine rupture in women attempting a
vaginal birth after previous cesarean delivery and uteroplacental
bleeding disorders (placental abruption and placenta previa).

Conde-Agudelo A et al Effects of birth spacing on maternal health: a
systematic review. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
Apr;196(4):297-308

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17403398>

**Navajo News Jean Howe, Chinle**

**The evolution of management of Actinomyces on a Pap report**

Actinomyces is an anaerobic Gram-positive bacterium that may be found as
normal flora in the mouth and GI tract. It can also colonize the female
genital tract and, in rare cases, cause pelvic abscesses. Such abscesses
tend to be slow-growing, are typically described as "woody", and may be
mistaken for a neoplasm. Actinomyces grows preferentially on foreign
bodies such as the intrauterine device (IUD) and the likelihood of
colonization increases with duration of use. For women using an IUD, the
finding of actinomyces on a pap report can be a common and perplexing
challenge, especially as the vast majority will be without symptoms and
at very low risk for serious disease.

I am intrigued by the management of actinomyces because it also serves
as a reminder about the evolution of medical knowledge and the
importance of common sense in clinical practice. Perhaps I'm revealing
my age but, when I was in training, a report of Actinomyces on a pap
inevitably led to a recall of the patient for removal of her IUD. This
caused a great deal of contraceptive consternation and an urgent search
for an acceptable alternative method. Soon after my training was
completed it became more acceptable to leave the IUD in situ, but only
if a relatively long course of penicillin-based antibiotics was
administered. More recently, awareness is growing that it is no longer
necessary to remove the IUD or treat in most cases.

A recent review article by Westhoff in the journal Contraception
provides useful background information. Studies of the Pap smear results
of IUD users reported a prevalence of 0 to 31% of
actinomyces-like-organisms noted on pap, with an average of 7%. (For
women without IUDs the rate of positive paps remained close to 0%).
Interestingly, the review also states that, in studies of women with
Actinomyces pelvic abscesses, only half of pap tests performed were
positive for the bacteria. Given the lack of specificity of this test
result, the author endorses the position of the UK Faculty of Family
Planning and the Planned Parenthood Federation of America that such
patients can continue IUD use. They should be informed of the potential
risk of subsequent pelvic abscess, which is not precisely known but is
believed to be substantially less than 1/1000. This review also notes
the finding that rate of actinomyces-positive pap results is lower with
levonorgestrel IUDs than with Paraguard IUDs.

Both UpToDate and ACOG provide a similar perspective. UpToDate
recommends that the patient be notified of the finding and examined. In
the absence of symptoms, the finding of actinomyces likely represents
colonization and IUD removal or antibiotic treatment is unnecessary. The
patient should be given instructions to seek medical care if symptoms of
PID are noted. If she is symptomatic, then removal of the IUD would be
an important part of management due to the heightened growth of
actinomyces on foreign bodies. This position is also endorsed by the
ACOG Practice Bulletin on IUDs, published in 2005, which states that
"The options for management of asymptomatic IUD users with actinomyces
on Pap test are expectant management, an extended course of oral
antibiotics, removal of the IUD, and both antibiotic use and IUD
removal."

A recent CME article of IUD use in Contemporary Ob/Gyn by IHS alumni
Tony Ogburn and Eve Espey seeks to dispel many misconceptions about IUD
use. Amongst other helpful recommendations, they make note of the
changes to the Paraguard package insert which endorses IUD use in
nulliparous women. This same revision removed genital actinomycosis from
the list of contraindications to Paraguard use.

This evolution of recommended medical practice, from a very conservative
management plan that undoubtedly increased the risk of unwanted
pregnancy for some women, to a more practical and evidence-based
approach encouraging symptom evaluation and ongoing IUD use for almost
all women, is refreshing.

**Resources:**

Westhoff C. IUDs and colonization or infection with Actinomyces.
Contraception 75 (2007) S48-S50.
<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17531616>

Ogburn T, Espey E, "Encouraging more patients to choose an IUD",
Contemporary Ob/Gyn, June 2007 72-77
<http://www.contemporaryobgyn.net/obgyn/article/articleDetail.jsp?id=431651>

Intrauterine Device, ACOG Practice Bulletin 59, January 2005

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15625179>

**Intrauterine Contraception, UpToDate**

<http://www.utdol.com/utd/content/topic.do?topicKey=gen_gyne/15313>

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

**Nurses Corner, Sandra Haldane, HQE**

#### Health Care Without Harm: Nurses Take Action {#health-care-without-harm-nurses-take-action-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/555467?sssdmh=dm1.275928&src=0_tp_nl_0#**](http://www.medscape.com/viewarticle/555467?sssdmh=dm1.275928&src=0_tp_nl_0) {#httpwww.medscape.comviewarticle555467sssdmhdm1.275928src0_tp_nl_0 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### A Complementary Approach to Pain Management {#a-complementary-approach-to-pain-management-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/556408?sssdmh=dm1.279748&src=0_tp_nl_0#**](http://www.medscape.com/viewarticle/556408?sssdmh=dm1.279748&src=0_tp_nl_0) {#httpwww.medscape.comviewarticle556408sssdmhdm1.279748src0_tp_nl_0 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-21 .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}

**One Test. Two Lives Campaign**

The One Test. Two Lives. campaign CDC focuses on ensuring that all women
are tested for HIV early in their pregnancy.  One Test. Two Lives.
provides quick access to a variety of resources for providers, and
materials for their patients, to help encourage universal voluntary
prenatal testing for HIV.
<http://www.cdc.gov/hiv/topics/perinatal/1test2lives/default.htm>

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

**Human Papillomavirus: HPV Information for Clinicians**

CDC recently updated the HPV brochure for clinicians and posted four
sets of counseling messages to assist providers in their HPV-related
discussions with patients. The counseling messages address (1)
information for parents about the HPV vaccine, (2) information for women
about the Pap and HPV tests, (3) information for women who receive a
positive HPV test result, and (4) information for patients receiving a
genital warts diagnosis.

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

####  {#section-23 .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}

**Preconception Health of Women Delivering Live-Born Infants ---
Oklahoma, 2000--2003**

The U.S. Public Health Service recommends that all women of childbearing
age consume \>400 µg of folic acid daily through either supplementation
or fortified foods. CDC recommends offering, as a component of maternity
care, one pre-pregnancy visit to a health care provider for women
planning pregnancy to enable women to receive risk assessment, health
education, and specific interventions to address identified risks before
conception. Analysis of data collected from women in Oklahoma during
2000--2003 from the Pregnancy Risk Assessment Monitoring System (PRAMS)
indicated that 21.5 percent of women with a recent live birth were not
aware of folic acid benefits before they became pregnant, 73.5 percent
did not consume multivitamins at least four times per week during the
month before pregnancy, and 84.8 percent did not receive preconception
counseling from a health-care provider. Although pre-pregnancy awareness
of the benefits of taking vitamins with folic acid in the prevention of
some birth defects was high among Oklahoma women with a recent live
birth, actual consumption of multivitamins during the month before
pregnancy was low. Promoting preconception health of women is a key
public health strategy in the United States to decrease morbidity and
mortality associated with negative maternal and infant outcomes.
Increased folic acid consumption before conception and during the first
trimester of pregnancy can reduce the incidence of neural tube defects
by 50--70 percent.

Surveillance of Preconception Health Indicators Among Women Delivering
Live-Born Infants \-\-- Oklahoma, 2000---2003 MMWR June 29, 2007 /
56(25);631-634

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5625a3.htm>

#### [Editorial comment:]{.underline} Greggory Woitte -- Hastings Indian Medical Center

**Preconception Counseling**

I am sure that most of your patients are similar to mine in that your
first visit with them is after they have become pregnant. They show up
at the clinic for a confirmatory pregnancy test, to schedule their first
prenatal visit and to get started on prenatal vitamins (or as I am
frequently seeing to start Flintstones vitamins). However, as I am sure
you are aware, by the time the patient reaches our doorstep, we have
missed a very important part of the pregnancy that we may have had some
dramatic affect upon.

Between 2000 and 2003, the state of Oklahoma developed and administered
a preconception survey. (See above) They found that 84.8% of women did
not have any preconception counseling by a provider. 21.5% of women did
not know about the benefits of preconception folic acid and equally
disturbing was that 73.5% did not take vitamins before trying to become
pregnant.

In accordance with the ACOG Committee Opinion No. 313, patients who are
in the reproductive ages should be questioned about the possibility of
becoming pregnant, especially if they are not on contraception. Women
should be encouraged to formulate a reproductive health plan. We, as
practitioners of Women's Health, should be encouraging women to take
steps to get as healthy as possible at every visit. This is especially
important in women of reproductive ages where we have the opportunity to
provide education regarding the benefits to the fetus, as well as to
identify patients at high risk for adverse pregnancy outcomes.

We also need to remind our colleagues from other disciplines of medicine
to ask their patients about potentially becoming pregnant and refer
those who may be in need of pre-conceptional counseling or those in need
of contraceptive counseling.

ACOG Committee Opinion Number 313. The importance of preconception care
in the continuum of women\'s health care. [American College of
Obstetricians and
Gynecologists](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="American College of Obstetricians and Gynecologists"%5BCorporate Author%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
[Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');)
2005 Sep;106(3):665-6.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16135611>

Center for Chronic Disease Prevention and Health Promotion
<http://www.cdc.gov/nccdphp/>

Office of Communication (770) 488-5131

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

**Dietary calcium is better than supplements at protecting bone health**

Women who get most of their daily calcium from food have healthier bones
than women whose calcium comes mainly from supplemental tablets

CONCLUSION: Calcium from dietary sources is associated with a shift in
estrogen metabolism toward the active 16 alpha-hydroxyl metabolic
pathway and with greater BMD and thus may produce more favorable effects
in bone health in postmenopausal women than will calcium from
supplements.

[Napoli
N](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Napoli N"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Effects of dietary calcium compared with calcium supplements on
estrogen metabolism and bone mineral density. [Am J Clin
Nutr.](javascript:AL_get(this, 'jour', 'Am J Clin Nutr.');) 2007
May;85(5):1428-33

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17490982>

**Calcium, Vitamin D supplements may help prevent weight gain in
postmenopausal women**

Largest national study of its kind finds popular nutritional supplements
have minimal, but statistically significant effects on weight change
over seven years. Postmenopausal women who take calcium and vitamin D
supplements may gain less weight than those who do not, although the
overall effect is small.

CONCLUSION: Calcium plus cholecalciferol supplementation has a small
effect on the prevention of weight gain, which was observed primarily in
women who reported inadequate calcium intakes

[Caan
B](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Caan B"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Calcium plus vitamin D supplementation and the risk of
postmenopausal weight gain. [Arch Intern
Med.](javascript:AL_get(this, 'jour', 'Arch Intern Med.');) 2007 May
14;167(9):893-902

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17502530>

**Down to the Bone: Issues in the Maintenance and Evaluation of Bone
Health: CME**

<http://www.medscape.com/viewprogram/7087?sssdmh=dm1.277363&src=nlcmealert>

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

#### Heavy Periods (Menorrhagia) {#heavy-periods-menorrhagia-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20070615/1820ph.html**](http://www.aafp.org/afp/20070615/1820ph.html) {#httpwww.aafp.orgafp200706151820ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Anemia in Pregnancy Briefly: The Common to the Unusual -- including IV
therapy**

BACKGROUND

Anemia is very common in pregnant women, and 99% of such women (in
non-malarious areas) are iron deficient. Iron deficiency is seen
frequently because of prior menstrual losses, prior pregnancy related
losses, and nutritional factors. As a result of a dilutional effect, the
normal hematocrit for third trimester pregnant women at sea level is
33+3 %. Women with a hematocrit over 30% should not be considered
anemic.

DIAGNOSIS

Sophisticated studies are usually not needed in the work up of a woman
with pregnancy associated anemia. The CBC that revealed the low
hemoglobin/hematocrit will usually also reveal a low MCV (microcytosis),
a low MCH (hypochromia), and an increased RDW (anisocytosis),
characteristic of iron deficiency. Women with mild (or acute) anemia may
not yet have these typical red cell morphologic changes however. The
most sensitive and specific test for iron deficiency during pregnancy
(even prior to overt anemia) is a low serum ferritin, which reflects
total body iron stores. Normal values are 40-200 ng/mL. Serum iron, TIBC
(transferrin), and the per cent transferrin saturation, are all less
accurate indices during pregnancy. Hemoglobin electrophoresis should be
reserved for women who, on the basis of their ethnicity or family
history, are suspected of having a hereditary hemoglobinopathy (e.g.,
thalassemia, sickle cell disease, etc.).

TREATMENT

a.  Oral iron therapy

Most women with iron deficiency can be treated with oral iron. Ferrous
sulfate 325 mg contains 57 mg of elemental iron, and is the most
efficient form. The evidence is unclear as to the value of adding
ascorbic acid. Oral iron commonly causes gastrointestinal symptoms
however. These are usually dose dependent, but may be severe enough that
women will not, or cannot, adhere to their regimen, even with stool
softeners and/or acid reducing agents. Slow-release iron formulations
may prevent gastric irritation, but not constipation, and are
significantly more expensive. Stools will become black after taking
iron, and asking about stool color is a good way to check adherence to
therapy. To see if the patient is responding to (or taking) therapy, a
reticulocyte count may be obtained 7 days after starting treatment, but
a rise in the hemoglobin or hematocrit will usually not occur until 3-4
weeks. It may also be prudent to prescribe supplemental folic acid, at
least 1 mg daily, as this nutrient will also commonly be deficient in
women who are iron deficient.

b\. Parenteral iron therapy

Anemia may become severe enough to cause symptoms (fatigue, tachycardia,
etc.). Since acute post partum hemorrhage is such a common event
(approximately 5 per cent of births), this has the potential to becoming
a life-threatening condition. Women with a known placenta previa are at
special risk. Fetal growth and oxygenation will usually not be affected
until the maternal hemoglobin is less than 5 g/mL however. In such
symptomatic or worrisome cases, where adherence is a limiting factor,
parenteral iron therapy may be considered.

There are 3 parenteral iron therapy options available in the United
States at the present time: iron dextran, ferric gluconate, and iron
sucrose. Iron dextran is no longer widely used because of its
significant risk of anaphylaxis (0.6%), or other hypersensitivity
reactions (0.2-3%). It is also usually given intramuscularly, and is
painful, can cause skin discoloration, and is unpredictably absorbed.
Ferric gluconate and iron sucrose are both given intravenously, and are
safe and effective alternatives, although they are somewhat more
expensive. Iron sucrose has the lowest rate of serious adverse reactions
(anaphylaxis 0.002%, hypersensitivity 0.005%), and so is our drug of
choice.

Our current protocol is to give iron sucrose 200 mg in 100 mL of normal
saline IV over 1 hour. A test dose (25 mg IV slow push) is not
necessary, but may be considered at the discretion of the provider. The
woman's exact dose can be calculated, taking into account her weight and
the current and desired hematocrit, but, since most women who will be
receiving the drug are severely anemic, we have elected to empirically
give 5 doses of 200 mg (total of 1000 mg) at 24-48 hour intervals. The
patient should be observed and vital signs and fetal heart rate
documented prior to her discharge. The hemoglobin or hematocrit may be
repeated 7 days after the last dose, as hematopoeisis proceeds rapidly
after intravenous iron administration. If you wish to see if total iron
stores have been replenished, a serum ferritin may provide guidance, and
a second course of iron sucrose considered.

In the rare event of a serious adverse reaction, the infusion should be
stopped, the patient hydrated with normal saline, and preparations for
possible need for respiratory support (endotracheal intubation)
initiated. The following drugs should be administered: epinephrine
0.3-0.5 of 1:1000 SQ every 5 minutes, diphenhydramine 50 mg IV, and
methylprenisolone 125 mg IV.

REFERENCES

1.  Baker WF. Iron deficiency in pregnancy, obstetrics, and gynecology.
    Hematol Oncol Clin North Am 2000; 14:1061-77.

2.  Bayoumeu F, et al. Iron therapy in iron deficiency anemia in
    pregnancy: Intravenous route versus oral route. Am J Obstet Gynecol
    2000; 186:518-22.

3.  Charytan C, et al. Efficacy and safety of iron sucrose for iron
    deficiency in patients with dialysis-associated anemia. Am J Kidney
    Dis 2001; 37:300-7.

4.  Van Wych DB, et al. Safety and efficacy of iron sucrose in patients
    sensitive to iron dextran. Am J Kidney Dis 2000; 36:88-97.

**Other**

**Contingent sequential screening is the most cost-effective form of
Down syndrome**

CONCLUSION: Analysis of this actual data from the FASTER Trial
demonstrates that the Contingent Sequential test is the most
cost-effective. This information can help shape future policy regarding
Down syndrome screening

[Ball
RH](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Ball RH"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
et al First- and Second-Trimester Evaluation of Risk for Down Syndrome.
[Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');)
2007 Jul;110(1):10-17

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17601890&dopt=Abstract>

**Aspirin during pregnancy could reduce risk of pre-eclampsia**

Women who receive aspirin or other antiplatelet drugs during pregnancy
are at lower risk of pre-eclampsia. INTERPRETATION: Antiplatelet agents
during pregnancy are associated with moderate but consistent reductions
in the relative risk of pre-eclampsia, of birth before 34 weeks\'
gestation, and of having a pregnancy with a serious adverse outcome.

[Askie
LM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Askie LM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Antiplatelet agents for prevention of pre-eclampsia: a
meta-analysis of individual patient data.
[Lancet.](javascript:AL_get(this, 'jour', 'Lancet.');) 2007 May
26;369(9575):1791-8

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17512048>

**Abnormal Doppler is the best predictor of adverse perinatal outcome in
IUGR**

RESULTS: We identified 151 singleton pregnancies with intrauterine
growth restriction meeting the inclusion criteria. On bivariate analysis
significant variables associated with adverse outcomes were as follows:
history of chronic hypertension, corticosteroid administration, and
gestational age of delivery. These were adjusted by using logistic
regression. The positive predictive values of abnormal Doppler for
respiratory distress syndrome and the composite of adverse outcomes were
36% and 42% respectively. Of the testing modalities compared, only
abnormal Doppler significantly predicted respiratory distress syndrome
and the composite of adverse outcome.

CONCLUSION: In cases of intrauterine growth restriction, the presence of
abnormal Doppler is the best predictor of adverse perinatal outcome.

[Gonzalez
JM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Gonzalez JM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Relationship between abnormal fetal testing and adverse perinatal
outcomes in intrauterine growth restriction [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
May;196(5):e48-51

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17466679>

**Changes in prepregnancy body mass index between the first and second
pregnancies and risk of large-for-gestational-age birth**

CONCLUSION: In comparison with women with normal BMI in both
pregnancies, any increase or decrease in prepregnancy BMI between normal
and obese is associated with increased risk of LGA birth. A modification
in the risk of LGA births by long-term maternal BMI status or maternal
genetic factors appears likely.

[Getahun
D](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Getahun D"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Changes in prepregnancy body mass index between the first and
second pregnancies and risk of large-for-gestational-age birth. [Am J
Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
Jun;196(6):530.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17547882>

**17-alpha-hydroxyprogesterone caproate decreases cervical ripening
during preterm**

CONCLUSION: Undelivered patients after preterm labor undergo progressive
shortening of the cervix, which is attenuated by 17P treatment.

[Facchinetti
F](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Facchinetti F"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Cervical length changes during preterm cervical ripening: effects
of 17-alpha-hydroxyprogesterone caproate. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
May;196(5):453.e1-4; discussion 421

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17466698>

**Betamethasone and dexamethasone comparable: Dexamethasone is more
effective in IVH**

CONCLUSION: Betamethasone and dexamethasone are comparable in reducing
the rate of most major neonatal morbidities and mortality in preterm
neonates. However, dexamethasone seems to be more effective in reducing
the rate of intraventricular hemorrhage compared with betamethasone

[Elimian
A](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Elimian A"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
et al Antenatal betamethasone compared with dexamethasone (betacode
trial): a randomized controlled trial. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Jul;110(1):26-30

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17601892&dopt=Abstract>

**Correlates of anxiety symptoms during pregnancy with perinatal
outcomes**

CONCLUSION: Anxiety symptoms during pregnancy appear to be associated
with similar psychosocial variables as anxiety at other times. There is
no evidence of an association of anxiety symptoms with adverse perinatal
outcomes among those studied thus far. However, significant gaps still
exist in the literature in this area.

[Littleton
HL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Littleton HL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Correlates of anxiety symptoms during pregnancy and association
with perinatal outcomes: a meta-analysis. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
May;196(5):424-32.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17466693>

**Safety of inhaled corticosteroids for asthma with regard to the
congenital malformation**

CONCLUSION: This study adds evidence to the safety of inhaled
corticosteroids for the treatment of asthma during pregnancy, with
regard to the likelihood of congenital malformation.

[Blais
L](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Blais L"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Use of inhaled corticosteroids during the first trimester of
pregnancy and the risk of congenital malformations among women with
asthma. [Thorax.](javascript:AL_get(this, 'jour', 'Thorax.');) 2007
Apr;62(4):320-8

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17121872>

**Maternal leptin across pregnancy in women with
small-for-gestational-age infants**

CONCLUSION: Maternal leptin was correlated with maternal adiposity;
however, after adjustment for body composition, leptin was lower across
pregnancy in women with SGA.

[Catov
JM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Catov JM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Maternal leptin across pregnancy in women with
small-for-gestational-age infants [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
Jun;196(6):558

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17547894>

**Green Journal Cochrane Update:**

**Oxytocin receptor antagonists for inhibiting preterm labour**

AUTHORS\' CONCLUSION: This review failed to demonstrate the superiority
of atosiban over betamimetics or placebo in terms of tocolytic efficacy
or infant outcomes. The finding of an increase in infant deaths in one
placebo-controlled trial warrants caution. A recent Cochrane Review
suggests that calcium channel blockers (mainly nifedipine) are
associated with better neonatal outcome and fewer maternal adverse
effects than betamimetics. However, a randomized comparison of
nifedipine with placebo is not available. Further well-designed
randomized controlled trials of tocolytic therapy are needed. Such
trials should incorporate a placebo arm.

Oxytocin receptor antagonists for inhibiting preterm labour. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Jul;110(1):180-1
<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17601917&dopt=Abstract>

**Interval \> 14 days between corticosteroids and delivery: Risk for
ventilatory support**

CONCLUSION: A time interval of \> 14 days between the administration of
antenatal corticosteroids and delivery is associated with an increased
risk for ventilatory support and surfactant use in neonates who deliver
at \> 28 weeks of gestation.

Ring AM et al The effect of a prolonged time interval between antenatal
corticosteroid administration and delivery on outcomes in preterm
neonates: a cohort study. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
May;196(5):457

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17466700>

**Sex hormone-binding globulin optimal to predict subsequent gestational
diabetes**

STUDY DESIGN: A nested case-control design was used to evaluate the
association of sex hormone-binding globulin, high-sensitive C-reactive
protein, and measures of fasting glucose and insulin (homeostasis
assessment model) obtained in the late first trimester and early second
trimester of pregnancy with the diagnosis of gestational diabetes
mellitus.

CONCLUSION: Among 3 biomarkers examined prospectively, first-trimester
nonfasting sex hormone-binding globulin appeared to be the optimal
marker to predict subsequent gestational diabetes mellitus.

Smirnakis KV et al Predicting gestational diabetes: choosing the optimal
early serum marker. [Am J Obstet Gynecol.  2007; 196(4):410.e1-6;
discussion
410.e6-7](http://www.medscape.com/medline/publicationbrowser/123?pmid=17403439)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17403439>

**Maternal serum levels of alpha-FP and hCG were statistically
associated with stillbirth risk**

CONCLUSIONS: Maternal serum levels of alpha-FP and hCG were
statistically associated with stillbirth risk. However, the predictive
ability was generally poor except for losses at extreme preterm
gestations, where prevention may be difficult and interventions have the
potential to cause significant harm.

Smith GC et al Maternal and biochemical predictors of antepartum
stillbirth among nulliparous women in relation to gestational age of
fetal death. [BJOG.  2007;
114(6):705-14](http://www.medscape.com/medline/publicationbrowser/123?pmid=17516962) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17516962>

**Variation in birth weight may be determined by fetal growth in the
first 12 weeks**

CONCLUSION: Variation in birth weight may be determined, at least in
part, by fetal growth in the first 12 weeks after conception through
effects on timing of delivery and fetal growth velocity.

Bukowski R et al Fetal growth in early pregnancy and risk of delivering
low birth weight infant: prospective cohort study. [BMJ.  2007;
334(7598):836](http://www.medscape.com/medline/publicationbrowser/123?pmid=17355993) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17355993>

**Factor XII deficiency is associated with recurrent miscarriage**

CONCLUSION: Factor XII deficiency is associated with recurrent
miscarriage. Data on the other factors either fail to show association
or are quite limited.

Sotiriadis A et al Fibrinolytic defects and recurrent miscarriage: a
systematic review and meta-analysis [Obstet Gynecol.  2007;
109(5):1146-55](http://www.medscape.com/medline/publicationbrowser/123?pmid=17470597) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17470597>

**Amniocentesis Results and Anxiety**

CONCLUSIONS: Rapid testing was a beneficial addition to karyotyping, at
least in the short term. This does not necessarily imply that early
results would be preferred to comprehensive ones if women had to choose
between them. Because there are no clear advantages in anxiety terms of
issuing karyotype results as soon as they become available, or on a
fixed date, women could be given a choice between them.

Hewison J et al A randomised trial of two methods of issuing prenatal
test results: the ARIA (Amniocentesis Results: Investigation of Anxiety)
trial. [BJOG.  2007;
114(4):462-8](http://www.medscape.com/medline/publicationbrowser/123?pmid=17378819) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17378819>

**Nitric oxide for preventing pre-eclampsia and its complications**

AUTHORS\' CONCLUSIONS: There is insufficient evidence to draw reliable
conclusions about whether nitric oxide donors and precursors prevent
pre-eclampsia or its complications.

Meher S; Duley L Nitric oxide for preventing pre-eclampsia and its
complications. Cochrane 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17443623>

**Gestational age and perinatal mortality: South Asian and black women
at increased risk**

Conclusions The risk of perinatal mortality increased earlier in
gestation among South Asian women than among white women. The most
important factor associated with antepartum stillbirth among white women
was placental abruption, but among South Asian and black women it was
birth weight below 2000 g.

Balchin I et al Racial variation in the association between gestational
age and perinatal mortality: prospective study. [BMJ.  2007;
334(7598):833](http://www.medscape.com/medline/publicationbrowser/123?pmid=17337455) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17337455>

**Usage of spot urine protein to creatinine ratios in the evaluation of
preeclampsia**

RESULTS: Random spot P:C ratios were strongly correlated with 24 hour
urine protein levels (Pearson r = 0.88). The optimal P:C cut-offs were
0.21 (300 mg per 24 hours) and 3.0 (5000 mg per 24 hours). A P:C ratio
of less than 0.21 (300 mg per 24 hours) had a negative predictive value
(NPV) of 83.3% and a P:C ratio of less than 3.0 (5000 mg per 24 hours)
had 100% NPV. CONCLUSION: Urine spot P:C ratio correlated well with 24
hour urine collections for protein but was not justified as a substitute
for timed collections.

[Wheeler
TL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Wheeler TL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Usage of spot urine protein to creatinine ratios in the evaluation
of preeclampsia [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
May;196(5):465

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17466704>

**No benefit to therapy in 1 elevated oral glucose tolerance test
value**

Conclusion: In our patient population, women with 1 elevated oral
glucose tolerance test value did not benefit from a structured program
of medical nutritional therapy and self- blood glucose monitoring.

[Fassett](http://www.ajog.org/article/PIIS0002937807003079/abstract#%23),
MJ et al Effects on perinatal outcome of treating women with 1 elevated
glucose tolerance test value [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
[Volume 196](http://www.ajog.org/issues?Vol=196), [Issue
6](http://www.ajog.org/issues/contents?issue_key=TOC@@JOURNALS@YAJOG@0196@0006),
Pages 597.e1-597.e4

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17547912>

**Limited support for fetal pulse oximetry in the presence of a
nonreassuring FHR**

AUTHORS\' CONCLUSIONS: The data provide limited support for the use of
fetal pulse oximetry when used in the presence of a nonreassuring CTG,
to reduce caesarean section for nonreassuring fetal status. The addition
of fetal pulse oximetry does not reduce overall caesarean section rates.
A better method to evaluate fetal well-being in labour is required.

[East
CE](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="East CE"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Fetal pulse oximetry for fetal assessment in labour. [Cochrane
Database Syst
Rev.](javascript:AL_get(this, 'jour', 'Cochrane Database Syst Rev.');)
2007 Apr 18;(2):CD004075

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17443538>

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

#### September 1, 2007

#### Moderator: Andrew Narva, MD

**Chronic Renal Disease: How is Primary Care Effected?**

-   What is an appropriate work up?

-   Anticipated benefits of acting now

-   What is the impact of diabetes on chronic renal disease?

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

Subscribe to the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26>

Unsubscribe from the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26>

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

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

**Updated Screening for Chlamydial Infection Recommendations, USPSTF**

-   The U.S. Preventive Services Task Force (USPSTF) recommends
    screening for chlamydial infection for all sexually active
    non-pregnant young women aged 24 and younger and for older
    non-pregnant women who are at increased risk . This is a grade [A
    Recommendation](http://www.ahrq.gov/clinic/uspstf07/ratingsv2.htm#arec).

-   The USPSTF recommends screening for chlamydial infection for all
    pregnant women aged 24 and younger and for older pregnant women who
    are at increased risk . This is a grade [B
    Recommendation](http://www.ahrq.gov/clinic/uspstf07/ratingsv2.htm#brec).

-   The USPSTF recommends against routinely providing screening for
    chlamydial infection for women aged 25 and older, whether or not
    they are pregnant, if they are not at increased risk . This is a
    grade [C
    Recommendation](http://www.ahrq.gov/clinic/uspstf07/ratingsv2.htm#crec).

-   The USPSTF concludes that the current evidence is insufficient to
    assess the balance of benefits and harms of screening for chlamydial
    infection for men . This is a grade [I
    Statement](http://www.ahrq.gov/clinic/uspstf07/ratingsv2.htm#irec).

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

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

#### Sexually active women benefit from HPV vaccine {#sexually-active-women-benefit-from-hpv-vaccine-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### INTERPRETATION: Administration of HPV vaccine to HPV-naive women, and women who are already sexually active, could substantially reduce the incidence of HPV16/18-related cervical precancers and cervical cancer {#interpretation-administration-of-hpv-vaccine-to-hpv-naive-women-and-women-who-are-already-sexually-active-could-substantially-reduce-the-incidence-of-hpv1618-related-cervical-precancers-and-cervical-cancer .Style-Heading-4-+-Arial-14-pt-Underline}

#### Ault KA Effect of prophylactic human papillomavirus L1 virus-like-particle vaccine on risk of cervical intraepithelial neoplasia grade 2, grade 3, and adenocarcinoma in situ: a combined analysis of four randomised clinical trials. [Lancet.  2007; 369(9576):1861-8](http://www.medscape.com/medline/publicationbrowser/123?pmid=17544766)  {#ault-ka-effect-of-prophylactic-human-papillomavirus-l1-virus-like-particle-vaccine-on-risk-of-cervical-intraepithelial-neoplasia-grade-2-grade-3-and-adenocarcinoma-in-situ-a-combined-analysis-of-four-randomised-clinical-trials.-lancet.-2007-36995761861-8 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17544766**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17544766) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17544766 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### HPV vaccine against human papillomavirus to prevent anogenital diseases {#hpv-vaccine-against-human-papillomavirus-to-prevent-anogenital-diseases-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: The quadrivalent vaccine significantly reduced the incidence of HPV-associated anogenital diseases in young women. {#conclusions-the-quadrivalent-vaccine-significantly-reduced-the-incidence-of-hpv-associated-anogenital-diseases-in-young-women. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Garland SM et al Quadrivalent vaccine against human papillomavirus to prevent anogenital diseases. [N Engl J Med.  2007; 356(19):1928-43](http://www.medscape.com/medline/publicationbrowser/123?pmid=17494926)  {#garland-sm-et-al-quadrivalent-vaccine-against-human-papillomavirus-to-prevent-anogenital-diseases.-n-engl-j-med.-2007-356191928-43 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17494926**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17494926) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17494926 .Style-Heading-4-+-Arial-14-pt-Underline}

**Vulvar Vaccinia Infection After Sexual Contact with a Military
Smallpox Vaccinee - 2006**

On October 10, 2006, an otherwise healthy woman visited a public health
clinic in Alaska after vaginal tears that she had first experienced 10
days before became increasingly painful. The patient reported having a
new male sex partner during September 22-October 1, 2006. This report
describes the clinical evaluation of the woman and laboratory testing
performed to identify the isolate. Health-care providers should be aware
of the possibility of vaccinia infection in persons with clinically
compatible genital lesions who have had recent contact with smallpox
vaccinees. <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5617a1.htm>

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

#### A Series on Adolescence Sexual Activity {#a-series-on-adolescence-sexual-activity-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Dating, sex, and substance use as correlates of adolescents'
subjective experience of age**

This study examined in a random community-based sample of 664
12--19-year-olds, the relation of subjective experience of age (SEA)
with chronological age, dating experience, sexual activity, and
substance use. The results revealed a positive linear relation between
SEA and chronological age: individuals who were chronologically older
felt subjectively older than their actual age. Several possible sources
of interindividual differences in SEA were identified. Adolescents who
were dating an older partner felt older compared to other dating
adolescents. Sexually experienced adolescents felt older than their
non-experienced counterparts. Smoking (in boys), higher alcohol use, and
higher drug use were also related to an older SEA. These results suggest
an increasing discrepancy between SEA and chronological age across the
teen years as young people experience the normative changes associated
with adolescence. Dating, sexual, and substance use activities may
figure importantly in the way that adolescents experience their age.

Arbeau KJ et al Dating, sex, and substance use as correlates of
adolescents' subjective experience of age Journal of Adolescence Volume
30, Issue 3, June 2007,  Pages 435-447

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16764917>

**Parental communication and youth sexual behaviour**

The role of parental communication and instruction concerning sexual
behaviour were studied in a community-based sample of 1083 youth aged
13--17 (mean age of 15 years; 51% girls, 49% White). The Youth Asset
Survey was administered along with items measuring demographics and
youth risk behaviours. After controlling for demographic factors,
multivariate analysis revealed that youth were much less likely to have
initiated sexual intercourse if their parents taught them to say no, set
clear rules, talked about what is right and wrong and about delaying
sexual activity. If youth were sexually active, they were more likely to
use birth control if taught at home about delaying sexual activity and
about birth control. Having only one sexual partner was associated with
having an adult role model who supports abstinence, being taught at home
about birth control, and being taught at home how to say no. If parents
reported talking with youth about birth control and sexually transmitted
disease (STD) prevention, youth were significantly more likely to use
birth control. Our conclusion is that parents have the opportunity and
ability to influence their children\'s sexual behaviour decisions.  

Aspy CB et al Parental communication and youth sexual behaviour Journal
of Adolescence Volume 30, Issue 3, June 2007,  Pages 449-466

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16750265>

**Adolescent use of psychologically, physically, and sexually abusive
behaviours in dating**

We examined the co-occurrence of and risk factors for adolescent boys'
and girls' self-reported use of psychologically, physically, and
sexually abusive behaviours in their dating relationships. The
participants were 324 boys and 309 girls in grades 7, 9, or 11 who
completed surveys at school. Descriptive analyses showed that 19% of
boys and 26% of girls reported having used two or more forms of dating
violence. One third of students in grade 7 had already used at least one
form of aggressive behaviour in this context.

Canonical correlation analyses indicated that boys' and girls' use of
multiple forms of dating violence were predicted by their attitudes
toward and experiences with violence. After controlling for general
abusiveness, boys' use of sexually abusive behaviour and girls' use of
psychologically abusive behaviour were linked to specific risk factors
that suggest an enactment of social scripts associated with their
respective gender roles.

Sears HA et al The co-occurrence of adolescent boys' and girls' use of
psychologically, physically, and sexually abusive behaviours in their
dating relationships Journal of Adolescence Volume 30, Issue 3, June
2007, Pages 487-504

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16884766>

**Validation of a 'triangular love scale' for adolescents: Intimacy,
passion, and commitment**

This study examined the psychometric properties of an adolescent version
of the 'triangular love scale' (TLS), which assesses three components of
romantic relationships: intimacy, passion, and commitment. Using data
from 435 Dutch adolescents aged 12--18 years, we found evidence for
convergent validity, showing that dimensions of intimacy, passion, and
commitment were all positively correlated with relationship satisfaction
and duration. Evidence was also found for divergent validity, as
adolescents' perceptions of the main (dis)advantages of being involved
in romantic relationships showed a specific pattern of associations with
intimacy, passion, and commitment. Finally, CFA analyses in LISREL
showed that a model in which all separate questionnaire items were
specified to load on three underlying, correlated factors (intimacy,
passion, commitment) fit the data adequately. Overall, this measure
seems appropriate for use with adolescents.

Overbeek G et al Brief report: Intimacy, passion, and commitment in
romantic relationships---Validation of a 'triangular love scale' for
adolescents Journal of Adolescence Volume 30, Issue 3, June 2007,  Pages
523-528

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17320166**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17320166) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17320166 .Style-Heading-4-+-Arial-14-pt-Underline}

**Partnerships: Developing Adolescent Health Community-Researcher
Partnerships**

RESULTS: Sites chose as their primary target population young women who
have sex with men (n = 8 sites), young men who have sex with men (n =
6), and intravenous drug users (n = 1). Of 1162 agencies initially
interviewed, 281 of 335 approached (84%) agreed to join the partnership
(average 19/site). A diverse array of community agencies were
represented in the final collaborative network; specific characteristics
included: 93% served the sites\' target population, 54% were
predominantly youth oriented, 59% were located in the geographical area
of focus, and 39% reported provision of HIV/STI (sexually transmitted
infection) prevention services. Relationship-building activities,
development of collaborative relationships, and lessons learned,
including barriers and facilitators to partnership, are also described.
CONCLUSIONS: Study findings address a major gap in the community partner
research literature. Health researchers and policymakers need an
effective partner selection framework whereby community-researcher
partnerships can develop a solid foundation to address public health
concerns.

Straub DM et al Partnership Selection and Formation: A Case Study of
Developing Adolescent Health Community-Researcher Partnerships in
Fifteen U.S. Communities. J Adolesc Health. 2007 Jun;40(6):489-498.  

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17531754>

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

**Mycoplasma genitalium among Adolescent Women and their Partners**

Results: Cumulatively, 13.6% (52/383) of women tested positive for M.
genitalium. All women with M. genitalium, except one, were sexually
experienced. M. genitalium was associated with number of sexual partners
(p \< .001) and C. trachomatis infection (p \< .03). M. genitalium was
more likely among male partners of M. genitalium-positive women (p \<
.02); 31.3% of untreated M. genitalium cases had infection lasting over
8 weeks. M. genitalium was not associated with the presence of clinical
signs or symptoms of infection.

Conclusions: Findings support sexual transmissibility of M. genitalium
and add to understanding of M. genitalium natural history and clinical
findings.

Tosh AK et al Mycoplasma genitalium among Adolescent Women and their
Partners. Journal of Adolescent Health, Volume 40, Issue 5, Pages
412-417 (May 2007)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17448398>

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

**Update on Male Chlamydia (Ct) Screening**

Summary of Recommendations

The consultants did not consider any recommendations pertaining to
whether programs should adopt or expand male Ct screening programs. For
state and local programs that have decided to screen, the following
guidance is provided to assist with decisions about which populations of
males to screen for Ct and how best to screen.

-   Males attending STD clinics should be screened for Ct

-   Males attending Job Corps should be screened for Ct

-   Males \<30 years of age entering jails should be screened for Ct

-   Males with Ct infection should be re-screened at 3 months for repeat
    Ct

-   Urine is the specimen of choice for screening asymptomatic men for
    Ct

-   Nucleic acid amplification test: NAATs are the test of choice. LET
    is not recommended for screening males for Ct

-   Pooling of urine specimens should be considered for Ct testing in
    low prevalence settings to conserve resources

-   Partner services should be offered to partners of males with Ct

11 page report with appendices: Male Chlamydia Screening Consultation   

Atlanta, Georgia-March 28 -- 29, 2006

1\) a review of venues and Ct prevalence;

2\) a review of prevalence of Ct among men in the U.S.;

3\) a review of behavioral and demographic features associated with Ct
among men;

4\) cost-effectiveness issues;

5\) laboratory issues;

6\) partner management; and

7\) re-infection.

#### [http://www.cdc.gov/std/chlamydia/ChlamydiaScreening-males.pdf]{.underline}  {#httpwww.cdc.govstdchlamydiachlamydiascreening-males.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

**Use of a Computer for HIV and Sexually Transmitted Infection Risk
Reduction**

RESULTS: Users were 58% nonwhite with mean age 24.7 years (74% \< 25).
Patients could use CARE with minimal to no assistance. Time for session
completion averaged 29.6 minutes. CARE usefulness was rated an average
of 8.2 on an ascending utility scale of 0 to 10. Patient themes raised
as strengths were novelty, simplicity, confidentiality, personalization,
and plan development, increased willingness to be honest, lack of
judgment, and a unique opportunity for self-evaluation. Staff themes
raised as strengths were enhanced data collection, handout
customization, education standardization, behavioral priming, and
expansion of services. Patient limitation themes included limited
responses and lack of personal touch. Staff limitation themes were
selecting users, cost, patient-provider role, privacy, and time for use.
CONCLUSIONS: CARE was well-received and easily usable by most
(especially 18-25-year-olds). Patient and staff perceptions support the
use of CARE as an adjunct to usual practice and as a method to expand
services. Honesty, reduced time constraints, and lack of judgment
associated with CARE appeared to enhance self-evaluation, which may
prove an important component in moving patients forward in the behavior
change process.

Mackenzie SL et al Patient and Staff Perspectives on the Use of a
Computer Counseling Tool for HIV and Sexually Transmitted Infection Risk
Reduction. J.  Adolesc Health. 2007 Jun;40(6):572.e9-572.e16.  

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17531766**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17531766) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17531766 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**(How) can we prevent type 2 diabetes?**

Our knowledge base in this field is still quite rudimentary, and we have
no information about truly long-term (ie, for decades) prevention of
type 2 diabetes.

Type 2 diabetes is a progressive disease. It develops over years as a
result of declining pancreatic ß-cell compensation for chronic and often
worsening insulin resistance. Preventing type 2 diabetes requires
modification of the underlying disease biology to slow, stop, or reverse
the decline in ß-cell compensation. Data from six randomized trials
reveal several interventions that reduce the number of high-risk people
who develop diabetes during relatively short periods of treatment.
Interventions that reduce body fat or that mitigate the effect of excess
fat to cause insulin resistance provide the greatest risk reduction and
the best evidence for real disease modification. At least two studies
indicate that disease modification is possible soon after glucose levels
enter the diabetes range. These findings, combined with the fact that
falling ß-cell compensation leads to rising glycemia, provide a
rationale for an intervention strategy that begins with lifestyle
modification and progresses to pharmacological therapy aimed at reducing
insulin resistance if lifestyle approaches fail to prevent glucose from
rising to the diabetes range. Our knowledge base in this field is still
quite rudimentary, and we have no information about truly long-term
(i.e., for decades) prevention of type 2 diabetes. Even for the short to
intermediate term, additional work is needed to determine optimal
application of the general strategy described above, to examine
combination approaches to prevention, and to test new interventions as
they become available. Such work should focus on disease modification,
not just cases of diabetes, as a major outcome.

[Buchanan
TA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Buchanan TA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
(How) can we prevent type 2 diabetes?
[Diabetes.](javascript:AL_get(this, 'jour', 'Diabetes.');) 2007
Jun;56(6):1502-7.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17389328>

**Prenatal Omega 3 Fatty Acid Consumption Improves Infant Problem
Solving**

Mothers who regularly ate a functional food containing an Omega 3 fatty
acid during pregnancy gave birth to infants with better problem solving
abilities as measured at nine months of age

CONCLUSION: These data point to a benefit for problem solving but not
for recognition memory at age 9 mo in infants of mothers who consumed a
DHA-containing functional food during pregnancy.

[Judge
MP](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Judge MP"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Maternal consumption of a docosahexaenoic acid-containing
functional food during pregnancy: benefit for infant performance on
problem-solving but not on recognition memory tasks at age 9 mo. [Am J
Clin Nutr.](javascript:AL_get(this, 'jour', 'Am J Clin Nutr.');) 2007
Jun;85(6):1572-7

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17556695>

**More Women than Men Having Mid-Life Stroke**

More women than men appear to be having a stroke in middle age,
according to a study

CONCLUSIONS: A higher prevalence of stroke may exist among women aged 45
to 54 years compared with similarly aged men. This potential disparity
could be due in part to inadequate stroke risk factor modification in
women and is deserving of further study.

[Towfighi
A](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Towfighi A"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al A midlife stroke surge among women in the United States.
[Neurology.](javascript:AL_get(this, 'jour', 'Neurology.');) 2007 Jun 20
<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17581944>

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

#### Diabetes Reduces Life Expectancy by 8 Years {#diabetes-reduces-life-expectancy-by-8-years-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Before heart disease even develops among patients with heart disease,
the effects on life expectancy have already begun, found researchers. In
an analysis of the Framingham Heart Study, diabetic men and women age 50
and older died on average 7.5 and 8.2 years earlier, respectively, than
those who did not have diabetes. CONCLUSIONS: The increase in the risk
of CVD and mortality from diabetes represents an important decrease in
life expectancy and life expectancy free of CVD. Prevention of diabetes
is a fundamental task facing today\'s society in the pursuit of healthy
aging

#### [Franco OH](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Franco OH"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), et al Associations of diabetes mellitus with total life expectancy and life expectancy with and without cardiovascular disease. [Arch Intern Med.](javascript:AL_get(this, 'jour', 'Arch Intern Med.');) 2007 Jun 11;167(11):1145-51 {#franco-oh-et-al-associations-of-diabetes-mellitus-with-total-life-expectancy-and-life-expectancy-with-and-without-cardiovascular-disease.-arch-intern-med.-2007-jun-11167111145-51 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17563022**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17563022) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17563022 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### GDM represents a significant risk factor for future DM development regardless of ethnicity {#gdm-represents-a-significant-risk-factor-for-future-dm-development-regardless-of-ethnicity-1 .Style-Heading-4-+-Arial-14-pt-Underline}

High glycosylated hemoglobin levels in women with gestational diabetes
are associated with the development of diabetes in the future, new
research indicates.

#### CONCLUSION: GDM represents a significant risk factor for future DM development regardless of ethnicity. Glycated haemoglobin values at GDM diagnosis have value in predicting future diabetes mellitus. {#conclusion-gdm-represents-a-significant-risk-factor-for-future-dm-development-regardless-of-ethnicity.-glycated-haemoglobin-values-at-gdm-diagnosis-have-value-in-predicting-future-diabetes-mellitus. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Oldfield MD](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Oldfield MD"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), et al Long term prognosis of women with gestational diabetes in a multiethnic population. [Postgrad Med J.](javascript:AL_get(this, 'jour', 'Postgrad Med J.');) 2007 Jun;83(980):426-3 {#oldfield-md-et-al-long-term-prognosis-of-women-with-gestational-diabetes-in-a-multiethnic-population.-postgrad-med-j.-2007-jun83980426-3 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17551077**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17551077) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17551077 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Prediction of Incident Diabetes Mellitus in Middle-aged Adults**

#### CONCLUSION: Parental diabetes, obesity, and metabolic syndrome traits effectively predict T2DM risk in a middle-aged white population sample and were used to develop a simple T2DM prediction algorithm to estimate risk of new T2DM during a 7-year follow-up interval {#conclusion-parental-diabetes-obesity-and-metabolic-syndrome-traits-effectively-predict-t2dm-risk-in-a-middle-aged-white-population-sample-and-were-used-to-develop-a-simple-t2dm-prediction-algorithm-to-estimate-risk-of-new-t2dm-during-a-7-year-follow-up-interval .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Wilson PW](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Wilson PW"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), et al Prediction of incident diabetes mellitus in middle-aged adults: the Framingham Offspring Study. [Arch Intern Med.](javascript:AL_get(this, 'jour', 'Arch Intern Med.');) 2007 May 28;167(10):1068-74 {#wilson-pw-et-al-prediction-of-incident-diabetes-mellitus-in-middle-aged-adults-the-framingham-offspring-study.-arch-intern-med.-2007-may-28167101068-74 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17533210**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17533210) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17533210 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Women With Heart Disease And Diabetes Less Likely To Receive Proper Care {#women-with-heart-disease-and-diabetes-less-likely-to-receive-proper-care .Style-Heading-4-+-Arial-14-pt-Underline}

#### Women with heart disease and diabetes are less likely to receive several types of routine outpatient medical care than men who have similar health problems, {#women-with-heart-disease-and-diabetes-are-less-likely-to-receive-several-types-of-routine-outpatient-medical-care-than-men-who-have-similar-health-problems .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Gender differences in the quality of cardiovascular and diabetic care were common and sometimes substantial among enrollees in Medicare and commercial health plans. Routine monitoring of such differences is both warranted and feasible. {#conclusion-gender-differences-in-the-quality-of-cardiovascular-and-diabetic-care-were-common-and-sometimes-substantial-among-enrollees-in-medicare-and-commercial-health-plans.-routine-monitoring-of-such-differences-is-both-warranted-and-feasible. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Bird CE](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Bird CE"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus) et al Does quality of care for cardiovascular disease and diabetes differ by gender for enrollees in managed care plans? [Womens Health Issues.](javascript:AL_get(this, 'jour', 'Womens Health Issues.');) 2007 May-Jun;17(3):131-8 {#bird-ce-et-al-does-quality-of-care-for-cardiovascular-disease-and-diabetes-differ-by-gender-for-enrollees-in-managed-care-plans-womens-health-issues.-2007-may-jun173131-8 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17434752**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17434752) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17434752 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Women's Health Headlines, Carolyn Aoyama, HQE {#womens-health-headlines-carolyn-aoyama-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**Why do Native American women have the poorest 5-year survival rate for
breast cancer?**

Encourage American Indian/Alaska Native women to join the Sister Study
TODAY!

The Sister Study needs your help

> Please help the Sister Study recruit more AI/AN women.

-   So far, less than 500 AI/AN women have enrolled out of a total of
    (37,000) in the Sister Study

-   Breast cancer is the 2nd leading cause of cancer death among Native
    women.

-   Their 5-year survival rate is lower than that of white women.

-   Scientists have very little information on cancer histories in
    American Indian/Alaska Native communities.

Please help recruit patients into this study: 

Eligibility criteria include the following:

35 and 74 years old

AND the patient has never had breast cancer

AND the patient lives in the U.S. or Puerto Rico

AND the patient (living, deceased), is a blood relative and had breast
cancer.

<https://sisterstudy.niehs.nih.gov/webscreener/DisplayPage.asp?_PageNumber=1>

**Motivational Interviewing training and Promoting Motivational
Incentives: NIDA**

Two new products designed to speed the adoption of science-based
interventions into clinical practice are now available from the National
Institute on Drug Abuse (NIDA), part of the National Institutes of
Health (NIH). These new \"Blending Team\" products are part of an
expanding portfolio that includes the latest research findings on drug
abuse approaches and interventions.  Blending Teams are composed of NIDA
researchers, community-based substance abuse treatment practitioners,
and trainers from the Substance Abuse and Mental Health Services
Administration\'s Addiction Technology Transfer Center Network.  In
addition to the Blending Teams, NIDA sponsors a number of Blending
conferences which are held periodically around the country to facilitate
communication between researchers and treatment providers.\
\
The two new Blending Team products are: \
\-- \"Motivational Interviewing Assessment: Supervisory Tools for
Enhancing Proficiency\" (MIA:STEP), tailored for clinical supervisors to
train front-line treatment providers to improve their motivational
interviewing skills.  It also includes a new package of tools designed
to enhance patient engagement and retention.\
\-- \"Promoting Awareness of Motivational Incentives\" (PAMI).  These
tools provide information about the science-based intervention called
motivational incentives (low or no-cost reinforcements such as vouchers,
prizes and privileges) and describes how the use of positive
reinforcement has reduced drug abuse and has enhanced client retention
in treatment programs. The PAMI products include support materials,
resources, PowerPoint presentations for both clinicians and for policy
makers, and an introductory video. \
\
Blending Team products and more information on the NIDA Blending
initiative can be accessed at <http://www.drugabuse.gov/blending/>

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

**Motivational Interviewing and virtually every other topic of
interest....**

Motivational Interviewing and virtually every other topic of interest to
Women's Health in Indian Country will be covered at the Native Women's
Health and MCH Conference**,** August 15 -17, 2007 in Albuquerque, NM.
It is not too late to sign up.

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

**Aiming Higher: Results from a State Scorecard on Health System
Performance**

The Commonwealth Fund Commission on a High Performance Health System
released the first-ever comprehensive comparison of health system
performance in all 50 states. 'Aiming Higher: Results from a State
Scorecard on Health System Performance' ranks states on 32 performance
indicators of access, quality, avoidable hospital use and costs, equity,
and \"healthy lives.\"\
\
The report compares each state\'s performance to benchmarks that have
already been achieved in states across the country. Although some states
ranked highly on multiple indicators, no single state or group of states
scored top marks in every area. Some, however, far surpassed others:
Hawaii and states in the Northeast and Upper Midwest often rank high in
multiple areas, while states with the lowest rankings tend to be
concentrated in the South. Across states, health care access and quality
were found to be highly correlated

<http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=494551&#doc494551>

**Women\'s emotional health and wellness materials**

The HRSA Office of Women's Health has recently developed a series of
tools under its Bright Futures for Women\'s Health and Wellness
Initiative (BFWHW) to promote emotional health and wellness among women
and adolescent girls.   This family of tools includes (1) an adult
female educational booklet, (2) an adolescent female educational
booklet, (3) an educational and awareness booklet for primary care
providers, (4) a poster for clinical settings, and (5) a community idea
kit.  These tools contain a compilation of evidence-based information,
tips, and messages on core elements of psychological, emotional, and
spiritual wellness. 

Pending final clearance, HRSA OWH will be printing a limited number of
hard copies of the tools in FY07 for distribution primarily to HRSA
grantees.  In order to make the tools available to the broadest possible
audience, we would like to provide CCWH members the opportunity to
supplement the print order in order to ensure distribution of the tools
to your selected audiences.  Based on existing estimates, the per-item
cost for each tool is as follows: Adult booklet: \$0.90; Adolescent
booklet: \$0.92; Clinical booklet: \$0.53; Clinical flyer: \$0.26;
Community booklet: \$1.03.   Please note these are estimates and may
change based upon final quantities ordered.  

Please let me know if you would be interested in riding the print order
for some or all of the BFWHW emotional health and wellness tools. Please
specify which tools you are interested in and the quantity you would
like.  Once we have the requisition number from PSC, we will provide
this to you for your printing orders through your respective agencies
and offices.   Thanks!

Reem M. Ghandour, M.P.A

HRSA Office of Women\'s Health

Parklawn Building, Room 18A-44

5600 Fishers Lane

Rockville, MD  20857

tel: 202-276-0345

fax: 301-443-8587

<Rghandour@hrsa.gov>

**Native American Rehabilitation Association: Children, Youth & Family
Services Director**

The Native American Rehabilitation Association of the NW, Inc. (NARA) is
a first class organization in terms of leadership, vision, services and
value to the AI/AN community. Please contact Jackie Mercer (in Microsoft
Outlook) if you are interested in this position.

Carolyn

RE: We are recruiting for the following key position.

Any help that you could give us in distributing this announcement would
be greatly appreciated.

This is a great opportunity to make a difference in the lives of Native
Families.

Thanks for your help,

Jackie Mercer

CEO

NARA NW

NARA NW POSITION ANNOUNCEMENT

CHILDREN, YOUTH & FAMILY SERVICES DIRECTOR

 

The Native American Rehabilitation Association of the NW, Inc (NARA NW)
is an Indian-owned & operated private, non-profit agency that provides
culturally appropriate physical & mental health services & substance
abuse treatment for American Indians, Alaska Natives & other vulnerable
people.  We are currently seeking a qualified and motivated team member
to lead our multi-disciplinary team serving families in the Portland
Native American Community.

 

The Children, Youth & Family Services Director is an exciting new
position we created to direct the daily operations of NARA Mental Health
Team, Family Wellness Program, Early Childhood Education and related
prevention programs (Meth, Youth Suicide, Elders) as well as assure that
all service delivery is in compliance with county, state and federal
regulations and funding source requirements. 

 

This position will plan, direct, and implement mental health and
designated prevention services for all 4 NARA locations.  Will provide
supervision of program leaders; provide/assure clinical
direction/supervision, develop and review mental health treatment,
approve programming schedules, coordinate staff in-service trainings,
and develop program policies and procedures.

 

Externally this position acts as a liaison with appropriate local,
county, state, and federal agencies and organizations as directed and
assure that assigned programs develop and maintain relationships with
tribes and the Portland Indian community.

<jobs@naranorthwest.org> or fax 503-224-4494
[[www.naranorthwest.org]{.underline}](../www.naranorthwest.org)

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

**Native Women's Health and MCH Conference**

-   August 15 -17, 2007

-   Albuquerque, NM

-   Questions? Contact <nmurphy@scf.cc>

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

**3rd Annual American Indian and Alaska Native Long Term Care
Conference**

-   September 5-6, 2007

-   Albuquerque, New Mexico

-   Visit
    [http://www.aianlongtermcare.org](http://www.aianlongtermcare.org/)

-   Contact <Bruce.Finke@ihs.gov>

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

-   September 16 -- 19, 2007

-   Denver, CO

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

**Second National Summit on Preconception Health and Health Care**

-   October 29-31 2007

-   Oakland, CA

-   CDC and March of Dimes

-   <http://www.marchofdimes.com/california/4947_24789.asp>

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

**Q. Should patients use sweat lodges during pregnancy?**

<http://www.ihs.gov/MedicalPrograms/MCH/M/Sfaqs.cfm#sweatLodge>

**New Breast feeding Family Support web page: Have pictures to share?**

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

There are several upcoming **Conferences**

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

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

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

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

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

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

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

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

#### The June / July 2007 OB/GYN CCC Corner is available at: {#the-june-july-2007-obgyn-ccc-corner-is-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0607.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0607.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn0607.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

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

A new diagnostic category: 'First Trimester GDM'

#### From your colleagues page 9 {#from-your-colleagues-page-9 .Style-Heading-4-+-Arial-14-pt-Underline}

Gordon Belcourt

FTC Releases Reports on Cigarettes and Smokeless Tobacco

Ben Garnett

Control over schedule: Most important predictor of provider work-life
balance and burnout

Scott Giberson

\-[Names-Based Reporting for All U.S. States by End of
2007](http://www.thebodypro.com/kaiser/2007/apr3_07/hiv_reporting.html?mb80h)

-Medicare Part D still has to make improvements for HIV patients and
providers

-U.S. AIDS Drug Assistance Program Waiting Lists growing

-HRSA's Special Projects of National Significance

-Behavioral Health HIV/AIDS Collaborative Training

and more.....

**Roberta Ward**

FDA Proposes New Warning Labeling About Suicidal Thinking / Behavior In
Young Adults

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

##### Obstetrics page 11

-Placental problems with previous caesarean delivery: Abruptio, previa

-Late Pregnancy Bleeding (ALSO serialization)

-Admission for nephrolithiasis during pregnancy: 80% risk of preterm
delivery

-Postpartum Depression Screening: Recommendations for Practice

-Fetal or infant death a traumatic event for parents: Assist grieving
parents

and more.....

**Gynecology page 13**

-Discharge 24 Hours After Vaginal Hysterectomy Safe, Acceptable

-Laparoscopic and fixed multiple dose methotrexate most effective for
ectopic

-Extended Oral Contraceptives Decrease Premenstrual Symptoms

-Fluoroquinolones No Longer Recommended for Treatment of Gonococcal
Infections

-Interventions to Reduce Hemorrhage During Myomectomy for Fibroids

and more.....

**Child Health page 15**

-Forty percent of 3-month-olds watch TV, DVDs, or videos

-Guidelines for School-Based STD Screening in Indian Country

-Urinary symptoms in adolescent females: STI or UTI?

-Sexually transmitted infections in preadolescent children

-Adjustments in opthalmia neonatorum (ON): Gonorrhea in pregnancy

**Chronic Illness and Disease page 16**

-Malabsorption of Oral Antibiotics in Pregnancy after Gastric Bypass
Surgery

-Sleeping Poorly \... and Maybe Depressed: Co morbidity in Formal Sleep
Studies

-Barriers to Smoking Cessation Services in Underserved Communities

-Management of Hypertriglyceridemia

-AHA Guidelines for CVD Prevention in Women Focus on Lifetime Risk
Factors 

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

American College of Obstetricians and Gynecologists

-Endometrial ablation. ACOG Practice Bulletin

-Seeking and Giving Consultation

-Disruptive Behavior

-Patents, Medicine, and the Interests of Patients

##### American Family Physician

-Therapies for Overactive Bladder- Nonpharmacologic vs. Anticholinergic

-Exercise Is an Effective Intervention in Overweight and Obese Patients

-Evaluation and Treatment of Acute Low Back Pain

-Restless Legs Syndrome: Pramipexole

**Agency for Healthcare Research and Quality**

AHRQ breastfeeding evidence review

**Ask a Librarian**

Quick Check for Drugs and Lactation

**Breastfeeding**

-Long-Term Breastfeeding among Native American Women

\-[Systematic review and meta-analysis confirms long-term positive
effects of
breastfeeding](http://www.who.int/child-adolescent-health/publications/NUTRITION/ISBN_92_4_159523_0.htm)

-FAQs - Breastfeeding and maternal illness

#### -RCT of very early mother-infant skin-to-skin contact and breastfeeding status {#rct-of-very-early-mother-infant-skin-to-skin-contact-and-breastfeeding-status .Style-Heading-4-+-Arial-14-pt-Underline}

**CCC Corner Digest**

-Social Change Might Save More Lives Than Medical Advances

-New HPV Brochures for Clinicians, CDC

-More stillbirths after previous cesarean delivery

-Young women with CIN: Any treatment increases preterm delivery - LEEP

-Public Opinion vs. Science Concerning Sex Education

-New Guideline for Screening Mammography for Women 40 to 49 Yrs

-Premature Rupture of Membranes, Practice Bulletin

-Quick Check for Drugs and Lactation

-Breastfeeding - it's all about synergy

-Extended OCP Regimen; Acceptable Breakthrough Bleeding

-Must See Website: Indian Health Service HIV-AIDS Program

-Ethics of medicine with economically vulnerable populations: 2nd in
series

-Do you walk around your vehicle before getting in it? You should

-Which Indian Health facilities lead the U.S. in national benchmarks?

-Emergence of a range of nonhormonal treatments for vasomotor symptoms

-Ultrasound affects mice brains in negative ways

-BTL: Nearly 1/2 of women under 25 yo request information on reversal

-Two summer programs for high school students

-Calcium Supplementation May Not Benefit Healthy Children

-Preconception counseling for women with DM and HTN: Which meds?

-Electronic Health Record (EHR) Implementation: Worth the effort?

-HIV/AIDS among AI/AN Fact Sheet

-New recommendations for gestational weight gain may be required

-Weaving it all together: 2007 Behavioral Health Conference

**Domestic Violence**

-The failure to protect Indigenous women from sexual violence in the USA

-Adverse sequelae of physical and sexual abuse in adulthood

-WH Pregnancy and DV education online session

\-[Domestic Violence and Your Patient\'s Health: Asking the Right
Questions](http://mp.medscape.com/cgi-bin1/DM/y/hBNXD0Ou5N60SzO0IRML0Ei)

**Elder Care News**

[Gynecologic Assessment of the Elderly Patient\
](http://mp.medscape.com/cgi-bin1/DM/y/hBNXD0Ou5N60SzO0IUVk0ER)

**Family Planning**

-Reasons for unprotected intercourse

-Adolescent sexual behavior: Strategies for reducing pregnancy and
childbearing

-Effect of Medicaid Family Planning Expansions on Unplanned Births

-Guidelines for Selection of Contraception in Women with Rheumatic
Diseases

**Featured Website**

MCHB Launches Web Site to Increase Awareness of Perinatal Depression

**Frequently asked questions**

What are the Unnecessary Tests done in Obstetrics and Gynecology?

**Indian Child Health Notes**

-Acute pain relief in children

-Pertussis: Secular Trends in the United States

-Persistence of racial disparities in fatal injuries to very young
children

**Information Technology**

How can we improve HIV screening in pregnancy? Preliminary GPRA Related
Results

International Health

Social context of maternal deaths and morbidity

#### MCH Alert

-Progress toward meeting Healthy People 2010 Maternal, Infant, and Child
objectives

-Mental disorders and nicotine dependence among pregnant women

#### MCH Headlines

-Improve the system - Improve the care: Underpinnings

-Drive It Right Kits

-Have you heard of: 'the Baby bottle tooth decay germ' aka Streptococcus
mutans? 

-Newly completed Pregnancy and Postpartum Quitline Toolkit

-K-12 Oral Health Education Curriculum

and more.....

#### Medical Mystery Tour

#### Which Indian Health facilities lead the entire U.S. in obstetric benchmarks? {#which-indian-health-facilities-lead-the-entire-u.s.-in-obstetric-benchmarks .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

-Urinary Tract Infections: A Primer for Clinicians

-Management of Breast Cysts Revisited

-CDC Issues New Treatment Recommendations for Gonorrhea 

\-[Optimizing Once-Daily Antiretroviral Regimens for Treatment-Naive
Patients With
HIV](http://mp.medscape.com/cgi-bin1/DM/y/hBOmG0Ou5N60Dzc0IWZw0GH)

**Menopause Management**

-Earlier hormone therapy closer to menopause tended to have reduced CHD
risk

#### -Low dose transdermal estradiol gel effective for postmenopausal symptoms {#low-dose-transdermal-estradiol-gel-effective-for-postmenopausal-symptoms .Style-Heading-4-+-Arial-14-pt-Underline}

-Updated Statement on Hormone Therapy 

**Midwives Corner**

Ultrasound affects mice brains in negative ways: First, do no harm

**Navajo News**

Adjustable Urethral Slings Offer Hope for Complex Incontinence Problems

**Nurses Corner**

#### Personal Digital Assistants: Practical Advice for Nurses in 2007 {#personal-digital-assistants-practical-advice-for-nurses-in-2007 .Style-Heading-4-+-Arial-14-pt-Underline}

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

CDC's Pregnancy Information Center

Lead Exposure Among Females of Childbearing Age

**Oklahoma Perspective**

Cesarean Delivery on Maternal Request

Osteoporosis

-Let's put DEXA and other radiation risks into perspective

-Cortisol Levels and BMD Among Premenopausal Women With Depression 

Patient Education

#### -Hypertriglyceridemia: What You Should Know {#hypertriglyceridemia-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Low Back Pain {#low-back-pain .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Placental cultures and histology poor predictors of infectious status
of the amniotic fluid

-Free beta-HCG outperforms intact HCG in a multimarker protocol

-Forum: Periodontal Health and Birth Outcomes - HRSA MCHB

-PREMAG inconclusive, but improvements of outcome are of potential
significance

-Insulin Glargine Use During Pregnancy Not Linked to Fetal Morbidity

and more.....

Primary Care Discussion Forum

Electronic Health Record (EHR) Implementation: Worth the effort?

STD Corner

-Guidelines for School-Based STD Screening in Indian Country

-Fluoroquinolones No Longer Recommended for Treatment of Gonococcal
Infections

-Let\'s talk about HIV counseling and testing -- New Facilitators\'
guide

-Does your lab have capacity to culture N gonorrhoeae for treatment
failures? 

# -Urinary symptoms in adolescent females: STI or UTI?

and more.....

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

-High rate of diabetes among indigenous people not due to thrifty gene

-Aspirin may be less effective heart treatment for women than men

-Cholesterol Could be Key to Treating Fetal Alcohol Syndrome

-Apples during pregnancy could reduce asthma risk in offspring

**Women's Health Headlines**

-Women's Early Drinking Problems More Likely to Escape Diagnosis

-Women and Health Coverage: The Affordability Gap

-WomenHeart Symposium 2007

###### Save the Dates: Upcoming events of interest page 59

#### What's new on the ITU MCH web pages page 59

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/F/MCHdiscuss.cfm>

7/12/07