[Special Note:]{.underline} New Primary Care Forum Topic, February 1,
2004

"Evidence based periodic health screening for the elderly"

Discussion facilitator: Bruce Finke, IHS Elder Care Initiative

Details below on how to subscribe or unsubscribe

OB/GYN Chief Clinical Consultant's Corner

Volume 2, No. 1 January, 2004

**[Contents:]{.underline}**

**[Abstract of the Month]{.underline}: page 3**

Health Status of American Indians Compared with Other Racial/Ethnic
Minority Populations

[From your colleagues:]{.underline} page 5

From Burt Attico: Sick of Lawsuits Campaign

From Jean Charles-Azure: **Assessment and Management of Adult Obesity:
Case Studies**

From Katy Ciacco Palatianos: How does your facility's UTI resistance
compare to your region?

From Terry Cullen: Online learning opportunity: Violence against Native
Women; How do Consumers Search for and Appraise Information on Medicines
on the Internet?

From Mary Helen Deer: Funding available: Colorectal cancer screening in
primary care

From Terry Friend: BTLs in non-Native women with Native partners

From James Galloway: Coronary Heart Disease in Women with Diabetes

From Lindley Gifford: When is best to screen for Chlamydia in
asymptomatic women?

From Joan Koval: Does Folate intake affect cervical dysplasia?

From Bill Lubke, Ken Moore: Clinical Guidelines for Common Genitourinary
Disorders

From Chuck North: Evidence Based Practice Resources

From Suzanne Schwendenman: Tobacco cessation in pregnancy:
Pharmacological methods?

From Ros Singleton: Pregnant women in their second or third trimester
should get flu vaccine

From Judy Thierry: Breast and cervical changes that are non-cancerous,
and abnormal Pap or mammogram; Should we start using progesterone to
treat preterm labor now?

From Alan Waxman: Summary of New Cervical Cancer Screening Guidelines
and New Technology Forum

**[Hot Topics:]{.underline}** **page 12**

##### Obstetrics: Persistent Fetal Occiput Posterior Position; Maternal Behaviors and Experiences Before, During, and After Pregnancy; Prenatal HIV Testing and Antiretroviral Prophylaxis at an Urban Hospital, 1997---2000; Does Assisted Reproduction Cause Spontaneous Abortion? 2003 Obstetrics Year in Review, Medscape; Postpartum Depression Treatments and the Impact of Antidepressant Drugs on Nursing; Spinal Anesthesia in Obstetrics \-- New Concepts and Developments; Cesarean Delivery Linked to Subsequent Stillbirths

Gynecology: Diaphragm Fitting; 2003 GYN Year in Review, Medscape;
Pharmacologic Treatment of Polycystic Ovary Syndrome; Chaperone Use
During Pap Smears

Child Health: Influenza-Associated Deaths Reported Among Children Aged
\<18 Years; 2004 CATCH Implementation Funds available;

Chronic Illness and Disease: The USPSTF recommendations on Obesity; Use
of Botanicals by Women: Toward Optimal Health; Lipid Changes on Hormone
Therapy and Coronary Heart Disease Events in the Heart and
Estrogen/Progestin Replacement Study (HERS); Dietary Fiber Decreases
Risk for Colorectal Cancer; Diagnosis of Systemic Lupus Erythematosus;
Hepatitis B; Bovine Spongiform Encephalopathy in a Dairy Cow \-\--
Washington State, 2003; What are some of the surgical options for the
morbidly obese?

[Features:]{.underline} page 15

AFP: [Cochrane for Clinicians]{.underline}: Does Metformin Improve
Clinical Features of Polycystic Ovary Syndrome? Thromboembolism;
[POEMS:]{.underline} Aspirin Prevents Preeclampsia and Complications;
Spinal Manipulation for Low Back Pain; Glucosamine and Chondroitin for
Osteoarthritis; Other: Hypertension in Pregnancy Signals Hypertension
Later; Omega-3 Fatty Acid and Heart Disease in Diabetic Women;
Anticholinergic Therapy for Overactive Bladder Symptoms

ACOG: ACOG Endorses JCAHO\'s Universal Protocol for Preventing Wrong
Site, Wrong Procedure, Wrong Person Surgery

**AHRQ:** A higher rate of cesarean delivery does not necessarily
correspond with better perinatal outcomes; Use of tocolytic therapy to
stop uterine contractions can prolong pregnancy and prevent preterm
birth; Personalized form letters may improve breast and cervical cancer
screening among low-income and minority women; Age, fertility status,
and other factors influence satisfaction with progestin treatment for
abnormal uterine bleeding; Benefits of adding radiation therapy to
tamoxifen after breast conserving surgery diminish with increasing age

**Breastfeeding:** Returning to Work While Breastfeeding; Breastfeeding
and Returning to Work in the Physician\'s Office; Revised American
Cancer Society Guidelines for Breast Cancer Screening, 5/2003

**Elder Care News:** February 1, 2004 Discussion facilitator: Bruce
Finke, IHS Elder Care Initiative Evidence based periodic health
screening for the elderly

**Frequently asked questions:** Should you give prophylaxis for GBS when
performing a scheduled cesarean delivery?

**Hormone Replacement Update**: HRT improves sleep; Thoughts on
individualizing hormone replacement therapy

**Information Technology:** Affordable electronic health record systems

International Health: Low Rate of Mother-to-Child Transmission of HIV-1
After Nevirapine Intervention

#### MCH Alert: Health care quality and disparities in access to services

#### Medscape: Ask the Experts topics in Women\'s Health and OB/GYN; OB GYN & Women\'s Health Discussion Board; Clinical Discussion Board; Free CME

#### Office of Women's Health, CDC: Interested in Federal funding? You may be interested in this web site; Centers for Disease Control and Prevention 2004 Program Announcements

Osteoporosis: **New Guidelines from ACOG: Osteoporosis;** Evidence Based
Practice: Screening for Osteoporosis in Postmenopausal Women; Vertebral
Compression Fractures in the Elderly; Osteoporosis and Health-Related
Quality-of-Life Outcomes; How important is calcium intake to bone health
for postmenopausal women?

Patient Education: Hepatitis B; Birth Control Using a Diaphragm; Using
Your Diaphragm; Returning to Work While Breastfeeding; Painful
Urination; Urinary Tract Infections During Pregnancy; Urinary Tract
Infections in Adults; Urinary Reflux; Urinary Tract Infections in
Children; Osteoporosis

###### Primary Care Discussion Forum: February 1, 2004 Discussion facilitator: Bruce Finke, IHS Elder Care Initiative Evidence based periodic health screening for the elderly

#### Violence against women: General Epidemiology; Improving Screening of Women for Violence - Basic Guidelines for Physicians; Factors in Perpetration; Sexual Violence Against Girls; Consequences of Child Abuse; Substance Abuse in Women Who Have Been Exposed to Violence; Pregnancy; General Physical and Mental Consequences; Effects on the Brain; Screening Protocols; Professional Issues Related to Screening; Intervention; Around the World

#### What's new on the ITU MCH web pages page 22

###### Save the Dates: Upcoming events of interest page 22

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

**Corner? page 23**

# 

# 

# 

# [Abstract of the Month]{.underline}

Health Status of American Indians Compared with Other Racial/Ethnic
Minority Populations \-\-- Selected States, 2001\--2002

MMWR November 28, 2003 52(47)1148-52

Despite overall declines in morbidity and mortality in the United States
in recent years, a persistent gap in health status remains between
American Indians (AIs) and non-Hispanic whites. This report compares the
health status of AIs with that of other racial/ethnic minority
populations by using data from a survey conducted during 2001\--2002 in
21 communities through the Racial and Ethnic Approaches to Community
Health (REACH) 2010 project. The results indicate that although AIs had
a higher prevalence of chronic disease risk factors than other
racial/ethnic minority populations, they also were more likely to use
preventive services. Culturally sensitive primary prevention strategies
to reduce risk factors and disease burden in AI communities should be
developed and implemented.

REACH 2010 is a community-based demonstration project designed to reduce
racial/ethnic disparities in health. As a part of the project
evaluation, CDC contracted with the National Opinion Research Center at
University of Chicago to conduct the REACH 2010 Risk Factor Survey. The
baseline survey was conducted during June 2001\--August 2002 in 21
minority communities in the United States. Sample designs were
customized for each of the 21 communities, taking into account
geography, racial/ethnic density, expected telephone coverage, and other
factors (e.g., suggestions received from the communities). In the 18
communities in which expected telephone coverage was \>80%, interviews
were conducted by telephone. Face-to-face interviews were conducted in
three communities in which 1) the expected telephone coverage was low or
inconclusive or 2) cooperation over the telephone was expected to be
difficult. The survey sampled eligible households and interviewed an
average of 1,000 minority residents aged [\>]{.underline}18 years in
each community. Uniform screening and interview questionnaires were used
for all households and were administered in English, Spanish,
Vietnamese, Khmer, or Chinese. The median response rate was 74% (range:
60%\--99%).

The 21 communities are located in 14 states (Alabama, California,
Georgia, Illinois, Louisiana, Massachusetts, Michigan, North Carolina,
New York, Oklahoma, South Carolina, Tennessee, Texas, and Washington).
The survey included two AI groups, 14 black groups, seven Hispanic
groups, and four Asian groups; five communities had multiple ethnic
groups. For this report, data for persons of the same race/ethnicity
from different communities were aggregated. The presence of a risk
factor or chronic condition was based on self-reported data. Obesity was
defined as body mass index of [\>]{.underline}30.0 kg/m^2^, calculated
from self-reported height and weight. Cardiovascular disease was defined
as having any of the following conditions: heart attack, coronary heart
disease, or stroke. High blood cholesterol was defined as ever being
told by a doctor or other health professional that blood cholesterol was
high. Women who had diabetes diagnosed only during pregnancy were not
considered to have diabetes. Data were weighted to represent the
communities surveyed, and SUDAAN was used to account for the complex
survey sampling designs.

The sample included 1,791 AIs, 10,953 blacks, 4,257 Hispanics, and 4,204
Asians. Among both men and women in these four groups, AIs had the
highest prevalences of obesity, current smoking, cardiovascular disease,
and diabetes. Among men, AIs also had the highest prevalences of
self-reported hypertension and high blood cholesterol levels. Among
women, blacks had the highest prevalences of these two conditions, and
AIs had the second highest prevalences. Approximately 80% of AIs had one
or more adverse risk factor or chronic condition, and one third had
three or more.

A substantial percentage of AIs received preventive services. Compared
with other minority populations, AIs with diabetes reported the highest
percentages of receiving hemoglobin A1C (HbA1C) and foot examinations.
AIs aged [\>]{.underline}65 years reported the highest prevalences of
receiving pneumonia vaccination. Overall, AIs had the second highest
rates for blood cholesterol screening, mammography, Papanicolaou (Pap)
smear, and influenza vaccination. A total of 84% of AIs had received at
least one preventive service.

MMWR November 28, 2003 52(47)1148-52

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5247a3.htm>

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

This study reveals significant improvements in the health status of
AI/AN compared to the past. On the other hand, there are persistent gaps
in health status for AI/AN. For more information on Health Disparities,
see MCH Alert, below.

Our mission in the Indian Health system is to provide the highest level
of care to our customers, the AI/AN population.

To achieve that end, we should continue to strive to provide the best
clinical care we possibly can. One of the ways you can help is to keep
abreast of what are considered the benchmark, or best clinical
practices.

One approach is to subscribe to the Primary Care Discussion Forum to
learn about / discuss best practice clinical care with national experts
in an e-mail format. The next facilitated discussion is planned for
February 1, 2004. See Primary Care posting below on page 20 for details
njm

**[Please note:]{.underline}**

You can expect 20-30 total e-mail messages per topic, 4 times a year.
Each discussion will last approximately 4-6 weeks.

If that is too much e-mail for you, then don't subscribe, or just
subscribe for those topics of special interest to your practice. You can
then unsubscribe after that topic is closed out.

When finished the full discussions and a summary are posted on the
Primary Care Discussion Forum web page:

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

It is easy to subscribe. Go to this page and fill in your name, then hit
search, then follow the instructions:

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

It is also easy to unsubscribe: go to this page and fill in your name,
then follow the instructions:

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

Or contact Jason Crim at
[jason.crim@mail.ihs.gov](mailto:jason.crim@mail.his.gov) to join the
Primary Care listserv. If other questions arise contact me for
questions, <nmurphy@anmc.org>

## 

## From your colleagues:

#### [From Burt Attico, Phoenix]{.underline}

###### Sick of Lawsuits Campaign

Frivolous lawsuits have adversely affected the development and
availability of reproductive medical technology in the United States. As
a result, some have lost access to several safe and effective
medications and devices. The Sick of Lawsuits Campaign, aims to educate
the public about how frivolous lawsuits threaten our health care system
[www.sickoflawsuits.org](http://www.sickoflawsuits.org/)

.

###### [From Jean Charles-Azure, HQE]{.underline}* *Assessment and Management of Adult Obesity: Case Studies

10 booklet set of a comprehensive guide to help physicians identify and
treat adult patients who are obese.
<http://www.ama-assn.org/ama/pub/category/11759.html>

###### [From Katy Ciacco Palatianos, HQE]{.underline}

###### How does your facility's UTI resistance compare to your region?

Urinary tract infections continue to plague us, and are now further
complicated by the increase in antibiotic resistance. Faster diagnostic
procedures, shorter treatment regimens, and wider selection of
antibiotics provide new hope for treatment and prevention. (From
Medscape)

[http://www.medscape.com/pages/editorial/resourcecenters/public/uti/rc-uti.ov]{.underline}

\*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

###### [From Terry Cullen, ITSC Tucson]{.underline}

###### ONLINE LEARNING OPPORTUNITY: VIOLENCE AGAINST NATIVE WOMEN

**Who:** Anyone seeking training and education on the laws and policies
that impact Native (American Indian and Alaska Native) women victims of
violence in the United States. No prior experience or training
necessary.

**When**: January 21-March 24, 2004. Students are expected to login to
the class a minimum of 2-3 times per week (anytime, day or night) to
participate in discussions, download required readings, and submit
assignments.
[www.uclaextension.edu/tribal](http://www.uclaextension.edu/tribal) or
call (310) 206-6671

**How do Consumers Search for and Appraise Information on Medicines on
the Internet?**

[Conclusions:]{.underline} The results showed that there was a range of
search and appraisal skills among participants, with many reporting a
limited awareness of how they found and evaluated Internet-based
information on medicines. Poor interpretation of written information on
medicines has been shown to lead to anxiety and poor compliance to
therapy. This issue is more important for Internet-based information
since it is not subject to quality control and standardization as is
written information on medicines. Therefore, there is a need for
promoting consumer search and appraisal skills when using this
information. Educating consumers in how to find and interpret
Internet-based information on medicines may help them use their
medicines in a safer and more-effective way.

How do Consumers Search for and Appraise Information on Medicines on the
Internet? A Qualitative Study Using Focus Groups

Geraldine Peterson, Parisa Aslani, Kylie A Williams J Med Internet Res
2003, December, 19;5(4):e33 <http://www.jmir.org/2003/4/e33/>

**[From Mary Helen Deer, National Indian Women\'s Health Resource
Center]{.underline}**

###### Funding available: COLORECTAL CANCER SCREENING IN PRIMARY CARE PRACTICE

Agency for Healthcare Research and Quality, National Cancer Institute

INDEX: HEALTHCARE RESEARCH, QUALITY; CANCER

###### [http://grants.nih.gov/grants/guide/pa-files/PAR-04-036.html]{.underline}

##### From Terry Friend, Pine Ridge

###### BTLs in non-Native women with Native partners

To what extent are IHS and tribal facilities Indian Health, Tribal, or
urban (ITU) providing sterilization procedures in non-Native women with
Native Partners?

Each Service Unit can use discretion in the above situations based on
local availability and contract care funds.

Practices that are not uncommon in the ITU system include:

-Provision of sterilization procedures (BTL and vasectomy) up till 6
weeks after delivery

-Provision of sterilization procedures at times of other abdominal
surgery, e.g., BTL at cesarean delivery

-Provision of the above services whether in ITU, or referral facility

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

The above practices reflect the fact that non-Native partners of Native
patients have a significant impact on Native American families, both
current and future. Some Service Units have taken a very short term cost
/ benefit approach and have even not allowed BTLs at the time of repeat
cesarean delivery, thereby requiring a non-Native partner to obtain a
second general anesthesia and abdominal procedure.

Other Service Units and tribes have correctly recognized that provision
of sterilization procedures positively impacts the current Native
America family, as well as decreases future direct and contract health
expenditures. This approach places value on the decision of Native
Americans and their families who have clearly stated their wishes for
permanent sterilization. This approach also saves the ITU funds by
decreasing the number of future pregnancies in families who have
thoughtfully made that decision.

All the same federal documentation rules apply in these situations. Here
are several answers to other frequently asked questions about
sterilization procedures in the ITU system.

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHfaq.asp#B>

##### From Jim Galloway, Phoenix, and Terry Cullen, Tucson

##### Coronary Heart Disease in Women with Diabetes

\"Diabetes and Cardiovascular Disease Review\" has very clinically
relevant articles to providers in Indian Health. This issue is focused
on Coronary Heart Disease in Women with Diabetes. The Diabetes &
Cardiovascular Disease Review is an American Diabetes
Association/American College of Cardiology newsletter featuring
information on treatment guidelines, research advances, and patient
education tools. Go to
<http://www.diabetes.org/info/link_healthprof.jsp> and scroll down to
Issue #5

##### 

##### From Lindley Gifford, Ketchikan 

**When is best to screen for Chlamydia in asymptomatic women?**

The U.S. Preventive Services Task Force (USPSTF) strongly recommends
that clinicians routinely screen all sexually active women aged 25 years
and younger, and other asymptomatic women at increased risk for
infection, for chlamydial infection (see Clinical Considerations for
discussion of risk factors).

That is a **Level A recommendation**.

[Rationale:]{.underline} The USPSTF found good evidence that screening
women at risk for chlamydial infection reduces the incidence of pelvic
inflammatory disease and fair evidence that community-based screening
reduces prevalence of chlamydial infection. The USPSTF concludes that
the benefits of screening substantially outweigh the potential harms
(select Potential Adverse Effects of Screening for discussion of
potential harms).

\* The USPSTF makes no recommendation for or against routinely screening
asymptomatic low-risk women in the general population for chlamydial
infection. **Level C recommendation.**

[Rationale:]{.underline} The USPSTF found at least fair evidence that
screening low-risk women could detect some additional cases of Chlamydia
trachomatis, but concludes that the potential benefits of screening
low-risk women may be small and may not justify the possible harms.

\* The USPSTF recommends that clinicians routinely screen all
asymptomatic pregnant women aged 25 years and younger and others at
increased risk for infection for chlamydial infection (see Clinical
Considerations for discussion of risk factors in pregnancy). **Level B
recommendation.**

[Rationale:]{.underline} The USPSTF found at least fair evidence that
screening and treatment of women at risk for chlamydial infection
improves pregnancy outcomes and concludes that the benefits of screening
outweigh potential harms.

\* The USPSTF makes no recommendation for or against routine screening
of asymptomatic, low-risk pregnant women aged 26 years and older for
chlamydial infection. **Level C recommendation.**

[Rationale:]{.underline} The USPSTF found fair evidence that the
benefits of screening low-risk pregnant women are small and may not
justify the possible harms.

\* The USPSTF concludes that the evidence is insufficient to recommend
for or against routinely screening asymptomatic men for chlamydial
infection. **Level I recommendation.**

[Rationale:]{.underline} No direct evidence was found to determine
whether screening asymptomatic men for chlamydial infection is effective
for reducing the incidence of new infections in women. The benefits and
harms of screening men cannot be determined, but the potential magnitude
of benefits could be large if the effectiveness of screening men can be
demonstrated.

Here is the URL for the above
<http://www.ahrq.gov/clinic/uspstf/uspschlm.htm>

Many other Chlamydia and related STD postings are available on the
Indian Health MCH web site:
<http://www.ihs.gov/MedicalPrograms/MCH/M/PROG01.cfm#SexuallyTransmittedDisease>

Here is the answer to a similar frequently asked question

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHfaq.asp#ScrnAll>

# [From Joan Koval, Anchorage]{.underline}

###### Does Folate intake affect cervical dysplasia? 

[Answer from Alan Waxman, MD]{.underline} (From the Primary Care
Discussion Forum)

The studies on micronutrients are not very conclusive. Folic acid has
been looked at as have antioxidants and tocopherols with contradictory
results. Folic acid is good for other things though, especially in
reproductive age women

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

Can a folate a day keep the colposcopist away?

I performed the following literature search to fill in the details.
Please note below that this has been studied in an AI/AN population njm

[Other references]{.underline}

Most of the studies below were case control studies.

The only randomized controlled trial was published in Italian. 'Assuming
you are not current on your Italian, here is the English version:

"The localized folate deficiency, which is sometimes misdiagnosed as
cervical dysplasia, because of morphological similarities between the
cytologic features of megaloblastosis seen with folate deficiency and
the changes associated with dysplasia, could be a component of the
dysplastic process. In this study we attempted the effect of oral folic
in women with cervical dysplasia. A total of 154 subjects with grade 1
or 2 CIN were randomly assigned either 10 mg of folic acid or a placebo
daily for 6 months. Clinical status, human papillomavirus type 16
infection and blood folate levels were monitored at 2 month intervals.
After 6-months no significant differences were observed between
supplemented and unsupplemented subjects regarding dysplasia status,
biopsy results, or prevalence of human papillomavirus type 16 infection.
Folate deficiency the initiation of cervical dysplasia, but folic acid
supplements do not alter the course of established disease"

Zarcone R, Bellini P, Carfora E, Vicinanza G, Raucci F. Folic acid and
cervix dysplasia Minerva Ginecol. 1996 Oct;48(10):397-400.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9005361&dopt=Abstract>

# Pro

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12846362&dopt=Abstract>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8191820&dopt=Abstract>

# Pro Case control

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12420947&dopt=Abstract>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12890803&dopt=Abstract>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12163690&dopt=Abstract>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11751445&dopt=Abstract>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11456227&dopt=Abstract>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11142083&dopt=Abstract>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10928104&dopt=Abstract>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9443028&dopt=Abstract>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1729576&dopt=Abstract>

# Suggestive, but not significant

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11435527&dopt=Abstract>

###### Con: Randomized controlled trial

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9005361&dopt=Abstract>

###### Con: Native American -- Case Control

Yeo AS, Schiff MA, Montoya G, Masuk M, van Asselt-King L, Becker TM.
Serum micronutrients and cervical dysplasia in Southwestern American
Indian women. Nutr Cancer. 2000;38(2):141-50

# [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11525590&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11525590&dopt=Abstract)

# Con

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12781848&dopt=Abstract>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11927495&dopt=Abstract>

###### Con Case control

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=13678724&dopt=Abstract>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10918169&dopt=Abstract>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9589431&dopt=Abstract>

# Reviews

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12791426&dopt=Abstract>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1332564&dopt=Abstract>

# [From Bill Lubke, Ken Moore, Anchorage]{.underline}

######### Clinical Guidelines for Common Genitourinary Disorders

The Urology Department at Alaska Native Medical Center has compiled a
set of guidelines for common urologic problems. Drs. Lubke and Moore,
and their colleagues, offer this useful set of consensus based practice
guidelines to all providers and staff.

<http://www.ihs.gov/NonMedicalPrograms/nc4/documents/UrologyGuidelines1504.doc>

Dr. Moore can be contacted for questions at <kpmoore@anmc.org> or 907
729 2700

**[From Chuck North, Albuquerque]{.underline}**

######### Evidence Based Practice Resources

Centre for Evidence Based Medicine, University of Toronto

[\<http://www.cebm.utoronto.ca\>]{.underline}

American College of Physicians Evidence-Based Medicine

<http://www.acponline.org/catalog/journals/ebm.htm>

American College of Physicians Journal Club

<http://www.acpjc.org/shared/purpose_and_procedure.htm>

Journal of Family Practice POEMS

<http://www.jfponline.com/display_archives.asp?YEAR=POEMs>

Patient Oriented Evidence that Matters (POEMS)

[http://www.infopoems.com/]{.underline}

Journal of Family Practice Evidence base practice monthly newsletter

<http://www.jfponline.com/service/subscriptions_ebr.asp>

**[From Suzanne Schwendenman, Pine Ridge]{.underline}**

###### Tobacco cessation in pregnancy: Pharmacological methods?

I have patient who is in the early 2^nd^ trimester and wants to use
nicotine patches during pregnancy for smoking cessation. My literature
review Currently Category D in pregnancy. Limited studies. I don\'t feel
comfortable prescribing it and feel it would be bad practice. Do you
have any new info to add?

**Answer:**

The basic issue is that pharmacological intervention should be the third
choice after exhausting all behavioral approaches. See the **UpToDate**
summary below.

Actually Bupropion works well and is not a known teratogen. It might be
a better choice of drugs, though teratogenicity is less an issue now
that she is early in the second trimester. njm

###### UpToDate

Smoking and pregnancy

<http://www.uptodateonline.com/application/topic.asp?file=maternal/6664&type=A&selectedTitle=4~6>

"....pharmacotherapy has not been recommended for all women during
pregnancy but is primarily targeted for women who are unlikely to quit.
The strength of the evidence was rated as C, indicating that it is an
important clinical scenario in which the expert panel achieved consensus
despite absence of randomized controlled trials. Given the known
benefits of smoking cessation during pregnancy, it appears reasonable to
offer pharmacotherapy to pregnant women who are at at high risk for
continued smoking: heavy smokers (\>10 cigarettes per day); those
smoking later in pregnancy; and those who have attempted to stop
previously.

General principles of prescribing drugs during pregnancy should be
followed. These include using the lowest dose necessary to achieve
success in order to minimize fetal exposure and, if possible, delaying
therapy until the second trimester in order to avoid the period of
embryogenesis when the fetus is most sensitive to teratogens.

The five A\'s (ask, advise, assess, assist, and arrange) have been
adopted by different agencies such as the National Cancer Institute and
the Agency for Health Care Policy and Research. Strategies are derived
from the Clinical Practice Guidelines published by the United States
Department of Health and Human Services, and have subsequently been
modified by various authors for use during pregnancy. The specific
action steps outlined have been gathered from various investigators and
guideline panels....."

**[From Ros Singleton, Anchorage]{.underline}**

###### Pregnant women in their second or third trimester should get flu vaccine

....and all children aged 6-23 months of age and those ≥2 years with
underlying chronic medical conditions...

Here is the list of high-risk patients that should get flu vaccine,
regardless of supplies on hand:

Administer remaining inactivated influenza vaccine ***only*** to persons
at highest risk for the complications of influenza. ***High risk
persons*** are:

-All children aged 6-23 months of age;

-Adults \> 65 years of age;

-Those [\>]{.underline}2 years with underlying chronic medical
conditions;

-Pregnant women in their second or third trimester.

For other details and clinical pearls see:

Update: Influenza Activity \-\-- United States, 2003\--04 Season

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5249a1.htm>

**[From Judy Thierry, HQE]{.underline}**

**Breast and cervical changes that are non-cancerous, and abnormal Pap
or mammogram**

The National Cancer Institute (NCI) has developed new materials to
educate women about breast and cervical changes that are non-cancerous,
and abnormal Pap or mammogram results.  They are looking for a limited
number of women who have had an abnormal mammogram or Pap test within
the last 2 years that was [not]{.underline} cancer to read the materials
and participate in a 1-hour telephone interview in English. 
Participants will be paid for their time.  Call 1-888-249-0029

**[From Judy Thierry, HQE, and George Gilson, Anchorage]{.underline}**

###### Should we start using progesterone to treat preterm labor now?

(Dr. Thierry sent the question above from the LBWCC Disparities
Subcommittee. Here are 2 brief responses by Dr. George Gilson)

**[Answer]{.underline}**

As ACOG says in the material below, there is nowhere near enough data to
start recommending progesterone yet (plus there is no commercial source
of the 17-OH-caproate (Delalutin) used in the study\.... and the
progesterone suppositories have to be made and administered daily\...and
you\'re supposed to start by 14 wks\....it just isn\'t ready for prime
time yet.

Use of progesterone to reduce preterm birth. ACOG Committee Opinion No.
291. American College of Obstetricians and Gynecologists. Obstet Gynecol
2003;102:1115-6.

ACOG members

[http://www.acog.com/publications/committee_opinions/co291.cfm]{.underline}

Non-ACOG members

<https://www.acog.com/from_home/publications/press_releases/nr10-31-03-2.cfm>

There is a good review of this topic in this article:

Progesterone for the Prevention of Preterm Delivery?

Barbara V. Parilla, MD; Scott N. MacGregor, DO

The authors present the evidence from two recent placebo-controlled
trials reporting lower rates of premature birth in high-risk patients
treated with progesterone.

<http://www.femalepatient.com/html/hom/obg/obg.asp>

The review above is in the following journal, which presents its table
of contents online, but not the actual article.

The Female Patient

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

###### Should we change our practice in regard to bacterial vaginosis to decrease preterm labor based on the 2 latest meta-analyses\*?

(Dr. Thierry sent the question above from the LBWCC Disparities
Subcommittee. Here is a brief response by Dr. George Gilson)

**[Answer]{.underline}**

The Bacterial Vaginosis / Preterm Labor association just won\'t die. The
meta-analyses below still doesn\'t trump a big collaborative RCT like
that done by the NICHD/MFM Network (Goldenberg, Iams, Mercer, et al)
that showed no benefit to tx of BV except in the subset of African
American women that had had more than 2 preterm births and had culture
proven BV (more than just wet preps).

Goldenberg RL et al The Preterm Prediction Study: sequential cervical
length and fetal fibronectin testing for the prediction of spontaneous
preterm birth. National Institute of Child Health and Human Development
Maternal-Fetal Medicine Units Network. Am J Obstet Gynecol. 2000
Mar;182(3):636-43.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10739521&dopt=Abstract>

Here\'s another pretty good RCT from the NICHD/MFMN with negative
(worse) results after use of metronidazole and erythromycin in fFN(+)
women at high risk for PTB:

Andrews et al. Randomized clinical trial of metronidazole plus
erythromycin to prevent spontaneous preterm delivery in fetal
fibronectin-positive women. Obstet Gynecol 2003; 101:847-55.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12738139&dopt=Abstract>

There are also several papers that show worse outcomes (\>PTB) when
metronidazole has used for this purpose. At the Society of Maternal
Fetal Medicine last Feb that was the take home conclusion of the many
papers presented on this topic. The Society of Maternal Fetal Medicine
this February 2004, so we should wait to hear what information that
meeting produces.

All the Cochrane library has a report on anything related to the use of
metronidazole in pregnancy is the following, which as you can see is not
about BV or PTL. This is because there aren\'t enough randomized
controlled trials to evaluate on this topic yet.

Gülmezoglu AM Interventions for trichomoniasis in pregnancy (Cochrane
Review). In: The Cochrane Library, Issue 4, 2003. Chichester, UK: John
Wiley & Sons, Ltd.

Reviewers\' conclusions

Metronidazole, given as a single dose, is likely to provide
parasitological cure for trichomoniasis, but it is not known whether
this treatment will have any effect on pregnancy outcomes. The cure rate
could probably be higher if more partners used the treatment.

\*The 2 meta-analyses that started this question

Leitich H, Bodner-Adler B, Brunbauer M, Kaider A, Egarter C, Husslein
P.Bacterial vaginosis as a risk factor for preterm delivery: a
meta-analysis. Am J Obstet Gynecol. 2003 Jul;189(1):139-47.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12861153&dopt=Abstract>

CONCLUSION: Bacterial vaginosis, early in pregnancy, is a strong risk
factor for preterm delivery and spontaneous abortion.

Leitich H, Brunbauer M, Bodner-Adler B, Kaider A, Egarter C, Husslein P.
Antibiotic treatment of bacterial vaginosis in pregnancy: a
meta-analysis. Am J Obstet Gynecol. 2003 Mar;188(3):752-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12634652&dopt=Abstract>

CONCLUSION: The screening of pregnant women who have bacterial vaginosis
and who have had a previous preterm delivery and treatment with an oral
regimen of longer duration can be justified on the basis of current
evidence. More studies are needed to confirm the effectiveness of this
strategy, both in high-risk patients without preterm labor and in
patients with preterm labor.

##### From Alan Waxman, Albuquerque

###### Summary of New Cervical Cancer Screening Guidelines and New Technology 

###### Primary Care Discussion Forum

This summary below applies to the December / January forum

**[Summary:]{.underline}**

The review of the new Pap screening guidelines have generated a fair
amount of lively discussion, and some passionate digressions onto
emergency contraception and chart transportation logistics.

There appears to be some discomfort among the respondents over delaying
the start of screening to age 21 or 3 years after the onset of vaginal
intercourse. The concern is of missing high grade lesions and cancer in
young women. The guidelines were based on the usual slow transition from
HPV infection to cancer and on the extreme rarity of squamous cell
cervical cancer in women under 21.

The other issue raised in the discussions was the role a woman's risk
status, i.e. multiple partners, risks for STDs, should play in
screening. These are risk factors for the acquisition of HPV. While the
data support that these factors put a woman at risk for cervical
disease, the screening guidelines are based on the premise that all
sexually active women are at some risk.

After the decision is made to start screening, the major risk factors
that dictate frequency of screening are those related to the risk of
developing cancer once HPV is present, i.e. immunocompromise, an
extensive transformation zone (DES exposure) or a prior history of high
grade cervical dysplasia or cancer. Old habits are hard to change.

In 1988, the recommendation was to space Paps after 3 annual negatives.
Women, for the most part, still had annual Paps. Only time will tell
whether these new, evidence-based guidelines will translate into a
change in the screening behavior of women...and their providers.

The forum Discussion is available here:

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

(the Discussion link will be updated when the discussion is completed)

**[Hot Topics:]{.underline}**

Some of the following postings are from Medscape, which is free to all,
but registration is required. Medscape can be accessed from anywhere
with Internet access. You just need to create a personal username and
password.

**[Obstetrics]{.underline}**

**Persistent Fetal Occiput Posterior Position**

Persistent occiput posterior position is associated with a higher rate
of most complications of labor and delivery. Only one in four
nulliparous women and just over one half of multiparous women with this
presentation achieve a spontaneous vaginal delivery

<http://www.aafp.org/afp/20040101/tips/23.html>

###### Maternal Behaviors and Experiences Before, During, and After Pregnancy

The new indicators are multivitamin use, infant checkups within 1 week
of hospital discharge among those discharged within 48 hours, and
postpartum contraceptive use. The data presented in this report can be
used to assist in program planning and evaluation, to inform policy
decisions, and to monitor progress toward *Healthy People 2010*
objectives.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5211a1.htm>

**Prenatal HIV Testing and Antiretroviral Prophylaxis at an Urban
Hospital, 1997\--2000**\
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5251a1.htm>

**Does Assisted Reproduction Cause Spontaneous Abortion?**

<http://www.aafp.org/afp/20040101/tips/22.html>

###### 2003 Obstetrics Year in Review, Medscape

Neonatal Encephalopathy Cerebral Palsy, prematurity, Elective Cesarean,
PP Hemorrhage, etc...

<http://www.medscape.com/viewarticle/466115_4>

Postpartum Depression Treatments and the Impact of Antidepressant Drugs
on Nursing

Postpartum depression, observed in approximately 13% of women who have
recently given birth, is the most prevalent serious complication of
pregnancy.

Dwenda Gjerdingen, MD, MS J Am Board Fam Pract 16(5):372-382, 2003

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14645327&dopt=Abstract>

###### Spinal Anesthesia in Obstetrics \-- New Concepts and Developments

Review considers the current state-of-the-art of spinal anesthesia, its
use in obstetric pain relief

<http://www.medscape.com/viewarticle/464413?mpid=21795>

###### Cesarean Delivery Linked to Subsequent Stillbirths

Delivery by caesarean section in the first pregnancy could increase the
risk of unexplained stillbirth in the second. In women with one previous
caesarean delivery, the risk of unexplained antepartum stillbirth at or
after 39 weeks\' gestation is about double the risk of stillbirth or
neonatal death from intrapartum uterine rupture

Smith GC, Pell JP, Dobbie R Caesarean section and risk of unexplained
stillbirth in subsequent pregnancy.*Lancet.* 2003;362:1779-1784

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14654315&dopt=Abstract>

or <http://www.medscape.com/viewarticle/465086?mpid=21795>

**[Gynecology]{.underline}**

###### Diaphragm Fitting

<http://www.aafp.org/afp/20040101/97.html>

######### 2003 GYN Year in Review, Medscape 

Cervical cancer screening, HRT and alternative therapies, BCM, surgical
innovations, etc...

<http://www.medscape.com/viewarticle/466115_3>

###### Pharmacologic Treatment of Polycystic Ovary Syndrome

Treatment of Associated Metabolic Abnormalities, Insulin Resistance and
Glucose Intolerance, Oligo / Amenorrhea and Infertility, Hirsutism and
Acne.

David A. Ehrmann, M.D.; Daniel Rychlik, M.D. Semin Reprod Med
21(3):277-283, 2003.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14593550&dopt=Abstract>

or <http://www.medscape.com/viewarticle/466019_4>

###### Chaperone Use During Pap Smears

<http://www.medscape.com/viewarticle/464821?mpid=21795>

**[Child Health]{.underline}**

###### Influenza-Associated Deaths Reported Among Children Aged \<18 Years - 2003\--04 

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5253a4.htm>

###### 2004 CATCH Implementation Funds available

This program is for providers who will work with local communities to
ensure that all children have Medical Homes and access to any needed
health care services. The 2004 CATCH Implementation Funds cycle started
in November 2003, with an application deadline of January 30, 2004. For
additional information and technical assistance, visit
[www.aap.org/catch/implementgrants.htm](http://www.aap.org/catch/implementgrants.htm)
or contact the CATCH program by email at catch@aap.org or by phone at
800/433-9016, ext 7085.

**[Chronic disease and Illness]{.underline}**

**Obesity: The USPSTF recommends.....**

.....that clinicians screen all adult patients for obesity and offer
intensive counseling and behavioral interventions to promote sustained
weight loss for obese adults.

**Rating: [B
Recommendation](../../../../../../../../clinic/3rduspstf/ratings.htm#brec).**

The USPSTF concludes that the evidence is insufficient to recommend for
or against the use of moderate- or low-intensity counseling together
with behavioral interventions to promote sustained weight loss in obese
adults.

**Rating: [I
Recommendation](../../../../../../../../clinic/3rduspstf/ratings.htm#irec).**

The USPSTF concludes that the evidence is insufficient to recommend for
or against the use of counseling of any intensity and behavioral
interventions to promote sustained weight loss in overweight adults.

**Rating: [I
Recommendation](../../../../../../../../clinic/3rduspstf/ratings.htm#irec).**

###### [**http://www.ahrq.gov/clinic/uspstf/uspsobes.htm**](http://www.ahrq.gov/clinic/uspstf/uspsobes.htm)

###### Use of Botanicals by Women: Toward Optimal Health

Botanicals are increasingly popular and are used more widely by women
than men, particularly women in their middle and advancing ages.\
Jodi Godfrey Meisler, M.S., R.D. J Womens Health 12(9) 2003\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14670163&dopt=Abstract>

Or
[**http://www.medscape.com/viewarticle/465300?mpid=22357**](http://www.medscape.com/viewarticle/465300?mpid=22357)

Lipid Changes on Hormone Therapy and Coronary Heart Disease Events in
the Heart and Estrogen/Progestin Replacement Study (HERS)

Changes in lipid levels with hormone therapy are not predictive of CHD
outcomes in women with heart disease in the HERS trial

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14597937&dopt=Abstract>

**or** <http://www.medscape.com/viewarticle/464567?mpid=22919>

**Dietary Fiber Decreases Risk for Colorectal Cancer**

###### [**http://www.aafp.org/afp/20040101/tips/21.html**](http://www.aafp.org/afp/20040101/tips/21.html)

###### 

###### Diagnosis of Systemic Lupus Erythematosus

<http://www.aafp.org/afp/20031201/2179.html>

###### Hepatitis B

<http://www.aafp.org/afp/20040101/75.html>

###### Bovine Spongiform Encephalopathy in a Dairy Cow \-\-- Washington State, 2003

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5253a2.htm>

###### What are some of the surgical options for the morbidly obese?

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

##### 

##### 

##### 

##### Features

## American Family Physician

###### 

Cochrane for Clinicians

Does Metformin Improve Clinical Features of Polycystic Ovary Syndrome?

[Reviewers\' Conclusions.]{.underline} Metformin is an effective
treatment for anovulation in women with polycystic ovary syndrome. Its
choice as a first-line agent seems justified, and there is some evidence
of benefit on parameters of the metabolic syndrome. Ovulation rates are
higher when combined with clomiphene (76 percent versus 46 percent when
used alone), but there is no evidence to indicate whether there is an
increased multiple pregnancy rate with this combination. There are no
data regarding its safety in long-term use in young women. It should be
used as an adjuvant to general lifestyle improvements, not as a
replacement for increased exercise and improved diet.
<http://www.aafp.org/afp/20031201/cochrane.html>

###### Evidence Based Practice

###### Thromboembolism

<http://www.aafp.org/afp/20040101/british.html>

###### 

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

**Aspirin Prevents Preeclampsia and Complications** (Level of Evidence:
1a)

[Bottom Line]{.underline}: The literature published to date consistently
shows that low-dose aspirin has a protective effect in women with risk
factors for preeclampsia. It does not increase the risk of bleeding
complications, including placental abruption. The methodology used did
not permit determination of absolute risk reduction and NNT. (Level of
Evidence: 1a)

<http://www.aafp.org/afp/20031201/tips/11.html>

**Spinal Manipulation for Low Back Pain** (Level of Evidence: 1a)

[Bottom Line:]{.underline} Spinal manipulation, whether chiropractic or
osteopathic, is no more or less effective than usual care (with
analgesics), physical therapy, exercises, or back school for acute and
chronic low back pain. Spinal manipulation is more effective than sham
(placebo) manipulation. There is not enough good research to support or
refute the effectiveness of acupuncture. (Level of Evidence: 1a)

**Glucosamine and Chondroitin for Osteoarthritis** (Level of Evidence:
1a)

[Bottom Line:]{.underline} Glucosamine and chondroitin produce a similar
significant effect on symptoms of osteoarthritis, improve joint mobility
for one in five patients, and also may slow joint-space narrowing. Onset
of action is several weeks. (Level of Evidence: 1a)

**\*POEM Rating system**: <http://www.infopoems.com/levels.html>

**\*POEM Definition:** <http://www.aafp.org/x19976.xml>

###### Hypertension in Pregnancy Signals Hypertension Later

<http://www.aafp.org/afp/20031201/tips/13.html>

###### Omega-3 Fatty Acid and Heart Disease in Diabetic Women 

<http://www.aafp.org/afp/20031201/tips/12.html>

###### Anticholinergic Therapy for Overactive Bladder Symptoms

<http://www.aafp.org/afp/20031201/tips/10.html>

##### ACOG

ACOG Endorses JCAHO\'s Universal Protocol for Preventing Wrong Site,
Wrong Procedure, Wrong Person Surgery

Patient safety is a critical component of ACOG\'s efforts to reform our
nation\'s health care system. ACOG recognizes that all health care
providers must make patient safety a top priority.

<http://www.acog.com/from_home/publications/press_releases/nr12-02-03.cfm>

##### AHRQ

**A higher rate of cesarean delivery does not necessarily correspond
with better perinatal** outcomes
<http://www.ahrq.gov/research/oct03/1003RA10.htm#head2>

**Use of tocolytic therapy to stop uterine contractions can prolong
pregnancy and prevent** preterm birth
<http://www.ahrq.gov/research/oct03/1003RA11.htm#head3>

**Personalized form letters may improve breast and cervical cancer
screening among low-**income and minority women
<http://www.ahrq.gov/research/oct03/1003RA14.htm#head6>

**Age, fertility status, and other factors influence satisfaction with
progestin treatment for** abnormal uterine bleeding
<http://www.ahrq.gov/research/oct03/1003RA9.htm#head1>

**Benefits of adding radiation therapy to tamoxifen after breast
conserving surgery diminish** with increasing age
<http://www.ahrq.gov/research/oct03/1003RA13.htm#head5>

##### Breastfeeding

###### Returning to Work While Breastfeeding [**http://www.aafp.org/afp/20031201/2199.html**](http://www.aafp.org/afp/20031201/2199.html)

**Breastfeeding and Returning to Work in the Physician\'s Office**

<http://www.aafp.org/afp/20031201/editorials.html>

**Research shows that a doctor\'s advice to breastfeed, early return to
work, and other** factors influence continued breastfeeding
<http://www.ahrq.gov/research/oct03/1003RA12.htm#head4>

###### Revised American Cancer Society Guidelines for Breast Cancer Screening, 5/2003

<http://www.medscape.com/viewarticle/455679>

**[Elder Care News]{.underline}**

###### Primary Care Discussion Forum Topic: Elder care

###### February 1, 2004

Discussion facilitator: Bruce Finke, IHS Elder Care Initiative

Topic: Evidence based periodic health screening for the
elderly....."What is really necessary in the "Annual Exam" for mature
adults"

This will also include a discussion of rpms based solutions to better
documentation

Issues to be addressed:

\- Do the guidelines make sense as a framework for providing high
quality care for our older

patients?

\- Can we do this in our hospitals and clinics?

\- Is an annual preventive care visit the way to ensure access to
preventive services for our older

patients?

##### 

##### Frequently asked questions

###### Should you give prophylaxis for GBS when performing a scheduled cesarean delivery?

No, it is not necessary to give GBS prophylaxis when performing a
cesarean delivery in the absence of rupture of membranes or labor.

Here are many other frequently asked questions about the 2002 CDC GBS
prophylaxis guidelines that pop up when you least suspect
<http://www.ihs.gov/MedicalPrograms/MCH/M/DP46.asp#top>

**[Hormone Replacement Update]{.underline}**

###### HRT improves sleep

Many postmenopausal women who maintain a hormone replacement requirement
will indicate improved sleep as one of the primary benefits.

Hormone replacement therapy and sleep-disordered breathing.

Shahar E et al Am J Respir Crit Care Med. 2003 May 1;167(9):1186-92

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12531779&dopt=Abstract>

or

here is a prospective, randomized, placebo-controlled, double-blind,
crossover study

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12850609&dopt=Abstract>

######### Thoughts on individualizing hormone replacement therapy

######### The question is, What measures can be used to individualize HRT?

Gavaler JS. Thoughts on individualizing hormone replacement therapy
based on the postmenopausal health disparities study data. Womens Health
(Larchmt). 2003 Oct;12(8):757-68.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14588126&dopt=Abstract>

or <http://www.medscape.com/viewarticle/463053?mpid=22357>

# [Information Technology]{.underline}

###### Affordable electronic health record systems

The American Academy of Family Physicians (AAFP) may help implement
affordable electronic health record systems in your practices. The AAFP
announced strategic business relationships with 9 leading information
technology companies \-- relationships that may help purchase hardware
and software for an EHR system at discounts of from 15 percent to 50
percent, depending on the product. Visit
<http://www.aafp.org/centerforhit.xml>

# [International Health Update]{.underline}

**Low Rate of Mother-to-Child Transmission of HIV-1 After Nevirapine
Intervention**

in a Pilot Public Health Program in Yaoundé, Cameroon

According to the WHO/UNAIDS, by the end of 2002, 3.2 million children
younger than 15 years of age had HIV infection/AIDS worldwide, of whom
2.8 million resided in sub-Saharan Africa.

Ahidjo Ayouba PhD et al J Acquir Immune Defic Syndr 34(3):274-280, 2003

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14600571&dopt=Abstract>

or <http://www.medscape.com/viewarticle/464274?mpid=22643>

#### [MCH Alert]{.underline}

###### HEALTH CARE QUALITY AND DISPARITIES IN ACCESS TO SERVICES

The National Healthcare Quality Report and the National Healthcare
Disparities Report provide baseline assessments of the quality of the
nation\'s health care and of differences in access to health care
services. The reports, prepared by the Agency for Healthcare Research
and Quality, represent the first comprehensive effort to measure the
quality of health care in America and differences in access to health
care services for priority populations.
[http://www.qualitytools.ahrq.gov](http://www.qualitytools.ahrq.gov/)

#### [Medscape\*]{.underline}

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

######### [**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 Discussion Board Index

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

**Clinical Discussion Board Index**

Hundreds of ongoing clinical discussions available

<http://boards.medscape.com/forums?14@@.eeab9d1>

**Free CME: 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.

**[Office of Women's Health, CDC]{.underline}**

Interested in Federal funding? You may be interested in this web site.

A single, comprehensive Web site that will contain information about
finding and applying for all federal grant programs. For more
information:

News Release - <http://www.hhs.gov/news/press/2003pres/20031209.html>

Grants Web site - [http://www.grants.gov](http://www.grants.gov/)

###### 

###### Funding: Centers for Disease Control and Prevention 2004 Program Announcements 

Can be accessed at
[\<http://www.cdc.gov/od/pgo/funding/grantmain.htm\>]{.underline}. The
letter of intent and/or application deadlines are soon. Eligibility
criteria vary. 

###### HIV Prevention Services for Racial/Ethnic Minority Populations

[\<http://www.cdc.gov/od/pgo/funding/04019.htm\>]{.underline}

###### HIV Prevention Projects For Community-Based Organizations 

[\<http://www.cdc.gov/od/pgo/funding/04064.htm\>]{.underline}

###### Practices to Improve Training Skills of Home Visitors

[\<http://www.cdc.gov/od/pgo/funding/04053.htm\>]{.underline}

###### Youth Violence Prevention Through Community-Level Change

<http://www.cdc.gov/od/pgo/funding/04054.htm>

###### Sociocultural and Community Risk Factors for Child Maltreatment and Youth Violence 

[\<http://www.cdc.gov/od/pgo/funding/04056.htm\>]{.underline}

**Exposure To Media Violence And Youth Violence**
[\<http://www.cdc.gov/od/pgo/funding/04060.htm\>]{.underline}

**[Osteoporosis]{.underline}**

**New Guidelines from ACOG: Osteoporosis**

**[Summary of recommendations]{.underline}**

**Level A**

**The following are based on good and consistent scientific evidence**

-Treatment should be initiated to reduce fracture risk in postmenopausal
women who have

experienced fragility or low impact fracture

-Treatment should be instituted in those postmenopausal women with bone
mineral density T

scores less than --2 by central DXA in the absence of risk factors and
in women with T scores

less then --1.5 in the presence of one or more risk factor

-First line pharmacologic options determined by the FDA to be safe and
effective for osteoporosis

prevention (biphosphonates \[alendronate and risedronate\], raloxifene
and estrogen) should be

used

-First line pharmacologic options determined by the FDA to be safe and
effective for osteoporosis

treatment (biphosphonates \[alendronate and risedronate\], raloxifene,
calcitonin, and PTH) should

be used

###### Level B

**The following are based on limited or inconsistent scientific
evidence**

-Women should be counseled about the following preventive measures

-Adequate calcium consumption, using dietary supplements if dietary
sources are

> inadequate

-Adequate Vitamin D consumption (400 -- 800 IU daily) and the natural
sources of this

nutrient

-Regular weight bearing and muscle strengthening exercises to reduce
falls, and prevent

> fractures

-Smoking cessation

-Moderate alcohol intake

-Fall prevention strategies

-Bone mineral density testing should be recommended for all
postmenopausal women aged 65

years or older

-Bone mineral density testing may be recommended for postmenopausal
women less than 65

years who have one or more risk factor for osteoporosis

-Bone mineral density testing should be performed on all postmenopausal
women with fractures

to confirm the diagnosis of osteoporosis and determine disease severity

-In the absence of new risk factors screening should not be performed
more frequently than every

2 years

**Level C**

**The following recommendations are based primarily on consensus and
expert opinion**

Women should be counseled on the risks of osteoporosis and related
fragility fractures. Such counseling should be part of the annual
gynecologic examination

Osteoporosis**:** Clinical Management Guidelines for
Obstetrician--Gynecologists.

Number 50, January 2003 Obstet Gynecol. 2004 Jan;103(1):203-216.

###### Non-ACOG members

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=14704265&dopt=Abstract]{.underline}](http://www.greenjournal.org/cgi/reprint/103/1/203)

ACOG members

<http://www.greenjournal.org/cgi/reprint/103/1/203.pdf>

###### 

###### Evidence Based Practice: Screening for Osteoporosis in Postmenopausal Women

<http://www.aafp.org/afp/20040101/putting.html>

###### Vertebral Compression Fractures in the Elderly

<http://www.aafp.org/afp/20040101/111.html>

###### 

###### Osteoporosis and Health-Related Quality-of-Life Outcomes 

People with osteoporosis are at higher risk of developing problems with
physical frailty and difficulties with activities of daily living, and
may be at risk for reduced quality of life in terms of going out for
entertainment and enjoying free time. Care should be taken to maintain
the quality of life for people with osteoporosis by helping them to keep
as physically functional as possible.

<http://www.cdc.gov/pcd/issues/2004/jan/kotz.htm>

How important is calcium intake to bone health for postmenopausal women?

There is now a general consensus of agreement that calcium is effective
in reducing bone loss in late postmenopausal women, particularly in
those women with low habitual calcium intake (\< 400 mg/d).

[http://www.medscape.com/viewarticle/460438?WebLogicSession=QAYEq4Us5KJyUl1zsrqupH4ZZrXUbSmswSfv2c5ae3yjAdRs9Y0w\|-4928315507780620134/184161392/6/7001/7001/7002/7002/7001/-1](http://www.medscape.com/viewarticle/460438?WebLogicSession=QAYEq4Us5KJyUl1zsrqupH4ZZrXUbSmswSfv2c5ae3yjAdRs9Y0w|-4928315507780620134/184161392/6/7001/7001/7002/7002/7001/-1)

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

###### Hepatitis B

###### [**http://www.aafp.org/afp/20040101/86ph.html**](http://www.aafp.org/afp/20040101/86ph.html)

###### 

###### Birth Control Using a Diaphragm

###### [**http://www.aafp.org/afp/20040101/103ph.html**](http://www.aafp.org/afp/20040101/103ph.html)

###### 

**Using Your Diaphragm**

<http://www.aafp.org/afp/20040101/105ph.html>

###### Returning to Work While Breastfeeding

<http://www.aafp.org/afp/20031201/2215ph.html>

###### Painful Urination

<http://www.aafp.org/afp/20040101/149ph.html>

###### Urinary Tract Infections During Pregnancy

<http://www.aafp.org/afp/20040101/157ph.html>

**Urinary Tract Infections in Adults**

<http://www.aafp.org/afp/20040101/159ph.html>

###### Urinary Reflux

<http://www.aafp.org/afp/20040101/152ph.html>

###### Urinary Tract Infections in Children

<http://www.aafp.org/afp/20040101/155ph.html>

###### Osteoporosis: Many, many resources from MedScape

[http://www.medscape.com/viewarticle/465142?mpid=22079&WebLogicSession=QAYI5QK4197Vg8mhXjfBlkWSpNXBbsvSLWcc1Rq3naJ3bMT35n2O\|-4928315507780620134/184161392/6/7001/7001/7002/7002/7001/-1](http://www.medscape.com/viewarticle/465142?mpid=22079&WebLogicSession=QAYI5QK4197Vg8mhXjfBlkWSpNXBbsvSLWcc1Rq3naJ3bMT35n2O|-4928315507780620134/184161392/6/7001/7001/7002/7002/7001/-1)

##### Primary Care Discussion Forum

The Primary Care Discussion Forum is one way to learn about / discuss
best practice clinical care with national experts in an e-mail format.

Our first discussion was a success. It included a short primer on "New
cervical cancer screening guidelines and technologies" by Alan Waxman,
MD. Dr. Waxman then facilitated an e-mail based discussion. Upcoming
discussions include:

###### February 1, 2004

[Discussion facilitator:]{.underline} Bruce Finke, IHS Elder Care
Initiative

Topic: Evidence based periodic health screening for the
elderly....."What is really necessary in the "Annual Exam" for mature
adults"

This will also include a discussion of rpms based solutions to better
documentation

Issues to be addressed:

\- Do the guidelines make sense as a framework for providing high
quality care for our older

patients?

\- Can we do this in our hospitals and clinics?

\- Is an annual preventive care visit the way to ensure access to
preventive services for our older

patients?

###### May 1, 2004

[Discussion facilitator:]{.underline} Donna Perry, Adolescent Medicine,
Chinle

Topic: Adolescent risk taking behaviors.....a.k.a. "Sex drugs and rock
and roll"

This will include discussion of methamphetamine (up to 15% AI youth in
some IHS Areas have tried it), alcohol and marijuana, driving while
"high" or riding with someone who it, and not wearing seatbelts.

**[Please note:]{.underline}**

You can expect 20-30 total e-mail messages per topic, 4 times a year.
Each discussion will last approximately 4-6 weeks.

If that is too much e-mail for you, then don't subscribe, or just
subscribe for those topics of special interest to your practice and then
unsubscribe after that topic is closed out.

When finished, the full discussions and a summary will be posted on the
Primary Care Discussion Forum web page:

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

It is easy to subscribe. Go to this page and fill in your name, then hit
search, then follow the instructions:

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

It is also easy to unsubscribe: go to this page and fill in your name,
then follow the instructions:

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

Or contact Jason Crim at
[jason.crim@mail.ihs.gov](mailto:jason.crim@mail.his.gov) to join the
Primary Care listserv.

If you are interested in a Web Board based approach, instead of e-mail,
then contact me, or if you have other questions, <nmurphy@anmc.org>

##### Violence against women series, MEDLINE Abstracts

###### Violence Against Women - General Epidemiology

##### [**http://www.medscape.com/viewarticle/463945?mpid=21519**](http://www.medscape.com/viewarticle/463945?mpid=21519)

###### Improving Screening of Women for Violence - Basic Guidelines for Physicians 

<http://www.medscape.com/viewprogram/2777?mpid=21519>

**Violence Against Women \-- Factors in Perpetration**

<http://www.medscape.com/viewarticle/463955?mpid=21519>

###### Sexual Violence Against Girls

<http://www.medscape.com/viewarticle/463957?mpid=21519>

###### Consequences of Child Abuse

<http://www.medscape.com/viewarticle/463965?mpid=21519>

Substance Abuse in Women Who Have Been Exposed to Violence

<http://www.medscape.com/viewarticle/463958?mpid=21519>

###### Violence Against Women and Pregnancy

<http://www.medscape.com/viewarticle/463956?mpid=21519>

###### Violence Against Women - General Physical and Mental Consequences

<http://www.medscape.com/viewarticle/463959?mpid=21519>

###### Violence Against Women - Effects on the Brain

<http://www.medscape.com/viewarticle/463964?mpid=21519>

###### Violence Against Women \-- Screening Protocols

<http://www.medscape.com/viewarticle/463966?mpid=21519>

###### Violence Against Women \-- Professional Issues Related to Screening

<http://www.medscape.com/viewarticle/463967?mpid=21519>

###### Violence Against Women - Intervention

<http://www.medscape.com/viewarticle/463968?mpid=21519>

###### Violence Against Women - Around the World

<http://www.medscape.com/viewarticle/463969?mpid=21519>

##### What's new on the ITU MCH web pages?

**101 ways to ask someone if they are safe**

<http://www.ihs.gov/MedicalPrograms/MCH/W/Dv03.cfm#101ways>

###### Breast Cancer Risk Assessment Tool, NCI

Enables a health care provider to print a woman's risk calculation
directly from the Internet

<http://www.ihs.gov/MedicalPrograms/MCH/W/Whcancer.asp#BreastCancerRiskAssessmentTool>

**Native Research Network Listserv (NRN) email listserv**

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdiscuss.asp#NativeResearchNetwork>

###### Colorectal Cancer second leading cause of cancer-related death in US

<http://www.ihs.gov/MedicalPrograms/MCH/W/Whcancer.asp#ColorectalCancersecond>

There are several upcoming **Conferences**

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

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

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

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

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

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

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

### **[Save the dates]{.underline}**

**19^th^ Annual Midwinter Conference for providers caring for Native
women and children**

Jan 30 -- Feb 1, 2004.

2004 brochure now available

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#January2004>

**Basic IHS Colposcopy Course April 26-29, 2004**

Albuquerque, New Mexico

[http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#April2004]{.underline}

For more information, contact:
[roberta.paisano@mail.ihs.gov]{.underline}

FYI: 2002 brochure

[http://www.ihs.gov/MedicalPrograms/MCH/M/ArchDownloads/2002_colposcopy.pdf]{.underline}

**Refresher IHS Course April 27-29, 2004**

Albuquerque, New Mexico

[http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#April2004]{.underline}

For more information, contact:
[roberta.paisano@mail.ihs.gov]{.underline}

FYI: 2002 brochure

[http://www.ihs.gov/MedicalPrograms/MCH/M/ArchDownloads/2002_colposcopy.pdf]{.underline}

###### 

###### 2004 National Women\'s Health Week celebration, May 9-15, 2004

Many resources to help with local activities

<http://www.4woman.gov/whw/2004/>

###### Learn more about National Women\'s Check-Up Day: May 10, 2004

<http://www.4woman.gov/whw/2004/Join-the-fun/check-up-day.html>

**3rd National Sexual Violence Prevention Conference, CDC **

May 25 - 28, 2004 

Los Angeles, California 

 <http://www.cdc.gov/ncipc/2004nsvpc.htm> 

#### National IHS PA / APN Annual Meeting

June 7-11, 2004

Scottsdale, Arizona

[**http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#June2004**](http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#June2004)

Contact Judy Whitecrane for questions <judy.whitecrane@mail.ihs.gov>

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

-   June 13-17, 2004

-   Denver, CO

-   Contact Barbara Fine at 301 443 1840

-   <http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#June2004>

-   2004 brochure
    <http://www.ihs.gov/MedicalPrograms/MCH/M/ConfDnlds/Brochure2004.doc>

**2004 Biennial OB/GYN meeting**

August 4-6, 2004

Albuquerque, New Mexico

Location and brochure to follow

Contact Neil Murphy for questions <nmurphy@anmc.org>

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004>

Did you miss something in the last OB/GYN Chief Clinical Consultant
Corner?

The **December 2003 OB/GYN CCC Corner** is available at:\
<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/CCCCorner12103B.doc>

Contents: Volume 1, No. 11 December, 2003

**[Abstract of the Month]{.underline}: Page 2**

Emergency Contraception: Pharmacy Access in Albuquerque, New Mexico

[From your colleagues:]{.underline} Page 4

From Burt Attico: Emergency Contraception\*: Semantics is a part of
\"the game.\"

From Burt Attico and Katy Ciacco Palatianos: Possible methods of
preventing cerebral palsy; **Chorioamnionitis and Cerebral Palsy in Term
and Near-Term Infants**

From Katy Ciacco Palatianos: To settle or not to settle?

From Sandra Dodge: 101 Way to ask someone if they are safe

From Bruce Finke: The Elder Care Initiative Office Moves East

From James Galloway and Terry Cullen: Diabetes & Cardiovascular Disease
Review

From Ursula Knoki-Wilson: \'Nurse Run Clinic\' models

From Kelly Moore: New Pediatric Chief Clinical Consultant: Steve Holve,
MD, Tuba City

From Chuck North: Redux -Chaperone Use by Family Physicians During the
Collection of a Pap Smear; Clarification: Non clean catch urine sampling
terminology

###### From Darrell Pratt: Looking for an OB/GYN?

**From Oida Vincent:** Are we required to obtain sensitivities on GBBS
for PCN allergic patients? Eager for Native American and Alaskan Native
applicants to Ph.D. program in the biomedical sciences.

**[Hot Topics:]{.underline}** **Page 10**

##### Obstetrics: Management of diabetes mellitus complicating pregnancy; Thrombophilic disorders and fetal loss: a meta-analysis; Screening for Congenital Cardiovascular Malformations; Can Eating More DHA Increase Duration of Pregnancy? Immunity to CMV Reduces Risk of Congenital Infection; Postpartum Depression Linked to Later Violence in Children;

###### Gynecology: Primary and Secondary Syphilis \-\-- United States, 2002; The 2001 Bethesda System Terminology; Depression in Older Women with Urinary Incontinence; Factors Affecting Accuracy of Mammography Screening; Multidose vs. Single-Dose Therapy in Ectopic Pregnancy; Weekly Therapy Is Effective in Prevention of Osteoporosis; Low-Dose Mifepristone Shrinks Uterine Fibroids; Low BMD Is Associated with Cognitive Decline in Women; Breast Cyst Aspiration

###### Child Health: Prophylaxis for Infants of Mothers with Hepatitis B; Evaluation of Bone Mass in Young Female Athletes; Hearing Assessment in Infants and Children; High School Students in BIA Schools: Tobacco, Alcohol, and other Drug Use; Adolescent's level of linguistic acculturation and their well-being

**Chronic Illness and Disease:** Diabetes Among Young American Indians
\-\-- Montana and Wyoming; Increases in HIV Diagnoses - 29 States,
1999---2002; Secondary Prevention in Women with Heart Disease; Fish Oil
Stabilizes Atherosclerotic Plaques

###### Other: Health Status of American Indians Compared with Other Racial/Ethnic Minority 

Populations \-\-- Selected States, 2001---2002; Common Problems in
Patients Recovering from Chemical Dependency

[Features:]{.underline} Page 12

###### AFP: POEMS HPV Triage for ASC-US Pap Results Makes Sense; Even Low Levels of Lead Can Lower IQ; False-Positive Mammograms Do Not Deter Women; Short-Interval Follow-up Mammography Is Low Yield; Oxybutynin or Tolterodine for Overactive Bladder? Use of Iron in Nonanemic, Fatigued Women; 

Other AFP Topics: Common Hyperpigmentation Disorders in Adults: Part I
Diagnostic Approach, Cafe au Lait, Macules, Diffuse Hyperpigmentation,
Sun Exposure, and Phototoxic Reactions; Common Hyperpigmentation
Disorders in Adults: Part II. Melanoma, Seborrheic Common
Hyperpigmentation Disorders in Adults: Part II. Melanoma, Seborrheic

Keratoses, Acanthosis Nigricans, Melasma, Diabetic Dermopathy, Tinea
Versicolor, and Postinflammatory Hyperpigmentation; Topical NSAIDs
Relieve the Pain of Mastalgia; Routine Vitamin Supplementation to
Prevent Cancer and Cardiovascular Disease: Recommendations and Rationale

**Annals of Family Medicine:** Women's Experiences of Abnormal Cervical
Cytology: Illness Representations, Care Processes, and Outcomes;
Periodic Abstinence From Pap (PAP) Smear Study: Women's Perceptions of
Pap Smear Screening; Factors Affecting the Detection Rate of Human
Papillomavirus; Cervical Cancer Screening

**ACOG:** ACOG Opinion Addresses Elective Cesarean Controversy; Use of
progesterone to reduce preterm birth; Dystocia and Augmentation of Labor
(ACOG Practice Bulletin)

AHRQ: Screening for High Blood Pressure: Recommendations and Rationale

**Breastfeeding:** Breastfeeding and Risk for Respiratory Disease in
Infants

Elder Care News: Influenza Vaccination; Anticoagulation in patients with
atrial fibrillation

**Hormone Replacement Update**: Minimizing Menopausal Symptoms From
Endocrine Therapy; Gabapentin Reduces Hot Flushes; Raloxifene Therapy
Does Not Affect Sexual Functioning

**Information Technology:** AHRQ to support patient safety and quality
of care through health information technology projects

International Health: A guide for health professionals working with
Aboriginal peoples

MCH Alert: Postpartum counseling perceptions and practices; Cost
estimates for Adolescent pregnancy and adolescent pregnancy prevention;

Web site offers one-stop shopping for information about federal grants

#### Medscape: Depressed Women Have More Sexual Dysfunction Than Depressed Men

#### Office of Women's Health, CDC: What's new in Women's Health Newsletter, CDC

Patient Education; [Funding opportunities]{.underline} Youth Violence
Prevention Through Community-Level Change; Sociocultural and Community
Risk and Protective Factors for Child Maltreatment and Youth Violence

#### Patient Education: How to prevent a stroke

**Primary Care Discussion Forum:** Cervical Cancer Screening: New
Guidelines and New Technologies; Emergency Contraception

#### What's new on the ITU MCH web pages Page 19

###### Save the Dates: Upcoming events of interest Page 20

**Did you miss something in the last OB/GYN Chief Clinical**

**Consultant (CCC) Corner? Page 21**

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@anmc.org>

\*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, contact Jason
Crim at: [jason.crim@mail.ihs.gov](mailto:jason.crim@mail.his.gov)

1/17/04