**Save the Dates**

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

-   June 19 - 23, 2005

-   Denver, CO (See 'Save the Dates' section below for details)

OB/GYN Chief Clinical Consultant's Corner

Volume 2, No. 10, October, 2004

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

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

Premenstrual syndrome, premenstrual dysphoric disorder, and beyond: a
clinical primer for practitioners.

[From your colleagues:]{.underline} page 3

**From Biennial Meeting:** Francis Byrn, M.D. Polycystic Ovarian
Syndrome / Insulin Resistance

From Rosemary Bolza: Where is the OB package for new EHR?

From Katy Ciacco Palantinos: "Informed Refusal\" document when patients
decline a procedure

**From Terry Cullen:** Commonwealth Fund/Harvard University Fellowship
in Minority Health Policy

From Lori de Ravello: Eliminating health disparities in pregnancy;
Celebrating Women\'s Health Research\
From Sandra Dodge: Goals for smoking in pregnancy: Healthy People 2010

Helpful lifestyle and diabetes data: mean weight, height, and body mass
index; Access to care

From Sandy Haldane: Please share this with any AN/AI college students
you know 

**From Steve Holve:** November Indian Child Health Notes: Highlights

From Jean Howe: Any solutions that can help the ongoing 'Meth' crisis in
your area?

From Bob Laliberte: LOCUM TENENS AVAILABILITY

From Judy Thierry: Periodontal Disease and Pregnancy Outcomes; Pregnancy
Risk Assessment Monitoring System (PRAMS) National Meeting:

**From Rebecca Werner:** Treatment for migraines in pregnant women

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

##### Obstetrics: page 7

Early delivery associated with severe periodontal disease; Infant
Mortality Rate Doubles with Short Umbilical Cord; Blunt Trauma in
Pregnancy; Seat Belt Use During Pregnancy

**Gynecology:** **page 7**

Which Women Develop Fever Following Hysterectomy? Sacrocolpopexy
consistently resolves vaginal vault prolapse; Primary and Secondary
Syphilis with Oral Sex

**Child Health:** **page 7**

SSRIs for children and adolescents should be prescribed judiciously;
Lack of Progress in physical activity in high school students; Inhalant
Abuse and Dependence Among Adolescents; Newborn Screening for Cystic
Fibrosis; Measures of sexual orientation in adolescent health surveys

**Chronic Illness and Disease:** **page 8**

Complementary Therapies in Primary Care Patients With Arthritis

[Features:]{.underline} page 9

AFP: Postmenopausal Estrogen and Cognitive Function; Blood Loss of 80 mL
or More Poorly Defines Menorrhagia; Many Pap Smears Unnecessary After
HysterectomyProphylactic Cerclage in Women with a Short Cervix;
Misoprostol for Uterine Evacuation in Missed Abortion; Postmenopausal
Estrogen Therapy and Dementia

##### ACOG: Inappropriate Use of the Terms Fetal Distress and Birth Asphyxia;

Cervical Cancer Screening in Adolescents; Multiple Gestation:
Complicated Twin, Triplet, and High-Order Multifetal Pregnancy: Sexually
Transmitted Diseases in Adolescents; Guidelines for Adolescent Health
Research

**AHRQ:** Studies show that obesity affects mammography accuracy and
screening rates; Initial surfactant treatment to prevent respiratory
distress in very premature infants is often delayed in routine practice;
Diagnosis of pain by primary care doctors is influenced by pain
severity, patient sex, and physician practice style

**Breastfeeding:** Workplace lactation program resource kit available

**Domestic Violence:** November 1, 2004:  Violence against Native women
Discussion

**Elder Care News:** Pharmacologic Prevention of Osteoporotic Fractures

**Family Planning:** Accuracy of Early Results with Home Pregnancy Test
Kits

**Frequently asked questions:** Should we perform routine urine dipstick
protein screening in our prenatal clinic? When should antenatal testing
start after an intrauterine fetal demise (IUFD)?

**Hormone Replacement Update**: ACOG Issues State-of-the-Art Guide to
Hormone Therapy

ACOG Frequently Asked Questions About Hormone Therapy for Patients;
Phytoestrogens do not improve hot flushes or other menopausal symptoms

**Information Technology:** Parklawn Library has a new identity

International Health: Effectiveness of Condoms in Reducing Heterosexual
Transmission of HIV

**MCH Alert:** New edition of adolescent pregnancy prevention knowledge
path released

**Office of Women's Health, CDC**: Social Determinants of Health at the
Local Level

**Osteoporosis**: Surgeon General encourages bone health throughout the
lifespan

**Patient Education**: Seat Belt Use During Pregnancy: Patient Education

**Primary Care Discussion Forum:** November 1, 2004:  Violence against
Native women Discussion; February 1, 2005:  Surgery for obesity?

#### Barbara Stillwater, Alaska Diabetes Prevention and Control: Is your diabetic patient non-adherent? Maybe she is depressed? **Doctors\' Interpersonal Skills Valued More than Their Training or Being Up-to-Date**

**What's new on the ITU MCH web pages: page 16**

###### Save the Dates: Upcoming events of interest page 17

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

# [Abstract of the Month]{.underline}

**Premenstrual syndrome, premenstrual dysphoric disorder, and beyond: a
clinical primer for practitioners.**

The management of adverse premenstrual symptoms has presented a
difficult challenge for clinicians. However, based on numerous
well-designed research studies over the last decade, we now have
diagnostic criteria for the severe form of the syndrome, premenstrual
dysphoric disorder, and a variety of evidence-based therapeutic
strategies.

This review presents a comprehensive, practical description of what the
clinician needs to know to diagnose and treat adverse premenstrual
symptoms at all levels of severity. Diagnostic criteria are described in
detail, including a discussion of the distinction between premenstrual
dysphoric disorder and premenstrual syndrome (PMS).

The rationale for including prospective symptom calendars as a routine
part of the diagnostic evaluation of severe symptoms is presented. The
differential diagnosis of cyclic symptoms, including depression and
anxiety disorders, menstrual migraine, and mastalgia, and an approach
for the management of each of these problems are presented.

A treatment approach is recommended that matches the treatment to the
degree of problems the woman is experiencing. Serotonin reuptake
inhibitors are the treatment of choice for severe symptoms, and most
women with PMS/premenstrual dysphoric disorder will respond to
intermittent, luteal phase-only therapy. Ovulation suppression should be
reserved for women who do not respond to other forms of therapy. The
role of oophorectomy is limited, and guidelines for its use are
presented.

Johnson SR. Premenstrual syndrome, premenstrual dysphoric disorder, and
beyond: a clinical primer for practitioners. Obstet Gynecol. 2004
Oct;104(4):845-59.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15458909&dopt=Abstract>

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

The 14 page document offers the primary care provider a best practices
benchmark for the treatment of premenstrual symptoms. As many of these
same symptoms can be associated with other disorders, one should
document the temporal aspects with a menstrual calendar before other
conditions can be ruled out. njm

## From your colleagues:

#### [From the Biennial Women's Health/MCH meeting, ABQ]{.underline}

#### This meeting was a huge success: Here is one of the many talks

Francis Byrn, M.D. - Polycystic Ovarian Syndrome and Insulin Resistance

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

Go here to review the many other materials uploaded to date:

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

#### 

**[From Rosemary Bolza, Ft. Defiance]{.underline}**

**Most commonly asked question this month: Where is the OB package for
new EHR?**

Fort Defiance has adopted the EHR (electronic health record) from the VA
system. There are no OB applications so we are making our own templates.
They have not found a way to use a prenatal flow record, so are going to
continue to use paper flow chart for now. Do you have any information
that would be helpful for electronic prenatal records?

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

I went to the 2 best IHS contacts for this, Howard Hays and Terry
Cullen. See below

Basically the EHR has only been released for preliminary testing / early
implementation at this time, e.g., before all the individual specialty
packages are ready. The obstetrics and pediatrics packages are being
worked on and will be released when ready.

We have looked extensively at an obstetrics package from Tripler Medical
Center (DOD) and are very excited, but there are a vast amount of
technical and financial issues to be resolved. njm

**[Howard Hays, PIMC]{.underline}**

The IHS Electronic Health Record is based very heavily on the VA\'s
Computerized Patient Record System (CPRS). The reasons for this are
multiple and straightforward, including: our legacy patient information
system (RPMS) is very closely related to the VA\'s VistA system, there
is an economy in adopting a system that is already in the public domain
and therefore virtually free, we have access to a development
environment at the VA that dwarfs our own, and the experience and impact
of CPRS at the VA has been very positive.

Having made that decision, we of course have known all along that the VA
does not provide prenatal or pediatric care, so it was a given that the
first iteration of IHS-EHR would be deficient in these areas. We have
tried to be very up front and unapologetic about this. It certainly
would not have made sense to delay the release of EHR until all of the
potential specialty aspects had been addressed. It is encouraging that
users are asking for more from EHR \-- it means to me that they are
using it, recognize its value, and are imagining additional
possibilities.

We are actively looking at ways to make EHR more useful for pediatric
and prenatal care providers, among others. We have a subject matter
expert group looking at essential functionality for child health
components of EHR, with special emphasis on compatibility with the
national Bright Futures initiative.

With respect to prenatal care, we are considering a number of possible
solutions. Among these are looking at commercial electronic prenatal
packages for incorporation into or interface with EHR, and exploring an
application for prenatal and obstetrical care developed for the
Department of Defense. The timeframe for having a fully functional
prenatal component for EHR is still quite unclear. In the meantime,
facilities using EHR are continuing to use paper forms for documentation
of prenatal care, but are also taking advantage of the capabilities of
EHR for medication and lab ordering, results retrieval, problem list
management, note authoring, and (in some cases) remote access to
information. It may be a hybrid for now, but it works and will continue
to get better.

**[Terry Cullen, Tucson]{.underline}**

".....we are, at this point, ONLY looking at the DOD option..."

#### 

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

**\"Informed Refusal\" \-- document all counseling when patients decline
a procedure**

Absence of documentation often burns the health care provider. I can
think offhand of many tort claims in which providers probably counseled
and referred, but medical record documentation did not adequate support
that full counseling of risks/benefits was conducted. Examples:

-biopsy

-colonoscopy

-definitive thyroidectomy following diagnosis of cancer on subtotal
thyroidectomy;

-other surgical diagnostic or therapeutic, w/suspicious sign/symptom
(thyroid nodule, cervical dysplasia)

-orthopedic surgery (ORIF where patient is not CHS-eligible)

-other surgical procedures (e.g., cesarean delivery; root canal or
completion of 2-step dental procedure)

-vaccinations (OSHA BBP regulation requires documentation when HBV
vaccine is declined)

-MRI for headache workup

-Rx adherence

-Rx not available on formulary

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

**Commonwealth Fund/Harvard University Fellowship in Minority Health
Policy**

We are now soliciting applications for 2005-06 (Y10). You are invited to
forward this announcement to interested candidates.

[[Program]{.underline}]{.smallcaps}: One-year, degree-granting,
full-time fellowship from July 2005 to June 2006.  Prepares physicians
for leadership roles in minority health/public health policy.  Leads to
MPH at Harvard School of Public Health or MPA at John F. Kennedy School
of Government.  Full graduate program incorporates intensive training in
health policy, public health, and administration: courses, seminars,
practicum, forums, conferences, site visits, faculty mentoring, and
leadership shadowing.

[[Qualifications]{.underline}]{.smallcaps}: U.S. citizenship; board
eligible or certified physicians; experience in minority health issues;
interest in health policy and public health; strong academic and
leadership skills; intention to pursue career in public health, health
policy, or academia.

[Funding]{.smallcaps}: \$50,000 stipend; tuition and fees; health
insurance; other program expenses.

For more information, please visit our program website at:
<http://www.mfdp.med.harvard.edu/fellows_faculty/cfhuf/>

**[From Lori de Ravello, HQW]{.underline}**

**Eliminating health disparities in pregnancy**

Eliminating health disparities between different racial/ethnic subgroups
is a national priority. Even at the earliest stages of pregnancy,
disparities in health are evident. A new study documents persistent
disparities in rates of unintended pregnancy, prenatal care, and
breastfeeding in California between women of different incomes,
educational levels and racial/ethnic groups. While, overall, the state
experienced an improvement in these maternal and infant health measures,
the aggregate improvements masked persistent gaps between different
groups of women.

A new issue brief prepared by researchers at the University of
California at San Francisco and the Kaiser Family Foundation, \"Social
and Economic Disparities in Maternal and Infant Health,\" analyzes
changes in racial/ethnic and socioeconomic disparities in maternal and
infant health in California in 1994/1995 and 1999/2001.
[[http://www.kff.org/womenshealth/7157.cfm]{.underline}](http://www.kff.org/womenshealth/7157.cfm)

**Celebrating Women\'s Health Research**\
The Center for Women\'s Health Research is pleased to announce a call
for abstracts for the Sixth Annual Women\'s Health Research Day to be
held Wednesday, March 23, 2005. Research Day will be preceded by a
Media/Science Forum on Tuesday, March 22, 2005.You and/or your trainees
are invited to submit abstracts for juried review by Monday, November
29, 2004.

The committee of jurors invites the submission of research abstracts of
excellent quality in all areas related to women\'s health including:
basic science, clinical, translational, epidemiologic, psychosocial, and
health services research. The deadline for receipt of abstracts is 5p.m.
on\
Monday November 29, 2004.\
To celebrate and acknowledge excellence in women\'s health research, the
following prizes will be awarded again this year: Center for Women\'s
Health Research Award for Excellence, McMahon Young Investigator Award,
Hulka Innovators Award, and the Judges Award. Winners will be selected
by an independent panel of judges and prizes will be presented at the
close of Women\'s Health Research Day.
[www.cwhr.unc.edu](http://www.cwhr.unc.edu/).

[From Sandra Dodge, Crownpoint]{.underline}

**Goals for smoking in pregnancy: Healthy People 2010**

The Healthy People 2010 objectives target an increase in smoking
cessation among pregnant smokers during the first trimester to 30% and
abstinence from cigarettes to 99% of all pregnant women.

\* During the study period, smoking during pregnancy decreased by 38%
among all women giving birth in the United States (from 18.4% in 1990 to
11.4% in 2002).

\* Every year from 1996-2001, a higher percentage of adolescents ages
15-19 smoked during pregnancy than women in any other age group. In
2002, the percentage of adolescents ages 15-19 who smoked during
pregnancy was the same as that for women ages 20-24, with the highest
percentage observed among adolescents ages 18-19.

\"Although the widespread public health message to abstain from smoking
during pregnancy has helped decrease maternal smoking, to reduce
prevalence further, implementation of additional interventions are
required,\"

Mathews TJ, Rivera CC. 2004. Smoking during pregnancy \-- United States,
1990-2002. Morbidity and Mortality Weekly Report 53(39):911-915\
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5339a1.htm>

**State Estimates of Neonatal Health-Care Costs Associated with Maternal
Smoking \-\-- CDC\
**<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5339a2.htm>

**Helpful lifestyle and diabetes data: mean weight, height, and body
mass index**

This report presents trends in national estimates of mean weight,
height, and body mass index (BMI) from the National Health Examination
and the National Health and Nutrition Examination Surveys between 1960
and 2002.

<http://www.cdc.gov/od/oc/media/pressrel/r041027>

 

**Access to care**

Recent interest has occurred in the need for improved conceptual data on
how the social environment impacts the health of populations.
<http://www.cdc.gov/cvh/library/data_set_directory/index.htm>

[From Sandy Haldane, HQE]{.underline}

Please share this with any AN/AI college students you know 

It is an incredible opportunity and very well organized American
University\'s Washington Internships for Native Students
(WINS)Applications for the Spring 2005 Semester are due October 8,
2004.\
The WINS Program is a unique experience for American Indian and Alaska
Native Students \[including graduate students\] to work and study in
Washington DC for a semester. Native American students from across the
country will combine a full-time internship in a Federal Agency with
traditional university courses. Students acquire essential hands-on
experience while continuing to make academic progress. Each fall and
spring term students can earn up to 12 credit hours. Summer students
will earn 6 credit hours.
[**www.american.edu/wins**](http://www.american.edu/wins)

[From Steve Holve, Tuba City]{.underline}

**November Indian Child Health Notes: Highlights**

-Winter is Coming

-The shocking answer of what to do about all those coughing children

-Obesity Prevention - The results of a multi-million dollar project to
reduce obesity in Native American school children. The results are\....I
guess you\'ll have to go to the website to find out.

-Meetings of Interest

<http://www.ihs.gov/medicalprograms/MCH/C/documents/ICHN1104.doc>

[From Jean Howe, Chinle]{.underline}

Do you have any solutions that can help the ongoing 'Meth' crisis in
your area?

"...... a really \"active\" issue is the ongoing methamphetamine crisis
and the issues about toxicology screening in pregnancy. We are trying to
work out an area-wide position on this..."

If you have any ideas that would help, please contact
[**Jean.Howe@ihs.gov**](mailto:Jean.Howe@ihs.gov)

[From Bob Laliberte, Phoenix]{.underline}

**LOCUM TENENS AVAILABILITY**

Dr. Robert Laliberte is a board certified obstetrician/gynecologist
currently stationed at Phoenix Indian Medical Center (PIMC).  He will be
retiring from the Commissioned Corps of the Public Health Service and
from PIMC on January 1, 2005 after more than 20 years service.  He plans
to do locum tenens work and plans to work 6 months a year.  His history
with the IHS began at Crow Agency, Montana and is concluding at PIMC; he
would like to continue working in IHS facilities with Native patients. 
Should any facilities want or need a locum Ob/Gyn for a one time
assignment or for a recurring assignment, Dr. Laliberte would like to
speak with you and can be reached at the numbers or e-mail that follow.

 Robert C. Laliberte, MD, FACOG

W (602) 263-1550 H (480) 987-0938

E-mail:  <LBLALIB@AOL.COM>

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

**Research and Policy Update: Periodontal Disease and Pregnancy
Outcomes-** **Nov. 3**

Webcast is on Wednesday November 3, 2004 (2:00-3:00pm Eastern,
1:00-2:00pm Central)

Kim A. Boggess MD, Department of Ob/Gyn, University of North Carolina

To join the webcast, you must register at least a day ahead of time at
<http://www.uic.edu/sph/cade/mchepi/>

**Pregnancy Risk Assessment Monitoring System (PRAMS) National Meeting:
Dec 6-7, 2004**

This year\'s theme will be \"Sweet 16: Celebrating the Past and Creating
the Future, and held at the CNN Center Hotel in Atlanta, Georgia. This
meeting is being held in conjunction with, and prior to, the 10th Annual
Maternal and Child Health Epidemiology Conference, December 8-10, 2004,
at the same location. <http://www.psava.com/prams2004/home.asp>

**[From Rebecca Werner, Sault Ste Marie, MI]{.underline}**

**Q**. **What do you use to treat pregnant women with migraines**? 

**A**. First of all make sure these are migraine headaches, and then
treat appropriately. See below

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

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

**[Obstetrics]{.underline}**

**Early delivery associated with severe periodontal disease**

CONCLUSION: Women with early spontaneous preterm birth were more likely
to have severe periodontal disease than women with indicated preterm
birth or term birth. Periodontal disease was not associated with
selected markers of upper genital tract inflammation.

Goepfert AR, Jeffcoat MK, Andrews WW, Faye-Petersen O, Cliver SP,
Goldenberg RL, Hauth JC. Periodontal disease and upper genital tract
inflammation in early spontaneous preterm birth. stet Gynecol. 2004
Oct;104(4):777-83.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15458901&dopt=Abstract>

**Infant Mortality Rate Doubles with Short Umbilical Cord**

CONCLUSION: Modifiable risk factors associated with the development of a
short cord were not identified. Case mothers and infants are more likely
to experience labor and delivery complications. Term case infants had a
2-fold increased risk of death, which suggests closer postpartum
monitoring of these infants.

Krakowiak P, et al. Risk factors and outcomes associated with a short
umbilical cord. Obstet Gynecol January 2004;103:119-27.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14704255>

**Blunt Trauma in Pregnancy**

<http://www.aafp.org/afp/20041001/1303.html>

**Seat Belt Use During Pregnancy: Patient Education**

<http://www.aafp.org/afp/20041001/1313ph.html>

**[Gynecology]{.underline}**

**Which Women Develop Fever Following Hysterectomy?**

CONCLUSION: Hysterectomy by abdominal approach and increased blood loss
at the time of surgery significantly increase the risk of febrile
morbidity. Preventive efforts should focus on methods to reduce
postoperative febrile morbidity, including meticulous surgical technique
and routine use and appropriate timing of prophylactic antibiotic
therapy

Peipert JF, et al. Risk factors for febrile morbidity after
hysterectomy. Obstet Gynecol January 2004;103:86-91.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14704250>

**Sacrocolpopexy consistently resolves vaginal vault prolapse**

CONCLUSION: Sacrocolpopexy is a reliable procedure that effectively and
consistently resolves vaginal vault prolapse. Patients should be
counseled about the low, but present risk, of reoperation for prolapse,
stress incontinence, and complications. Prospective trials are needed to
understand the effect of sacrocolpopexy on functional outcomes.

Nygaard IE, et al Abdominal sacrocolpopexy: a comprehensive review.
Obstet Gynecol. 2004 Oct;104(4):805-23.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15458906&dopt=Abstract>

**Transmission of Primary and Secondary Syphilis by Oral Sex**

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5341a2.htm>

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

**SSRIs for children and adolescents should be prescribed judiciously**

The recent FDA advisory panel recommendation that antidepressants should
include a strong warning about the suicide risks for children and
adolescents has merit but some believe it shouldn\'t preclude using
these drugs.

Sibley KM, Kramer DA. Reframing the SSRI issue. J Am Acad Child Adolesc
Psychiatry. 2004 Oct;43(10):1188-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15381878>

**Lack of Progress in physical activity in high school students, CDC**

Progress has not been made toward reaching the national health
objectives for 2010 related to PE. In 2003, only 55.7% of high school
students were enrolled in a PE class, only 28.4% were attending PE class
daily, and only 39.2% were physically active during PE class. In
addition, female students and students in higher grades were
consistently at greatest risk for not reaching the national health
objectives for PE. To help schools implement comprehensive school health
programs aimed at increasing physical activity among youth, CDC
developed Guidelines for School and Community Programs to Promote
Lifelong Physical Activity Among Young People. Although the guidelines
recommend daily PE for all students, only 5.8% of senior high schools
require daily PE or its equivalent for the entire school year for
students in all grades in the school.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5336a5.htm>

**Inhalant Abuse and Dependence Among Adolescents in the United
States.**

CONCLUSIONS: Adolescents with an inhalant use disorder may represent a
subgroup of highly troubled youths with multiple vulnerabilities.
Because early use is associated with progression to abuse and
dependence, prevention programs should target elementary school age
children.

Wu LT, Pilowsky DJ, Schlenger WE. 2004. Inhalant abuse and dependence
among adolescents in the United States. Journal of the American Academy
of Child & Adolescent Psychiatry 43(10):206-1214

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15381887>

# Newborn Screening for Cystic Fibrosis

### #1 Evaluation of Benefits and Risks #2 Recommendations for Newborn Screening Programs

Newborn screening systems should ensure parental and provider education
and communication of screening results to primary-care providers in a
manner that will ensure prompt referral to diagnostic centers. For CF,
these should be centers skilled in providing both sweat tests to young,
presymptomatic children with CF and accurate and effective counseling to
families, including those with infants identified as carriers. States
are recommended to work with each other and with professional
organizations and federal agencies to develop approaches to provide
newborn screening information to parents during the prenatal and
perinatal periods on all conditions, including CF, to facilitate
informed choices and appropriate responses to positive screen results.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5313a1.htm>

**Measures of sexual orientation in adolescent health surveys**

CONCLUSIONS: Specific recommendations include standardizing wording
across future surveys, and pilot testing items with diverse ages and
ethnic groups of teens before use. All three dimensions of orientation
should be assessed where possible; when limited to single items, sexual
attraction may be the best choice. Specific wording suggestions are
offered for future surveys. Saewyc EM, Bauer GR, Skay CL, et al. 2004.
Measuring sexual orientation in adolescent health surveys: Evaluation of
eight school-based surveys.

Journal of Adolescent Health 35(4):e2-e15.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15450548>

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

**Use of Complementary Therapies Among Primary Care Clinic Patients With
Arthritis**

The frequency and types of CAM therapy used by Hispanic and non-Hispanic
white women and men with osteoarthritis, rheumatoid arthritis, or
fibromyalgia were examined. Most (90.2%) had ever used CAM for
arthritis, and 69.2% were using CAM at the time of the interview.
Current use was highest for oral supplements (mainly glucosamine and
chondroitin) (34.1%), mind-body therapies (29.0%), and herbal topical
ointments (25.1%).

<http://www.cdc.gov/pcd/issues/2004/oct/03_0036.htm>

##### Features

## American Family Physician\*\*

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

Postmenopausal Estrogen and Cognitive Function

**Clinical Question:** Does postmenopausal estrogen therapy improve
global cognitive function?

**Bottom Line:** Postmenopausal estrogen therapy does not improve-and
may worsen-global cognitive function. Adverse effects may be more
pronounced in women with preexisting reduced cognitive function. (Level
of Evidence: 1b)

<http://www.aafp.org/afp/20041001/tips/18.html>

**Blood Loss of 80 mL or More Poorly Defines Menorrhagia**

**Clinical Question:** Is the definition of menorrhagia as 80 mL or more
of blood loss during menstruation clinically meaningful?

**Bottom Line:** The definition of menorrhagia as more than 80 mL of
blood loss should not be used because it does not predict clinically
meaningful outcomes. (Level of Evidence: 2c)

<http://www.aafp.org/afp/20041001/tips/19.html>

**Many Pap Smears Unnecessary After Hysterectomy**

**Clinical Question:** How often do women who are not at risk of
developing cervical cancer have Papanicolaou (Pap) smear screening?

**Bottom Line:** Many American women who have had a hysterectomy with
removal of the cervix for benign disease continue to receive routine Pap
smear screening, despite a lack of supporting evidence and a clear
recommendation from the USPSTF against routine screening. Conversely,
the vast majority of American women who die of cervical cancer were
underscreened or never screened for cervical disease, most likely as a
result of real or perceived cost barriers. The money saved by not
inappropriately performing Pap tests on low-risk women would cover the
cost of screening for the 17 million women in the United States who
currently are underscreened for cervical cancer (*Sar-aiya M, et al.
Observations from the CDC. An assessment of Pap smears and
hysterectomies among women in the United States. J Womens Health Gend
Based Med 2002;11:103-9*). (Level of Evidence: 2b)

<http://www.aafp.org/afp/20041001/tips/20.html>

**Prophylactic Cerclage in Women with a Short Cervix**

**Clinical Question:** Does ultrasonographic screening for a short
cervix at 22 to 24 weeks of gestation, followed by prophylactic cerclage
in women who screen positive, reduce the rates of preterm birth?

**Bottom Line:** Ultrasonographic screening for cervical length of 15 mm
or less at 22 to 24 weeks of gestation identifies women at risk of
preterm delivery at less than 33 weeks. A 4-percent absolute risk
reduction for early preterm births was not statistically significant in
the group treated with prophylactic cerclage but may be considered
clinically significant if proved. The study was too small to detect
clinically important differences in perinatal morbidity and mortality.
(Level of Evidence: 1b-) <http://www.aafp.org/afp/20041001/tips/21.html>

**Misoprostol for Uterine Evacuation in Missed Abortion**

**Clinical Question:** Is vaginal administration of misoprostol an
effective treatment for missed abortion?

**Bottom Line:** Intravaginal misoprostol is a reasonable third
alternative to expectant observation and surgical intervention for
missed abortion. Further study is needed to determine which treatment is
best, although randomized trials will be difficult to undertake because
women may not be willing to be randomized. (Level of Evidence: 4)

<http://www.aafp.org/afp/20041001/tips/22.html>

**Postmenopausal Estrogen Therapy and Dementia**

**Clinical Question:** Does estrogen therapy alone reduce the risk of
dementia and cognitive impairment in postmenopausal women?

**Bottom Line:** Estrogen therapy alone does not reduce-and may actually
increase-the risk of dementia and mild cognitive impairment in
postmenopausal women 65 years or older. (Level of Evidence: 1b)

<http://www.aafp.org/afp/20041001/tips/23.html>

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

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

##### ACOG

**Inappropriate Use of the Terms Fetal Distress and Birth Asphyxia:**

**Committee Opinion 303**

ABSTRACT: The Committee on Obstetric Practice is concerned about the
continued use of the term \"fetal distress\" as an antepartum or
intrapartum diagnosis and the term \"birth asphyxia\" as a neonatal
diagnosis. The Committee reaffirms that the term fetal distress is
imprecise and nonspecific. The communication between clinicians caring
for the woman and those caring for her neonate is best served by
replacing the term fetal distress with \"nonreassuring fetal status,\"
followed by a further description of findings (eg, repetitive variable
decelerations, fetal tachycardia or bradycardia, late decelerations, or
low biophysical profile). Also, the term birth asphyxia is a nonspecific
diagnosis and should not be used.

Inappropriate use of the terms fetal distress and birth asphyxia. ACOG
Committee Opinion No. 303. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2004;104:903--4.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15458919>

**Cervical Cancer Screening in Adolescents: Committee Opinion No. 300**

ABSTRACT: The American Cancer Society recently published a
recommendation that cervical cancer screening should begin approximately
3 years after the onset of vaginal intercourse or no later than age 21
years. Once initiated, screening should occur annually for young women.
The decision about the initiation of cervical cytology screening in an
adolescent patient should be based on the clinician\'s assessment of
risks, including 1) age of first sexual intercourse, 2) behaviors that
may place the adolescent patient at greater risk for human
papillomavirus infection, and 3) risk of noncompliance with follow-up
visits. Patients and parents need to be provided with information about
this new recommendation so they understand that there is still a need
for preventive health care other than Pap testing. Additional research
is needed to facilitate the provision of the best care for adolescent
patients and avoid overtreatment of abnormal cervical cytology.

Cervical cancer screening in adolescents. ACOG Committee Opinion No.
300. American College of Obstetricians and Gynecologists. Obstet Gynecol
2004;104:885--9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15458916>

**Multiple Gestation: Complicated Twin, Triplet, and High-Order
Multifetal Pregnancy: Practice Bulletin NUMBER 56, OCTOBER 2004**

**Summary of Recommendations**

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

-   Tocolytic agents should be used judiciously in multiple gestations.

-   Women with high-order multiple gestations should be queried about
    nausea, epigastric pain, and other unusual third-trimester symptoms
    because they are at increased risk to develop HELLP syndrome, in
    many cases before symptoms of preeclampsia have appeared.

-   The higher incidence of gestational diabetes and hypertension in
    high-order multiple gestations warrants screening and monitoring for
    these complications.

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

-   The National Institutes of Health recommends that women in preterm
    labor with no contraindication to steroid use be given one course of
    steroids, regardless of the number of fetuses.

-   Cerclage, hospitalization, bed rest, or home uterine activity
    monitoring have not been studied in high-order multiple gestations,
    and, therefore, should not be ordered prophylactically. There
    currently is no evidence that their prophylactic use improves
    outcome in these pregnancies.

-   Because the risks of invasive prenatal diagnosis procedures, such as
    amniocentesis and chorionic villus sampling, are inversely
    proportional to the experience of the operator, only experienced
    clinicians should perform these procedures in high-order multiple
    gestations.

-   Women should be counseled about the risks of high-order multiple
    gestation before beginning ART.

-   Management of discordant growth restriction or death of one fetus in
    a high-order multiple gestation should be individualized, taking
    into consideration the welfare of the other fetus(es).

Multiple gestation: complicated twin, triplet, and high-order multifetal
pregnancy. ACOG Practice Bulletin No. 56. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2004;104:869--83.

Non-ACOG members

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15458915>

ACOG Members only

<http://www.acog.org/publications/educational_bulletins/pb056.cfm>

**Sexually Transmitted Diseases in Adolescents**

**Committee Opinion No. 301**

ABSTRACT: Sexually transmitted diseases are common among adolescents in
the United States. Female adolescents face numerous obstacles to care
and experience a disproportionate burden related to the sequelae of
sexually transmitted diseases. These diseases are a primary cause of
short and long-term morbidity in adolescents that can result in
infertility, chronic pelvic pain, ectopic pregnancy, vertical
transmission to newborns, malignancy, chronic illness, and even death.
Clinicians treating female adolescents should be prepared to offer
confidential and comprehensive counseling, screening, and treatment
according to established guidelines. They should also work within their
communities and at the state and national levels to assure access to
medical care for all adolescents. Adolescence is a period during which
life-long health behaviors are established. It is, therefore, a critical
time for promoting responsible behaviors and reducing risks through
health promotion and prevention strategies.

Sexually transmitted diseases in adolescents. ACOG Committee Opinion No.
301. American College of Obstetricians and Gynecologists. Obstet Gynecol
2004;104:891--8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15458917>

**Guidelines for Adolescent Health Research**

**Committee Opinion 302**

ABSTRACT: The risks of exposure to violence, human immunodeficiency
virus, and other sexually transmitted diseases; alcohol, tobacco, and
prescribed and illicit drug use; and unintended pregnancy, among others,
threaten the health and well-being of adolescents in the United States.
Research is needed in these and other areas to improve adolescent health
care and to aid in health policy decisions. Adolescents often are
prevented from participating in such research because of inadequate
understanding of their legal status and the ethical considerations
regarding their participation in research. There is confusion about what
constitutes appropriate levels of protection for studies involving
adolescents as research subjects and uncertainty about the need for
parental permission. This document is designed to clarify the informed
consent and parental permission issues as they pertain to adolescent
health research.

Guidelines for adolescent health research. ACOG Committee Opinion No.
302. American College of Obstetricians and Gynecologists. Obstet Gynecol
2004;104:899--902

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15458918>

##### AHRQ

**Studies show that obesity affects mammography accuracy and screening
rates**

<http://www.ahrq.gov/research/aug04/0804RA3.htm#head1>

**Initial surfactant treatment to prevent respiratory distress in very
premature infants is often delayed in routine practice**

<http://www.ahrq.gov/research/aug04/0804RA5.htm#head3>

**Diagnosis of pain by primary care doctors is influenced by pain
severity, patient sex, and physician practice style**

<http://www.ahrq.gov/research/sep04/0904RA31.htm#head1>

##### Breastfeeding

**Workplace lactation program resource kit available**

Business Backs Breastfeeding: A Flexible Workplace Program for
Breastfeeding Mothers is a resource kit containing instructions, tips,
and template materials to help employers support workplace lactation
programs. The kit and other breastfeeding resources are available at
[[http://www.Ross.com/BF/backtowork.asp]{.underline}](http://www.Ross.com/BF/backtowork.asp)
or
[[http://www.ross.com/images/library/Business]{.underline}](http://www.ross.com/images/library/Business)

**[Domestic Violence]{.underline}**

## November 1, 2004:  Violence against Native women 

This moderated discussion is open to all on the Primary Care Listserv

Moderator: Terry Cullen. This discussion will include:

-scope of violence against Native women

-tools for patient evaluation

-best practice policies and procedures

-ideas about available resources.

### 

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

Subscribe to the Primary Care listserv

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

Unsubscribe from the Primary Care listserv

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

Questions on how to subscribe, contact <nmurphy@anmc.org> directly

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

**Pharmacologic Prevention of Osteoporotic Fractures**

<http://www.aafp.org/afp/20041001/1293.html>

**Osteoporosis Management: Out of Subspecialty Practice and into Primary
Care: Editorial**

<http://www.aafp.org/afp/20041001/editorials.html>

**[Family Planning]{.underline}**

**Accuracy of Early Results with Home Pregnancy Test Kits**

Home pregnancy tests give women the opportunity to determine whether
they are pregnant within the privacy of their own homes. These tests
have become so popular that they are now the most commonly used
over-the-counter disposable health kits. Home pregnancy tests were
introduced in 1975 and, since then, more than 20 brands have become
available. These testing kits use modern immunometric assays, and the
manufacturers claim that the tests can be used on the first day of the
missed period. In addition, the manufacturers claim that the tests are
accurate more than 99 percent of the time. Because these tests are used
to confirm an intended or unintended pregnancy, verifying the accuracy
of these claims is important. Cole and colleagues assessed the validity
of the claim of more than 99 percent accuracy of home pregnancy tests on
the first day of the missed period.

In the first phase of the study, urine human chorionic gonadotropin
(hCG) levels were assessed during early pregnancy by checking urine
samples from women who were between four weeks and zero days and four
weeks and three days from their last menstrual period and were pregnant.
This information was used to statistically determine the mean, 5th, and
95th percentiles of hCG concentration.

The next step was to test each of the 18 brands of home pregnancy tests
using five concentrations of urine hCG. Each brand was tested six
different times. The urine concentration of hCG was established by
adding recombinant hCG in concentrations of zero, 12.5, 25, 50 and 100
mIU per mL. Sensitivity was defined as the urine concentration at which
six of six tests gave positive results at the suggested or extended
time.

The calculated mean urine hCG concentration after missed menses was 49
mIU per mL, the 5th percentile was 12.4 mIU per mL, and the 95th
percentile was 241 mIU per mL. The home pregnancy tests had to be able
to detect a urine concentration level of 12.4 mIU per mL to confirm
intrauterine pregnancies 95 percent of the time. To be 95 percent
accurate at days 1, 2, and 3 after missed menses, the concentration of
urine hCG had to be 21, 35, and 58 mIU per mL. Of the 18 brands
included, only one test had a sensitivity that detected the 12.5 mIU per
mL level. If read at the suggested time, only 44 percent of the brands
could detect urine hCG concentrations at 100 mIU per mL. When extended
time was allowed or a response that was \"faintly\" positive was
considered, all 18 brands were positive at 100 mIU per mL. The authors
estimated that 100 mIU per mL was equivalent to the 84th percentile at
the time of the missed period, so these tests would detect only about 16
percent of pregnancies.

The authors conclude that the utility of home pregnancy tests is
questionable and that clinicians should be aware of the limitations of
these tests. They recommend that these issues be addressed because a
missed diagnosis of pregnancy can have a significant impact on prenatal
care and changes in medications and behaviors that are consistent with
healthy pregnancy

Cole LA, et al. Accuracy of home pregnancy tests at the time of missed
menses. Am J Obstet Gynecol January 2004;190:100-5.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14749643>

**[Frequently asked questions]{.underline}**

**Q.** **Should we perform routine urine dipstick protein screening in
our prenatal clinic?**

**A.** No, the urine dipstick tests are not sensitive, nor specific
enough for routine screening for pre-eclampsia. There is more to the
story, though

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

**Q. When should antenatal testing start after an intrauterine fetal
demise (IUFD)?** 34 weeks? or prior to the gestational age of the IUFD?

**A.** Probably neither, unless you know the exact etiology of the prior
IUFD, but there is more.

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

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

**ACOG Issues State-of-the-Art Guide to Hormone Therapy - Released**

Experts Expand Prior Post-WHI Advice on Estrogen

Herbal Remedies Don\'t Relieve Hot Flashes;\
Too Soon to Know if Testosterone Enhances Libido

129 page monograph covering the gamut of issues

<https://www.acog.com/from_home/publications/press_releases/nr09-30-04-2.cfm>

**ACOG Frequently Asked Questions About Hormone Therapy for Patients**

New Recommendations based on ACOG\'s Task Force Report on Hormone
Therapy

<https://www.acog.com/from_home/publications/press_releases/nr10-01-04.cfm>

**Phytoestrogens do not improve hot flushes or other menopausal
symptoms**

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

Krebs EE, Ensrud KE, MacDonald R, Wilt TJ. Phytoestrogens for treatment
of menopausal symptoms: a systematic review. Obstet Gynecol. 2004
Oct;104(4):824-36.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15458907&dopt=Abstract>

# [Information Technology]{.underline}

**The Parklawn Library has a new identity**

Now called the Health Services Research Library (HSRL), the new name
better reflects the Library\'s core collection. The change also
coincides with the Library\'s recent organizational realignment as a
branch of the National Institutes of Health Library.

To find out more about the collections and services offered by the
Health Services Research Library, visit the new HSRL website at:
[[http://hsrl.nihlibrary.nih.gov]{.underline}](http://hsrl.nihlibrary.nih.gov/).

Services and collections available online include:

\* AskUs Live! Digital Reference Service

\* 100s of Online Journals

\* Databases - over 25

\* Document Delivery - full text of articles delivered to you by email

\* Online Library Catalog

[Please bookmark this new site now. Your old bookmarks will not redirect
to the new website.]{.underline}

For assistance in using the new website, or for any other comment or
question, please call our Information Desk at 301-443-2673 or email the
Library at <hsrlrefdesk@nih.gov>

# [International Health Update]{.underline}

**Effectiveness of Condoms in Reducing Heterosexual Transmission of
HIV**

**Cochrane for Clinicians**

*Reviewers\' Conclusions.* This review indicates that consistent use of
condoms results in an 80 percent reduction in HIV infection incidence.
Consistent use is defined as using a condom for all acts of penetrative
vaginal intercourse. Because the studies used in this review did not
report on whether condoms were used correctly for every act of
intercourse, effectiveness and not efficacy is estimated. This estimate
refers to the male condom in general, not specifically to the latex
condom, because studies tended not to specify the type of condom that
was used. Thus, condom effectiveness in reducing HIV transmission is
similar to, although lower than, that for contraception.

<http://www.aafp.org/afp/20041001/cochrane.html>

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

**New edition of adolescent pregnancy prevention knowledge path
released**

The new edition of the Adolescent Pregnancy Prevention knowledge path is
an electronic resource guide on recent, high-quality resources that
analyze data, describe public health campaigns and prevention programs,
and report on research aimed at identifying causes and promising
intervention strategies.
[[http://www.mchlibrary.info/KnowledgePaths/kp_adolpreg.html]{.underline}](http://www.mchlibrary.info/KnowledgePaths/kp_adolpreg.html)

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

######### 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.

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

**Social Determinants of Health at the Local Level**

Recent interest has occurred in the need for improved conceptual data on
how the social environment impacts the health of populations. This
directory contains an extensive list of existing data sets that can be
used to address these determinants. The data sets are organized
according to 12 dimensions, or broad categories, of the social
environment. Each dimension is subdivided into various components.
<http://www.cdc.gov/cvh/library/data_set_directory/index.htm>

**[Osteoporosis]{.underline}** **(see also Elder Care News, above)**

**Surgeon General encourages bone health throughout the lifespan**

Bone Health and Osteoporosis: A Report of the Surgeon General presents
scientific evidence related to the prevention, assessment, diagnosis,
and treatment of bone disease and provides a tool for educating
Americans about how they can promote bone health throughout their lives.
The report, commissioned by Congress, was initiated by a federal
interagency work group, followed by a Surgeon General\'s Workshop
convened in December 2002.

Experts from across the country provided guidance and insights. The
report presents information on the magnitude of the problem, challenges
in diagnosis and treatment, the impact of disease on minority
populations, promising prevention strategies, how to improve
professional education and promote public awareness, and ways to enhance
access to key health services. The report is intended for use by
policymakers; national, state, and local public health officials; health
system leaders; health professionals; community advocates; and
individuals. The executive summary and full report, along with other
relevant materials, are available at
[[http://www.surgeongeneral.gov/library/bonehealth]{.underline}](http://www.surgeongeneral.gov/library/bonehealth)

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

**Seat Belt Use During Pregnancy: Patient Education**

<http://www.aafp.org/afp/20041001/1313ph.html>

**Antibiotics: When They Can and Can\'t Help**

<http://www.aafp.org/afp/20041001/1345ph.html>

**[Primary Care Discussion Forum]{.underline}**

## November 1, 2004:  Violence against Native women 

Moderator: Terry Cullen

This discussion will include:

-scope of violence against Native women

-tools for patient evaluation

-best practice policies and procedures

-ideas about available resources.

**February 1, 2005:  Surgery for obesity?**

Moderator: Hope Baluh

This discussion will include:

-Is it time for Obesity Surgery in the IHS?

-How are primary care providers addressing the obesity epidemic now?

-Would non-surgical programs to address this issue be safer? easier?
more effective?

-Cost effectiveness\... what\'s cheaper? What about results?

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

Subscribe to the Primary Care listserv

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

Unsubscribe from the Primary Care listserv

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

Questions on how to subscribe, contact <nmurphy@anmc.org> directly

**[Barbara Stillwater]{.underline}**

**Is your diabetic patient non-adherent? Maybe she is depressed?**

CONCLUSIONS: In a primary care population, diabetes self-care was
suboptimal across a continuum from home-based activities, such as
healthy eating, exercise, and medication adherence, to use of preventive
care. Major depression was mainly associated with patient-initiated
behaviors that are difficult to maintain (e.g., exercise, diet,
medication adherence) but not with preventive services for diabetes.

Lin EH, et al. Relationship of depression and diabetes self-care,
medication adherence, and preventive care. Diabetes Care. 2004
Sep;27(9):2154-60

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15333477>

**Doctors\' Interpersonal Skills Valued More than Their Training or
Being Up-to-Date**\
U.S. adults believe it is extremely important for their doctors to have
strong interpersonal skills such as being respectful (85%) and listening
carefully to health care concerns and questions (84%), though they also
value highly good medical judgment (80%)
[http://www.harrisinteractive.com/news/newsletters/wsjhealthnews/WSJOnline_HI_Health-CarePoll2004vol3_iss19.pdf](http://www.magnetmail.net/ls.cfm?r=12268528&sid=284444&m=58193&u=AHA_HFSF_1&s=http://www.harrisinteractive.com/news/newsletters/wsjhealthnews/WSJOnline_HI_Health-CarePoll2004vol3_iss19.pdf)

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

**Updated Diabetes in Pregnancy Management Guidelines Available**

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/DMPreg102504_002.doc>

There are several upcoming **Conferences**

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

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

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

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

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

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

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

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

**20th Annual Midwinter Conference**

-   For providers caring for Native women and children

-   February 25 - 27, 2005 **Final dates**

-   Telluride, CO
    <http://www.ihs.gov/MedicalPrograms/MCH/M/ConfDnlds/Tellurideagenda10-2004.doc>

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

**\
17th Annual IHS Research Conference: International Meeting on Inuit and
Native American Child Health: Innovations in clinical care and
research**

> April 29-May 1, 2005, Seattle, WA

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

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

-   June 19 - 23, 2005

-   Denver, CO

-   Contact [Yvonne Malloy](mailto:YMalloy@acog.org) YMalloy@acog.org

-   [2004
    Brochure](http://www.ihs.gov/MedicalPrograms/MCH/M/ConfDnlds/Brochure2004.doc)
    (WORD 252k) NB: still 2004 info

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

-   June 19th at 8:00 am: NEONATAL RESUSCITATION PROGRAM

```{=html}
<!-- -->
```
-   NRP Class size limited. Sign up now NB: still 2004 info (WORD 24k)

> <http://www.ihs.gov/MedicalPrograms/MCH/M/ConfDnlds/NeonatalResuscitationProvider.doc>

-   Meeting Website

> <http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#June05>

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

The **September 2004 OB/GYN CCC Corner** is available at:\
<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCCorner92104.doc>

Here is the September Table of Contents

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

Overview of the WISEWOMAN Projects: Health Promotion for Disadvantaged
Women

[From your colleagues:]{.underline} page 3

From Biennial Women's Health / MCH Meeting: Multiple slide sets
presented

**From George Gilson:** New Perinatology Corner module: Free CME / CEUs
from IHS - Preterm Labor and Preterm Premature Rupture of Membranes

From Sandy Haldane: Save the dates - AWHONN 2005 Convention **June
11-15, 2005 Salt Lake City, UT**

**From Steve Holve:** September Indian Child Health Notes

**From Jane Powers**: Office for Victims of Crime - Child Abuse Project

**From Lori de Ravello**: Focus groups of Y-K Delta Alaska Natives:
attitudes toward tobacco use and tobacco dependence interventions

**From Laura Shelby:** **CDC, Sexually Transmitted Disease Training
Log;** Starting a School-Based Chlamydia Screening and Treatment Program

From Judy Thierry: You Need to...Prepare for the Baby's Arrival- New
poster; Tobaccco Cessation PCC+ form available online; March of Dimes
PeriStats Web Site: Your online source for perinatal statistics; LEARN
about perinatal periods of risk and National Fetal and Infant Mortality
Review City MatCH / Healthy Start

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

**Obstetrics:** **page 7**

Treatment for cervical intraepithelial neoplasia and risk of preterm
delivery; Outpatient cervical ripening: Successful; Use of Vitamins
Containing Folic Acid Among Women of Childbearing; Delaying Epidural Not
Necessary During Labor; Resistance exercise may help to avoid insulin
therapy for overweight women with GDM; Intracervical (rather than
posterior fornix) placement of dinoprostone decreases time to delivery;
**Venlafaxine Associated With Neonatal Complications**; Complementary
and alternative medicine for labor pain

**Gynecology:** **page 8**

LEEP - not the best for treating young women who have not completed
reproduction; JCAHO Sentinel events: Major issues -- Communication,
teamwork, and staff competency; Surgical Prophylaxis: Start early and
keep it simple; Start GYN prophylaxis 60 minutes prior to surgery;

GYN surgery involving the rectum or colon: Prophylaxis; Pelvic floor
physiotherapy is effective treatment for persistent postnatal SUI;
Estimating blood loss: can teaching significantly improve visual
estimation? High intrauterine pressure improves success in thermal
balloon endometrial ablation; Serious complications associated with
global endometrial ablation not yet reported;

Stress urinary incontinence affects one third of adult women and is
usually reduced or eliminated with either nonsurgical or surgical
therapy; Self-testing for human papillomavirus (HPV) DNA is feasible for
cervical cancer screening; Efficacy of Cone Biopsy of the Uterine Cervix
During Frozen Section for the Evaluation of Cervical Intraepithelial
Neoplasia Grade 3

**Child Health:** **page 11**

No benefit seen for suctioning meconium-stained newborns; Role of
vaginal douching in the reproductive health of adolescents and young
women; Whole environment intervention improves asthma associated
morbidity in children; SIDS Resource kits available; Protecting our
children from environmental hazards in the face of limited data

**Chronic Illness and Disease:** **page 12**

Tamoxifen for breast cancer prevention: a framework for clinical
decisions; New cholesterol guidelines pose a challenge for doctors and
patients; Broken Promises - What is the status of American Indian /
Alaska Native Health?

[Features:]{.underline} page 14

AFP: Misoprostol Therapy for Incomplete Abortion; Estrogen Sources Have
Similar Effects; Women Have Greater Analgesia from Butorphanol than
Morphine; Genital Herpes: Clinical Evidence Concise; Making Decisions
with Families at the End of Life

**ACOG:** Management of Postterm Pregnancy; Guidelines for Diagnostic
Imaging During Pregnancy

**AHRQ:** The Worst Headache: Web M + M; Treatment of high cholesterol
in women should be based on all risk factors for heart disease, not just
lipid levels; Child abuse is associated with increased risk of death in
young children with abdominal injuries; Women who undergo hysterectomy
for abnormal uterine bleeding report improved health-related quality of
life

**Breastfeeding:** Babies Were Born to Be Breastfed: Few Babies
Breastfed Long; Breastfeeding Protects Against Asthma and Atopy

**Domestic Violence:** Health Cares About Domestic Violence Day: October
13^th^; The Legacy of Child Maltreatment: Long-Term Health Consequences
for Women

**Elder Care News:** Effect of Raloxifene on the Incidence of Elevated
Low Density Lipoprotein

**Family Planning:** Emergency Contraception

**Frequently asked questions:** Should we perform routine urine dipstick
protein screening in our prenatal clinic?

**Hormone Replacement Update**: One our four women who attempt to stop
HRT are unsuccessful

**Information Technology:** Ten Questions to Ask Before Buying an
Electronic Medical Record

**International Health:** [Routine cervical cancer screening constitutes
nearly two thirds of total annual cervical HPV-related health care
costs](http://mdconsult.chtah.com/a/hBBJLAOAPMgn1ASgjDSAPMu5kLK/curb17);
Sprawl: The New Manifest Destiny? Health Effects

**MCH Alert:** New Report Maps Women's Health in the U.S.; A new
PeriStats database and Web interface increases access to detailed MCH
data in US; New ways to measure quality in Child Health Programs -
Toolbox, AHRQ

######### Medscape: Safety and Efficacy of Testosterone in Menopausal Women: Restoring Sexual Desire

**Office of Women's Health, CDC:** Can Changes in Sexual Behaviors Among
High School Students Explain the Decline in Teen Pregnancy Rates in the
1990s?

Osteoporosis: Vitamin D and Derivatives Should Not Be Administered
Concurrently With Doxercalciferol

**Patient Education:** Emergency Contraception; End-Of-Life Choices for
Families; Management of Gestational Diabetes Mellitus and Pharmacists\'
Role in Patient Education

**Primary Care Discussion Forum:** November 1, 2004: Violence against
Native women

**Barbara Stillwater, Alaska Diabetes Prevention and Control:** Weight
predicts diabetes; Soda Increases Risk of Diabetes 83%; New Diet
Guidelines Call for More Exercise and Grains; Diabetes Triples Risk of
Heart Failure for Women; Health Disparities among Minority and
Underserved Women**;** NIH: School Based Interventions to Prevent
Obesity

#### What's new on the ITU MCH web pages: 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>

or 907 729 3154 (with voicemail)

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

10/29/04