# ![](media/image1.jpeg){width="5.992361111111111in" height="1.33125in"} {#section .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

 

Chief Clinical Consultant's Corner

Volume 6, No. 12; December 2008/January 2009

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

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

-Are all aromatase inhibitors alike?

-Hormone Therapy in Breast Cancer---An Overview from IHS Experts

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

#### David Boyd {#david-boyd .Style-Heading-4-+-Arial-14-pt-Underline}

-Tribal Alcohol Screening and Brief Intervention (ASBI) Program

Scott Giberson

-Indian Health Service HIV Testing Guidance and Resources are now
available on-line

-Funding Opportunity: Comprehensive Alcohol Research Center on HIV/AIDS

#### Myra Tucker, CDC {#myra-tucker-cdc .Style-Heading-4-+-Arial-14-pt-Underline}

-Maternal and Child Health Journal Issue Dedicated to AI/AN Mothers and
Children

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

##### Obstetrics

-Excess gestational weight gain and macrosomia risk

-Gestational weight gain and gestational diabetes mellitus: perinatal
outcomes

-Pregnancy and fertility following bariatric surgery: a systematic
review

-Perinatal outcomes in the setting of active phase arrest of labor\
-Association between vitamin D deficiency and primary cesarean section

**Gynecology**

-Clinical practice guidelines on vaginal graft use

-Probability of hysterectomy after endometrial ablation

-Dual prophylaxis for venous thromboembolism prevention in gynecologic
cancer patients

-Effectiveness of tension-free vaginal tape compared with transobturator
tape

-A 12-month prospective evaluation of transcervical sterilization using
implantable polymer matrices (Essure)

**Child Health**

-Increased Risk of Adverse Neurological Development for Late Preterm
Infants

-Risk factors for unintentional injuries in children: are grandparents
protective?

-Effect of breastfeeding duration on lung function at age 10 years

-Parental alcohol screening in pediatric practices

-Early antiretroviral therapy and mortality among HIV-infected infants

**Chronic Illness and Disease**

-1 in 25 older Americans at risk for serious medication interaction

-General and abdominal adiposity and risk of death in Europe

-Metformin, sulfonylureas, or other antidiabetes drugs and the risk of
lactic acidosis or hypoglycemia

-Effect of fibre, antispasmodics, and peppermint oil in the treatment of
irritable bowel syndrome

-Genotype score in addition to common risk factors for prediction of
type 2 diabetes\
-Clinical risk factors, DNA variants, and the development of type 2
diabetes

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

American College of Obstetricians and Gynecologists

-Hormone Therapy and Heart Disease

-Antibiotic Prophylaxis for Infective Endocarditis

-At-risk drinking and illicit drug use: ethical issues in obstetric and
gynecologic practice

-Management of Abnormal Cervical Cytology and Histology

-Sonohysterography

**Agency for Healthcare Research and Quality**

-Depression symptoms are similar in pregnant and nonpregnant women

-Correlates of medical and legal help seeking among women reporting
intimate partner violence

-Education and physical activity among American Indian elders

### -Recent U.S. Food and Drug Administration (FDA) Advisory; Oral Sodium Phosphate (OSP) Products for Bowel Cleansing 

**Ask a Librarian**

**Behavioral Health Insights**

-Suicide and Antiepileptics -- Real Concerns?

**Breastfeeding**

-Herbal Galactogogues

**CCC Corner Digest**

**Domestic Violence**

-Office of Violence against Women Fact Sheet

-Breaking the barriers: the promise of computer-assisted screening for
intimate partner violence

**Elder Care News**

-Intensive Case-Based Training in Palliative Care

**Family Planning**

-Contraceptive nonuse among US women at risk for unplanned pregnancy

-Levonorgestrel-releasing intrauterine device better than OCPs in
metabolic and inflammatory outcomes

**Featured Website**

Improved healthfinder.gov makes health information quicker and easier to
use

**Frequently asked questions**

-Q. Should I withhold contraception from a woman who is not 'current' on
her pap?\
**Indian Child Health Notes**

-Etiquette-Based Medicine

-Changes to the Pneumococcal Polysaccharide Vaccination (PPV23)
Recommendation

-A Collaborative School-Based Oral Health Program

-A Tribute to Dr. Roger Gollub

International Health

-Warfare and neglected diseases

#### MCH Alert

-Diabetes Curriculum for Improved Care of among American Indians and
Alaska Natives

-2008 Edition of Women's Health Data Book Released

-MCH Library Releases Online Resource Brief on Women's Health

-AAP Updates Training on Safer Sleep Environments to Prevent Sudden
Infant Death Syndrome

-The Scientific Basis for Maternity Practice

-The Effects of Contact with Stillborn Infants on Maternal Anxiety and
Depression

#### MCH Headlines

-Project Making Medicine

-2009 Childhood Obesity Conference: Creating Healthy Places for All
Children

-Breastfeeding Initiation DVD Resource

-Max's Magical Delivery Fit for Kids

#### Medical Mystery Tour

-Test your knowledge on Polycystic Ovarian Syndrome (PCOS); The Answers

#### MedScape

**Menopause Management**

-Cigarette smoking, androgen levels, and hot flushes in midlife women

-Testosterone for low libido in postmenopausal women not taking estrogen

**Midwives Corner**

-Midwifery care unequivocally supported and recommended by Cochrane
Review

**Navajo News**

-Navajo Area Women's Health Provider Meeting

#### -Navajo Nation Passes "Healthy Start Act"; Requires Workplaces to Accommodate Breastfeeding {#navajo-nation-passes-healthy-start-act-requires-workplaces-to-accommodate-breastfeeding .Style-Heading-4-+-Arial-14-pt-Underline}

**Nurses Corner**

-Registered nurses are key to preventing medical errors during critical
care

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

-Condoms and STDs: Updated Fact Sheet for Public Health Personnel

-Biomarker Test Not Ready for Routine Clinical Use

-Assessing the Burden of HPV-Associated Cancers in the United States

-Human Papillomavirus (HPV) Vaccine Safety

Patient Education

-Interactive Media Laboratory---Smoking Cessation for Pregnancy and
Beyond

Perinatology Picks

-Labor before a primary cesarean delivery: reduced risk of uterine
rupture

-Methods of Delivering the Placenta at Caesarean Section

-External cephalic version-related risks: a meta-analysis\
-A systematic review of the role of intrapartum hypoxia-ischemia in the
causation of neonatal encephalopathy

Primary Care Discussion Forum

-A summary of the recent discussion forum on geriatric medication issues

STD Corner

-Partner services programs for HIV infection, syphilis, gonorrhea, and
Chlamydia infection

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

# -QuickStats: Percentage of Large-for-Gestational-Age\* Births

**Women's Health Headlines**

-Sexual Assault Response Team training available

#### -"What's new in PubMed on adolescent dating violence" {#whats-new-in-pubmed-on-adolescent-dating-violence .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### 

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

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

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

**Are all aromatase inhibitors alike?**

The anti-estrogen tamoxifen was the gold-standard adjuvant therapy for
hormone-receptor-positive (HR+) early breast cancer for several decades,
but has recently been displaced by the third-generation aromatase
inhibitors (AIs). Three AIs are commercially available: letrozole,
anastrozole and exemestane. All are more effective and at least as well
tolerated as tamoxifen as adjuvant therapy for HR+ breast cancer in
postmenopausal women. Despite the wealth of data comparing AIs with
tamoxifen, it is unclear whether the three AIs are clinically
equivalent, owing to the lack of head-to-head trials directly comparing
them. Preclinical and small clinical studies suggest that letrozole is
the most potent inhibitor of aromatase, reducing circulating estrogen
levels to a greater degree than the other agents. However, whether this
greater activity translates into superior clinical efficacy remains to
be determined. In the absence of direct comparative data, cross-trial
comparisons have been used to gain insights into any safety or efficacy
differences. All three AIs have been compared directly with tamoxifen,
and efficacy relative to tamoxifen has been compared across trials,
although such analyses are complicated by differences in treatment
schedules, patient populations and trial designs. Definitive conclusions
cannot yet be drawn, but some important differences are coming to light,
with upfront letrozole appearing particularly effective at preventing
early distant metastasis, an event strongly associated with
breast-cancer-related death. No safety differences between the AIs have
yet been identified. This article explores the pharmacologic and
clinical differences between the AIs, based on data from clinical and
preclinical studies.

Blackwell KL. Are all aromatase inhibitors alike? Breast Cancer Res
Treat. 2008 Dec 20. \[Epub ahead of print\]
<http://www.ncbi.nlm.nih.gov/pubmed/19101793>

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

We are fortunate to have guest editorialists for this issue who are
experts in the treatment of breast cancer. Laura Tillman, MD and Shannon
Myers, FNP direct a Breast Clinic at Phoenix Indian Medical Center that
is a model practice within the IHS. They have provided the following
overview of Hormone Therapy in Breast Cancer for your consideration.

**Hormone Therapy in Breast Cancer**

**SERMs -- Selective Estrogen Receptor Modulators and AIs - Aromatase
Inhibitors**

Hormone therapy is a form of systemic therapy for breast cancer. It can
be used as adjuvant therapy to reduce risk of recurrence but may also be
used for treatment in more advanced breast cancers. Selective Estrogen
Receptor Modulators (SERMs) and Aromatase Inhibitors (AIs) are two main
classes of hormonal drugs used for breast cancer. Both SERMs and AIs are
used to treat estrogen receptor positive (ER+) breast cancer.

SERMs are selective estrogen-receptor modulators, or drugs that block
the naturally circulating estrogen in breast tissues and other
estrogen-sensitive tissues in your body. SERMs are called \"selective\"
because they bind to particular estrogen receptors. This selective
binding action is sometimes called estrogen inhibition, or estrogen
suppression. SERMs do not prevent the production of estrogen, but they
help to slow or stop the growth of estrogen-sensitive cancer cells by
starving them of a full dose of natural estrogen.

Tamoxifen was the first SERM produced, and has been in use for over 30
years. Initially, it was used in metastatic disease, but we now know
that it is effective in reducing recurrence of primary breast cancer and
improving overall survival in both postmenopausal and premenopausal
women. It has also been shown to reduce the incidence of recurrence of
breast cancer in the contralateral breast. Tamoxifen is prescribed for 5
years and there are now studies looking at the use of tamoxifen for even
longer periods of time. More recently, tamoxifen has been approved in
the United States as a prevention strategy for women at high risk for
developing breast cancer. However, it does have side effects. The most
serious side effects are blood clots, stroke, uterine cancer and
cataracts. The most common side effects are hot flashes and vaginal
dryness.

Aromatase Inhibitors have a different mechanism of action than SERMs.
AIs prevent estrogen production instead of blocking estrogen receptors
the way SERMs do. AIs reduce the amount of estrogen in the body. AIs do
not block estrogen production by the ovaries, but they can block other
tissues from making this hormone. That is why AIs are used in women who
are in
[menopause](http://www.nci.nih.gov/dictionary/db_alpha.aspx?expand=m#menopause),
when the ovaries are no longer producing estrogen. AIs may be used as a
first-line therapy or after treatment with tamoxifen. Currently, there
are three AIs approved by the U.S. Food and Drug Administration:
anastrazole (Arimidex), exemestane (Aromasin) and letrozole (Femara).
The most serious side effect is bone thinning (osteoporosis). The most
common side effects are hot flashes and body aches.

For more information about the use of SERMs and AIs and about breast
cancer in American Indian and Alaska Native women, please consult the
articles below or contact Dr. Tillman or Ms. Myers at Phoenix Indian
Medical Center. <Laura.Tillman@ihs.gov>; <Shannon.Myers@ihs.gov>.

Carpenter R. Choosing early adjuvant therapy for postmenopausal women
with hormone-sensitive breast cancer: aromatase inhibitors versus
tamoxifen. Eur J Surg Oncol. 2008 Jul;34(7):746-55. Epub 2008 Mar 4.
<http://www.ncbi.nlm.nih.gov/pubmed/18296017>

Buijs C, de Vries EG, Mourits MJ, Willemse PH. The influence of
endocrine treatments for breast cancer on health-related quality of
life. Cancer Treat Rev. 2008 Nov;34(7):640-55. Epub 2008 Jun 2.
<http://www.ncbi.nlm.nih.gov/pubmed/18514425>

Breast International Group (BIG) 1-98 Collaborative Group, Thürlimann B,
Keshaviah A, Coates AS, Mouridsen H, Mauriac L, et al. A comparison of
letrozole and tamoxifen in postmenopausal women with early breast
cancer. N Engl J Med. 2005 Dec 29;353(26):2747-57.
<http://www.ncbi.nlm.nih.gov/pubmed/16382061>

Wingo PA, King J, Swan J, Coughlin SS, Kaur JS, Erb-Alvarez JA,
Jackson-Thompson J, Arambula Solomon TG. Breast cancer incidence among
American Indian and Alaska Native women: US, 1999-2004. Cancer. 2008 Sep
1;113(5 Suppl):1191-202.

<http://www.ncbi.nlm.nih.gov/pubmed/18720389>

Tillman L, Myers S, Pockaj B, Perry C, Bay RC, Al-kasspooles M. Breast
cancer in Native American women treated at an urban-based Indian health
referral center 1982-2003. Am J Surg. 2005 Dec;190(6):895-902.
<http://www.ncbi.nlm.nih.gov/pubmed/16307942>

Flum DR, Stuart S, Wilcox M. Processes and outcomes of care among Navajo
women with breast cancer. JAMA. 2003 Oct 15;290(15):1996-7.
<http://www.ncbi.nlm.nih.gov/pubmed/14559952>

Free Full Text:
<http://jama.ama-assn.org/cgi/content/full/290/15/1996-a>

MedScape CME: Comprehensive Breast Care: An Update for the Menopause
Practitioner <http://www.medscape.com/viewprogram/17686>

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

#### David Boyd, HQE {#david-boyd-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**Tribal Alcohol Screening and Brief Intervention (ASBI) Program**

American Indians and Alaska Natives suffer far higher rates of
alcohol-related injuries and deaths than any other racial or ethnic
group. Trauma remains the largest cause of death and disability in
Indian country, especially in those between 15 and 44 years of age. The
ASBI program was developed to help young adults who are at high risk for
alcohol-related injuries understand the connection between their
drinking and their current injury or medical problem.

**WHAT IS ASBI?**

ASBI uses alcohol screening, brief feedback, and motivational
interviewing with young adults who arrive in Indian Health Service (IHS)
trauma centers, emergency rooms, or primary care clinics with an
alcohol-related injury. Intervention at these "teachable moments" can
interrupt the alcohol--injury cycle that causes so much personal,
family, and community suffering.

**WHO CAN PERFORM ASBI?**

ASBI can be performed by any trained healthcare provider, including
physicians, nurses, social workers, and community health educators. The
skills needed are compassionate, nonjudgmental listening and the ability
to guide patients to the connection between their alcohol consumption
and their injury.

**WHO DOES ASBI TARGET?**

Alcohol use occurs on a continuum, ranging from people who abstain to
people who are physically dependant. The ASBI program serves a specific
subset of people----hazardous and harmful drinkers---- who obtain
medical care in IHS hospitals or clinics. The National Institute of
Alcohol Abuse and Alcoholism estimates that 20% of the U.S. population
are hazardous/harmful drinkers (see Figure 1). Because the rate of
injury and death from alcohol-related incidents is much higher in
American Indian and Alaska Natives, the impact of this program on the
behavior of hazardous/harmful drinkers can be enormous.

![](media/image2.jpeg){width="6.197916666666667in"
height="1.1875in"}Figure 1: Percent of people in the U.S. who are
hazardous/harmful drinkers.

**WHAT ARE THE GOALS OF ASBI?**

The primary goal of this program is to reduce injuries and deaths in
American Indians and Alaska Natives by teaching them to take action to
reduce their risks from harmful or hazardous drinking. ASBI screening
and intervention helps reduce repeat visits to hospitals due to
alcohol-related injuries and decreases health disparities in behavioral
health and chronic diseases. The ASBI program also reduces
harmful/hazardous drinking in patients who go to primary health clinics
with minor alcohol-related injuries.

**HOW MUCH TIME DOES ASBI TAKE?**

The screening and intervention process takes only 4--14 minutes. First,
healthcare providers use the 3-question AUDIT-C tool to identify harmful
or hazardous drinkers. Next, the Yale Brief Negotiated Interview is
conducted to raise the subject of drinking, provide feedback, enhance
motivation, and negotiate possible behavior change. This process results
in a written drinking agreement for motivated patients. Many ASBI
programs also use a letter, phone call, or follow-up visit to boost the
effectiveness of the intervention.

**HOW EFFECTIVE IS ASBI?**

A large randomized controlled trial at a level 1 trauma center of
injured persons who tested positive for alcohol use revealed that
alcohol use was initially reduced in both the control and intervention
groups at 6 months but remained reduced in the brief intervention group
at 1 year.

![](media/image3.jpeg){width="5.770833333333333in"
height="2.4791666666666665in"}

**WHAT ARE THE NEXT STEPS?**

The Indian Health Service has a 1.9 million service population, which
includes a considerable number of people who could benefit from this
effective program. In 2008, training of healthcare professionals in
program techniques will continue at national conferences and training
sessions. Plans to monitor program implementation and evaluate outcomes
in current settings are underway. For system-wide implementation, ASBI
needs additional funding, further recognition, local community support,
and spread to primary care and behavioral health clinics.

**For Additional Information Contact**: David R. Boyd, MDCM, FACS,
National Trauma Systems Coordinator; IHS Emergency Services; IHS; 801
Thompson Ave Suite 320; Rockville, MD  20852; <David.Boyd@ihs.gov>;
(301)443-1557

**Program Development and Support**: The IHS-Tribal ASBI Program was
developed by Dr. David Boyd, Dr. Anthony Dekker, and Dr. Jim Flaherty.
The program is fully endorsed by the Area Office Chief Medical Officers
and Behavioral Health Consultants and widely by clinicians throughout
the Service Unit Clinics. It has also been supported with consultation
and program assistance from National leaders in the field such as Dr.
Larry Gentilello, Dr. Carl Soderstrom, Dr. Daniel Hungerford, Dr. Janet
Selway, Dr. Carol Scumer, Dr. Gail D'Onofrio, Dr. Linda Degutis, Dr.
Susan Boyd, and Ms. Carol Rottenbiller

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

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

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

**Indian Health Service HIV Testing Guidance and Resources are now
available on-line**

The IHS HIV Program is now able to provide guidance as well as other
resources and templates for use by health care clinics to move forward
in advancing HIV services toward more universal HIV testing. Many
questions often arise about guidance from IHS regarding HIV testing. As
we begin to develop more sites and clinics with successful HIV testing
practices, we are able to formulate guidance to assist with
implementation, advocacy and awareness. Please refer to the following
url within the IHS HIV Website:
<http://www.ihs.gov/MedicalPrograms/HIVAIDS/index.cfm?module=testing&option=ihsGuidance>
.

Once you have clicked on this page, additional resources can be found by
navigating through the top box which lists:  "More HIV Testing and
Guidance Information".  

**Funding Opportunity: Comprehensive Alcohol Research Center on
HIV/AIDS**

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) is
soliciting applications for funding to launch a research center that
looks at the relationship between alcohol and HIV/AIDS.

The \$2-million [Comprehensive Alcohol Research Center on
HIV/AIDS](http://www.grants.gov/search/search.do?&mode=VIEW&flag2006=true&oppId=18206 )
grant will support establishment of a research center that \"is
multidisciplinary, thematically integrated, synergistic, and will serve
as a national resource for NIAAA,\" according to the grant announcement.

\"NIAAA seeks to encourage basic research that can be translated into
interventions in order to reduce infection and transmission of HIV,\"
the agency noted. \"NIAAA will give highest priority to research that
will develop and test biomedical prevention technologies that apply
basic knowledge of HIV infection to intervention strategies for
preventing the spread of HIV between individuals and within communities
in the context of alcohol use; and develop knowledge of the interaction
between alcohol and new agents or drug regimens to prevent and treat
comorbidities and comortalities (malignancies, liver and cardiovascular
diseases, metabolic disorders, and other complications) associated with
long-term HIV disease and antiretroviral treatment in the context of
alcohol use.\" 
<http://www.jointogether.org/news/funding/opportunities/2008/comprehensive-alcohol.html>

Nonprofits, for-profit entities, schools, governments, and others may
apply. Application deadline is May 1, 2009.

For full details, see the [grant announcement
online](http://grants.nih.gov/grants/guide/rfa-files/RFA-AA-09-002.html).

#### Myra Tucker, CDC {#myra-tucker-cdc-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Maternal and Child Health Journal Issue Dedicated to AI/AN Mothers and
Children**

The first *Maternal and Child Health Journal* issue dedicated to AI/AN -
*Research for Maternal and Child Health Practice in American Indian and
Alaska Native Communities* - was published recently. \"It has been the
realization of a dream to bring this journal issue to fruition,\"
explains Myra Tucker, BSN, MPH (CAPT USPHS), and tribal liaison in the
Division of Reproductive Health (DRH). Working with journal editors and
authors to produce this special issue has been a natural partnership for
DRH, which conducts a broad range of surveillance, research, and
programmatic activities to develop the evidence base for improving
maternal and infant health in the US.

Questions? Contact Ms. Tucker at <mjt2@cdc.gov>.

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

#### Obstetrics {#obstetrics-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Excess gestational weight gain: modifying fetal macrosomia risk
associated with maternal glucose**

OBJECTIVE: To estimate how maternal weight gain and maternal glucose
relate to fetal macrosomia risk (greater than 4,000 g) among a
population universally screened for gestational diabetes mellitus (GDM).

METHODS: Between 1995 and 2003, 41,540 pregnant women in two regions
(Northwest/Hawaii) of a large U.S. health plan had GDM screening using
the 50-g glucose challenge test; 6,397 also underwent a 3-hour, 100-g
oral glucose tolerance test. We assessed the relationship between level
of maternal glucose with glucose screening and fetal macrosomia risk
after adjustment for potential confounders, including maternal age,
parity, and ethnicity and sex of the newborn. We stratified by maternal
weight gain (40 lb or fewer compared with more than 40 lb) because
excessive maternal weight gain modified results.

RESULTS: Among women with both normal and abnormal GDM screenings,
increasing level of maternal glucose was linearly related to macrosomia
risk (P\<.001 for trend in all groups). Women with excessive weight gain
(more than 40 lb) had nearly double the risk of fetal macrosomia for
each level of maternal glucose compared with those with gestational
weight gain of 40 lb or fewer. For example, among women with normal
post-glucose challenge test glucose levels (less than 95 mg/dL) and
excessive weight gain, 16.5% had macrosomic newborns compared with 9.3%
of women who gained 40 lb or fewer. Moreover, nearly one third of women
(29.3%) with GDM who gained more than 40 lb had a macrosomic newborn
compared with only 13.5% of women with GDM who gained 40 lb or fewer
during pregnancy (P=.018).

CONCLUSION: Excessive pregnancy weight gain nearly doubles the risk of
fetal macrosomia with each increasing level of maternal glucose, even
among women with GDM.

Hillier TA, Pedula KL, Vesco KK, Schmidt MM, Mullen JA, LeBlanc ES,
Pettitt DJ. Excess gestational weight gain: modifying fetal macrosomia
risk associated with maternal glucose. Obstet Gynecol. 2008
Nov;112(5):1007-14. <http://www.ncbi.nlm.nih.gov/pubmed/18978099>

**Gestational weight gain and gestational diabetes mellitus: perinatal
outcomes**

OBJECTIVE: To examine the association between gestational weight gain
and perinatal outcome in women with gestational diabetes mellitus (GDM).

METHODS: This is a retrospective cohort study of women with nonanomalous
singleton pregnancies with GDM enrolled in the Sweet Success California
Diabetes and Pregnancy Program between 2001 and 2004. Gestational weight
gain, calculated from prepregnancy weight and weight at last prenatal
Sweet Success visit, was subgrouped into below, within, and above the
Institute of Medicine (IOM) weight-gain guidelines. Perinatal outcomes
were examined using chi2 test and multivariable regression analysis with
15-35-lb weight gain as the reference group. RESULTS: There were 31,074
women meeting study criteria. Compared with women with gestational
weight gain within the IOM guidelines, women who gained above the
guidelines had higher odds of having large for gestational age neonates
(adjusted odds ratio \[aOR\] 1.72, 95% confidence interval \[CI\]
1.53-1.93, number needed to harm 10), preterm delivery (aOR 1.30, 95% CI
1.14-1.48, number needed to harm 32), and primary cesarean delivery (aOR
1.52, 95% CI 1.26-1.83, number needed to harm 10). Women who gained
below the guidelines had higher odds of having small for gestational age
neonates (aOR 1.39, 95% CI 1.01-1.90) and maintaining diet-controlled
GDM (aOR 1.47, 95% CI 1.34-1.63) and lower odds of having large for
gestational age neonates (aOR 0.60, 95% CI 0.52-0.67).

CONCLUSION: Women diagnosed with GDM who had gestational weight gain
above the IOM guidelines have higher risk of undesirable outcomes,
including preterm delivery, having macrosomic neonates, and cesarean
delivery. Women who gained below guidelines are more likely to remain on
diet control but have small for gestational age neonates.

Cheng YW, Chung JH, Kurbisch-Block I, Inturrisi M, Shafer S, Caughey AB.
Gestational weight gain and gestational diabetes mellitus: perinatal
outcomes. Obstet Gynecol. 2008 Nov;112(5):1015-22.
<http://www.ncbi.nlm.nih.gov/pubmed/18978100>

**Pregnancy and fertility following bariatric surgery: a systematic
review**

CONTEXT: Use of bariatric surgery has increased dramatically during the
past 10 years, particularly among women of reproductive age.

OBJECTIVES: To estimate bariatric surgery rates among women aged 18 to
45 years and to assess the published literature on pregnancy outcomes
and fertility after surgery.

EVIDENCE ACQUISITION: Search of the Nationwide Inpatient Sample
(1998-2005) and multiple electronic databases (Medline, EMBASE,
Controlled Clinical Trials Register Database, and the Cochrane Database
of Reviews of Effectiveness) to identify articles published between 1985
and February 2008 on bariatric surgery among women of reproductive age.
Search terms included bariatric procedures, fertility, contraception,
pregnancy, and nutritional deficiencies. Information was abstracted
about study design, fertility, and nutritional, neonatal, and pregnancy
outcomes after surgery.

EVIDENCE SYNTHESIS: Of 260 screened articles, 75 were included. Women
aged 18 to 45 years accounted for 49% of all patients undergoing
bariatric surgery (\>50,000 cases annually for the 3 most recent years).
Three matched cohort studies showed lower maternal complication rates
after bariatric surgery than in obese women without bariatric surgery,
or rates approaching those of nonobese controls. In 1 matched cohort
study that compared maternal complication rates in women after
laparoscopic adjustable gastric band surgery with obese women without
surgery, rates of gestational diabetes (0% vs. 22.1%, P \< .05) and
preeclampsia (0% vs. 3.1%, P \< .05) were lower in the bariatric surgery
group. Findings were supported by 13 other bariatric cohort studies.
Neonatal outcomes were similar or better after surgery compared with
obese women without laparoscopic adjustable gastric band surgery (7.7%
vs. 7.1% for premature delivery; 7.7% vs. 10.6% for low birth weight, P
\< .05; 7.7% vs. 14.6% for macrosomia, P \< .05). No differences in
neonatal outcomes were found after gastric bypass compared with nonobese
controls (26.3%-26.9% vs. 22.4%-20.2% for premature delivery, P = not
reported \[1 study\] and P = .43 \[1 study\]; 7.7% vs. 9.0% for low
birth weight, P = not reported \[1 study\]; and 0% vs. 2.6%-4.3% for
macrosomia, P = not reported \[1 study\] and P = .28 \[1 study\]).
Findings were supported by 10 other studies. Studies regarding
nutrition, fertility, cesarean delivery, and contraception were limited.

CONCLUSION: Rates of many adverse maternal and neonatal outcomes may be
lower in women who become pregnant after having had bariatric surgery
compared with rates in pregnant women who are obese; however, further
data are needed from rigorously designed studies.

Maggard MA, Yermilov I, Li Z, Maglione M, Newberry S, Suttorp M, Hilton
L, Santry HP, Morton JM, Livingston EH, Shekelle PG. Pregnancy and
fertility following bariatric surgery: a systematic review. JAMA. 2008
Nov 19;300(19):2286-96. <http://www.ncbi.nlm.nih.gov/pubmed/19017915>

**Perinatal outcomes in the setting of active phase arrest of labor**\
OBJECTIVE: To examine the association between active phase arrest and
perinatal outcomes. METHODS: This was a retrospective cohort study of
women with term, singleton, cephalic gestations diagnosed with active
phase arrest of labor, defined as no cervical change for 2 hours despite
adequate uterine contractions. Women with active phase arrest who
underwent a cesarean delivery were compared with those who delivered
vaginally, and women who delivered vaginally with active phase arrest
were compared with those without active phase arrest. The association
between active phase arrest, mode of delivery, and perinatal outcomes
was evaluated using univariable and multivariable logistic regression
models. RESULTS: We identified 1,014 women with active phase arrest: 33%
(335) went on to deliver vaginally, and the rest had cesarean
deliveries. Cesarean delivery was associated with an increased risk of
chorioamnionitis (adjusted odds ratio \[aOR\] 3.37, 95% confidence
interval \[CI\] 2.21-5.15), endomyometritis (aOR 48.41, 95% CI
6.61-354), postpartum hemorrhage (aOR 5.18, 95% CI 3.42-7.85), and
severe postpartum hemorrhage (aOR 14.97, 95% CI 1.77-126). There were no
differences in adverse neonatal outcomes. Among women who delivered
vaginally, women with active phase arrest had significantly increased
odds of chorioamnionitis (aOR 2.70, 95% CI 1.22-2.36) and shoulder
dystocia (aOR 2.37, 95% CI 1.33-4.25). However, there were no
differences in the serious sequelae associated with these outcomes,
including neonatal sepsis or Erb\'s palsy. CONCLUSION: Efforts to
achieve vaginal delivery in the setting of active phase arrest may
reduce the maternal risks associated with cesarean delivery without
additional risk to the neonate.

Henry DE, Cheng YW, Shaffer BL, Kaimal AJ, Bianco K, Caughey AB.
Perinatal outcomes in the setting of active phase arrest of labor.
Obstet Gynecol. 2008 Nov;112(5):1109-15.

<http://www.ncbi.nlm.nih.gov/pubmed/18978113>

**Association between Vitamin D Deficiency and Primary Cesarean
Section**

Background: At the turn of the 20th century, women commonly died in
childbirth due to \"rachitic pelvis\". Although rickets virtually
disappeared with the discovery of the hormone \"vitamin\" D, recent
reports suggest vitamin D deficiency is widespread in industrialized
nations. Poor muscular performance is an established symptom of vitamin
D deficiency. The current US cesarean birth rate is at an all-time high
of 30.2%. We analyzed the relationship between maternal serum
25-hydroxyvitamin D \[25(OH)D\] status, and prevalence of primary
cesarean section.

Methods: Between 2005 and 2007, we measured maternal and infant serum
25(OH)D at birth, and abstracted demographic and medical data from the
maternal medical record, at an urban teaching hospital in Boston, USA,
with 2,500 births per year. We enrolled 253 women, of whom 43 (17%) had
a primary cesarean.

Results: There was an inverse association with having a cesarean section
and serum 25(OH)D levels. We found that 28% of women with serum 25(OH)D
\<37.5 nmol/L had a cesarean section, compared to only 14% of women with
25(OH)D \>/=37.5nmol/L (p=0.012). In multivariable logistic regression
analysis controlling for race, age, education level, insurance status,
and alcohol use, women with 25(OH)D \<37.5 nmol/L were almost 4 times as
likely to have a cesarean than women with 25(OH)D \>/=37.5 nmol/L (AOR
3.84; 95% CI 1.71 to 8.62).

Interpretation: Vitamin D deficiency was associated with increased odds
of primary cesarean section.

[Merewood
A](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Merewood A"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Mehta
SD](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Mehta SD"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
Chen TC, Bauchner H, Holick MF. Association between Vitamin D Deficiency
and Primary Cesarean Section. J Clin Endocrinol Metab. 2008 Dec 23.
\[Epub ahead of print\] <http://www.ncbi.nlm.nih.gov/pubmed/19106272>

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

**Clinical practice guidelines on vaginal graft use from the society of
gynecologic surgeons**\
OBJECTIVE: To develop guidelines regarding whether graft or native
tissue repair should be done in transvaginal repair of anterior,
posterior, or apical pelvic organ prolapse.

METHODS: The Society of Gynecologic Surgeons formed a work group to
develop evidence-based guidelines. Published data from 1950 to November
27, 2007, from the companion systematic review were reviewed to develop
guidelines on biologic and synthetic graft use compared with native
tissue repair in vaginal prolapse repair. The work group formulated
guidelines based on its overall assessment of the evidence. The approach
to grading the quality of evidence and the strength of recommendations
was based on a modification of the Grades for Recommendation Assessment,
Development, and Evaluation system.

RESULTS: It is suggested that native tissue repair remains appropriate
when compared with biologic graft use. Nonabsorbable synthetic graft use
may improve anatomic outcomes of anterior vaginal wall repair, but there
are trade-offs in regard to additional risks. The group suggests issues
that should be included in the preoperative counseling of patients in
whom clinicians propose to use a vaginally placed graft.

CONCLUSION: Based on the overall low quality of evidence, only weak
recommendations could be provided. This highlights the need for
practitioners to fully explain the relative merits of each alternative
and carefully consider patients\' values and preferences to arrive at an
appropriate decision. Future research is likely to change the estimates
in the net benefit and risk and the confidence around these assessments.

Murphy M; Society of Gynecologic Surgeons Systematic Review Group.
Clinical practice guidelines on vaginal graft use from the society of
gynecologic surgeons. Obstet Gynecol. 2008 Nov;112(5):1123-30.
<http://www.ncbi.nlm.nih.gov/pubmed/18978115>

FDA Public Health Notification: Serious Complications Associated with
Transvaginal Placement of Surgical Mesh in Repair of Pelvic Organ
Prolapse and Stress Urinary Incontinence

<http://www.fda.gov/cdrh/safety/102008-surgicalmesh.html>

**Probability of hysterectomy after endometrial ablation**

OBJECTIVE: To investigate risk factors for hysterectomy after
endometrial ablation.

METHODS: This was a retrospective cohort analysis of data from Kaiser
Permanente Northern California members, aged 25-60 years undergoing
endometrial ablation from 1999 to 2004 and collected through 2007. Risk
factors assessed included age, presence of leiomyomas, setting of
procedure (inpatient or outpatient), and type of endometrial ablation
procedure (first generation, radio frequency, hydrothermal, or thermal
balloon). Univariable and survival analyses were performed to identify
risk factors and estimate probability of hysterectomy.

RESULTS: From 1999 to 2004, 3,681 women underwent endometrial ablation
at 30 Kaiser Permanente Northern California facilities. Hysterectomy was
subsequently performed in 774 women (21%), whereas 143 women (3.9%) had
uterine-conserving procedures. Age was a significant predictor of
hysterectomy (P\<.001). Cox regression analysis found that compared with
women aged older than 45 years, women aged 45 years or younger were 2.1
times more likely to have hysterectomy (95% confidence interval
1.8-2.4). Hysterectomy risk increased with each decreasing stratum of
age and exceeded 40% in women aged 40 years or younger. Overall, type of
endometrial ablation procedure, setting of endometrial ablation
procedure, and presence of leiomyomas were not predictors of
hysterectomy. In analysis of individual procedure types, concomitant
myomectomy was associated with a decreased risk of hysterectomy for
patients receiving first-generation endometrial ablation (P=.002), and
outpatient location for hydrothermal endometrial ablation increased
hysterectomy risk (P\<.001).

CONCLUSION: Age is more important than type of procedure or presence of
leiomyomas in predicting subsequent hysterectomy after endometrial
ablation. Women undergoing endometrial ablation at younger than 40 years
of age are at elevated risk of hysterectomy, and rather than plateauing
within several years of endometrial ablation, hysterectomy risk
continues to increase through 8 years of follow-up.

Longinotti MK, Jacobson GF, Hung YY, Learman LA. Probability of
hysterectomy after endometrial ablation. Obstet Gynecol. 2008
Dec;112(6):1214-20. <http://www.ncbi.nlm.nih.gov/pubmed/19037028>

**A protocol of dual prophylaxis for venous thromboembolism prevention
in gynecologic cancer patients\
**OBJECTIVE: To evaluate a quality improvement protocol for venous
thromboembolism prevention in postoperative gynecologic cancer patients.

METHODS: On January 1, 2006, we initiated a universal protocol of dual
prophylaxis with sequential compression devices and three times daily
heparin (or daily low molecular weight heparin) until discharge in
gynecologic cancer patients having major surgery. Patients with both
malignancy and age over 60 years (or history of prior clot) were
discharged on 2 weeks of anticoagulant. Before January 2006, all
patients were given sequential compression devices starting before the
induction of anesthesia, continuing until discharge from the hospital.
Records of gynecologic cancer service patients admitted in 2005 and 2006
were reviewed, excluding patients with a history of heparin-induced
thrombocytopenia or those admitted on an anticoagulant. Any pulmonary
embolism or deep vein thrombosis diagnosed within 6 weeks of surgery was
identified. We performed chi2 and Wilcoxon rank sum tests as well as
multivariable regression analysis for confounders.

RESULTS: Six of the 311 women meeting inclusion criteria in 2006 (1.9%)
and 19 of 294 (6.5%) in 2005 had venous thromboembolism (odds ratio
0.33, 95% confidence interval 0.12-0.88, multivariable analysis
adjusting for baseline differences between the groups). Heparin was
given to 98.1% of patients in the hospital in 2006, and 91.1% of those
meeting high-risk criteria were discharged on an anticoagulant. No
differences in major bleeding complications were seen between years.

CONCLUSION: A protocol of dual prophylaxis with prolonged prophylaxis in
high-risk patients was successfully implemented and was associated with
a significant reduction in the rate of venous thromboembolism without
increasing bleeding complications.

Einstein MH, Kushner DM, Connor JP, Bohl AA, Best TJ, Evans MD, Chappell
RJ, Hartenbach EM. A protocol of dual prophylaxis for venous
thromboembolism prevention in gynecologic cancer patients. Obstet
Gynecol. 2008 Nov;112(5):1091-7.
<http://www.ncbi.nlm.nih.gov/pubmed/18978110>

**Effectiveness of tension-free vaginal tape compared with
transobturator tape in women with stress urinary incontinence and
intrinsic sphincter deficiency: a randomized controlled trial**

OBJECTIVE: To compare efficacy of transobturator tape with tension-free
vaginal tape (TVT) in the treatment of stress urinary incontinence in
women with intrinsic sphincter deficiency. METHODS: One hundred
sixty-four women diagnosed with urodynamic stress incontinence and
intrinsic sphincter deficiency with or without concomitant pelvic organ
prolapse repair were randomized to receive TVT or transobturator tape.
The primary outcome was the presence or absence of urodynamic stress
incontinence at 6 months postoperatively. Secondary outcomes were the
rate of operative complications, symptomatic stress incontinence
requiring further surgery, and quality-of-life questionnaires.

RESULTS: Of 180 women eligible to participate, 164 were enrolled and
underwent surgery. Of the 138 patients assessed at 6 months with
urodynamic studies, 14 of 67 (21%) had urodynamic stress incontinence in
the TVT group compared with 32 of 71 (45%) in the transobturator tape
group (P=.004), with nine women in the transobturator tape group having
repeat sling surgery compared with none in the TVT group. In the
intention-to-treat analysis, the incident rate difference for request of
repeat surgery was 9.7% (95% confidence interval \[CI\] 0-19.9); repeat
surgery would be requested in one of every six transobturator tape
procedures compared with 1 of every 16 TVT procedures. The risk ratio of
repeat surgery was 2.6 (95% CI 0.9-9.3) times higher in the
transobturator tape group.

CONCLUSION: Retropubic TVT is a more effective operation than the
transobturator tape sling in women with urodynamic stress incontinence
and intrinsic sphincter deficiency.

Schierlitz L, Dwyer PL, Rosamilia A, Murray C, Thomas E, De Souza A, Lim
YN, Hiscock R. Effectiveness of tension-free vaginal tape compared with
transobturator tape in women with stress urinary incontinence and
intrinsic sphincter deficiency: a randomized controlled trial. Obstet
Gynecol. 2008 Dec;112(6):1253-61.
<http://www.ncbi.nlm.nih.gov/pubmed/19037033>

**A 12-month prospective evaluation of transcervical sterilization using
implantable polymer matrices (Essure)**

OBJECTIVE: To evaluate placement efficacy and reliability of an
intratubal occlusion device for permanent contraception and to assess
tolerability and overall satisfaction.

METHODS: Seven hundred seventy women with known parity were recruited to
participate in a prospective, multicenter study. Bipolar, low-level
radiofrequency energy delivery and porous silicon inserts were used.
Inserts were placed bilaterally in the fallopian tube lumen. Subsequent
bilateral occlusion was assessed with hysterosalpingography.

RESULTS: Overall, bilateral placement success was achieved in 611 of 645
women (95%). Bilateral occlusion was confirmed in 570 of 645 (88.4%).
The 1-year pregnancy prevention rate as derived with life-table methods
was 98.9%.

CONCLUSION: This transcervical sterilization system offers an effective
contraceptive method, which was well tolerated and had a high
satisfaction rate.

[Vancaillie
TG](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Vancaillie TG"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Anderson
TL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Anderson TL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Johns
DA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Johns DA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus).
A 12-month prospective evaluation of transcervical sterilization using
implantable polymer matrices. Obstet Gynecol. 2008 Dec;112(6):1270-7.

<http://www.ncbi.nlm.nih.gov/pubmed/19037035>

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

**Increased Risk of Adverse Neurological Development for Late Preterm
Infants**

OBJECTIVE: To assess the risks of moderate prematurity for cerebral
palsy (CP), developmental delay/mental retardation (DD/MR), and seizure
disorders in early childhood.

STUDY DESIGN: Retrospective cohort study using hospitalization and
outpatient databases from the Northern California Kaiser Permanente
Medical Care Program. Data covered 141 321 children \>/=30 weeks born
between Jan 1, 2000, and June 30, 2004, with follow-up through Jun 30,
2005. Presence of CP, DD/MR, and seizures was based on International
Classification of Diseases, Ninth Revision codes identified in the
encounter data. Separate Cox proportional hazard models were used for
each of the outcomes, with crude and adjusted hazard ratios calculated
for each gestational age group.

RESULTS: Decreasing gestational age was associated with increased
incidence of CP and DD/MR, even for those born at 34 to 36 weeks
gestation. Children born late preterm were \>3 times as likely (hazard
ratio, 3.39; 95% CI, 2.54-4.52) as children born at term to be diagnosed
with CP. A modest association with DD/MR was found for children born at
34 to 36 weeks (hazard ratio, 1.25; 95% CI, 1.01-1.54), but not for
children in whom seizures were diagnosed. CONCLUSIONS: Prematurity is
associated with long-term neurodevelopmental consequences, with risks
increasing as gestation decreases, even in infants born at 34 to 36
weeks.

Petrini JR, Dias T, McCormick MC, Massolo ML, Green NS, Escobar GJ.
Increased Risk of Adverse Neurological Development for Late Preterm
Infants. J Pediatr. 2008 Dec 8. \[Epub ahead of print\]
<http://www.ncbi.nlm.nih.gov/pubmed/19081113>

**Risk factors for unintentional injuries in children: are grandparents
protective?**

OBJECTIVE: We sought to identify sociodemographic and familial
correlates of injury in children aged 2 to 3 years.

METHODS: The Healthy Steps data set describes 5565 infants who were
enrolled at birth in 15 US cities in 1996-1997 and had follow-up until
they were 30 to 33 months of age. Data were linked to medical claims
reporting children\'s medically attended office visits by age 30 to 33
months. Each claim was accompanied by a reason for the visit. An
analytical sample of 3449 was derived from the children who could be
effectively followed up and linked to medical charts. Missing data were
imputed by using multiple imputation with chained equations. The
analytical sample showed no systematic evidence of sample selection
bias. Multivariate logistic regression was used to determine the odds
ratios of injury events.

RESULTS: Odds of medically attended injuries were decreased for children
who received care from grandparents. Odds were increased for children
who lived where fathers did not co-reside or in households where the
parents never married. Statistical results were robust to the addition
of a variety of covariates such as income, education, age, gender, and
race.

CONCLUSIONS: Children are at higher risk for medically attended injury
when their parents are unmarried. Having grandparents as caregivers
seems to be protective. Household composition seems to play a key role
in placing children at risk for medically attended injuries.

Bishai D, Trevitt JL, Zhang Y, McKenzie LB, Leventhal T, Gielen AC,
Guyer B. Risk factors for unintentional injuries in children: are
grandparents protective? Pediatrics. 2008 Nov;122(5):e980-7.
<http://www.ncbi.nlm.nih.gov/pubmed/18977965>

**Effect of breastfeeding duration on lung function at age 10 years: a
prospective birth cohort study**

INTRODUCTION: The protective effects of breastfeeding on early life
respiratory infections are established, but there have been conflicting
reports on protection from asthma in late childhood. The association of
breastfeeding duration and lung function was assessed in 10-year-old
children.

METHODS: In the Isle of Wight birth cohort (n = 1456), breastfeeding
practices and duration were prospectively assessed at birth and at
subsequent follow-up visits (1 and 2 years). Breastfeeding duration was
categorised as \"not breastfed\" (n = 196); \"\<2 months\" (n = 243);
\"2 to \<4 months\" (n = 142) and \"\>or=4 months\" (n = 374). Lung
function was measured at age 10 years (n = 1033): forced vital capacity
(FVC), forced expiratory volume in 1 s (FEV(1)), FEV(1)/FVC ratio and
peak expiratory flow (PEF). Maternal history of asthma and allergy was
assessed at birth. The effect of breastfeeding on lung function was
analysed using general linear models, adjusting for birth weight, sex,
current height and weight, family social status cluster and maternal
education. RESULTS: Compared with those who were not breastfed, FVC was
increased by 54.0 (SE 21.1) ml (p = 0.001), FEV(1) by 39.5 (20.1) ml(p =
0.05) and PEF by 180.8 (66.1) ml/s (p = 0.006) in children who were
breastfed for at least 4 months. In models for FEV(1) and PEF that
adjusted for FVC, the effect of breastfeeding was retained only for PEF
(p = 0.04).

CONCLUSIONS: Breastfeeding for at least 4 months enhances lung volume in
children. The effect on airflow appears to be mediated by lung volume
changes. Future studies need to elucidate the mechanisms that drive this
phenomenon.

Ogbuanu IU, Karmaus W, Arshad SH, Kurukulaaratchy RJ, Ewart S. Effect of
breastfeeding duration on lung function at age 10 years: a prospective
birth cohort study. Thorax. 2009 Jan;64(1):62-6. Epub 2008 Nov 10.
<http://www.ncbi.nlm.nih.gov/pubmed/19001004>

**Parental alcohol screening in pediatric practices**

OBJECTIVES: Pediatricians are in an ideal position to screen parents of
their patients for alcohol use. The objective of this study was to
assess parents\' preferences regarding screening and intervention for
parental alcohol use during pediatric office visits for their children.

METHODS: A descriptive multicenter study that used 3 pediatric primary
care clinic sites (rural, urban, suburban) was conducted between June
2004 and December 2006. Participants were a convenience sample of
consecutively recruited parents who brought children for medical care.
Parents completed an anonymous questionnaire that contained
demographics; 2 alcohol-screening tests (TWEAK and Alcohol Use Disorders
Identification Test); and items that assessed preferences for who should
perform alcohol-screening, acceptance of screening, and preferred
interventions if the screening result was positive.

RESULTS: A total of 929 of 1028 eligible parents agreed to participate,
and 879 of 929 completed surveys that yielded sufficient data for
analysis. Most participants were mothers. A total of 101 of 879 parents
screened positive on either the TWEAK or the Alcohol Use Disorders
Identification Test. Parents with a negative alcohol screen
(alcohol-negative) were more likely than parents with a positive alcohol
screen (alcohol-positive) to report that they would agree to being asked
about their alcohol use. There were no significant differences in
preferences within alcohol-positive and alcohol-negative groups for
screening by the pediatrician or computer-based questionnaire. Most
preferred interventions for the alcohol-positive group were for the
pediatrician to initiate additional discussion about drinking and its
effect on their child, give educational materials about alcoholism, and
refer for evaluation and treatment. Alcohol-positive men were more
accepting than alcohol-positive women of having no intervention.

CONCLUSIONS: A majority of parents would agree to being screened for
alcohol problems in the pediatric office. Regardless of their alcohol
screen status, parents are accepting of being screened by the
pediatrician, a computer-based questionnaire, or a paper-and-pencil
survey. Parents who screen positive prefer that the pediatrician discuss
the problem further with them and present options for referral.

Wilson CR, Harris SK, Sherritt L, Lawrence N, Glotzer D, Shaw JS, Knight
JR. Parental alcohol screening in pediatric practices. Pediatrics. 2008
Nov;122(5):e1022-9. <http://www.ncbi.nlm.nih.gov/pubmed/18977952>

**Early antiretroviral therapy and mortality among HIV-infected
infants**

BACKGROUND: In countries with a high seroprevalence of human
immunodeficiency virus type 1 (HIV-1), HIV infection contributes
significantly to infant mortality. We investigated
antiretroviral-treatment strategies in the Children with HIV Early
Antiretroviral Therapy (CHER) trial.

METHODS: HIV-infected infants 6 to 12 weeks of age with a CD4 lymphocyte
percentage (the CD4 percentage) of 25% or more were randomly assigned to
receive antiretroviral therapy (lopinavir-ritonavir, zidovudine, and
lamivudine) when the CD4 percentage decreased to less than 20% (or 25%
if the child was younger than 1 year) or clinical criteria were met (the
deferred antiretroviral-therapy group) or to immediate initiation of
limited antiretroviral therapy until 1 year of age or 2 years of age
(the early antiretroviral-therapy groups). We report the early outcomes
for infants who received deferred antiretroviral therapy as compared
with early antiretroviral therapy.

RESULTS: At a median age of 7.4 weeks (interquartile range, 6.6 to 8.9)
and a CD4 percentage of 35.2% (interquartile range, 29.1 to 41.2), 125
infants were randomly assigned to receive deferred therapy, and 252
infants were randomly assigned to receive early therapy. After a median
follow-up of 40 weeks (interquartile range, 24 to 58), antiretroviral
therapy was initiated in 66% of infants in the deferred-therapy group.
Twenty infants in the deferred-therapy group (16%) died versus 10
infants in the early-therapy groups (4%) (hazard ratio for death, 0.24;
95% confidence interval \[CI\], 0.11 to 0.51; P\<0.001). In 32 infants
in the deferred-therapy group (26%) versus 16 infants in the
early-therapy groups (6%), disease progressed to Centers for Disease
Control and Prevention stage C or severe stage B (hazard ratio for
disease progression, 0.25; 95% CI, 0.15 to 0.41; P\<0.001). Stavudine
was substituted for zidovudine in four infants in the early-therapy
groups because of neutropenia in three infants and anemia in one infant;
no drugs were permanently discontinued. After a review by the data and
safety monitoring board, the deferred-therapy group was modified, and
infants in this group were all reassessed for initiation of
antiretroviral therapy.

CONCLUSIONS: Early HIV diagnosis and early antiretroviral therapy
reduced early infant mortality by 76% and HIV progression by 75%.

Violari A, Cotton MF, Gibb DM, Babiker AG, Steyn J, Madhi SA,
Jean-Philippe P, McIntyre JA; CHER Study Team. Early antiretroviral
therapy and mortality among HIV-infected infants. N Engl J Med. 2008 Nov
20;359(21):2233-44. <http://www.ncbi.nlm.nih.gov/pubmed/19020325>

Free Full Text:

<http://content.nejm.org/cgi/content/full/359/21/2233>

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

**Use of prescription and over-the-counter medications and dietary
supplements among older adults in the United States**

CONTEXT: Despite concerns about drug safety, current information on
older adults\' use of prescription and over-the-counter medications and
dietary supplements is limited.

OBJECTIVE: To estimate the prevalence and patterns of medication use
among older adults (including concurrent use), and potential major
drug-drug interactions.

DESIGN, SETTING, AND PARTICIPANTS: Three thousand five
community-residing individuals, aged 57 through 85 years, were drawn
from a cross-sectional, nationally representative probability sample of
the United States. In-home interviews, including medication logs, were
administered between June 2005 and March 2006. Medication use was
defined as prescription, over-the-counter, and dietary supplements used
\"on a regular schedule, like every day or every week.\" Concurrent use
was defined as the regular use of at least 2 medications.

MAIN OUTCOME MEASURE: Population estimates of the prevalence of
medication use, concurrent use, and potential major drug-drug
interactions, stratified by age group and gender. RESULTS: The
unweighted survey response rate was 74.8% (weighted response rate,
75.5%). Eighty-one percent (95% confidence interval \[CI\], 79.4%-83.5%)
used at least 1 prescription medication, 42% (95% CI, 39.7%-44.8%) used
at least 1 over-the-counter medication, and 49% (95% CI, 46.2%-52.7%)
used a dietary supplement. Twenty-nine percent (95% CI, 26.6%-30.6%)
used at least 5 prescription medications concurrently; this was highest
among men (37.1%; 95% CI, 31.7%-42.4%) and women (36.0%; 95% CI,
30.2%-41.9%) aged 75 to 85 years. Among prescription medication users,
concurrent use of over-the-counter medications was 46% (95% CI,
43.4%-49.1%) and concurrent use of dietary supplements was 52% (95% CI,
48.8%-55.5%). Overall, 4% of individuals were potentially at risk of
having a major drug-drug interaction; half of these involved the use of
nonprescription medications. These regimens were most prevalent among
men in the oldest age group (10%; 95% CI, 6.4%-13.7%) and nearly half
involved anticoagulants. No contraindicated concurrent drug use was
identified.

CONCLUSIONS: In this sample of community-dwelling older adults,
prescription and nonprescription medications were commonly used
together, with nearly 1 in 25 individuals potentially at risk for a
major drug-drug interaction.

Qato DM, Alexander GC, Conti RM, Johnson M, Schumm P, Lindau ST. Use of
prescription and over-the-counter medications and dietary supplements
among older adults in the United States. JAMA. 2008 Dec
24;300(24):2867-78. <http://www.ncbi.nlm.nih.gov/pubmed/19109115>

**General and abdominal adiposity and risk of death in Europe**

BACKGROUND: Previous studies have relied predominantly on the body-mass
index (BMI, the weight in kilograms divided by the square of the height
in meters) to assess the association of adiposity with the risk of
death, but few have examined whether the distribution of body fat
contributes to the prediction of death.

METHODS: We examined the association of BMI, waist circumference, and
waist-to-hip ratio with the risk of death among 359,387 participants
from nine countries in the European Prospective Investigation into
Cancer and Nutrition (EPIC). We used a Cox regression analysis, with age
as the time variable, and stratified the models according to study
center and age at recruitment, with further adjustment for educational
level, smoking status, alcohol consumption, physical activity, and
height.

RESULTS: During a mean follow-up of 9.7 years, 14,723 participants died.
The lowest risks of death related to BMI were observed at a BMI of 25.3
for men and 24.3 for women. After adjustment for BMI, waist
circumference and waist-to-hip ratio were strongly associated with the
risk of death. Relative risks among men and women in the highest
quintile of waist circumference were 2.05 (95% confidence interval
\[CI\], 1.80 to 2.33) and 1.78 (95% CI, 1.56 to 2.04), respectively, and
in the highest quintile of waist-to-hip ratio, the relative risks were
1.68 (95% CI, 1.53 to 1.84) and 1.51 (95% CI, 1.37 to 1.66),
respectively. BMI remained significantly associated with the risk of
death in models that included waist circumference or waist-to-hip ratio
(P\<0.001). CONCLUSIONS: These data suggest that both general adiposity
and abdominal adiposity are associated with the risk of death and
support the use of waist circumference or waist-to-hip ratio in addition
to BMI in assessing the risk of death.

Pischon T, Boeing H, Hoffmann K, Bergmann M, Schulze MB, Overvad K, et
al.,\
General and abdominal adiposity and risk of death in Europe. N Engl J
Med. 2008 Nov 13;359(20):2105-20.
<http://www.ncbi.nlm.nih.gov/pubmed/19005195>

Free Full Text:

<http://content.nejm.org/cgi/content/full/359/20/2105>

National Heart, Lung, and Blood Institute Guidelines on managing
overweight and obesity:

<http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf>

**Metformin, sulfonylureas, or other antidiabetes drugs and the risk of
lactic acidosis or hypoglycemia: a nested case-control analysis**

OBJECTIVE: Lactic acidosis has been associated with use of metformin.
Hypoglycemia is a major concern using sulfonylureas. The aim of this
study was to compare the risk of lactic acidosis and hypoglycemia among
patients with type 2 diabetes using oral antidiabetes drugs. RESEARCH
DESIGN AND METHODS: This study is a nested case-control analysis using
the U.K.-based General Practice Research Database to identify patients
with type 2 diabetes who used oral antidiabetes drugs. Within the study
population, all incident cases of lactic acidosis and hypoglycemia were
identified, and hypoglycemia case subjects were matched to up to four
control patients based on age, sex, practice, and calendar time.

RESULTS: Among the study population of 50,048 type 2 diabetic subjects,
six cases of lactic acidosis during current use of oral antidiabetes
drugs were identified, yielding a crude incidence rate of 3.3 cases per
100,000 person-years among metformin users and 4.8 cases per 100,000
person-years among users of sulfonylureas. Relevant comorbidities known
as risk factors for lactic acidosis could be identified in all case
subjects. A total of 2,025 case subjects with hypoglycemia and 7,278
matched control subjects were identified. Use of sulfonylureas was
associated with a materially elevated risk of hypoglycemia. The adjusted
odds ratio for current use of sulfonylureas was 2.79 (95% CI 2.23-3.50)
compared with current metformin use. CONCLUSIONS: Lactic acidosis during
current use of oral antidiabetes drugs was very rare and was associated
with concurrent comorbidity. Hypoglycemic episodes were substantially
more common among sulfonylurea users than among users of metformin.

Bodmer M, [Meier
C](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Meier C"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Krähenbühl
S](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Krähenbühl S"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
Jick SS, Meier CR. Metformin, sulfonylureas, or other antidiabetes drugs
and the risk of lactic acidosis or hypoglycemia: a nested case-control
analysis. Diabetes Care. 2008 Nov;31(11):2086-91. Epub 2008 Sep 9.
<http://www.ncbi.nlm.nih.gov/pubmed/18782901>

**Effect of fibre, antispasmodics, and peppermint oil in the treatment
of irritable bowel syndrome: systematic review and meta-analysis**

OBJECTIVE: To determine the effect of fibre, antispasmodics, and
peppermint oil in the treatment of irritable bowel syndrome.

DESIGN: Systematic review and meta-analysis of randomised controlled
trials.

DATA SOURCES: Medline, Embase, and the Cochrane controlled trials
register up to April 2008. Review methods Randomised controlled trials
comparing fibre, antispasmodics, and peppermint oil with placebo or no
treatment in adults with irritable bowel syndrome were eligible for
inclusion. The minimum duration of therapy considered was one week, and
studies had to report either a global assessment of cure or improvement
in symptoms, or cure of or improvement in abdominal pain, after
treatment. A random effects model was used to pool data on symptoms, and
the effect of therapy compared with placebo or no treatment was reported
as the relative risk (95% confidence interval) of symptoms persisting.

RESULTS: 12 studies compared fibre with placebo or no treatment in 591
patients (relative risk of persistent symptoms 0.87, 95% confidence
interval 0.76 to 1.00). This effect was limited to ispaghula (0.78, 0.63
to 0.96). Twenty two trials compared antispasmodics with placebo in 1778
patients (0.68, 0.57 to 0.81). Various antispasmodics were studied, but
otilonium (four trials, 435 patients, relative risk of persistent
symptoms 0.55, 0.31 to 0.97) and hyoscine (three trials, 426 patients,
0.63, 0.51 to 0.78) showed consistent evidence of efficacy. Four trials
compared peppermint oil with placebo in 392 patients (0.43, 0.32 to
0.59).

CONCLUSION: Fibre, antispasmodics, and peppermint oil were all more
effective than placebo in the treatment of irritable bowel syndrome.

Ford AC, Talley NJ, Spiegel BM, Foxx-Orenstein AE, Schiller L, Quigley
EM, Moayyedi P. Effect of fibre, antispasmodics, and peppermint oil in
the treatment of irritable bowel syndrome: systematic review and
meta-analysis. BMJ. 2008 Nov 13;337:a2313. doi: 10.1136/bmj.a2313.
<http://www.ncbi.nlm.nih.gov/pubmed/19008265>

Free Full Text:

<http://www.bmj.com/cgi/content/full/337/nov13_2/a2313>

**Genotype score in addition to common risk factors for prediction of
type 2 diabetes**\
BACKGROUND: Multiple genetic loci have been convincingly associated with
the risk of type 2 diabetes mellitus. We tested the hypothesis that
knowledge of these loci allows better prediction of risk than knowledge
of common phenotypic risk factors alone.

METHODS: We genotyped single-nucleotide polymorphisms (SNPs) at 18 loci
associated with diabetes in 2377 participants of the Framingham
Offspring Study. We created a genotype score from the number of risk
alleles and used logistic regression to generate C statistics indicating
the extent to which the genotype score can discriminate the risk of
diabetes when used alone and in addition to clinical risk factors.

RESULTS: There were 255 new cases of diabetes during 28 years of
follow-up. The mean (+/-SD) genotype score was 17.7+/-2.7 among subjects
in whom diabetes developed and 17.1+/-2.6 among those in whom diabetes
did not develop (P\<0.001). The sex-adjusted odds ratio for diabetes was
1.12 per risk allele (95% confidence interval, 1.07 to 1.17). The C
statistic was 0.534 without the genotype score and 0.581 with the score
(P=0.01). In a model adjusted for sex and self-reported family history
of diabetes, the C statistic was 0.595 without the genotype score and
0.615 with the score (P=0.11). In a model adjusted for age, sex, family
history, body-mass index, fasting glucose level, systolic blood
pressure, high-density lipoprotein cholesterol level, and triglyceride
level, the C statistic was 0.900 without the genotype score and 0.901
with the score (P=0.49). The genotype score resulted in the appropriate
risk reclassification of, at most, 4% of the subjects.

CONCLUSIONS: A genotype score based on 18 risk alleles predicted new
cases of diabetes in the community but provided only a slightly better
prediction of risk than knowledge of common risk factors alone.

Meigs JB, Shrader P, Sullivan LM, McAteer JB, Fox CS, Dupuis J, et al.,
Genotype score in addition to common risk factors for prediction of type
2 diabetes. N Engl J Med. 2008 Nov 20;359(21):2208-19.
<http://www.ncbi.nlm.nih.gov/pubmed/19020323>

**Clinical risk factors, DNA variants, and the development of type 2
diabetes**

BACKGROUND: Type 2 diabetes mellitus is thought to develop from an
interaction between environmental and genetic factors. We examined
whether clinical or genetic factors or both could predict progression to
diabetes in two prospective cohorts.

METHODS: We genotyped 16 single-nucleotide polymorphisms (SNPs) and
examined clinical factors in 16,061 Swedish and 2770 Finnish subjects.
Type 2 diabetes developed in 2201 (11.7%) of these subjects during a
median follow-up period of 23.5 years. We also studied the effect of
genetic variants on changes in insulin secretion and action over time.

RESULTS: Strong predictors of diabetes were a family history of the
disease, an increased body-mass index, elevated liver-enzyme levels,
current smoking status, and reduced measures of insulin secretion and
action. Variants in 11 genes (TCF7L2, PPARG, FTO, KCNJ11, NOTCH2, WFS1,
CDKAL1, IGF2BP2, SLC30A8, JAZF1, and HHEX) were significantly associated
with the risk of type 2 diabetes independently of clinical risk factors;
variants in 8 of these genes were associated with impaired beta-cell
function. The addition of specific genetic information to clinical
factors slightly improved the prediction of future diabetes, with a
slight increase in the area under the receiver-operating-characteristic
curve from 0.74 to 0.75; however, the magnitude of the increase was
significant (P=1.0x10(-4)). The discriminative power of genetic risk
factors improved with an increasing duration of follow-up, whereas that
of clinical risk factors decreased. CONCLUSIONS: As compared with
clinical risk factors alone, common genetic variants associated with the
risk of diabetes had a small effect on the ability to predict the future
development of type 2 diabetes. The value of genetic factors increased
with an increasing duration of follow-up.

Lyssenko V, Jonsson A, Almgren P, Pulizzi N, Isomaa B, Tuomi T, Berglund
G, Altshuler D, Nilsson P, Groop L. Clinical risk factors, DNA variants,
and the development of type 2 diabetes. N Engl J Med. 2008 Nov
20;359(21):2220-32. <http://www.ncbi.nlm.nih.gov/pubmed/19020324>

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

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

**ACOG Committee Opinion No. 420, Hormone Therapy and Heart Disease**

**ABSTRACT:** The effect of menopausal hormone therapy on coronary heart
disease has been the subject of much concern. The Heart and
Estrogen/Progestin Replacement Study (HERS) and Women\'s Health
Initiative studies found an increased risk of cardiovascular events with
conjugated equine estrogen and medroxyprogesterone acetate use. However,
recent evidence suggests that women in early menopause who are in good
cardiovascular health are at low risk of adverse cardiovascular outcomes
and as such should be considered candidates for the use of conjugated
equine estrogen or conjugated equine estrogen and medroxyprogesterone
acetate for relief of menopausal vasomotor symptoms. Hormone therapy use
should be limited to the treatment of menopausal symptoms at the lowest
effective dosage over the shortest duration possible, and continued use
should be reevaluated on a periodic basis.

American College of Obstetricians and Gynecologists, ACOG Committee
Opinion No. 420, November 2008: hormone therapy and heart disease.
Obstet Gynecol. 2008 Nov;112(5):1189-92.

<http://www.ncbi.nlm.nih.gov/pubmed/18978127>

**ACOG Committee Opinion No. 421, Antibiotic Prophylaxis for Infective
Endocarditis**

**ABSTRACT:** The recommendations for endocarditis prophylaxis from the
American Heart Association have changed for three main reasons: 1) most
cases of endocarditis are not attributable to an invasive procedure but
rather are the result of randomly occurring bacteremia from routine
daily activities; 2) prophylaxis may only prevent a small number of
cases of infective endocarditis in women undergoing genitourinary
procedures; and 3) the risk of antibiotic associated adverse events
exceeds the benefit, if any, from prophylactic antibiotic therapy. The
specific changes pertinent to the obstetrician-gynecologist are
discussed.

American College of Obstetricians and Gynecologists, ACOG Committee
Opinion No. 421, November 2008: antibiotic prophylaxis for infective
endocarditis. Obstet Gynecol. 2008 Nov;112(5):1193-4.
<http://www.ncbi.nlm.nih.gov/pubmed/18978128>

**ACOG Committee Opinion No. 422: At-risk drinking and illicit drug use:
ethical issues in obstetric and gynecologic practice**

**ABSTRACT:** Drug and alcohol abuse is a major health problem for
American women regardless of their socioeconomic status, race,
ethnicity, and age. It is costly to individuals and to society.
Obstetrician-gynecologists have an ethical obligation to learn and use a
protocol for universal screening questions, brief intervention, and
referral to treatment in order to provide patients and their families
with medical care that is state-of-the-art, comprehensive, and
effective. In this Committee Opinion, the American College of
Obstetricians and Gynecologists\' Committee on Ethics proposes an
ethical rationale for this protocol in both obstetric and gynecologic
practice, offers a practical aid for incorporating such care, and
provides guidelines for resolving common ethical dilemmas related to
drug and alcohol use that arise in the clinical setting.

American College of Obstetricians and Gynecologists. ACOG Committee
Opinion No. 422: at-risk drinking and illicit drug use: ethical issues
in obstetric and gynecologic practice. Obstet Gynecol. 2008
Dec;112(6):1449-60. <http://www.ncbi.nlm.nih.gov/pubmed/19037056>

**ACOG Practice Bulletin No. 99, Management of Abnormal Cervical
Cytology and Histology**

**Summary of Recommendations**

***The following recommendations are based on good and consistent
scientific evidence (Level A):***

-   Premenopausal women 21 years and older with ASC-US cytology results
    may undergo immediate colposcopy or may undergo triage testing to
    determine which of them should be referred to colposcopy. Triage
    testing may be performed by a single test for high-risk (oncogenic)
    types of HPV or by repeat cytology screening at 6 months and 12
    months. When the index cytology test specimen was obtained by
    liquid-based cytology or when an HPV specimen was co-collected,
    \"reflex\" HPV testing is the preferred approach.

-   Colposcopy is recommended in premenopausal women 21 years and older
    with ASC-US who are HPV positive, those with two consecutive ASC-US
    cytology results or with LSIL, or women of any age with ASC-H

-   For premenopausal women 21 years and older with an HPV-positive
    ASC-US, or ASC-H or LSIL cytology result in whom CIN 2,3 is not
    identified, follow-up without treatment is recommended using either
    repeat cervical cytology tests at 6 months and 12 months or an HPV
    test at 12 month-intervals; a repeat colposcopy is indicated for a
    cytology result of ASC-US or higher-grade abnormality or a positive
    high-risk HPV test result. After two consecutive negative cytology
    results or one negative HPV result women can return to routine
    screening.

-   In women 21 years and older with HSIL cytology results, immediate
    loop electrosurgical excision or colposcopy with endocervical
    assessment are both acceptable management options. In adolescents
    and pregnant women with HSIL cytology results, colposcopy is
    recommended. Immediate excision is not acceptable in adolescents and
    pregnant women. A diagnostic excisional procedure is recommended for
    all nonpregnant women with HSIL when colposcopy is unsatisfactory or
    when CIN of any grade is identified on endocervical assessment.

-   Posttreatment management options for women 21 years and older who
    have CIN 2,3 include a single HPV DNA test at 6--12 months, cytology
    alone at 6-month intervals or a combination of cytology and
    colposcopy at 6-month intervals. For adolescents who have undergone
    treatment, cytology follow-up is preferred. Colposcopy with
    endocervical sampling is recommended for women who are HPV DNA
    positive or have a result of ASC-US or greater on repeat cytology.
    If the HPV DNA test is negative or if two consecutive repeat
    cytology test results are negative, routine screening commencing at
    12 months is recommended for at least 20 years.

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

-   Women 21 years or older with ASC-US who test negative for HPV, or
    whose HPV status is unknown and who test negative for abnormalities
    using colposcopy, should have a repeat cytology test in 1 year.
    Women with ASC-US who have two negative results on repeat cytology
    at 6-month intervals can return to routine screening.

-   In adolescents (before age 21 years) with ASC-US or LSIL cytology
    results, or CIN 1 histology results preceded by ASC-US or LSIL or
    AGC-NOS cytology results, follow-up is recommended at 12-month
    intervals. At the first follow-up visit (at 12 months), only
    adolescents with HSIL or greater on the repeat cytology should be
    referred to colposcopy. At the 24-month follow-up, those with an
    ASC-US or greater result should be referred to colposcopy. Human
    papillomavirus DNA testing is unacceptable for adolescents. If HPV
    testing is inadvertently performed, a positive result should not
    influence management.

-   In nonpregnant women with ASC and LSIL cytology results who are
    undergoing colposcopy, endocervical sampling using a brush or
    curette is preferred for women in whom no lesions are identified and
    those with an unsatisfactory colposcopy results. Endocervical
    sampling is acceptable for women with satisfactory colposcopy
    results and a lesion identified in the transformation zone.
    Endo-cervical assessment either with colposcopy or by sampling is
    recommended for all nonpregnant women with HSIL cytology results.
    Endocervical curettage is unacceptable in pregnant women.

-   The recommended management of pregnant women with a histology
    diagnosis of CIN 1 is follow-up without treatment. Treatment of
    pregnant women for CIN 1 is unacceptable.

-   In a woman 21 years and older with CIN 1 that has persisted for at
    least 2 years, either continued follow-up or treatment is
    acceptable. If treatment is selected and the colposcopy result is
    satisfactory, either excision or ablation is acceptable. If
    treatment is selected and the colposcopy examination is
    unsatisfactory, the ECC is positive, or the woman has been
    previously treated, excision is recommended and ablative procedures
    are unacceptable.

-   Pregnant women with biopsy-proven CIN 2 or CIN 3 in whom there is no
    suspicion of invasive cancer may postpone re-evaluation with
    cytology and colposcopy to no sooner than 6 weeks postpartum.
    Treatment during pregnancy is unacceptable unless invasion is
    suspected. When invasion is suspected, a diagnostic excisional
    procedure is recommended.

-   For women 21 years and older, the preferred management of CIN 2,3
    identified at the margins of a diagnostic excisional procedure or in
    an endocervical sample obtained at the end of the procedure is
    reassessment using cytology with endocervical sampling at 4--6
    months following treatment. Performing a repeat diagnostic
    excisional procedure is acceptable, as is a hysterectomy if a repeat
    diagnostic procedure is not feasible and for women with a histology
    diagnosis of recurrent or persistent CIN 2,3

-   In nonpregnant women 21 years and older, both excision and ablation
    are acceptable treatment modalities in the presence of histology
    diagnoses of CIN 2,3 and satisfactory colposcopy results. Ablation
    is unacceptable when colposcopy has not been performed, the
    endocervical sampling is positive for any grade of CIN, the
    colposcopy result is unsatisfactory, or a woman has recurrent CIN
    2,3.

-   Colposcopy with endocervical sampling is recommended and HPV DNA
    testing is preferred for women with all subcategories of AGC and
    AIS. In addition, endometrial sampling is recommended in women 35
    years and older and in women younger than 35 years with clinical
    indications suggesting they may be at risk of neoplastic endometrial
    lesions (e.g., unexplained vaginal bleeding, chronic anovulation, or
    atypical endometrial cells). Colposcopy can be performed either at
    the initial evaluation or after the results are known. If no
    endometrial pathology is identified, colposcopy is recommended.
    Endometrial and endocervical sampling are unacceptable in pregnant
    women.

-   Women 21 years and older with either atypical endocervical,
    endometrial, or glandular cells NOS who do not have CIN or glandular
    neoplasia identified histologically should receive repeat cytology
    testing combined with HPV DNA testing at 6 months if they are HPV
    DNA positive and at 12 months if they are HPV DNA negative. Referral
    to colposcopy is recommended for women who subsequently test
    positive for high-risk HPV DNA or who are found to have ASC-US or
    greater on their repeat cytology tests. If both tests are negative,
    women can return to routine cytology testing.

-   Women with AGC, favors neoplasia or AIS cytology results should
    undergo a diagnostic excisional procedure unless invasive disease is
    identified during the initial colposcopy workup. The diagnostic
    excisional procedure used in this setting should provide an intact
    specimen with interpretable margins. Concomitant endocervical
    sampling is preferred, except in pregnant women.

-   Hysterectomy is unacceptable as the primary therapy for CIN.

-   Diagnostic ablation or excision is unacceptable as the initial
    management for ASC or LSIL.

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

-   Pregnant women with biopsy-proven CIN 2 or CIN 3 in whom there is no
    suspicion of invasive cancer may postpone re-evaluation with
    cytology and colposcopy to no sooner than 6 weeks postpartum.
    Treatment during pregnancy is unacceptable unless invasion is
    suspected. When invasion is suspected, a diagnostic excisional
    procedure is recommended.

-   For women 21 years and older, the preferred management of CIN 2,3
    identified at the margins of a diagnostic excisional procedure or in
    an endocervical sample obtained at the end of the procedure is
    reassessment using cytology with endocervical sampling at 4--6
    months following treatment. Performing a repeat diagnostic
    excisional procedure is acceptable, as is a hysterectomy if a repeat
    diagnostic procedure is not feasible and for women with a histology
    diagnosis of recurrent or persistent CIN 2,3.

-   In nonpregnant women 21 years and older, both excision and ablation
    are acceptable treatment modalities in the presence of histology
    diagnoses of CIN 2,3 and satisfactory colposcopy results. Ablation
    is unacceptable when colposcopy has not been performed, the
    endocervical sampling is positive for any grade of CIN, the
    colposcopy result is unsatisfactory, or a woman has recurrent CIN
    2,3.

-   Colposcopy with endocervical sampling is recommended and HPV DNA
    testing is preferred for women with all subcategories of AGC and
    AIS. In addition, endometrial sampling is recommended in women 35
    years and older and in women younger than 35 years with clinical
    indications suggesting they may be at risk of neoplastic endometrial
    lesions (e.g., unexplained vaginal bleeding, chronic anovulation, or
    atypical endometrial cells). Colposcopy can be performed either at
    the initial evaluation or after the results are known. If no
    endometrial pathology is identified, colposcopy is recommended.
    Endometrial and endocervical sampling are unacceptable in pregnant
    women.

-   Women 21 years and older with either atypical endocervical,
    endometrial, or glandular cells NOS who do not have CIN or glandular
    neoplasia identified histologically should receive repeat cytology
    testing combined with HPV DNA testing at 6 months if they are HPV
    DNA positive and at 12 months if they are HPV DNA negative. Referral
    to colposcopy is recommended for women who subsequently test
    positive for high-risk HPV DNA or who are found to have ASC-US or
    greater on their repeat cytology tests. If both tests are negative,
    women can return to routine cytology testing.

-   Women with AGC, favors neoplasia or AIS cytology results should
    undergo a diagnostic excisional procedure unless invasive disease is
    identified during the initial colposcopy workup. The diagnostic
    excisional procedure used in this setting should provide an intact
    specimen with interpretable margins. Concomitant endocervical
    sampling is preferred, except in pregnant women.

-   Hysterectomy is unacceptable as the primary therapy for CIN.

-   Diagnostic ablation or excision is unacceptable as the initial
    management for ASC or LSIL.

-   In nonpregnant women 21 years and older with HSIL in whom CIN 2,3
    has not been identified, three management options are acceptable:
    diagnostic excisional procedure; review of the cytology, histology,
    and colposcopy findings and management of the patient according to
    the revised interpretation; or if the colposcopy is satisfactory and
    endocervical sampling is negative, observation with colposcopy and
    cytology at 6 month-intervals for 1 year. A diagnostic excisional
    procedure is recommended for women with repeat HSIL cytology results
    at either the 6-month or 12-month visit. Women with two consecutive
    negative cytology results can return to routine screening.

-   In adolescents (before age 21 years) with HSIL cytology results, a
    satisfactory colposcopy result, negative endocervical sampling, and
    no CIN 2,3 identified on colposcopy biopsy, follow-up is recommended
    at 6-month intervals with Pap testing and colposcopy for up to 24
    months. If during follow-up a high grade colposcopy lesion is
    identified or HSIL cytology results persist for 1 year, biopsy is
    recommended. If HSIL persists for 24 months without identification
    of CIN 2,3, or if the colposcopy result is unsatisfactory, a
    diagnostic excisional procedure is recommended. After two
    consecutive negative cytology results, women can return to routine
    cytology testing.

-   For adolescents and young women with a histology diagnosis of CIN
    2,3 NOS and a satisfactory colposcopy result either treatment or
    observation for up to 24 months using both colposcopy and cytology
    at 6-month intervals is acceptable. When a histology diagnosis of
    CIN 2 is specified, observation is preferred. When a histology
    diagnosis of CIN 3 is specified or when the colposcopy result is
    unsatisfactory, treatment is recommended. If the colposcopy
    appearance of the lesion worsens or if an HSIL cytology result or a
    high-grade colposcopy lesion persists for 1 year, repeat biopsy is
    recommended. After two consecutive negative cytology results, women
    with normal colposcopy results can return to routine cytology
    screening. Treatment is recommended if CIN 3 is subsequently
    identified or if CIN 2,3 persists for 24 months.

-   In nonpregnant women 21 years and older with HSIL or AGC-NOS
    cytology results in whom CIN 1 has been identified on colposcopy
    three management options are acceptable: diagnostic excisional
    procedure; review of the cytology, histology, and colposcopy
    findings and management of the patient according to the revised
    interpretation; or if the colposcopy is satisfactory and
    endocervical sampling is negative, observation with colposcopy and
    cytology at 6-month intervals for 1 year. A diagnostic excisional
    procedure is recommended for women with repeat HSIL cytology results
    at either the 6-month or 12-month visit. Women with two consecutive
    negative cytology results can return to routine cytology screening.

-   In women 21 years and older with atypical endocervical, endometrial,
    or glandular cells NOS, HPV DNA testing is preferred at the time of
    colposcopy (if not already performed). For women of unknown HPV
    status who do not have CIN or glandular neoplasia identified
    histologically, the recommended postcolposcopy management is to
    repeat cytology testing at 6-month intervals. After four consecutive
    negative cytology results, women can return to routine cytology
    testing.

-   Women with a cervical biopsy diagnosis of AIS should undergo
    excision to exclude invasive cancer. A conization technique that
    preserves specimen orientation and permits optimal interpretation of
    histology and margin status is recommended. After conization,
    hysterectomy is preferred for women who have completed childbearing.
    Conservative management is acceptable if the margins of the specimen
    and the postprocedure endocervical curettage results are negative
    and future fertility is desired. If conservative management is
    planned and the margins of the specimen are involved or the
    postprocedure endocervical curettage specimen contains CIN or AIS,
    re-excision is preferred. Reevaluation at 6 months using a
    combination of cervical cytology, HPV DNA testing, and colposcopy
    with endocervical sampling is acceptable in this circumstance.
    Long-term follow-up after treatment is recommended for all women
    with AIS.

American College of Obstetricians and Gynecologists. ACOG practice
bulletin no. 99: management of abnormal cervical cytology and histology.
Obstet Gynecol. 2008 Dec;112(6):1419-44.
<http://www.ncbi.nlm.nih.gov/pubmed/19037054>

**ACOG Technology Assessment No. 5, Sonohysterography**

**ABSTRACT:** The goal of sonohysterography is to visualize the
endometrial cavity in more detail than is possible with routine
transvaginal ultrasound. The procedure consists of the manual injection
of sterile fluid under real-time ultrasonographic imaging. The most
common indication for sonohysterography is abnormal uterine bleeding.
The procedure should not be performed in a woman who is pregnant or who
could be pregnant, or who has a pelvic infection or unexplained pelvic
tenderness. Physicians who perform or supervise diagnostic
sonohysterography should be skilled in vaginal ultrasonography and
transcervical placement of catheters; should have training, experience,
and demonstrated competence in gynecologic ultrasonography and
sonohysterography; and should keep careful records. Portions of this
document were developed jointly with the American College of Radiology
and the American Institute of Ultrasound in Medicine.

American College of Obstetricians and Gynecologists. ACOG Technology
Assessment No. 5. Sonohysterography. Obstet Gynecol 2008;112: 1467--9.
<http://www.ncbi.nlm.nih.gov/pubmed/19037058>

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

**Depression symptoms are similar in pregnant and nonpregnant women**

The symptoms of major depression are essentially the same in women who
are pregnant and women who are not, according to a new study by Stanford
University researcher Rachel Manber, Ph.D., and her colleagues. The
researchers compared three groups of women---pregnant women with major
depression, nonpregnant women with major depression, and pregnant women
without depressive symptoms. Depressed pregnant women and depressed
nonpregnant women had similar severity of depressive symptoms. However,
depressed pregnant women had fewer intense feelings of suicide and
guilt, and had significantly less difficulty falling asleep, but were
more likely to show slowed movement and/or speech.

These findings are consistent with previous findings that childbearing
alone has a modest, clinically insignificant effect on psychiatric
symptoms. While pregnancy appears to reduce the intensity of some
symptoms of depression, standardized measures of depression severity can
be used to assess depression during pregnancy.

The researchers recommend that symptoms of psychological distress should
not be written off as a normal part of pregnancy and that more attention
should be focused on screening and identifying depressed pregnant women.
They recruited the two samples of pregnant women (61 depressed and 41
nondepressed) from a larger study conducted at Stanford University
through obstetric clinics and ads in local parent and baby magazines.
Fifty-three depressed nonpregnant women were recruited from a larger
study of acupuncture treatment for depression at the University of
Arizona. All of the women were in the same age range, and the two
depressed groups had equivalent severity of depressive symptoms.

The researchers administered two standardized measures of depression,
the Hamilton Rating Scales for Depression and the Beck Depression
Inventory, to all of the women participating in the study.

The study was funded in part by the Agency for Healthcare Research and
Quality (HS09988). More details are in \"Depression symptoms during
pregnancy,\" by Dr. Manber, Christine Blasey, Ph.D., and John J. B.
Allen, Ph.D., in *Archives of Women\'s Mental Health* 11, pp. 43--48,
2008. <http://www.ahrq.gov/research/dec08/1208RA12.htm>

PubMed Abstract: <http://www.ncbi.nlm.nih.gov/pubmed/18270654>

#### Correlates of medical and legal help seeking among women reporting intimate partner violence The duration and severity of domestic abuse that women endure serve as a predictor of whether they will seek medical and legal help, a new study finds. Researchers in Seattle conducted telephone interviews with 1,509 women who participated in a health plan covering Washington and Northern Idaho and said they had experienced physical, sexual, or psychological abuse since reaching the age of 18. Women who were sexually or physically abused were more likely to seek medical care and legal assistance than women who reported only psychological abuse. For example, sexually abused women were 1.3 times as likely to seek medical care as women who were psychologically abused. The longer the abuse continued, the more likely the woman was to obtain legal help. For example, compared with women who were abused for 0 to 2 years, women who were physically abused for 3 to 10 years were 1.4 times more likely to seek legal services. Those who suffered physical abuse for more than 10 years were 1.9 times as likely to get legal help. Women who were psychologically abused were more inclined to obtain legal than medical services. {#correlates-of-medical-and-legal-help-seeking-among-women-reporting-intimate-partner-violence-the-duration-and-severity-of-domestic-abuse-that-women-endure-serve-as-a-predictor-of-whether-they-will-seek-medical-and-legal-help-a-new-study-finds.-researchers-in-seattle-conducted-telephone-interviews-with-1509-women-who-participated-in-a-health-plan-covering-washington-and-northern-idaho-and-said-they-had-experienced-physical-sexual-or-psychological-abuse-since-reaching-the-age-of-18.-women-who-were-sexually-or-physically-abused-were-more-likely-to-seek-medical-care-and-legal-assistance-than-women-who-reported-only-psychological-abuse.-for-example-sexually-abused-women-were-1.3-times-as-likely-to-seek-medical-care-as-women-who-were-psychologically-abused.-the-longer-the-abuse-continued-the-more-likely-the-woman-was-to-obtain-legal-help.-for-example-compared-with-women-who-were-abused-for-0-to-2-years-women-who-were-physically-abused-for-3-to-10-years-were-1.4-times-more-likely-to-seek-legal-services.-those-who-suffered-physical-abuse-for-more-than-10-years-were-1.9-times-as-likely-to-get-legal-help.-women-who-were-psychologically-abused-were-more-inclined-to-obtain-legal-than-medical-services. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Duterte, E.E., Bonomi, A.E., Kernic, M.A., and others (2008, January). \"Correlates of medical and legal help seeking among women reporting intimate partner violence.\" (AHRQ grant HS10909). *Journal of Women\'s Health* 17(1), pp. 85-95. [**http://www.ncbi.nlm.nih.gov/pubmed/18240985**](http://www.ncbi.nlm.nih.gov/pubmed/18240985)  {#duterte-e.e.-bonomi-a.e.-kernic-m.a.-and-others-2008-january.-correlates-of-medical-and-legal-help-seeking-among-women-reporting-intimate-partner-violence.-ahrq-grant-hs10909.-journal-of-womens-health-171-pp.-85-95.-httpwww.ncbi.nlm.nih.govpubmed18240985 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Higher education among American Indian elders increases their
likelihood of engaging in physical activity**

American Indians and Alaska Natives (AI/ANs) report lower levels of
leisure-time physical activity than majority populations. This lack of
exercise puts them at risk for obesity, hypertension, type 2 diabetes,
and cardiovascular disease, which are becoming more prevalent in many
AI/AN communities. However, as with many other groups, more educated
AI/AN elders have higher levels of physical activity than their less
educated counterparts, finds a new study.

University of Washington researchers correlated education with physical
activity level among 125 sedentary AI/AN elders (age 50 to 74 years)
enrolled in a 6-week trial comparing 2 approaches to physical activity
monitoring. They correlated educational level with total caloric
expenditure for moderate-intensity physical activities (leisure, work,
exercise, and chore-related) and distance traveled during a 6-minute
walk test of fitness (6MWT).

Groups at different educational levels (less than high school, completed
high school, General Education Degree or some vocational education, and
college education) did not differ significantly in adjusted caloric
expenditure due to all exercise activity. However, after controlling for
relevant demographic and health factors, groups did differ significantly
in caloric expenditure due to moderate to vigorous exercise, with the
differences increasing significantly with higher levels of educational
attainment. A similar significant positive trend was found between
higher levels of education and increased distance covered during the
6MWT. The study was supported by the Agency for Healthcare Research and
Quality (HS10854).

See \"Education is associated with physical activity among American
Indian elders,\" by Craig N. Sawchuk, Ph.D., Andy Bogart, M.S., Stephen
Charles, B.A., and others, in the *American Indian Alaska Native Mental
Health Research* 15(1), p. 1-17, 2008.

<http://www.ahrq.gov/research/oct08/1008RA7.htm>

PubMed Abstract: <http://www.ncbi.nlm.nih.gov/pubmed/18493902>

### 

### **Recent U.S. Food and Drug Administration (FDA) Advisory**

**Oral Sodium Phosphate (OSP) Products for Bowel Cleansing (marketed as
Visicol and OsmoPrep, and oral sodium phosphate products available
without a prescription)**

**Audience:** All healthcare professionals, consumers\
\[Posted 12/11/2008\] FDA has become aware of reports of acute phosphate
nephropathy, a type of acute kidney injury, associated with the use of
oral sodium phosphate products (OSP) for bowel cleansing prior to
colonoscopy or other procedures. These products include the prescription
products, Visicol and OsmoPrep, and OSPs available over-the-counter
without a prescription as laxatives (e.g., Fleet Phospho-soda). In some
cases when used for bowel cleansing, these serious adverse events have
occurred in patients without identifiable factors that would put them at
risk for developing acute kidney injury.\
\
FDA is requiring the manufacturer of Visicol and OsmoPrep, the two OSPs
available by prescription only, to add a Boxed Warning to the labeling
for these products. FDA is also requiring that the manufacturer develop
and implement a risk evaluation and mitigation strategy (REMS), which
will include a Medication Guide, to ensure that the benefits of these
products outweigh the risk of acute phosphate nephropathy, and to
conduct a postmarketing clinical trial to further assess the risk of
acute kidney injury with use of these products. FDA recommends, in light
of the risk of acute phosphate nephropathy, over-the-counter laxative
OSP products should not be used for bowel cleansing. Consumers should
only use OSPs for bowel cleansing pursuant to a prescription from a
healthcare professional.
<http://www.fda.gov/medwatch/safety/2008/safety08.htm#OSP>

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

As your partner at the HSRL, I'm here to help you meet your information
needs. If you need to find information at either patient point-of-care
or as background information for a specific project, I can help. I am
here to save you time and ensure you get the information you need. As
your information needs evolve, I will expand and enhance my skills and
work hard to stay on top of the latest information resources useful to
the Indian Health Service. As your direct link to the HSRL and partner
in your work, I can support you in the following ways:

-   Help with complex and difficult literature searches to support
    direct patient care and patient care activities

-   Participate and be a partner in IHS projects and development team
    activities

-   Assist in manuscript preparation (verify references; editing)

-   Set up current awareness alerts in your field of interest

-   Create customized databases in bibliographic software programs
    (Endnote; Reference Manager) to organize your information for easy
    retrieval when you need it

-   Provide instruction on how to search literature databases and other
    information resources more efficiently

Diane Cooper, MSLS\
Biomedical Information Consultant for IHS\
Division of Library Services\
National Institutes of Health\
Bethesda, MD 20892\
301.594.2449\
[[cooperd@mail.nih.gov]{.underline}](mailto:cooperd@mail.nih.gov)

[[Diane.Cooper2@ihs.gov]{.underline}](mailto:Diane.Cooper2@ihs.gov)

Health Services Research Library (HSRL)\
[[http://hsrl.nihlibrary.nih.gov]{.underline}](http://hsrl.nihlibrary.nih.gov/)

##### Behavioral Health Insights Peter Stuart, IHS Psychiatry CCC

**Suicide and Antiepileptics -- Real Concerns?**

FDA ALERT \[1/31/2008, Updated 12/16/2008\] - The FDA has completed its
analysis of reports of suicidality (suicidal behavior or ideation
\[thoughts\]) from placebo-controlled clinical trials of drugs used to
treat epilepsy, psychiatric disorders, and other conditions. Based on
the outcome of this review, FDA is requiring, under the authorities
granted under the Food and Drug Administration Amendments Act (FDAAA) of
2007, that all manufacturers of drugs in this class include a Warning in
their labeling and develop a Medication Guide to be provided to patients
prescribed these drugs to inform them of the risks of suicidal thoughts
or actions.

The drugs affected by these safety labeling changes are commonly
referred to as antiepileptic or anticonvulsant drugs (see the list
below). FDA's pooled analyses of 199 clinical trials of eleven
antiepileptic drugs used as mono- and adjunctive therapies showed that
patients who were randomized to receive one of the antiepileptic drugs
had almost twice the risk of suicidal behavior or ideation (0.43%)
compared to patients randomized to receive placebo (0.24%). This
increase in the risk of suicidal thoughts or behavior represents the
occurrence of approximately one additional case of suicidal thinking or
behavior for every 530 patients treated with an antiepileptic drug.

The risk of suicidal thoughts or behavior was generally consistent among
the eleven drugs analyzed and was observed in patients who were treated
for epilepsy, psychiatric disorders, and other conditions. The relative
risk for suicidal thoughts or behavior was higher in the clinical trials
for epilepsy compared to trials for psychiatric or other conditions.
However, the absolute risk differences were similar in the clinical
trials for epilepsy and psychiatric indications.

The increased risk was observed as early as one week after starting
antiepileptic drug treatment and throughout the observed duration of
treatment. The increased risk of suicidal thoughts or behavior was
generally consistent among the eleven drugs with varying mechanisms of
action and across a range of indications. This observation suggests that
the risk applies to all antiepileptic drugs used for any indication.

All patients who are currently taking or starting on any antiepileptic
drug for any indication should be monitored for notable changes in
behavior that could indicate the emergence or worsening of suicidal
thoughts or behavior or depression.

**Psychiatry CCC Editorial Comment:** This advisory is part of a larger
concern about adverse consequences of medications used to treat
neuropsychiatric conditions. The actual event numbers involved were
quite small (4 suicides in a population \~27,000 for a rate of
16/100,000 -- lower than the background rate of suicides in our
populations) and this was a post-hoc analysis of drug company reporting
data thus reducing the power of the analysis to clearly identify
causation. The FDA chose to keep the concern at an advisory level and
not add a black box warning after extensive hearings.

Unfortunately, similar discussions and reviews related to
antidepressants resulted in black box warnings. Recent data suggests
that with the black box warnings there has been a reduction in the use
of antidepressants particularly in adolescents -- now followed by
increases in suicide rates that may or may not be linked to the
reduction.

The bottom line -- treating neuropsychiatric conditions whether they are
classically "psychiatric" or not require attention to the mood and
emotional status of a person. This includes doing a basic assessment of
propensity for self or other injury, mood and substance abuse history,
and impulsivity, and incorporating the findings into the treatment plan.
If there is a 1) a reasonable indication, 2) appropriate treatment
targets and 3) reasonable alignment between the provider and the patient
on treatment and treatment risks providers should continue to
assertively treat such disorders. They remain some of the biggest
contributors to mortality and morbidity in our populations and major
sources of distress and suffering.

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

#### [**http://www.fda.gov/cder/drug/InfoSheets/HCP/antiepilepticsHCP.htm**](http://www.fda.gov/cder/drug/InfoSheets/HCP/antiepilepticsHCP.htm)  {#httpwww.fda.govcderdruginfosheetshcpantiepilepticshcp.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

We are very fortunate to have Dr. Frank Nice as a guest writer. He is
highly respected in many arenas including the use of medications during
breastfeeding. He is considered by many lactation professionals to be
THE expert on the use of herbs during lactation. He holds numerous
degrees in pharmacological sciences and administration and currently
serves as a pharmacist at the National Institutes of Health. He retired
from USPHS after 30 years of service, has published numerous articles
about breastfeeding, medication, and herbs and continues to tirelessly
contribute to the betterment of public health. Please welcome Frank J.
Nice RPh, DPA, CPHP

# Herbal Galactogogues 

As with prescription drugs and over the counter (OTC) medications,
consumers use herbals to treat a variety of ailments and to maintain
health. In fact, lactation consultants recommend, and breastfeeding
mothers take, herbals called galactogogues, to help increase milk
supply, usually by initiating the breast milk letdown reflex, but also
sometimes by aiding in breast milk ejection. Commonly used galactogogues
include blessed thistle, chaste tree fruit, fennel, fenugreek, garlic,
goat's rue, and milk thistle. Herbs, among others, that may also act as
galactogogues include alfalfa, anise, borage, caraway, coriander,
dandelion, dill, hops, marshmallow root, nettle, oat straw, red clover,
red raspberry, and vervain.

Blessed thistle, chaste tree fruit, fennel, fenugreek, garlic, goat's
rue, and milk thistle are considered major galactogogues in that they
are the primary herbs used as galactogogues and are commonly used alone.
Alfalfa, anise, borage, caraway, coriander, dandelion, dill, hops,
marshmallow, nettle, oat straw, red clover, red raspberry, and vervain
are considered minor galactogogues because they are not as commonly used
and commonly are used in combination with each other, often in
homeopathic preparations. If one looks at the list of minor
galactogogues, along with some of the major galactogogues, it is
apparent that many of these herbs find use as food products, especially
within particular ethnic groups.

Common daily doses for the major galactogogues are: blessed thistle: 2-6
grams; chaste

tree fruit: 30-40 mg; fennel: equivalent to 100-600mg; fenugreek: 6
grams; garlic: 4-9

grams; goat's rue: 1-2 ml of tincture; milk thistle: 12-15 grams daily.
Dosage forms may

include oral capsules, alcoholic extracts, tinctures, oils, seeds, and
infusions.

Common daily doses for the minor galactogogues are: alfalfa: up to 60
grams; anise: 10-42 grams; borage: 1-2 grams; caraway: 1.5-6 grams;
coriander: 3 grams; dandelion: 15 grams; dill: 3 grams; hops: 500 mg or
one bottle of stout beer; marshmallow root: 3 grams; nettle: 1.8 grams;
oat straw: 100 grams; red clover: 40-80 mg; red raspberry: 2.7 grams;
vervain: 30-50 grams. Dosage forms are the same as for the major
galactogogues and also include teas and beer (hops).

Interesting facts about the major galactogogues include: blessed and
milk thistle: these are two distinct herbs, other thistles are also used
as galactogogues; chaste tree fruit: also known as chasteberry and
vitex, if used in higher doses for breast pain, may negatively affect
nursing performance; fennel: may also aid in milk ejection; fenugreek:
the most commonly used herbal galactogogue, do not use if allergic to
peanuts or legumes; mother and baby may smell like maple syrup; garlic:
increases nursing time because baby likes smell of garlic, but if baby
does not, opposite may occur; goat's rue: contains galegin, a precursor
of metformin, which also shows galactogogue properties, increases milk
production in goats, sheep, and cattle.

Interesting facts about some of the minor galactogogues: alfalfa: do not
use if allergic to peanuts or legumes or in mothers with systemic lupus
erythematosus; anise: has mild estrogenic properties, which may aid in
milk ejection; borage: potential blood thinner in large amounts;
caraway: avoid volatile oil form; coriander; also known as cilantro,
avoid if allergic to celery; dandelion: contraindicated in bile duct
blockage and bowel obstruction; dill: acts as diuretic to reduce
postpartum edema; hops: aids milk letdown; marshmallow root: not the
Kraft variety, acts as diuretic; nettle: acts as diuretic; oat straw:
yes, regular oat meal; red clover: avoid fermented type, potential blood
thinner; red raspberry: may aid in milk ejection, may decrease milk
supply after two weeks use; vervain: contraindicated in pregnancy due to
oxytocic properties.

For more information, please contact Dr. Nice at
<Frank.Nice@nih.hhs.gov>

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

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

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

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

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

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

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

**Office of Violence against Women Fact Sheet:**

**Are Indian and Alaska Native Women at Risk of Experiencing Violence?**

According to a December 2004 study by the Bureau of Justice Statistics,
American Indians are twice as likely to experience sexual assault crimes
compared to all other races. In 2000, the National Institute of Justice
published a report on the findings of the National Violence against
Women Survey which revealed that one in three Indian women reported
having been raped during her lifetime.

**What is OVW Doing to Stop Violence against American Indian and Alaska
Native Women?**

The Office on Violence against Women (OVW) was created by the Violence
against Women Act of 1994. Since opening its doors in 1995, OVW has
awarded more than \$1 billion in grant funding to state, local, and
tribal governments to address violence against women. \
\
Over the past decade, OVW has used more than \$100 million in
Congressionally-appropriated funding to make grant awards through the
STOP Violence Against Indian Women Discretionary Grant Program, and
through OVW's other grant programs, to more than 120 tribal
governments.\
\
OVW offers a comprehensive training and technical assistance program
designed to provide support and assistance to tribal governments to
increase their capacity to develop a coordinated community response to
domestic violence, sexual assault, and stalking, and to appropriately
administer grant funds.  

**What is the "Safety for Indian Women from Sexual Assault Demonstration
Initiative"?**

OVW has supported demonstration initiatives for Indian country,
including its most recent initiative, the Safety for Indian Women from
Sexual Assault Offenders Demonstration Initiative. Under this \$2
million Initiative, four Federally-recognized Indian tribes received
funding to increase their capacity to respond to the needs of Indian
women who are victims of sexual assault, and to strengthen the
collaboration between the tribal and Federal officials who share
responsibility for responding to sexual assault in these communities.

**Have OVW Grants Helped Tribal Communities End Violence Against Indian
Women?**

OVW will make awards totaling just over \$30 million to tribal
governments under the new Grants to Indian Tribal Governments Program
during the summer of 2007. Between January 1, 2004 and June 30, 2005,
more than 100 tribal governments used grant funding from OVW to improve
their community's response to violence against American Indian and
Alaska Native women. Among the key accomplishments of this group,
include:

-   Providing training on how to respond to crimes of domestic violence,
    sexual assault, and stalking to more than 650 law enforcement
    officers, nearly 150 prosecutors, and more than 130 judges, and 81
    probation and parole officers.

-   Responding to 2,514 incidents of crimes related to violence against
    women. More than 1,700 of these cases were investigated, and nearly
    1,100 offenders were arrested and charged.

-   Providing advocacy and supportive services to approximately 13,000
    women and children from tribal communities, and helping more than
    15,000 women obtain protective order relief.

<http://www.ovw.usdoj.gov/ovw-fs.htm#fs-indian-country>

**Breaking the barriers: the promise of computer-assisted screening for
intimate partner violence**

Although intimate partner violence (IPV) affects hundreds of thousands
of women, the majority of women seen in health care settings are not
screened for IPV. Many women are hesitant to disclose their abusive
situations to their health care providers and, sadly, there is evidence
that when women do disclose violence, their health care providers do not
give them needed support and information. This article discusses the
importance of IPV screening and barriers that may contribute to the
current lack of screening by providers and the low disclosure rate by
IPV survivors, describes how computer-assisted screening for IPV can
address those barriers, and reports the findings of an integrative
review of studies about computer-assisted self-interview (CASI) IPV
screening. Computer screening strategies consistently identified a
higher prevalence of IPV and were the approach preferred by the study
participants. The findings of these initial studies provide support for
the development and testing of computer screening and intervention
strategies for IPV.

Renker PR. Breaking the barriers: the promise of computer-assisted
screening for intimate partner violence. J Midwifery Womens Health. 2008
Nov-Dec;53(6):496-503.

<http://www.ncbi.nlm.nih.gov/pubmed/18984505>

#### Elder Care News Bruce Finke, Elder Care Initiative {#elder-care-news-bruce-finke-elder-care-initiative .Style-Heading-4-+-Arial-14-pt-Underline}

**The Mayo Clinic and the Indian Health Service proudly announce**

**"An Intensive Case-Based Training in Palliative Care"**

May 4-8, 2009; Rochester, Minnesota

This new and innovative intensive program will build on the principles
and practice of palliative care previously introduced at the
***Education in Palliative and End-of-Life Care-Oncology (EPEC-O ™)***
conferences. It is designed to address some of the suggestions for
additional training made by participants. This course will be taught at
the Mayo Clinic by its faculty and IHS experts in palliative care.
Actual cases will be presented and examined in detail, with an emphasis
on an interdisciplinary approach to palliative care. Trainees will gain
hands-on experience in dealing with real-life scenarios in the
state-of-the-art Simulation Center. Trainees will also round with
palliative care and pain management teams and attend weekly
interdisciplinary case conferences.

A portion of the course will be presented by telemedicine as part of the
***International Telehealth Palliative Care Symposium*** sponsored by
the Alaska Native Tribal Health Consortium. Cultural considerations in
providing palliative care for indigenous people will be emphasized.

**There is no cost to attend**. Funding, provided through the generosity
of the Fort Defiance Service Unit, under the direction of Dr. Franklin
Freeland CEO, will cover travel and per diem for teams of three or four
individuals. Teams should be drawn from individual facilities or Service
Units and include a physician, nurse and a social worker. Additionally,
a pharmacist or other involved professional will be considered as part
of a team.

Approximately 8 teams, 28-32 individuals, will be accepted. Teams with
individuals who attended one of the previous EPEC-O™ conferences are
strongly encouraged to attend, though this is not a prerequisite.

**The deadline for applications is February 28, 2009.** Applications
will be accepted on a first request, first served basis. Register on
line at [http://www.csc.ihs.gov](http://www.csc.ihs.gov/).

For questions or more information please contact: Timothy Domer, MD at
<Timothy.domer@ihs.gov>.

The Indian Health Service Clinical Support Center (CSC) is providing
meeting support and will act as the accredited sponsor for the **2009
"An Intensive Case-Based Training in Palliative Care"** to be held from
1:00 pm Monday, May 4 through 12:00 noon Friday, May 8, 2009, in
Rochester, Minnesota.

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

**Contraceptive nonuse among US women at risk for unplanned pregnancy**

BACKGROUND: This study was conducted to assess risk factors for
contraceptive nonuse among a nationally representative sample of US
women and explored the influence of future pregnancy intentions on
contraceptive nonuse.

STUDY DESIGN: Using data from the 2002 National Survey of Family Growth
(NSFG), we analyzed 12 months of contraceptive behavior among 3687 women
at risk for unplanned pregnancy.

RESULTS: Compared with contraceptive users, contraceptive nonusers were
more likely to be older than 40 years (OR 6.3, 95% CI 2.7-14.7), black
(OR 1.8, 95% CI 1.2-2.8), less educated (OR 2.4, 95% CI 1.4-4.0),
uninsured (OR 1.6, 95% CI 1.1-2.4), Medicaid recipients (OR 1.9, 95% CI
1.2-2.9) or having infrequent intercourse (OR 3.8, 95% CI 2.7-5.3). We
found no significant association between future pregnancy intentions and
contraceptive behavior.

CONCLUSIONS: While family planning efforts have traditionally focused on
disadvantaged women, older women and women who have infrequent sex are
also at high risk for nonuse. Future pregnancy intentions, as currently
assessed by the NSFG, is not a useful indicator of contraceptive
behavior.

Wu J, Meldrum S, Dozier A, Stanwood N, Fiscella K. Contraceptive nonuse
among US women at risk for unplanned pregnancy. Contraception. 2008
Oct;78(4):284-9. Epub 2008 Jul 22.
<http://www.ncbi.nlm.nih.gov/pubmed/18847575>

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

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

**Comparison of metabolic and inflammatory outcomes in women who used
oral contraceptives and the levonorgestrel-releasing intrauterine device
in a general population**

OBJECTIVE: We compared the metabolic and cardiovascular parameters of a
reference group of women with those of women who used 2 contraceptive
regimes that are used worldwide: the levonorgestrel-releasing
intrauterine device and oral contraceptives.

STUDY DESIGN: We investigated a cohort of 2814 women at age 31 years
from the general population-based Northern Finland Birth Cohort who were
born in 1966. Women were classified as oral contraceptive users (n = 687
women), levonorgestrel-releasing intrauterine device users (n = 168
women), or no use of hormonal contraception (reference group; n = 1959
women). The analyses were adjusted for body mass index, current alcohol
use, household income, and area of residence.

RESULTS: Compared with the reference group, oral contraceptive users had
higher systolic and diastolic blood pressure, raised levels of
inflammatory indices (C-reactive protein), and impaired insulin
sensitivity. Levonorgestrel-releasing intrauterine device users
displayed a lower high-density lipoprotein and total cholesterol, but a
similar cholesterol/ high-density lipoprotein ratio, and higher
leukocyte count compared with the reference group. Oral contraception
users were insulin-resistant compared with levonorgestrel-releasing
intrauterine device users with higher blood pressure, raised lipid
levels (such as total cholesterol and triglycerides) and insulin levels,
and lower homeostasis model assessment and insulin sensitivity, despite
smaller waist and lower waist-hip ratio.

CONCLUSION: Oral contraception usage was associated with adverse
findings in several metabolic, cardiovascular, and inflammatory
parameters, which is consistent with an increased future risk of
cardiovascular and metabolic disease. These findings should invite more
criticism of recent trends that encourage the prescription of oral
contraceptives for years during reproductive life and especially in
premenopausal women. In contrast, levonorgestrel-releasing intrauterine
device or progestin-only pills may offer long-term health benefits over
oral contraceptives and should be preferred to oral contraceptives for
women in their forties and/or with metabolic risk factors for
cardiovascular diseases and type 2 diabetes mellitus.

Morin-Papunen L, Martikainen H, McCarthy MI, Franks S, Sovio U,
Hartikainen AL, Ruokonen A, Leinonen M, Laitinen J, Järvelin MR, Pouta
A. Comparison of metabolic and inflammatory outcomes in women who used
oral contraceptives and the levonorgestrel-releasing intrauterine device
in a general population. Am J Obstet Gynecol. 2008
Nov;199(5):529.e1-529.e10. Epub 2008 Jun 4.
<http://www.ncbi.nlm.nih.gov/pubmed/18533124>

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

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

**Featured Website** <http://www.healthfinder.gov/>

**Improved healthfinder.gov Makes Health Information Quicker and Easier
to Use**

An improved and more accessible version of
[healthfinder.gov](http://www.healthfinder.gov/), a federal Web site
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\"Many Americans struggle with complex health information Web sites.
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Healthfinder.gov\'s features include links to over 6,000 government and
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This feature was developed through a joint effort between HHS\' Office
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\"Health professionals have benefited from online access to task force
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advantage,\" said AHRQ Director Carolyn M. Clancy, M.D. \"We are pleased
to join with ODPHP to offer myhealthfinder as a personalized,
evidence-based prevention decision support tool.\"

The redesign of healthfinder.gov was based on proven clear communication
practices. In addition, several possible versions of the Web site and
the new prevention content were consumer tested to ensure that the site
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Improved healthfinder.gov Makes Health Information Quicker and Easier to
Use*.* Press Release, September 22, 2008. Office of Disease Prevention
and Health Promotion and the Agency for Healthcare Research and Quality,
Rockville, MD.
<http://www.ahrq.gov/news/press/pr2008/healthfinderpr.htm>

<http://www.healthfinder.gov/>

#### Frequently asked questions, Neil Murphy, ANMC, Southcentral Foundation {#frequently-asked-questions-neil-murphy-anmc-southcentral-foundation .Style-Heading-4-+-Arial-14-pt-Underline}

**Q. Should I withhold contraception from a woman who is not 'current'
on her pap?**\
**A.** No, there should be no barriers to the use of FDA approved
contraception.

With a 48% unintended pregnancy rate nationwide, the Indian Health
system adheres to the national benchmarks on this....namely that there
should be no obstacles placed in front of FDA approved birth control
methods.

Potential barriers could include....

[Real barriers:]{.underline} the legal standing of an adolescent in her
health care, having a 'current' pap smear, first pelvic exams performed
for 'baseline' data

[Perceived barriers]{.underline}: lack of confidentiality, fear of side
effects, sexual activity history documented in medical records

This is especially important now that cervical cancer screening has so
many permutations that aren't 'annual', but based on age, sexual debut,
and prior HPV status, etc....

...so while we encourage 'bundling' in some quality assurance issues
(induction of labor, etc...) the old bundling of cervical cancer
screening and birth control method is not recommended.

In the Indian Health system, the stated policy is that we support the
use of all FDA approved birth control methods, (see Chapter 13 below)

All of our recent meetings (the ACOG / IHS Postgraduate Course, our
biennial MCH/Women's Health meetings, etc...) have emphasized the Quick
Start system (see Westhoff below).

Questions about adolescent rights in your state?

Alan Guttmacher Institute:

Go to the **\"State Policies in Brief\"** links

[http://www.guttmacher.org/sections/adolescents.php?scope=U.S.%20specific](http://www.guttmacher.org/sections/adolescents.php?scope=U.S. specific)

See Meeting Lecture Notes - Authors: Ogburn, Espey

<http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm>

**Background:**

There is a 48% unintended pregnancy rate nationwide. Cervical cancer
rates in reproductive age women pale in comparison.

Let's look at adolescents as an example...

The pregnancy and abortion rates among adolescents in the United States
are higher than in other industrialized nations as a result of
intermittent, improper, and lack of use of contraception.

**INCREASING ACCESS TO CONTRACEPTION** --- Barriers that impede the
adolescent\'s access to contraception services should be recognized and
removed, when possible.

**Access to confidential services** --- The provider should recognize
and respect an adolescent\'s need for privacy as a basic premise for
providing confidential services. This goal can be achieved by
facilitating a relationship with an adolescent that is independent from
his or her parents.

The adolescent should be given an opportunity to provide her medical
history and to obtain gynecological and sexual information directly from
the clinician. Both the parents and the adolescent may need to be
educated regarding the new emphasis on direct interaction with the
adolescent, as this approach is different from the approach used when
children are younger and communication occurs primarily between the
clinician and the parents.

As an example, the following statement may be made to an accompanying
parent or guardian, \"I would like to make this visit a positive
experience for your daughter. It is important to respect an
adolescent\'s privacy as a normal part of her growing up. I would first
like to have the opportunity to review health information with you,
followed by reviewing health information with your daughter alone.
Usually, whatever is discussed between my teenage patients and me is
confidential, except in certain situations, such as if she has thoughts
of suicide, thoughts of physically harming someone, or reports she has
or is being physically or sexually abused. If you feel you need to know
more about what she and I have discussed, I strongly encourage you and
your daughter to talk to each other directly.\"

The age of the adolescent is a factor in whether she will choose the
option of complete confidentiality. A young teenager may express a
preference to have her mother present throughout the office visit,
particularly when the mother is aware of the teenager\'s sexual behavior
and is the one who desires the teenager to use a contraceptive method.
Despite such a situation, encouraging some independent time with the
adolescent is important to obtain a more detailed history about other
possible high-risk behaviors.

The provider who is not comfortable providing confidential contraceptive
services to a minor should provide names and phone numbers of other
clinicians or free clinics skilled in providing this care to
adolescents.

**Medical record** --- To keep certain portions of the sexual history in
the medical record private, all of this information should be contained
in a section identified as confidential. The confidential section may
then be released only with the adolescent\'s permission to a parent,
guardian, or other nonmedical party.

**Legal issues** --- A minor\'s right to access contraceptive services
in a health care setting without parental involvement varies from state
to state. Many states give adolescents the right to consent to
contraceptive services; no specific provisions have been found in
consent laws for minors in others. The need for parental consent also
may be related to state or federal funding for contraceptive services in
local clinics. Thus, a provider should become familiar with the rulings
in his or her own state and local clinic protocols.

**Deferring the pelvic examination** --- Many adolescents perceive the
pelvic examination to be a barrier to accessing contraceptive services.
A pelvic examination is necessary to obtain a Papanicolaou (Pap) smear
for cervical dysplasia and neoplasia and to test for sexually
transmitted infections (STIs), but is not required by the Food and Drug
for the initiation or reinstitution of oral contraceptives.

According to the American Cancer Society and American College of
Obstetricians and Gynecologists, cervical cancer screening by a Pap test
should begin approximately three years after first penile-vaginal sexual
intercourse or age 21 years, whichever comes first. If urine testing for
sexually transmitted infection (STI, gonorrhea and Chlamydia) is
available and a Pap test is not indicated, the speculum and bimanual
components of the pelvic examination may be deferred in an asymptomatic
adolescent. In all such cases, external genital inspection must be
performed. If urine testing is not available, swabs for gonorrhea and
chlamydia testing must be obtained directly from the endocervix via
speculum examination. A speculum and bimanual examination and microscopy
of vaginal secretions are necessary if the adolescent has gynecologic
and genital complaints such as an abnormal-looking discharge or
intermenstrual spotting. If urine testing is not available, swabs for
gonorrhea and chlamydia testing must be obtained directly from the
endocervix via speculum examination.

The first pelvic examination is a milestone for the adolescent and needs
to be a private and positive experience to foster communication on
sensitive topics between the adolescent and her healthcare providers.
Some clinicians offer their adolescent patients the option of having the
parent, partner, or a friend present for support during the examination.
If this option is offered, it is important to recognize the adolescent
may prefer to have the examination alone, but feels obligated to allow
her mother or partner to be present for the procedure. In any patient in
whom signs of physical trauma are noted, the adolescent should be
interviewed alone to elicit a history of possible physical or sexual
abuse.

Pelvic examination is not required by the Food and Drug Administration
(FDA) for the initiation or reinstitution of oral contraceptives. The
OCP package insert states: \"Physical examination may be deferred until
after initiation of oral contraceptives if requested by the woman and
judged appropriate by the clinician\". Thus, deferring the pelvic
examination may be considered at the first visit if the teenager has no
genital complaints (e.g., abnormal vaginal discharge, pruritus, odor,
etc) and:

-   She has avoided going to a clinic or physician\'s office out of fear
    of a pelvic examination, or

-   She is having her menstrual period during the visit, or

-   Scheduling an appointment for initiating contraception involves a
    long delay because of the time allocated for complete physical and
    pelvic examination

Teenagers appreciate that they have a choice in this matter. Subsequent
performance of the pelvic examination may be facilitated by making an
effort to alleviate fears related to the adolescent\'s perception of the
pain and embarrassment she thinks she will suffer from the procedure.
With appropriate education, one program found that among teenagers who
deferred the pelvic examination for the situations cited by the FDA, 69
percent returned for the pelvic examination at the three-month visit and
78 percent by the six-month visit.

**INCREASING CONTRACEPTIVE USE AND ADHERENCE** --- Oral contraceptive
pills (OCPs) are the most popular prescriptive contraceptive method used
by adolescents (44 percent), followed by condoms (37 percent), and depot
medroxyprogesterone acetate (DMPA) (10 percent).

Although a variety of hormonal contraceptive methods are available, this
discussion will focus on those commonly used by adolescents: OCPs and
DMPA. In addition, the transdermal patch will be discussed since it
appears to be increasing in popularity among adolescents. Use of the
vaginal ring is increasing among older adolescents who are comfortable
inserting it. There also is an emerging interest in the intrauterine
device. The approved progestin-only subdermal implant (single rod) is
effective for three years and is another viable option for adolescents
in the future.

Emergency contraception, which is discussed in detail separately, is
available by prescription and should be mentioned to all sexually active
adolescents.

**Motivating factors** --- The sexually active adolescent is more likely
to seek contraception in the following situations:

-   Perceiving pregnancy as a negative outcome

-   Having long-term educational goals

-   Being of older age

-   Experiencing a pregnancy scare or actual pregnancy

-   Having family, friends, and/or a clinician who sanction the use of
    contraception

Adolescents are more likely to use condoms if they understand condoms
can prevent HIV/AIDS, if they carry condoms and are not embarrassed to
use them, and if they are worried about getting AIDS.

**Initiating contraception** --- Adolescents vary in their readiness to
initiate contraception. From a developmental perspective, sexually
active girls in early adolescence have difficulty planning events and
activities; they often live for the moment. Therefore, implementing a
contraceptive method that requires planning and forethought is difficult
at this age without monitoring and adult support. Girls in middle and
late adolescence are more capable of higher-level planning, decision
making, and problem solving, skills essential to effective contraceptive
behavior.

**Education** --- Several points should be discussed at the time of
initiating a contraceptive:

-   Selecting the best method based on frequency of use and convenience

-   Risk of side effects

-   Tips on adherence

-   Use of condoms to protect against STIs

-   Practical suggestions to promote use, such as keeping condoms in a
    purse

-   The availability of and indications for emergency contraception

Sometimes an adolescent is sexually active and does not desire a
pregnancy but is undecided about starting a method. In these cases, the
discussion should raise her awareness of her risk of pregnancy and STIs.
Reviewing stories of her sister(s), friends, or peers at school who are
teen mothers may be helpful. Girls who are not engaging in sexual
activity also should be educated about the use of condoms and emergency
contraception, in case their status changes.

In other cases, a nervous mother or grandmother may desire reliable
hormonal contraception for her daughter or granddaughter who is not yet
sexually active. The adolescent may have demonstrated an interest in
boys and/or may have an older sister who is a teenage mother. In these
cases, the clinician should have an open discussion with the adolescent
and the parent regarding parental fears, trust, and parent-monitoring
skills. Finally, the pros and cons of starting hormonal contraception in
an adolescent with growth potential should be considered against the
risk of pregnancy. Gaining the adolescent\'s trust, valuing her opinion,
and obtaining her consent for contraception in this case are important.

-   Selecting the best method --- A careful history should be obtained
    prior to beginning the counseling process. This step will help the
    clinician facilitate counseling regarding any possible absolute or
    relative contraindications to starting an estrogen-progesterone
    product.

-   Anticipated adverse effects --- The anticipated side effects from
    hormonal contraception should be reviewed. Breakthrough bleeding or
    amenorrhea from OCPs, DMPA, and the transdermal patch can be very
    upsetting. These methods are likely to be discontinued unless the
    adolescent has been counseled about potential problems and their
    treatment. As an example, in one study of women treated with DMPA,
    women who were told about the possibility of amenorrhea were 2.5
    times more likely to continue DMPA than those not given this
    information.

A rash and itching at the application site may be of concern to
adolescents using the transdermal patch. Partial or complete detachment
of the transdermal patch was reported in 35 percent of adolescents in
one study, compared with less than 5 percent in adults. Of note, no
detachments were reported when the patch was worn on the arm. The likely
explanation may be inadequate care in application and increased activity
among teenagers compared with adults.

Noncontraceptive benefits --- Reviewing the noncontraceptive benefits of
OCPs, DMPA, and the transdermal patch with adolescents also is
important. Benefits of OCPs and the transdermal patch include improved
bone density and protection against ovarian cancer, endometrial cancer,
salpingitis, ectopic pregnancy, benign breast disease, dysmenorrhea, and
iron deficiency. The same benefits, with the exception of improved bone
density, are provided by DMPA.

**Informed consent** --- Although it is not necessary to obtain written
informed consent before the initiation of hormonal contraception in
adolescents, the use of a structured informed consent form can ensure
that the risks and benefits are adequately discussed. The form used by
Texas Children\'s Hospital for combination hormonal contraceptives is
provided as an example.

**Barriers to use and adherence** --- Barriers to the use of hormonal
contraception by adolescents include fear of side effects, some of which
are not substantiated by evidence.

**Fear of side effects** --- A fear of side effects from OCPs and DMPA
injections is a common barrier to the use of hormonal methods. As an
example, in one review, adolescents in a private practice setting were
overwhelmingly more concerned about weight gain from OCPs and those in
an urban hospital-based adolescent clinic were concerned about weight
gain, blood clots, birth defects, and infertility.

Weight gain --- Many adolescents are concerned that oral contraceptives
cause weight gain. However, available data suggest this is not the case.
In the review described above. Adolescents who did not adhere to their
OCPs were more likely to feel they had gained weight, although actual
weight often was unchanged. Most young women did not gain more than 2.3
kg while using OCPs or 3.6 kg while using DMPA during a two-year period.

In another study, the effect of OCP use on body weight and fat
distribution was assessed in 49 healthy young women initiating treatment
with a low-dose OCPs (30 mcg ethinyl
[estradiol](http://www.uptodateonline.com/online/content/topic.do?topicKey=ped_drug/70684&drug=true)
plus 75 mcg gestodene); anthropometric measurements before and after the
initiation of OCP use were compared with those in 31 age-and-weight
matched women not using OCPs. Baseline body mass index (BMI), percent
fat, percent water, and waist-to-hip ratio (WHR) did not change
significantly after six cycles in the OCP users. A similar number of
women gained weight in both groups (30.6 percent of users, 35.4 percent
of controls); the typical weight gain in the OCP group was only 0.5 kg.
The weight gain in these women was caused by accumulation of fat, not
body water. Approximately 20 percent of women in both groups lost
weight. Thus, adolescents should be reassured that OCP use does not
result in an increase in body weight or percent body fat over that seen
in nonusers.

Adolescents also are increasingly concerned about weight gain from DMPA.
Although weight gain and DMPA use may be concomitant events, a causal
relationship has not been established. Factors other than DMPA may be
playing a role. As an example, in one study, after six months of DMPA
use, weight gain was greater among black than white subjects (4.2 versus
1.2 percent increase or mean weight gain of 2.9 versus 0.9 kg). A higher
baseline weight, eating restraint, eating disinhibition, and other
medications were predictive for weight gain in the black adolescents. In
contrast, the only predictive factor for weight gain in white
adolescents was a higher baseline weight. Thus, weight gain while using
DMPA appears to occur in adolescents with a propensity for weight gain.

Bone density --- DMPA and ultra low-dose estrogen (20 mcg) pills may
interfere with achieving optimal peak bone mass in very young women by
causing loss in bone density or interference with the increase during a
time of expected bone accretion.

Rare cases of osteoporosis, including osteoporotic fractures, have been
reported postmarketing in patients taking DMPA. For this reason, the
United States Food and Drug Administration has a labeling change to
include a warning that DMPA be used as a long-term birth control method
(e.g., longer than two years) only if other birth control methods are
inadequate.

It is important to review information regarding DMPA and bone density
with adolescents. The general opinion is that, if possible, DMPA should
be avoided in a girl during early adolescence. However, the data are not
sufficient to limit the use of the transdermal patch in adolescents; nor
are they sufficient to limit the use of DMPA in older adolescents. In
fact, some experts argue that for adolescents in whom DMPA is the only
acceptable contraceptive option, the benefit of pregnancy prevention
outweighs the potential risk to bone health. This conclusion is based
upon the following points:

-   Pregnancy also appears to decrease BMD

-   Most adolescents who use DMPA do so for less than two years

-   There is at least partial recovery of bone density after
    discontinuation of DMPA

-   The adolescent can modify other lifestyle factors to maximize bone
    health (i.e., calcium intake, exercise, avoidance of tobacco use).

-   Estrogen supplementation may provide additional bone protection and
    may be warranted for girls in whom BMD may already be decreased
    (e.g., family history of osteoporosis, anorexia nervosa, chronic
    renal disease). The optimal dose and route for estrogen
    supplementation is not known; (0.625 mg equine estrogen per day is
    the only oral dose that has been tested).

-   Spinal bone mineral density can be monitored with dual energy
    absorptiometry (DXA) and compared with normative data to determine
    whether DMPA should be continued or discontinued. DXA should be
    obtained in all young women who use DMPA continuously for two years.

The Society for Adolescent Medicine has published a position paper
regarding the black box warning for DMPA. The position paper suggests
that:

-   With adequate explanation of benefits and potential risks, DMPA may
    continue to be prescribed to adolescent girls who need contraception

-   Decisions regarding bone density monitoring of adolescents using
    DMPA for contraception should be individualized; the decisions
    should be made by the clinician in concert with the adolescent, and
    potentially the adolescent\'s guardian

-   Duration of use of DMPA need not be restricted to two years

-   Adolescents using DMPA should be encouraged to take 1300 mg and 400
    IU [[vitamin
    D]{.underline}](http://www.uptodateonline.com/online/content/topic.do?topicKey=ped_drug/27837&drug=true)
    and to exercise each day. Calcium and vitamin D supplements are
    available separately in tablet form or combined in a single tablet.

-   Estrogen supplementation should be considered for girls who are
    doing well on DMPA and have osteopenia or are at risk for osteopenia
    and who have no contraindications to estrogen

-   Pelvic inflammatory disease --- The relationship between OCPs pelvic
    inflammatory disease (PID) is complex. Whereas some studies indicate
    that the use of OCPs increases the risk of PID, others suggest that
    OCPs increase the risk for cervicitis and endometritis, but not
    salpingitis, thereby decreasing the severity of PID.

No association between DMPA and risk of PID has been reported. The
intrauterine device (IUD) itself does not increase the risk for PID.
However, the presence of the IUD may increase the severity of PID in an
adolescent due to their increased risk for STIs.

Venous thromboembolism --- The association between OCPs and risk of
venous thromboembolism (VTE) appears to be related to estrogen dose and
type of progestin. Even low-dose OCPs (30 to 50 mcg estrogen pills) can
be associated with a modest increase (three- to sixfold) in the risk of
VTE. OCPs containing third-generation progestins also may be associated
with a slight increase in risk of VTE.

Many adolescents and their parents also have raised questions about the
reports of increased risk of VTE from the transdermal patch. The FDA has
required the label for the transdermal patch to contain a warning
regarding the possible increased risk of thrombotic events related to a
higher-than-average circulating estrogen level. This warning is
controversial because it is unclear whether the increased circulating
estrogen level will in fact be associated with a higher frequency of
adverse events.

The risk of VTE with OCPs or the transdermal patch should be considered
in relation to the risk of VTE during pregnancy. The risk of VTE may be
3- to 10-fold higher in pregnant than nonpregnant women.

Nonetheless, it is important to take a careful personal and family
history of deep venous thrombosis to identify those adolescent women who
might be at high risk before prescribing an OCP or the patch (e.g.,
those who have antiphospholipid antibodies or nephrotic syndrome).

Other effects --- Other side effects from OCPs of concern to adolescents
include birth defects (11 percent) and infertility (10 percent). Many
adolescents hear about these effects from an adult who may have used
higher-dose OCPs in the 1960s and 1970s or is otherwise misinformed.
This situation underscores the importance of dispelling misconceptions
about the adverse effects of OCPs, as well as DMPA, especially in
adolescent women. There is no evidence to support an association between
OCPs and either birth defects or infertility.

**Summary** --- The perceived adverse effects of hormonal contraception
is a real barrier to the use of this method among some adolescents.

-   Weight gain is a common concern. However, there is no evidence to
    suggest OCP use results in an increased body weight or percentage of
    body fat beyond that seen in nonusers. Among users of DMPA, weight
    gain appears to occur in those who have an underlying propensity for
    weight gain.

-   DMPA and low-dose estrogen OCPs may interfere with the achievement
    of peak bone mass in very young adolescent women. The general
    opinion is that, if possible, DMPA should be avoided in girls during
    early adolescence. The data are not sufficient to limit the use of
    the transdermal patch in adolescents; nor are they sufficient to
    limit the use of DMPA in older adolescents.

-   Low-dose OCPs are associated with a modest increase in the risk of
    venous thromboembolism.

-   Inadvertent OCP administration during early pregnancy has not been
    associated with an increase in risk of congenital anomalies.

-   OCPs do not increase the risk of infertility; in fact, the risk of
    primary infertility may be reduced in women who have taken an OCP.

**Choosing a method and promoting adherence**

**Here is just one example of a BCM to provoke thought...**

**OCPs** --- Common examples of adherence problems with OCPs include not
refilling OCP prescriptions, forgetting to take the pill, starting the
next pack late, using pills sporadically, and not using a backup method
when needed. In one study, 33 percent of adolescents missed a pill in
the previous three months. Therefore, the adolescent should be provided
clear verbal and written instructions. The clinician should ascertain
she has sufficient reading skills to interpret labels and instructions.
To optimize compliance with OCPs, an adolescent should be told only
three things to remember:

-   When to start the pill

-   Take the pill every day at the same time, especially when doing
    something else regularly like teeth brushing

-   Call the clinic/office if there are any questions

She should be asked to repeat these three instructions to assess and
promote her understanding of them. In addition, she should be given an
easy-to-read list stating the clinic\'s name, a contact person, phone
number, and instructions for when she misses pills. She should not rely
on her friends or family for information if she has a problem with her
medication.

-   When to start the pill --- OCPs can be started at any time. In
    adolescents, they are typically started on the first day of the next
    menstrual period or the Sunday after the onset of the menstrual
    period (\"Sunday start method\"). The rationale for this delayed
    start date is to make sure that the adolescent is not pregnant.
    However, as many as 25 percent of adolescents who seek OCPs from
    family planning clinics never take the first pill. Failure to begin
    the pill may occur due to ambivalence, confusion about starting
    instructions, or intervening pregnancy.

> To address this issue, a \"same day\" or \"Quick start\" method is now
> the preferred approach. The Quick start method requires increased
> attention to the adolescent\'s self report of sexual activity since
> her last menstrual period, the accuracy of the pregnancy test in the
> context of her sexual history, and the use of emergency contraception
> when applicable. (See Westhoff below)
>
> Extended cycle pill or continuous pill use --- A schedule that
> involves continuous pill use for 84 days followed by a week of
> pill-free days may help to increase OCP adherence in adolescents who
> wish to avoid a monthly period. The desire to avoid monthly periods
> may be related to participation in athletic events or summer camps or
> to the general discomfort and \"hassle\" of monthly periods.

**Continuation rates** --- Continuation rates for OCPs in adolescents
vary based upon the location of services. In free urban community and
hospital-based clinics, rates after one year range from 9 to 40 percent.
By comparison, a 75 percent continuation rate was noted at one year in a
suburban practice. Intermittent use of contraception, method-switching,
and periodic abstinence appear to be common in African-American
adolescent females; in one series, one-third of such subjects on OCPs
reported frequent periodic abstinence in any month.

Intermediate continuation rates have been noted with DMPA. In a
retrospective chart review in an urban clinic, the one-year continuation
rates were 45 percent with DMPA and 12 percent with OCPs. Lower values
(32 percent at one year and 13 percent at two years) with DMPA were
noted among inner city, minority adolescents with high pregnancy rates.
Among those who discontinued therapy, 40 percent restarted the method at
a later time.

Data regarding adherence rates with the transdermal patch in adolescents
are limited. In one study of the feasibility and acceptability of the
patch in adolescents, 31 of 50 participants (62 percent) completed all
three-months of the study, and of these, 87 percent reported perfect
compliance and 77 percent planned to continue using the patch.

**SPECIAL CIRCUMSTANCES**

**The mentally handicapped adolescent** --- The mentally handicapped
adolescent has access to contraception under the supervision of a parent
or guardian. The availability of DMPA given every three months, the
transdermal patch, and continuous OCPs with withdrawal bleeding every
three months has significantly increased access to more convenient
hormonal contraception, improved adherence, and made menstrual hygiene
issues easier.

In most states, following an evaluation by three clinicians and
acquisition of parental consent, a mentally handicapped adolescent has
access to permanent sterilization after 21 years of age. In some states,
under special circumstances such as an ambulating, profoundly mentally
handicapped adolescent, sterilization of a mentally handicapped
adolescent younger than 21 years of age may be approved after a process
involving a review by an ethics committee and/or a court system.

**The chronically ill adolescent** --- Hormonal contraception for the
chronically ill adolescent can be a challenge. Estrogen-based hormonal
contraceptives, as an example, should not be offered to an adolescent
with significant valvular disease who is not being treated with an
anticoagulant. Although DMPA is useful in such cases, its effect on
fluid retention should be evaluated and monitored.

Similarly, estrogen-based hormonal contraceptives should not be offered
to an adolescent with antiphospholipid antibody abnormalities,
uncontrollable hypertension, and vascular involvement. DMPA is useful in
such cases; there have been no reports of SLE flares with long-term DMPA
use.

In addition, multiphasic or ultra-low OCPs are not recommended in
adolescents taking many anticonvulsants because anticonvulsants other
than [valproic
acid](http://www.uptodateonline.com/online/content/topic.do?topicKey=ped_drug/180190&drug=true)
increase the clearance of sex steroids. DMPA is a good alternative
because
[progesterone](http://www.uptodateonline.com/online/content/topic.do?topicKey=drug_l_z/212059&drug=true)
levels are high enough to be unaffected by increased P-450 activity.

Medications that alter the effectiveness of estrogen-based hormonal
contraceptives by increasing clearance of sex steroids include
[rifampin](http://www.uptodateonline.com/online/content/topic.do?topicKey=ped_drug/155269&drug=true),
[griseofulvin](http://www.uptodateonline.com/online/content/topic.do?topicKey=ped_drug/85209&drug=true),
and anticonvulsants. Herbal medication such as St. John\'s Wort also can
increase clearance of sex steroids. There are inadequate data to support
any significant drug interaction between common antibiotics and
estrogen-based hormonal contraceptives. Thus it is important the choice
of hormonal contraceptives be reviewed in the context of the chronic
illness, potential increase in estrogen-related complications, and drug
interactions during the counseling process. The risk of pregnancy needs
to be weighed against the risk of a medical complication from hormonal
contraception. In addition, emergency contraception should be discussed
with adolescents whose current treatment may be teratogenic to the fetus
or in whom pregnancy would severely compromise health.

**Resources:**

Westhoff C et al Initiation of Oral Contraceptives Using a Quick Start
Compared with a Conventional Start: A Randomized Controlled Trial.
Obstet Gynecol. 2007 Jun;109(6):1270-1276.

<http://www.ncbi.nlm.nih.gov/pubmed/17540797>

Chapter 13 - Maternal and Child Health

Section 3-13.12 F, IHS Manual, Part 3 - Professional Services,

Contraceptive Services - All available Food and Drug Administration
(FDA) approved types of contraceptive (mechanical, chemical and natural)
methods should be available to those clients requesting such services.
The choice of method will be that of the patient based on a careful
explanation of each method in accordance with the medical judgment of
the provider. Adequate follow-up should be available to respond promptly
to complications or side effects of the various methods as well as to
assure proper and effective use of the selected method.

<http://www.ihs.gov/PublicInfo/Publications/IHSManual/Part3/pt3chapt13/pt3chpt13.htm#12f>

Issues concerning the use of hormonal contraception by adolescents

<http://www.uptodateonline.com/online/content/topic.do?topicKey=adol_med/2363&selectedTitle=2~150&source=search_result#6>

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

**December 2008**

**Quote of the month**

*"The trouble with the world is that the ignorant are cocksure and the
intelligent are full of doubt"*

Anonymous

**Etiquette-Based Medicine**

"Patients ideally deserve to have a compassionate doctor, but might they
be satisfied with one who is simply well-behaved? When I hear patients
complain about doctors, their criticism often has nothing to do with not
feeling understood or empathized with. Instead, they object that \"he
just stared at his computer screen,\" \"she never smiles,\" or \"I had
no idea who I was talking to.\" During my own recent hospitalization, I
found the Old World manners of my European-born surgeon --- and my
reaction to them --- revealing in this regard."

This is the opening paragraph from a thought provoking essay recently
published in the NEJM. The author reviews how much effort has been
expended in the past few decades to teach medical students to be more
humane and compassionate. He believes there has been no similar effort
to teach clinicians "good manners".

He uses an analogy with the recent decrease in ICU infections with the
use of strict checklist protocols. Rather than a "sophisticated"
approach such as developing new antibiotics, success was achieved by
strictly following simple hygiene rules. Changing attitudes is hard...
changing behavior is much easier. He makes the argument that we might do
as well by patients with developing a checklist of better behaviors that
we can teach medical students.

**Editorial Comment**

At first glance it seems wrong to value form over content. Yet, the
author makes a compelling case that patient satisfaction might be better
served. It is an especially interesting concept since for most of us our
work in Indian Health involves a cross cultural component. The author is
a psychiatrist and feels that training students to be empathic is
laudable but difficult. As he summarizes, "I'm not sure I teach students
to see things through the patient's eye, or to tolerate suffering. I
think I can, however, train them to shake a patient's hand, sit down
during a conversation, and pay attention.

Read the whole post at no charge at the link below:

Kahn, MW. Etiquette-Based Medicine. N [Eng J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2008 May
8;358(19):1988-9

<http://content.nejm.org/cgi/content/full/358/19/1988>

**Infectious Disease Updates,** **Rosalyn Singleton, MD**

**Changes to the Pneumococcal Polysaccharide Vaccination (PPV23)
Recommendation**

The Advisory Committee on Immunization Practices (ACIP) met on Oct.
22^nd^, 2008, and reviewed and expanded the recommendation for the use
of the 23-valent pneumococcal polysaccharide vaccine (PPV23). Persons 19
-- 64 years of age with asthma as well as persons 19 -- 64 years of age
who are current smokers were added to the recommendation, and should
routinely receive PPV23.

In addition, the ACIP pneumococcal working group, which included
representatives from IHS and tribal health programs, presented
information related to the routine use of PPV23 in American
Indian/Alaska Native (AI/AN)populations. Based on this information, the
ACIP voted to make the following changes to the recommendation for the
use of PPV23 in AI/AN children and adults.

1.  Previously, the ACIP recommendation stated that routine use of PPV23
    after receipt of pneumococcal conjugate vaccine "*could be
    considered"* for AI/AN children.^1^ In addition to being confusing
    for providers, the working group found that there are limited data
    on the effectiveness of this strategy in reducing invasive
    pneumococcal disease, and noted limited data that suggest that PPV23
    vaccination after receipt of pneumococcal conjugate vaccine could
    cause hyporesponsiveness, although the clinical implications of this
    finding are not known. Based on this information the ACIP approved
    the following change to the recommendation re: the use of PPV23 for
    AI/AN children. The new recommendation reads:

> *Routine use of PPV23 after PCV7 is not recommended for Alaska Native
> or American Indian children aged 24-59 months. However, in special
> situations, public health authorities may consider recommending the
> use of PPV23 after PCV7 for Alaska Native or American Indian children
> aged 24-59 months who are living in areas where the risk of invasive
> pneumococcal disease is increased.*

2.  The previous ACIP pneumococcal recommendation stated that "Persons
    aged 2-64 years who are living in environments or social settings in
    which the risk for invasive pneumococcal disease or its
    complications is increased (e.g.., Alaskan Natives and certain
    American Indian populations) should be vaccinated*.\"*^2^The working
    group found that there was no data to support such a broad
    recommendation, and expressed concern that the recommendation was
    confusing for providers and offensive to some AI/AN people. Based on
    this information, the ACIP voted to approve the following change to
    this recommendation:

> *Routine use of PPV23 is not recommended for Alaska Native or American
> Indian persons younger than 65 years old unless they have underlying
> medical conditions that are PPV23 indications.  However, public health
> authorities may consider recommending PPV23 for Alaska Natives and
> certain American Indians aged 50-64 years who are living in areas
> where the risk of invasive pneumococcal disease is increased.*

In summary, routine use of PPV23 is still indicated for people,
including AI/AN people, who (bold indicates new risk groups):

-   Are 65 years and older

-   Have a chronic health condition (e.g. chronic cardiovascular disease
    chronic pulmonary disease (**including asthma**), diabetes mellitus,
    alcoholism, and chronic liver disease (cirrhosis), or CSF leaks.

-   **Are a current smoker**

-   Have functional or anatomic asplenia (e.g., sickle cell disease or
    splenectomy)

*^1^"Preventing Pneumococcal Disease Among Infants and Young Children.
Recommendations of the Advisory Committee on Immunization Practices
(ACIP). October 06, 2000 / 49(RR09);1-38*

^2^Ibid

**Recent literature on American Indian/Alaskan Native Health, Michael L.
Bartholomew, MD**

**Results of a Collaborative School-Based Oral Health Program in a
Remote First Nations Community**

Dental caries continues to be a significant infectious disease
afflicting American Indians and Alaska Native children. Multiple
programs addressing oral health have been implemented with varying
success. Dr. Steve Holve presented the current state of oral health in
AI/AN communities in the October 2006 edition of the *IHS Primary Care
Provider*.^1^ Concerns about oral health of native or aboriginal
children extend across national boundaries. Aboriginal children of
Canada appear to have an increase prevalence of poor oral health, often
2-3 times poorer than other populations in Canada. Dental decay rates in
Canada have been cited to be 3 to 5 times greater in aboriginal children
than in non-aboriginal children. Causes for this increase have been
bottle caries, high sugar diets, limited access to dental health care
and oral hygiene.

This cross-sectional study reports the results of a collaborative
school-based oral health program in a remote First Nations community
over the past three years. The Pediatric Residency Program at the
University of British Columbia established a partnership with the people
of Hartley Bay. After meeting with the community and its elders, oral
health was identified as a problem. Four possible interventions
addressing oral health were presented. The community chose a school
based intervention consisting of supervised, daily school-based
brush-ins after lunch, weekly fluoride rinse, and fluoride varnish
applications for those under 9 years of age, dental health anticipatory
guidance, and classroom presentations on oral health. All the children
in the community participated. Fifty-eight children were enrolled into
the study of which 26 students were given pre-enrollment complete dental
examinations. 18 children who were initially enrolled were lost to
follow-up. Therefore only 40 students completed the study. Thirteen
students had both pre and post intervention evaluations. Each
participant was given a Decayed, Missing, and Filled Surfaces (DFMS)
score for primary or permanent teeth, cavity free status and an oral
health habits questionnaire.

Over the three-year period, the children evaluated pre and post
intervention had significant improvement in DMFS scores. Improvement in
cavity free status and oral health habits were also seen. The success of
this study underscores the importance of collaboration and community
input in the design of public health interventions.

Macnab AJ, Rozmus J, Benton D, Gagnon, FA. 3-Year Results of a
Collaborative School-Based Oral Health Program in a Remote First Nations
Community. *Rural and Remote Health* 8:882. 2008.
<http://www.ncbi.nlm.nih.gov/pubmed/18444770>

Reference:

^1^Holve S. Fluoride Varnish Applied at Well Child Care Visits Can
Reduce Early Childhood Caries. *IHS Primary Care Provider* 2006.
31(10):243-245.

January 2009

# Editor's Comment from Steve Holve, CCC Pediatrics

**The recent death of Dr. Roger Gollub was an unexpected tragedy. I am
using this editorial space to reprint a tribute to Dr. Gollub from
Robert McSwain, Director of the Indian Health Service. I would urge you
to contribute to the memorial fund listed in the last paragraph.**

It is my sad duty to inform you that Dr. Roger Gollub, who recently
retired from the U.S. Public Health Service Commissioned Corps, died
unexpectedly on November 19, 2008, in Kotzebue, Alaska.  Dr. Gollub had
retired in September after serving in the USPHS for over 24 years.
During his career, he devoted himself to working with American Indians
and Alaska Natives in their communities.

Dr. Gollub was a brilliant and committed scientist and pediatrician. He
began his career as a staff pediatrician at the Gallup Indian Medical
Center in Gallup, New Mexico.  After two years in the Epidemiology
Intelligence Service of the Centers for Disease Control in an assignment
with the Colorado Department of Health, he subsequently served for 11
years as the epidemiologist for the IHS Albuquerque Area.  During that
time, Dr. Gollub was pediatric advisor to the National IHS Head Start
Program and collaborated with other pediatricians on a five-year Healthy
Tomorrows grant to serve children with special needs. 

For the past seven years, he served as a full-time pediatrician in the
South central Foundation Primary Care Clinic at the Alaska Native
Medical Center in Anchorage.  His clinical services included outreach to
rural Alaska villages.  Dr. Gollub was in Kotzebue providing a pediatric
clinic on the day of his death.

 

He loved the adventure of living in Alaska, and frequently shared his
resulting photographs and stories with friends.  Dr. Gollub chose to
retire from the Corps in September so he could also pursue his dream and
commitment to research and working with the Alaska Native Head Start
program, while continuing his clinical services part-time.

He lived his life serving others. His tragic and untimely death has
highlighted some of the public health issues facing the communities he
served and his commitment to prevention. Although Dr. Gollub's
co-workers were always amazed at his vast knowledge and teachings, he
believed those around him were his greatest teachers, and that he was
their student. 

Dr. Gollub was born in University City, Missouri.  Not surprisingly, he
was the valedictorian of his high school class.  He attended Yale
University, obtained his medical degree from John Hopkins University,
and completed his pediatric residency at Case Western Reserve
University.

Dr. Gollub is survived by his wife, Diane Abrahams-Gollub; two
daughters, Anna and Sarah, his mother, Sheila Gollub; brother, David,
and numerous co-workers and friends.  His family has established a
memorial fund in Dr. Gollub's name to benefit the Head Start program for
Alaska Native children. Contributions can be sent to the Alaska USA
Federal Credit Union, Account \# 1429780 and Routing \# 325272021.  The
address of the bank is P.O. Box 196613 Anchorage, AK 99508-6613. 
Further information is available at
[www.drrogergollubcommunity.org](../www.drrogergollubcommunity.org)

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

**Warfare and neglected diseases**

Last year *The Lancet* ran a series of research articles looking at the
implications of understanding health as a human right. In the third
article in the series, Chris Beyrer and colleagues explore the
intersection of so-called "neglected diseases" and civil conflict. Using
detailed case studies from Burma and Colombia, they make a convincing
argument that conflict can drive substantial increases in the rates of
these diseases.

"Neglected diseases" is a blanket term that covers various tropical
infections, many resulting from protozoans or helminthes. They are
neglected because they are unprofitable to treat, even though by most
estimates they collectively account for about a fourth of the global
burden of disease (above better-known infections like malaria or
tuberculosis). These diseases afflict the poorest people in poor
countries. In the wealthy world, then, there is little motivation to
research these diseases or provide therapy for them; in the poor
countries in which they are found, there is little infrastructure to do
either.

Burma is ruled by a military junta with one of the worst human rights
records in the world; over forty percent of state expenditure goes to
the military, and less than three percent is directed to health.
Neighboring Thailand has nearly eliminated *Wuchereria bancrofti*, the
cause of the disabling chronic disease lymphatic filariasis, by mass
chemotherapy in affected zones using diethylcarbamazine. Burma's rulers,
in contrast, provide neither the drugs nor the community health workers
to deliver them. Filariasis affects roughly 10% of Burma's population,
and some 40% show signs of exposure. Not only are Burma's citizens
affected, but fleeing refugees are threatening *W. bancrofti* control in
nearby countries. In Colombia, Beyrer and colleagues document increases
in leishmaniasis, yellow fever, and *Trypanosoma cruzi* (the cause of
Chagas' disease, a progressive cardiomyopathy) in the most violent rural
areas. Neither treatment nor preventive measures can be effectively
applied in guerilla-controlled areas; in fact, vaccines and drugs have
even been hijacked.

Conflict allows neglected diseases to burgeon in many ways. It restricts
disease surveillance, limits access to diagnostic and curative services,
and disables preventive measures like control of disease-bearing insects
or distribution of vaccines. In addition, affected patients may present
at very late stages because of difficulty in accessing care, and
infections may spread rapidly as displaced people move beyond previous
community boundaries. Donors and researchers may be (understandably)
reluctant to investigate or treat outbreaks in unsafe conditions. The
diversion of money from health care to the military clearly also plays a
role in many conflicts.

The authors do not offer much in the way of strategies to improve health
in conflict settings. In addition, they do not draw the obvious
connections with other kinds of health problems exacerbated by warfare.
We know, for instance, that maternal morbidity and mortality suffer when
access to care is lost, and childhood deaths rise as community
infrastructure breaks down and safe food and water can no longer be
assured. The focus on neglected infectious diseases seems narrow. But
their conclusion is right: "resolving these health problems cannot be
better done than with peace, reconciliation, and the end of chronic
conflicts."

Beyrer C et al. Neglected diseases, civil conflicts, and the right to
health. The Lancet 370(9587):619-627, 2007
<http://www.ncbi.nlm.nih.gov/pubmed/17707757>

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

**Curriculum Aims to Decrease Incidence and Improve Care of Diabetes
among American Indians and Alaska Natives**

Diabetes Education in Tribal Schools: Health is Life in Balance is a
K-12 curriculum designed to enhance the understanding and appreciation
of the problems of diabetes in American Indian and Alaska Native (AI/AN)
communities, to empower students to make healthy lifestyle choices, and
to stimulate general student interest in diabetes-based science careers.
The Diabetes Education in Tribal Schools (DETS) curriculum was developed
by the National Institute of Diabetes and Digestive and Kidney Diseases
in collaboration with the Indian Health Service Division of Diabetes
Treatment and Prevention, the Centers for Disease Control and Prevention
Native Diabetes Wellness Program, eight tribal colleges and
universities, and the National Institutes of Health Office of Science
Education. The curriculum comprises multidisciplinary units with lessons
that incorporate National Science Education Standards and AI/AN cultural
and community knowledge. The DETS Web site contains information on the
curriculum\'s background, mission, instructional content, federal
agencies and contributing partners, tribal colleges and universities,
and participating schools. A press release about the DETS national
launch, answers to frequently asked questions, and the 2008 DETS
implementation test evaluation research summary are also provided.

The curriculum is available at:
<http://www3.niddk.nih.gov/fund/other/dets/index.htm>.

**2008 Edition of Women's Health Data Book Released**

Women\'s Health USA 2008, the seventh edition of the data book,
selectively highlights emerging issues and trends in women\'s health
using a variety of data sources. The data book, developed by the Health
Resources and Services Administration, includes information and data on
population characteristics, health status, and health services
utilization. New topics in the 2008 edition include occupational injury,
maternal mortality, digestive disorders, oral health, eye health, and
urologic disorders. Racial and ethnic, sex and gender, and socioeconomic
disparities in women\'s health are also highlighted. The data book is
intended to be a concise reference for policymakers and program managers
at the federal, state, and local levels to identify and clarify issues
affecting the health of women.

It is available at <http://mchb.hrsa.gov/whusa08/>.

**MCH Library Releases Online Resource Brief on Women's Health**

Women\'s Health: Resource Brief is an electronic guide to recent
resources on Web sites, federal offices of women\'s health, and other
related resources for health professionals and families. The brief,
produced by the MCH Library, contains links to related bibliographies,
knowledge paths, and organizations developed by the library. Topics
include AIDS and HIV in pregnancy, assisted reproductive technologies,
breastfeeding and working mothers, depression during pregnancy, domestic
violence, maternal morbidity and mortality, nutrition and physical
activity for women, nutrition during pregnancy, preconception and
pregnancy, and smoking and substance use during pregnancy.

The brief is available at
<http://www.mchlibrary.info/guides/womenshealth.html>.

MCH Library resources on this and other maternal and child health topics
are available at <http://www.mchlibrary.info/guides.html>.

**AAP Updates Training on Creating a Safer Sleep Environment to Prevent
Sudden Infant Death Syndrome**

Reducing the Risk of SIDS in Child Care Speaker\'s Kit is a tool
designed for use by health and education professionals to educate
communities about sudden infant death syndrome in child care. The
updated kit, produced by the American Academy of Pediatrics\' Healthy
Child Care America Back to Sleep Campaign, is available in two formats:
a PowerPoint version or a downloadable print version, including
speaker\'s notes. Content is available in English and Spanish.
Additional supplements available in English only include a sample policy
and an alternative sleep position waiver from the North Carolina Healthy
Start Foundation.

The kit is available at
<http://www.healthychildcare.org/section_SIDS.cfm#train>.

Readers: An article published in the October 2008 issue of Pediatrics
describes a study to evaluate the use of the speaker\'s kit combined
with a training and evaluation effort that incorporated direct
observation of child care provider practices. The abstract is available
at
<http://pediatrics.aappublications.org/cgi/content/abstract/122/4/788>.

**Report Addresses the Scientific Basis for Maternity Practice**

Evidence-Based Maternity Care: What It Is and What It Can Achieve
presents a discussion of maternity care in the U.S. health care system
and identifies key indicators that show the need for improvement. The
report, developed by Childbirth Connection in collaboration with the
Reforming States Group and the Milbank Memorial Fund, summarizes results
of systematic reviews that could be used to improve maternity care
quality, identifies barriers to the use of evidence-based maternity
care, and offers policy recommendations and other strategies that could
lead to wider implementation of evidence-based maternity care in the
United States.

Resources and tools are included.

The report is available at:
<http://www.childbirthconnection.org/article.asp?ck=10575> .

**Article Explores the Effects of Contact with Stillborn Infants on
Maternal Anxiety and Depression**

\"Seeing and holding a stillborn baby are associated with fewer anxiety
and depressive symptoms among mothers of stillborn babies than not doing
so,\" write the authors of an article published in the December 2008
issue of Birth. In the mid-20th century, mothers of stillborn infants
rarely had the opportunity to see and hold their newborns. Later in the
century, many hospitals began to promote rituals through which mothers
could see and hold their stillborn infants, believing that this process
would facilitate healthy maternal grief responses. Recently, this
practice has been called into question. The goal of the study described
in this article was to determine the association between seeing and
holding a stillborn infant with maternal anxiety and depression. The
authors assessed both the mothers\' probability of seeing and holding
their infants and the risk for symptoms of anxiety and depression during
a subsequent pregnancy and in the long term.

For the study, 2,292 women who reported a singleton stillbirth after 20
weeks\' gestation and certainty about whether they were currently
pregnant completed interactive questionnaires that explored various
topics related to stillbirth. Anxiety and depression rates were
measured.

The authors found that

\* The great majority of mothers saw (95%) and held (90%) their
stillborn infants, and few expressed regret that they did so.

\* Almost 80% of mothers who did not see and hold their stillborn
infants expressed regret that they did not do so.

\* Among participants, 42% and 62% reported symptoms of anxiety and
depression, respectively.

\* Among mothers who did not see their stillborn infants, those who
never were given the opportunity and those who actively resisted tended
to have more anxiety symptoms than those who reported that they simply
did not wish to see the infant.

\* Among mothers who saw their stillborn infants, those who reported
that they were given no other options or that the subject was not
discussed with them had fewer symptoms of depression than mothers who
reported having seen the infant because of their own wish to do so.

\* Mothers who perceived that health professionals left the decision to
them by offering them the option to see and hold the infant when they
had no strong wishes of their own tended to have more symptoms of
depression than those who spontaneously wished to see their infant.

\* Mothers who were pregnant at the time of the investigation and who
had seen and held their stillborn infants had fewer symptom of
depression but more symptoms of anxiety than their counterparts who had
not seen or held their stillborn infants. However, long-term results
suggest that the negative effects are transient.

The authors conclude that \"since caregiver interaction may influence a
grieving mother\'s responses during the acute crisis, active management
that includes responsiveness, support, and a staff willing to facilitate
contact with a stillborn baby is necessary and may provide long-term
benefits to the mother.\"

Cacciatore J, Radestad I, Froen F. 2008. Effects of contact with
stillborn babies on maternal anxiety and depression. Birth
35(4):313-320. Abstract available at
<http://www3.interscience.wiley.com/journal/121523277/abstract>.

**MCH Headlines Judy Thierry HQE**

**Project Making Medicine**; S**pecialized training in the treatment of
child physical and sexual abuse**

From Dee Big Foot: \"I am pleased to announce that we have received a
grant from Indian Health Service and the Children' Bureau to provide
specialized training in the treatment of child physical and sexual
abuse.  This funding will allow the Indian Country Child Trauma Center
at the University of Oklahoma Health Sciences Center to offer 4 regional
trainings with 45 training slots available at each regional location.

 

If you are interested in attending the training in your region, please
check out our website at [www.icctc.org](http://www.icctc.org/) for
information about the application process.  A limited amount of travel
funds are available for applicants who successful apply; I strongly
encourage two or more applicants from each site to allow for carpooling
or other creative ways to get the most out of the limited funds. 

 

Please share this information with your colleagues or other mental
health or wellness providers in your area.  I do not have current email
information for many of our past training participants and I would
greatly appreciate if you could help disseminate this announcement as
widely as possible. 

Location and Dates:

Phoenix, AZ - February 17-19, 2009

Portland, OR - March 10-12, 2009

Minneapolis, MN - April 13-15, 2009

Anchorage, AK - June 2-5, 2009

 If you have questions, please contact me at <dee-bigfoot@ouhsc.edu> or
Janie Braden at <Janie-braden@ouhsc.edu>.  You may also call
405-271-8858. 

 

**2009 Childhood Obesity Conference: Creating Healthy Places for All
Children**

The 5th biennial Childhood Obesity Conference is the largest gathering
of professionals focused on the prevention of pediatric overweight in
the nation with over 1,800 in attendance. The conference is devoted to
providing the most pressing and innovative issues related to childhood
obesity. Showcased will be presentations focused on issues, strategies
and programs as they relate to the environmental, organizational, media
advocacy and policy, nutrition and physical activity education, and
family and clinical approaches to childhood obesity.

**Goals**

-   Showcase evidenced-based prevention interventions to reduce
    overweight and obesity in high risk and low income communities.

-   Feature community efforts to implement environmental and policy
    strategies that promote and sustain healthy eating and activity
    behaviors.

-   Accelerate the obesity prevention movement to promote health
    equities and reduce disparities at the local, state and national
    levels.

-   Promote collaboration among diverse stakeholders to ensure access to
    healthy foods and physical activity for all children.

**Registration:**

To register, sponsor, exhibit, or apply for a poster session, visit
**[www.childhood-obesity.net](http://www.childhood-obesity.net/)** or
call **(800) 858-7743**.

**Early Registration** *(on or before May 8th)* **\$350**

**Late Registration** *(after May 8th)* **\$400**

**Location:**

Westin Bonaventure Hotel \| 404 South Figueroa Street \| Los Angeles, CA
90071

**Breastfeeding Initiation DVD Resource**

These DVD's are a must for all hospitals, nurseries, rooming-in programs
and delivery units, even for sites that send their mom's out for
delivery. This is the most explicit documentation and visual/audio
education that I have seen on breastfeeding initiation.

  **\
**1. Making Enough Milk, The Key to Successful Breastfeeding...Planning
for Day One

2\. A Preemie Needs His Mother. First Steps to Breastfeeding Your
Premature Baby\
3. Breastfeeding, A Guide to Getting Started\
4. Breastfeeding Management, Educational Tools for Physicians and Other
Professionals

Breastmilk Solutions has 4 DVD's @ 65\$ each or \$225 for the set of
four -- bulk orders may be priced
lower.  <http://www.breastmilksolutions.com/order.html>                                   
**          **

**FitTV and Discover Communications with DHHS and AHRQ present:**

**Max's Magical Delivery Fit for Kids**

A \~ 30 minute DVD for Parents and Kids! (5 -- 9 year olds)

4 kids enter Max's world when a giant wooden packing crate arrives at
the house on Saturday morning interrupting *Super Amazing Asteroid
Freaks* video game.  A food mobile that runs on bananas (and the peels),
vegetables, but not too much -- burp! and other technologies are in the
box to taking the kids on an inquiry \_ "what is too much?", "how
often?" and "how much exercise it takes to burn off food".  They
discover with a special camera that their mom did not eat breakfast and
Max ate "way too much" on the way over to deliver the crate.  A "Mission
Impossible" sequence with special guest, Surgeon General Richard Carmona
issues the challenge of a *5 a day. * The suitcase self destructs of
course -- into a bunch of grapes. 

Physical activity using clocks to measure \# of jumping jacks, balloon
bouncing, and jumping rope -- beating your own best effort is offered.
Seasonal, all weather, indoor activities, varied landscapes, individual
and group activities, equipment and no equipment required activities are
presented.  Screen time, 5 a day, is reintroduced -- the voices trail
off as they go outside to leave mom jump roping in the debris.

The parent box

Max instructs Mom in 5 simple steps in nutrition:

≥       "Portions" -- meat, rice, veggies, peanut butter, bread, -
visuals provided.

≥       "Switch it up" -- white for whole wheat, whole wheat pasta, fish
and poultry, low fat -- skim, steam and bake and grilling,

≥       Healthy Snack options -- easy to reach, water, veggies, low fat
chips,

≥       Moderation with those sweets --

≥       Involve the whole family, - eat together encourages slower
eating and other tips

[Fitness Sequence]{.underline} - Mom has to "pedal to 'power up' the
message" on an exercise bicycle with pictures and vignettes of family
walks, bike rides, carwashes, sports with kids, toddlers playing on play
sets, and parent/kid play.  "Don't forget water!" Sweating is a good
sign. The arithmetic is 30 minutes of exercise to each 1 hour of TV/
computer time.  Lastly the President's Challenge is presented - 5 times
a week for 6 weeks is for kids and adults with personal activity log. 

[http://www.presidentschallenge.org/home_kids.aspx](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.presidentschallenge.org/home_kids.aspx)

Lively and attention holding, reinforcing educational tips with visuals
and healthy children interacting makes the DVD useable in the classroom
or waiting room.

The only thing that would have made it fit my 1950's - 60's childhood
was for the kids to grab hammers and nails and dismantle the crate and
build a fort or tree house.  

Order the video: <http://gold.ahrq.gov/eorders/order_page4907.cfm>

#### Medical Mystery Tour, Neil Murphy, ANMC, Southcentral Foundation {#medical-mystery-tour-neil-murphy-anmc-southcentral-foundation .Style-Heading-4-+-Arial-14-pt-Underline}

**Test your knowledge on Polycystic Ovarian Syndrome (PCOS); The
Answers:**

**1. Menstrual cycles become more irregular in women with polycystic
ovarian syndrome (PCOS) as they approach menopause? True/False**

**Answer**

-False

Actually perimenopause may cause women with PCO to have a little more
regular menstrual spacing. This change may be related to the elevation,
or relative normalization, of the FSH levels as the woman ages. This
change in the LH / FSH ratio seems to revert the ovarian function
towards normal in this population.

'Having said that, it does not imply that the basic PCO metabolic
abnormalities have dissipated with age. The patient is still at risk for
dyslipidemia, etc.... so the patient should still aggressively manage
her Metabolic Syndrome with weight loss and optimizing her health
status.

Resource:

Polycystic ovary syndrome and the postmenopausal woman. Ireland K, Child
T.

J Br Menopause Soc. 2006 Dec;12(4):143-8.

<http://www.ncbi.nlm.nih.gov/pubmed/17178014>

**2. Medical management of adolescents with PCOS is most appropriately
directed towards:**

**a. Maximizing fertility**

**b. Preventing excessive weight gain**

**c. Arresting the progression of hirsutism**

**d. Decreasing insulin levels**

**Answer**

-Preventing excessive weight gain

While PCO is associated with insulin resistance in 75% of cases, and one
key to its management is controlling the insulin resistance, it is the
control of excess body weight that is the most direct management for the
overall syndrome.

As was shown in the Diabetes Prevention Program, intense lifestyle
changes and weight loss can decrease the onset of diabetes in 60%, while
treatment with metformin can decrease the subsequent onset of diabetes
by 30%.

Though it is not easy, exercise and weight loss should predate oral
contraceptive use and metformin use. As this is a lifelong syndrome, we
also do not know the lifelong effects of agents like metformin on 12 -13
year old girls. In addition, we do not know the lifetime effect of early
treatment with oral contraceptive agents which are begun before the
maximum skeletal peak bone accrual.

At first it is reasonable to initiate a work up for a proinflammatory
milieu and hyperinsulinemia. One could consider a C-reactive protein
(CRP) and a provoked insulin challenge (integrated insulin level \>150
uIU/mL).

Then one should obtain a detailed nutritional history with the help of a
nutritionist. This step can be especially important in adolescents as it
can reveal particularly unique dietary indiscretions that are amenable
to counseling.

Next, a physical activity regimen should be recommended. As the
magnitude of weight loss can be overwhelming, reachable goals should be
set and frequent follow-up scheduled to provide positive feedback. Many
of the benefits can be seen after they lose only 10% of their body
weight. It is much easier to lose 20 lbs. than 75 lbs., hence short term
goals should be realistic to be of benefit.

Next, if metformin is used, then a very gradual increase is suggested to
allay the anticipated gastrointestinal side effects. Start at 500 mg and
increase no quicker than 500 mg per week until the usual maintenance
dose of 1500 mg /day is achieved. Remember, there is no hurry, this is a
lifelong syndrome and metformin is currently the only agent of its kind
in our armamentarium at this juncture.

There is some evidence in patients with a BMI \> 30 that 2000 mg / day
may be a better option, though again the gastrointestinal side effects
are often the rate limiting factor.

**Resources:**

[Guzick
DS](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Guzick DS"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus).
Polycystic ovary syndrome. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2004
Jan;103(1):181-93.

<http://www.ncbi.nlm.nih.gov/pubmed/14704263>

Ibáñez L, Ferrer A, Ong K, Amin R, Dunger D, de Zegher F. Insulin
sensitization early after menarche prevents progression from precocious
pubarche to polycystic ovary syndrome. J Pediatr. 2004 Jan;144(1):23-9.

<http://www.ncbi.nlm.nih.gov/pubmed/14722514>

[Knowler
WC](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Knowler WC"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Reduction in the incidence of type 2 diabetes with lifestyle
intervention or metformin. N Engl J Med. 2002 Feb 7;346(6):393-403.

<http://www.ncbi.nlm.nih.gov/pubmed/11832527>

Moran LJ, Noakes M, Clifton PM, Tomlinson L, Galletly C, Norman RJ.
Dietary composition in restoring reproductive and metabolic physiology
in overweight women with polycystic ovary syndrome. J Clin Endocrinol
Metab. 2003 Feb;88(2):812-9.

<http://www.ncbi.nlm.nih.gov/pubmed/12574218>

**3. Intrauterine growth retardation is associated with an increased
risk of PCOS in offspring? True/False**

**Answer**

-True

It seems that PCO, like many other disorders in the reproductive
lifespan, does have an in utero initiation. Mothers with obesity, GDM,
macrosomic infants, IUGR infants, or SGA infants are associated with the
stigmata of the PCOS phenotype when the offspring are followed through
menarche.

PCOS mothers showed a significantly higher prevalence of SGA newborns
which cannot be completely attributed to pregnancy complications, and
seems to be more related to the PCOS condition of the mother.

Though genetics are clearly important, there may be epigenentic
programming that put the mother herself at risk for insulin resistance.
Evidence in non-human primates reveal that fetal exposure to elevated
levels of androgens can result in elevated levels of luteinizing hormone
(LH) later in life.

There may be a sequence in the associations between reduced fetal growth
and components of the postnatal endocrine system; minor fetal growth
reduction appears to be associated with amplified adrenarche, whereas
more pronounced prenatal growth restriction seem to precede functional
ovarian hyperandrogenism and hyperinsulinemia during adolescence. In
conclusion, these findings corroborate the hypothesis that the frequent
concurrence of precocious pubarche (with pronounced adrenarche),
functional ovarian hyperandrogenism, and hyperinsulinemia in girls may
result from a common early origin (low birth weight serving as a
marker), rather than from a direct interrelationship later in life.

There is evidence that if children have early adrenarche, an elevated
BMI, and/or have acanthosis nigricans, they should be followed closely
for PCO, as early as 6 years old.

**Resources:**

Ibáñez L, Potau N, Francois I, de Zegher F. Precocious pubarche,
hyperinsulinism, and ovarian hyperandrogenism in girls: relation to
reduced fetal growth. J Clin Endocrinol Metab. 1998 Oct;83(10):3558-62.

<http://www.ncbi.nlm.nih.gov/pubmed/9768664>

Birth weight in offspring of mothers with polycystic ovarian syndrome.
Sir-Petermann T, Hitchsfeld C, Maliqueo M, Codner E, Echiburú B, Gazitúa
R, Recabarren S, Cassorla F. Hum Reprod. 2005 Aug;20(8):2122-6.

<http://www.ncbi.nlm.nih.gov/pubmed/15802312>

**4. Brothers of women with PCOS are at greater risk for which of the
following conditions?**

**a. Decrease sperm counts**

**b. Type 2 diabetes**

**c. Hirsutism**

**d. Increased pregnancy wastage**

**Answer**

-Type 2 diabetes

Sons of PCOS women exhibit higher body weight from early infancy. In
addition, insulin resistance became evident as the subjects got older,
which may place them at risk for the development of type 2 diabetes and
cardiovascular disease.

Unfortunately, in the early family history studies, the fathers of PCOS
patients could not be found in the kindreds. The males had severe
metabolic syndrome and fatal myocardial infarctions and were not
available to be studied.

It may be that the female family members may actually be protected by
the presence of estrogen earlier in life. Often the family history
obtained in the office will identify multiple sisters and multiple
cousins with PCOS, rather just sporadically throughout the pedigree.
Most likely there is polygenic pattern that we are far from
understanding.

**Resource:**

Recabarren SE, Smith R, Rios R, Maliqueo M, Echiburú B, Codner E,
Cassorla F, Rojas P, Sir-Petermann T. Metabolic profile in sons of women
with polycystic ovary syndrome. J Clin Endocrinol Metab. 2008
May;93(5):1820-6.

<http://www.ncbi.nlm.nih.gov/pubmed/18230657>

**5. The most appropriate first line modality for ovulation induction in
women with PCOS is**

**a. Ovarian drilling**

**b. Clomiphene citrate**

**c. Metformin**

**d. Exogenous gonadotropins**

**Answer**

-Clomiphene citrate

Clomiphene is superior to metformin in achieving live birth in infertile
women with the polycystic ovary syndrome, although multiple birth is a
complication.

'Having said that, it is not unreasonable to treat a PCO patient who is
open to pregnancy with metformin. For those couples in whom an immediate
pregnancy is not perceived to be absolutely necessary, metformin does
increase the rate of live birth and it allows the couple to pursue a
more normal lifestyle without the need for precisely timed coitus,
etc...

Another related approach is to use metformin to optimize the metabolic
milieu so that she is healthier when she does achieve pregnancy. In this
longer term scenario, then clomiphene does become a second line agent
after the patient has lost some weight and improved her lipid profile.
If the patient is young enough, one can use the prospect of a future
pregnancy as a motivator over a 3 - 6 month period to encourage weight
loss so that perhaps the patient could pursue pregnancy in a
non-medicated state.

In fact weight loss should be really considered as a first option for
women who are infertile and overweight. It has been demonstrated that
weight loss can improve the fertility of obese women through the
recovery of spontaneous ovulation, whereas others will have improved
response to ovarian stimulation in infertility treatment. Therefore, it
is proposed that following the initial assessment of infertility and
body mass index or other measurement of obesity, various weight
management interventions, including diet, exercise or
pharmacotherapeutic approaches, should be considered for overweight and
obese infertile women.

**Resources:**

Clark AM, Thornley B, Tomlinson L, Galletley C, Norman RJ. Weight loss
in obese infertile women results in improvement in reproductive outcome
for all forms of fertility treatment. Hum Reprod. 1998 Jun;13(6):1502-5.

<http://www.ncbi.nlm.nih.gov/pubmed/9688382>

Legro RS, Barnhart HX, Schlaff WD, Carr BR, Diamond MP, Carson SA,
Steinkampf MP, Coutifaris C, McGovern PG, Cataldo NA, Gosman GG, Nestler
JE, Giudice LC, Leppert PC, Myers ER; Cooperative Multicenter
Reproductive Medicine Network. Clomiphene, metformin, or both for
infertility in the polycystic ovary syndrome. N Engl J Med. 2007 Feb
8;356(6):551-66.

<http://www.ncbi.nlm.nih.gov/pubmed/17287476>

Legro RS. A 27-year-old woman with a diagnosis of polycystic ovary
syndrome. JAMA. 2007 Feb 7;297(5):509-19.

<http://www.ncbi.nlm.nih.gov/pubmed/17284701>

Norman RJ, Noakes M, Wu R, Davies MJ, Moran L, Wang JX. Improving
reproductive performance in overweight/obese women with effective weight
management. Hum Reprod Update. 2004 May-Jun;10(3):267-80.

<http://www.ncbi.nlm.nih.gov/pubmed/15140873>

Pasquali R, Antenucci D, Casimirri F, Venturoli S, Paradisi R, Fabbri R,
Balestra V, Melchionda N, Barbara L. Clinical and hormonal
characteristics of obese amenorrheic hyperandrogenic women before and
after weight loss. J Clin Endocrinol Metab. 1989 Jan;68(1):173-9.

<http://www.ncbi.nlm.nih.gov/pubmed/2642485>

**Correction from last month's issue:**

There was an error in the description of Category III fetal heart rate
tracings.

The correct description of Category III is:

• Absent baseline FHR *variability* and any of the following:

\- Recurrent late decelerations

\- Recurrent variable decelerations

\- Bradycardia

• Sinusoidal pattern

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

#### A Sampling of recent CME offerings from MedScape: {#a-sampling-of-recent-cme-offerings-from-medscape .Style-Heading-4-+-Arial-14-pt-Underline}

#### Female Contraception: Reducing the Rate of Unintended Pregnancy {#female-contraception-reducing-the-rate-of-unintended-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/18691**](http://www.medscape.com/viewprogram/18691) {#httpwww.medscape.comviewprogram18691 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Multimodal Techniques for Smoking Cessation: A Review of Their Efficacy and Utilisation and Clinical Practice Guidelines  {#multimodal-techniques-for-smoking-cessation-a-review-of-their-efficacy-and-utilisation-and-clinical-practice-guidelines .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/18741**](http://www.medscape.com/viewprogram/18741)  {#httpwww.medscape.comviewprogram18741 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### NCCN Clinical Practice Guidelines in Oncology Symposium: Breast Cancer {#nccn-clinical-practice-guidelines-in-oncology-symposium-breast-cancer .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/17588**](http://www.medscape.com/viewprogram/17588) {#httpwww.medscape.comviewprogram17588 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Healthier Life Steps: A Clinician-Patient Guide from the AMA  {#healthier-life-steps-a-clinician-patient-guide-from-the-ama .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/17742**](http://www.medscape.com/viewprogram/17742)  {#httpwww.medscape.comviewprogram17742 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Adherence to Treatment: Improving the Management of Postmenopausal
Osteoporosis** <http://www.medscape.com/viewprogram/17802>

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

#### Hormone Replacement Therapy Virtual Symposium {#hormone-replacement-therapy-virtual-symposium .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/17129**](http://www.medscape.com/viewprogram/17129) {#httpwww.medscape.comviewprogram17129 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

######### General MedScape access:

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

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

######### 

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

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

**Clinical Discussion Board Index, Medscape**

Hundreds of ongoing clinical discussions available

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

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

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

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

**Menopause Management**

**Cigarette smoking, androgen levels, and hot flushes in midlife women**

OBJECTIVE: To test the hypothesis that cigarette smoking is associated
with hot flushes through a mechanism involving androgen levels,
progesterone levels, sex hormone-binding globulin levels, or the ratio
of androgens to estrogens.

METHODS: Women with and without hot flushes were recruited from
Baltimore, Maryland, and the surrounding counties. Women were between 45
and 54 years of age, with at least three menstrual periods in the
previous 12 months, and were not postmenopausal. Study participants
completed a questionnaire and gave a blood sample for hormone
measurements.

RESULTS: Current smokers had significantly higher androstenedione levels
and a higher androgen-to-estrogen ratio than never smokers. Current
smokers had significantly lower progesterone levels compared with never
smokers. Former and current cigarette smokers had increased odds of
experiencing hot flushes compared with never smokers (former: odds ratio
\[OR\] 1.41, 95% confidence interval \[CI\] 0.99-2.01; current: OR 2.43,
95% CI 1.28-4.62). This association, however, was not attenuated by the
addition of hormones to the smoking and hot-flush model.

CONCLUSION: Cigarette smoking is associated with hot flushes through a
mechanism that may not involve alterations in hormone levels or their
ratios.

Cochran CJ, Gallicchio L, Miller SR, Zacur H, Flaws JA. Cigarette
smoking, androgen levels, and hot flushes in midlife women. Obstet
Gynecol. 2008 Nov;112(5):1037-44.

#### [**http://www.ncbi.nlm.nih.gov/pubmed/18978103**](http://www.ncbi.nlm.nih.gov/pubmed/18978103)  {#httpwww.ncbi.nlm.nih.govpubmed18978103 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Testosterone for low libido in postmenopausal women not taking
estrogen**

BACKGROUND: The efficacy and safety of testosterone treatment for
hypoactive sexual desire disorder in postmenopausal women not receiving
estrogen therapy are unknown.

METHODS: We conducted a double-blind, placebo-controlled, 52-week trial
in which 814 women with hypoactive sexual desire disorder were randomly
assigned to receive a patch delivering 150 or 300 microg of testosterone
per day or placebo. Efficacy was measured to week 24; safety was
evaluated over a period of 52 weeks, with a subgroup of participants
followed for an additional year. The primary end point was the change
from baseline to week 24 in the 4-week frequency of satisfying sexual
episodes.

RESULTS: At 24 weeks, the increase in the 4-week frequency of satisfying
sexual episodes was significantly greater in the group receiving 300
microg of testosterone per day than in the placebo group (an increase of
2.1 episodes vs. 0.7, P\<0.001) but not in the group receiving 150
microg per day (1.2 episodes, P=0.11). As compared with placebo, both
doses of testosterone were associated with significant increases in
desire (300 microg per day, P\<0.001; 150 microg per day, P=0.04) and
decreases in distress (300 microg per day, P\<0.001; 150 microg per day,
P=0.04). The rate of androgenic adverse events - primarily unwanted hair
growth - was higher in the group receiving 300 microg of testosterone
per day than in the placebo group (30.0% vs. 23.1%). Breast cancer was
diagnosed in four women who received testosterone (as compared with none
who received placebo); one of the four received the diagnosis in the
first 4 months of the study period, and one, in retrospect, had symptoms
before undergoing randomization.

CONCLUSIONS: In postmenopausal women not receiving estrogen therapy,
treatment with a patch delivering 300 microg of testosterone per day
resulted in a modest but meaningful improvement in sexual function. The
long-term effects of testosterone, including effects on the breast,
remain uncertain.

Davis SR, Moreau M, Kroll R, Bouchard C, Panay N, Gass M, Braunstein GD,
Hirschberg AL, Rodenberg C, Pack S, Koch H, Moufarege A, Studd J;
APHRODITE Study Team. Testosterone for low libido in postmenopausal
women not taking estrogen. N Engl J Med. 2008 Nov 6;359(19):2005-17.
<http://www.ncbi.nlm.nih.gov/pubmed/18987368>

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

####  {#section-28 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Midwifery care unequivocally supported and recommended by Cochrane
Review**

Okay, first the bottom line---Cochrane Review loves midwifery care.
Check out these two direct quotes: **"**Midwife-led care confers
benefits for pregnant women and their babies and is recommended." and
**"**Authors\' conclusions: All women should be offered midwife-led
models of care and women should be encouraged to ask for this option."
Wow, wow, and wow. As midwifes we certainly knew this, but this is some
awesome confirmation of the value of the midwifery model of care.

Here are the statistical results: "We included 11trials (12,276 women).
Women who had midwife-led models of care were less likely to experience
antenatal hospitalisation, risk ratio (RR) 0.90, 95% confidence interval
(CI) 0.81 to 0.99), the use of regional analgesia (RR 0.81, 95% CI 0.73
to 0.91), episiotomy (RR 0.82, 95% CI 0.77 to 0.88), and instrumental
delivery (RR 0.86, 95% CI 0.78 to 0.96) and were more likely to
experience no intrapartum analgesia/anaesthesia (RR 1.16, 95% CI 1.05 to
1.29), spontaneous vaginal birth (RR 1.04, 95% CI 1.02 to 1.06), to feel
in control during labour and childbirth (RR 1.74, 95% CI 1.32 to 2.30),
attendance at birth by a known midwife (RR 7.84, 95% CI 4.15 to 14.81)
and initiate breastfeeding (RR 1.35, 95% CI 1.03 to 1.76). In addition,
women who were randomized to receive midwife-led care were less likely
to experience fetal loss before 24 weeks' gestation (RR 0.79, 95% CI
0.65 to 0.97), and their babies were more likely to have a shorter
length of hospital stay (mean difference -2.00, 95% CI -2.15 to -1.85).
There were no statistically significant differences between groups for
overall fetal loss/neonatal death (RR 0.83, 95% CI 0.70 to 1.00), or
fetal loss/neonatal death of at least 24 weeks (RR 1.01, 95% CI 0.67 to
1.53)."

These are some fabulous numbers that all midwives can feel very proud of
and can share with whoever needs to be educated on the value of what we
do. The authors also do a good job of describing the midwifery model of
care. For example: "The midwife-led model of care is based on the
premise that pregnancy and birth are normal life events and is
woman-centered. The midwife-led model of care includes: continuity of
care; monitoring the physical, psychological, spiritual and social
wellbeing of the woman and family throughout the childbearing cycle;
providing the woman with individualized education, counseling and
antenatal care; continuous attendance during labor, birth and the
immediate postpartum period; ongoing support during the postnatal
period; minimizing technological interventions; and identifying and
referring women who require obstetric or other specialist attention."

Overall, this Cochrane review is a document midwives and others in IHS
can use if they are needing support to establish, or re-establish, a
midwifery service; or to expand the number of midwives so all women in a
service unit have the opportunity to be attended by a midwife; or, at
some sites, to just remind ourselves, other providers, and the women and
families we serve how blessed we are in IHS to have midwifery care as
the standard of care. Enjoy.

If you are having trouble getting a copy of this landmark document
please contact me at <lisa.allee@ihs.gov> and I will send you a copy
electronically or via snail mail!

Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus
other models of care for childbearing women. *Cochrane Database of
Systematic Reviews* 2008, Issue 4. Art. No.: CD004667. DOI:
10.1002/14651858.CD004667.pub2.

<http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004667/frame.html>

<http://www.ncbi.nlm.nih.gov/pubmed/18843666>

**Navajo News John Balintona, Northern Navajo Medical Center, Shiprock,
NM**

The following is a continuation of the excerpts from the Navajo Area
Women's Health Provider Meeting held in Chinle, Arizona on September 12,
2008. Navajo Area Chief Clinical Consultant for Women's Health, Jean
Howe, presiding.

# WOMEN'S HEALTH CARE ISSUES

1.  **GPRA SCREENING RATES**

    a.  NAIHS met the target goal GPRA rates for the following
        categories in 2007.

        i.  Pap smear screening: 59.8%

        ii. Mammogram screening: 43.1%

        iii. Colorectal cancer screening: 27.2%

2.  **Syphilis Outbreak Update**

    a.  Rates appear to be trending lower in NAIHS for 2007.

    b.  Group continues to advocate for frequent screening, especially
        during pregnancy when 3 screening tests are recommended (1^st^
        prenatal visit, early 3^rd^ trimester, admission to L&D)

3.  **Contraceptive Options**

    a.  Attendees discussed the contraceptive options in each site on
        the NAIHS.

    b.  Reviewed the cost of various contraceptive options.

    c.  Implanon training may be available for area providers. A course
        is planned for the upcoming ACOG meeting in September 2008 in
        Salt Lake City. Tentative plan for training at the upcoming
        Telluride Conference.

4.  **Infertility Management**

    a.  Group reviewed the options for infertility management in the
        area.

    b.  Two sites, Gallup and Shiprock, continue to provide tubal
        reanastamosis services. Referring providers are strongly advised
        to contact either site directly as selection criteria may be
        strict and is at the discretion of the provider of the service.

5.  **Immunization Update**

    a.  Attendees reviewed the use of the following pertinent
        immunizations

        i.  Influenza vaccine

> -Suggest October 1^st^ for start date of vaccinations

ii. Tdap

> -Advise immunization of postpartum patients

iii. HPV

> -Currently available area-wide

6.  **SANE/SART Program**

    a.  Group reviewed the progress to date in implementing SANE exams
        in selected facilities on the Navajo Nation and options for
        forensic examination services in surrounding communities.

#### Navajo Nation Passes "Healthy Start Act"; Requires Workplaces to Accommodate Breastfeeding {#navajo-nation-passes-healthy-start-act-requires-workplaces-to-accommodate-breastfeeding-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### This legislation requires workplaces on the Navajo Nation to submit a written plan on how they will accommodate breastfeeding women in the workplace and allows women unpaid time to breastfeed their infants or to use a breast pump. This news was picked up by wire services across the country. One example of the news coverage can be found at: {#this-legislation-requires-workplaces-on-the-navajo-nation-to-submit-a-written-plan-on-how-they-will-accommodate-breastfeeding-women-in-the-workplace-and-allows-women-unpaid-time-to-breastfeed-their-infants-or-to-use-a-breast-pump.-this-news-was-picked-up-by-wire-services-across-the-country.-one-example-of-the-news-coverage-can-be-found-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://seattletimes.nwsource.com/html/nationworld/2008301621_webnavajobreastfeed23.html**](http://seattletimes.nwsource.com/html/nationworld/2008301621_webnavajobreastfeed23.html)  {#httpseattletimes.nwsource.comhtmlnationworld2008301621_webnavajobreastfeed23.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Nurses Corner Sandra Haldane, HQE**

**Registered nurses are key to detecting, correcting, and preventing
medical errors during critical care**

Since registered nurses (RNs) play a pivotal role in preventing or
reducing the impact of medical errors during critical care,
interventions should build on factors that enhance their effectiveness
in preventing, intercepting, or correcting these errors, suggests a new
study.

Using entries in daily logbooks maintained by a random sample of 502
critical care nurses over a 28-day period, Ann E. Rogers, Ph.D., R.N.,
of the University of Pennsylvania School of Nursing, and colleagues
examined the type and frequency of medical errors detected by critical
care nurses. They found 367 errors identified by 184 of the nurse
participants during the data-gathering period. Errors in medication
administration (most commonly, wrong drug, wrong dosage, or dose not
given) were the most frequent problems. They accounted for 163 of the
errors---43 percent of which involve giving the wrong dosage of a
prescribed medication. Procedural errors were the next most common (115
errors reported), followed by charting errors (55 instances), and
transcription errors (55 instances).

The nurses caught only 43 of the 367 errors---mostly medication errors
or overlooked allergies---before they reached the patient. Yet, nurses
were particularly effective at discovering and correcting errors that
had been made by other nurses and other members of the health care team.
The incredibly busy pace of critical care units may play a role in
errors, with an average of 187 activities performed for each patient
each day. Heavy workloads and fatigue are also factors that may affect
the ability of RNs to intercept or correct errors, note the researchers.
Their results did not show differences in error types or rates based on
the size of the critical care unit or of the hospital.

Because procedures for administering medications and other health care
procedures are similar across health care institutions despite how they
are organized or their size, the researchers suggest that future studies
should focus on system- and process-related factors. Their study was
funded in part by a grant from the Agency for Healthcare Research and
Quality (HS11963).

#### More details are in \"Role of registered nurses in error prevention, discovery and correction,\" by Dr. Rogers, Grace E. Dean, Ph.D., R.N., Wei-Ting Hwang, Ph.D., and Linda D. Scott, Ph.D., R.N., in the April 2008 ***Quality and Safety in Health Care*** 17(2), pp.117-121. [**http://www.ahrq.gov/research/sep08/0908RA2.htm**](http://www.ahrq.gov/research/sep08/0908RA2.htm)  {#more-details-are-in-role-of-registered-nurses-in-error-prevention-discovery-and-correction-by-dr.-rogers-grace-e.-dean-ph.d.-r.n.-wei-ting-hwang-ph.d.-and-linda-d.-scott-ph.d.-r.n.-in-the-april-2008-quality-and-safety-in-health-care-172-pp.117-121.-httpwww.ahrq.govresearchsep080908ra2.htm .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-31 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Condoms and STDs: Updated Fact Sheet for Public Health Personnel**

This fact sheet presents evidence concerning the male latex condom and
the prevention of STDs, including HIV, based on information about how
different STDs are transmitted, the physical properties of condoms, the
anatomic coverage or protection that condoms provide, and epidemiologic
studies assessing condom use and STD risk. This fact sheet updates
previous CDC fact sheets on male condom effectiveness for STD prevention
by incorporating additional evidence-based findings from published
epidemiologic studies.

Updated fact sheet - <http://www.cdc.gov/condomeffectiveness/latex.htm>

New fact sheet in brief -
<http://www.cdc.gov/condomeffectiveness/brief.html>

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

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

**Biomarker Test Not Ready for Routine Clinical Use**

Experts respond to new study on diagnostic markers for the early
detection of ovarian cancer published in the November 2008 issue of
*Clinical Cancer Research*. CDC states that although this study makes an
important contribution, more research is needed before the OvaSure test
is accepted into clinical practice for screening women in the general
population or for women at ''high risk'' of ovarian cancer. Read CDC's
letter to the editor and other letters to the editor.

<http://www.cdc.gov/genomics/update/current.htm>

**Assessing the Burden of HPV-Associated Cancers in the United States**

CDC's Division of Cancer Prevention and Control led an effort to produce
a journal supplement entitled \"Assessing the Burden of HPV-Associated
Cancers in the United States (ABHACUS).\" This supplement uses cancer
registry data to estimate how many HPV-associated cancers occurred in
the United States before the release of the HPV vaccine, and to examine
current patterns in the distribution of these cancers. Six articles in
the supplement focus on cancer sites known to be associated with HPV,
including the cervix, vulva, vagina, penis, anus, and some sites in the
head and neck (oral cavity and oropharynx). Other articles focus on
related topics such as disparities in these types of cancers, how CDC
programs address such disparities, behavioral risk factors related to
these cancers, and background of the HPV vaccine.

<http://www.cdc.gov/cancer/hpv/what_cdc_is_doing/>

**Human Papillomavirus (HPV) Vaccine Safety**

This page provides links to information on HPV vaccine safety, HPV
vaccine and disease information.

<http://www.cdc.gov/vaccinesafety/concerns/human_papillomavirus_vaccine.htm>

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

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

#### Link to CDC Women's Health Index page: {#link-to-cdc-womens-health-index-page .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.cdc.gov/women/index.htm**](http://www.cdc.gov/women/index.htm)  {#httpwww.cdc.govwomenindex.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

**Interactive Media Laboratory---Smoking Cessation for Pregnancy and
Beyond**

Virtual class for health care personnel working with pregnant clients to
stop smoking.\
Web site with tips, tools, interactive clinical situations with actor
patients that make it quite real.

You can order a CDROM to work off line depending on speed of your
internet. <http://iml.dartmouth.edu/education/cme/Smoking/>

####  {#section-39 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Perinatology Picks  {#perinatology-picks .Style-Heading-4-+-Arial-14-pt-Underline}

**Labor before a primary cesarean delivery: reduced risk of uterine
rupture in a subsequent trial of labor for vaginal birth after
cesarean**

OBJECTIVE: To estimate the effect of the onset of labor before a primary
cesarean delivery on the risk of uterine rupture if vaginal birth after
cesarean (VBAC) is attempted in the next pregnancy.

METHODS: Longitudinally linked birth records were used to follow women
from a primary cesarean delivery to a trial of labor at term for their
next birth. The effects of characteristics of both the trial of labor
and primary cesarean deliveries on the risk of uterine rupture were
examined.

RESULTS: Of 10,160 women who had a trial of labor, 39 (0.38%) had a
uterine rupture. Women who were induced or augmented for their trial of
labor had a greater relative risk (RR) of uterine rupture (crude RR
4.24, 95% confidence interval \[CI\] 2.23-8.07). Women whose primary
cesarean delivery was planned or followed induction of labor also had an
increased risk of uterine rupture (crude RR 2.61, 95% CI 1.24-5.49), and
this risk remained after adjustment for other factors. Women with a
history of either spontaneous labor or vaginal birth had one uterine
rupture for every 460 deliveries; women without this history who
required induction or augmentation to proceed with a VBAC attempt had
one uterine rupture for every 95 deliveries.

CONCLUSION: Labor before the primary cesarean delivery can decrease the
risk of uterine rupture in a subsequent trial of labor. A history of
primary cesarean delivery preceded by spontaneous labor is favorable for
VBAC.

Algert CS, Morris JM, Simpson JM, Ford JB, Roberts CL. Labor before a
primary cesarean delivery: reduced risk of uterine rupture in a
subsequent trial of labor for vaginal birth after cesarean. Obstet
Gynecol. 2008 Nov;112(5):1061-6.
<http://www.ncbi.nlm.nih.gov/pubmed/18978106>

**Methods of Delivering the Placenta at Caesarean Section**

**Cochrane Abstract:**

BACKGROUND: Worldwide, caesarean section is the most common major
operation performed on women. Some of the reported short-term
morbidities include haemorrhage, postoperative fever and endometritis.
The method of delivering the placenta is one procedure that may
contribute to an increase or decrease in the morbidity of caesarean
section. Two common methods used to deliver the placenta at caesarean
section are cord traction and manual removal.

OBJECTIVES: To compare the effects of manual removal of the placenta
with cord traction at caesarean section.

SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth
Group's Trials Register (30 September 2007).

SELECTION CRITERIA: All randomised controlled trials comparing manual
removal and cord traction or spontaneous of delivery of the placenta.

DATA COLLECTION AND ANALYSIS: Two authors independently assessed studies
and extracted data.

MAIN RESULTS: We included 15 studies (4694 women). There was significant
heterogeneity for the duration of surgery, blood loss and haematological
outcomes. The only possible contributing factor found was greater
protection from blood loss in two trials in which cord traction was
combined with uterine massage. A random-effects model meta-analysis was
used for these outcomes. Manual removal of the placenta was associated
with more endometritis (relative risk (RR) 1.64, 95% confidence interval
(CI) 1.42 to 1.90; 4134 women, 13 trials); more blood loss (ml)
(weighted mean difference (WMD) 94.42 ml, 95% CI 17.19 to 171.64; 2001
women, eight trials); more blood loss \>1000 ml (RR 1.81, 95% CI 1.44 to
2.28; 872 women, two trials); lower haematocrit after delivery (%) (WMD
--1.55, 95% CI --3.09 to --0.01; 384 women, two trials); greater
haematocrit fall after delivery (%) (WMD 0.39, 95% CI 0.00 to 0.78; 1777
women, five trials); longer duration of hospital stay (days) (WMD 0.39
days, 95% CI 0.17 to 0.61; 546 women, three trials). The duration of
surgery was shorter in one trial but not overall. There were no
significant differences in feto-maternal haemorrhage, blood transfusion,
puerperal fever (numbers studied for these outcomes were small).

AUTHORS' CONCLUSION: Delivery of the placenta with cord traction at
caesarean section has more advantages compared to manual removal. These
are less endometritis; less blood loss; less decrease in haematocrit
levels postoperatively; and shorter duration of hospital stay. Future
trials should provide information on interval between the delivery of
the infant and of the placenta, change in lochia, blood splashing during
placental removal and uterine pain after operation, as well as the
effects of delayed cord clamping.

Cochrane Abstract: Methods of delivering the placenta at caesarean
section. Obstet Gynecol. 2008 Nov;112(5):1173-4.
<http://www.ncbi.nlm.nih.gov/pubmed/18978121>

**External cephalic version-related risks: a meta-analysis**\
OBJECTIVE: To systematically review the literature on external cephalic
version-related complications and to assess if the outcome of a version
attempt is related to complications.

DATA SOURCES: In March 2007 we searched MEDLINE, EMBASE, and the
Cochrane Central Register of Controlled Trials.

METHODS OF STUDY SELECTION: Studies reporting on complications from an
external cephalic version attempt for singleton breech pregnancies after
36 weeks of pregnancy were selected. We calculated odds ratios (ORs)
from studies that reported both on complications as well as on the
position of the fetus immediately after the procedure.

TABULATION, INTEGRATION, AND RESULTS: We found 84 studies, reporting on
12,955 version attempts that reported on external cephalic
version-related complications. The pooled complication rate was 6.1%
(95% CI 4.7-7.8), 0.24% for serious complications (95% confidence
interval \[CI\] 0.17-0.34) and 0.35% for emergency cesarean deliveries
(95% CI 0.26-0.47). Complications were not related to external cephalic
version outcome (OR 1.2 (95% CI 0.93-1.7). CONCLUSION: External cephalic
version is a safe procedure. Complications are not related to the fetal
position after external cephalic version.

Grootscholten K, Kok M, Oei SG, Mol BW, van der Post JA. External
cephalic version-related risks: a meta-analysis. Obstet Gynecol. 2008
Nov;112(5):1143-51.

<http://www.ncbi.nlm.nih.gov/pubmed/18978117>

**A systematic review of the role of intrapartum hypoxia-ischemia in the
causation of neonatal encephalopathy**

The object of this review was to determine the incidence, morbidity, and
mortality of an umbilical arterial pH \< 7.0; the incidence of
hypoxic-ischemic encephalopathy; and the proportion of cerebral palsy
associated with intrapartum hypoxia-ischemia in nonanomalous term
infants. A systematic review of the English language literature on the
association between intrapartum hypoxia-ischemia and neonatal
encephalopathy was conducted by using PubMed and Embase. For
nonanomalous term infants, the incidence of an umbilical arterial pH \<
7.0 at birth is 3.7 of 1000, of which 51 of 297 (17.2%) survived with
neonatal neurologic morbidity, 45 of 276 (16.3%) had seizures, and 24 of
407 (5.9%) died during the neonatal period. The incidence of neonatal
neurologic morbidity and mortality for term infants born with cord pH \<
7.0 was 23.1%. The incidence of hypoxic-ischemic encephalopathy is 2.5
of 1000 live births. The proportion of cerebral palsy associated with
intrapartum hypoxia-ischemia is 14.5%. The vast majority of cases of
cerebral palsy in nonanomalous term infants are not associated with
intrapartum hypoxia-ischemia.

Graham EM, Ruis KA, Hartman AL, Northington FJ, Fox HE. A systematic
review of the role of intrapartum hypoxia-ischemia in the causation of
neonatal encephalopathy. Am J Obstet Gynecol. 2008 Dec;199(6):587-95.
<http://www.ncbi.nlm.nih.gov/pubmed/19084096>

#### Primary Care Discussion Forum Ann Bullock, Cherokee, NC {#primary-care-discussion-forum-ann-bullock-cherokee-nc .Style-Heading-4-+-Arial-14-pt-Underline}

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

Subscribe to the Primary Care listserv

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

Unsubscribe from the Primary Care listserv

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

Questions on how to subscribe, contact <ANNBULL@nc-cherokee.com>
directly.

**A summary of the recent discussion forum on geriatric medication
issues from**

**Chris Lamar:**

Thank you to everyone who provided feedback and comments on the
discussion of geriatric medication issues. To summarize and conclude our
case, we started with an elderly woman in her 80s who came in for a
routine follow-up. It was quickly noted that she had been taking a
number of inappropriate medications:\
 \
a) Pain management was uncoordinated; rather than treating her pain,
each condition was being managed by a different medication and she was
receiving overlapping, duplicative, and inappropriate treatments.
Ibuprofen was also discontinued due to increased risk of renal problems
and interactions with the pharmacodynamics of antihypertensive therapy.
She was eventually able to be managed with acetaminophen PRN although
other appropriate regimens were suggested.\
 \
b) Treatment to goal in chronic diseases often is not as aggressively
sought in the elderly even though they have the greatest rate of
benefit. Treatment to goal (which are often the same as those who are
younger), should still be the primary target, tempered by an awareness
of the increased risks of adverse events common in the elderly. Our
patient received better lipid management and tighter blood pressure
control with maximization of ACEI and reduction of risk of bradycardia
by removal of the diltiazem (which also interacted with the
simvastatin). The A1c was above target somewhat and we\'ll have to
monitor her since her metformin was discontinued due to reduced renal
function. Because the risk of hypoglycemia is increased in the elderly
(both frequency of and the resulting morbidity), most would aim for an
AIC around 8% in someone her age.  Bedtime long or medium-acting insulin
may be an option to improve blood sugar control with careful monitoring
for hypoglycemia.\
 \
c) It is not uncommon for patients to be on a medication that was
started based on old guidelines or for a condition that is no longer
pertinent. Digoxin was discontinued because there wasn't a clear
indication.  There may have been when it was started -- but indications
change and often medications remain behind. There were also questions
about why she was on lansoprazole without complaints or a diagnosis of
ulcer or GERD; further, chronic use of proton pump inhibitors may
increase the risk of osteoporosis. Glucosamine, an herbal treatment for
arthritis, was also discontinued because of new data from recent studies
showing no benefit of therapy and no evidence of improvement in our
patient.\
 \
d) Some medications are inappropriate for use in the elderly, period.
 Many of these confer great risk (including fall risk).  The Beers list
is a good source for identifying these medications (see attached
sample). Tylenol PM and alprazolam are both high risk medications
appearing on the Beers list and were removed from the patient\'s
treatment.\
 \
e) Although warfarin is certainly indicated in our patient, the
difficulties of frequent monitoring made her unwilling to take the
medication, in spite of benefits in the reduction of risk of stroke.
Aspirin, while not demonstrably as effective, may provide some benefit.
Sometimes we realize that we need to accept the patient\'s informed
decision over our beliefs and treatment guidelines.\
 \
f) Elderly patients may suffer from some level of cognitive impairment
that may necessitate the assistance of a family member or a friend or
the simplification of pharmacologic therapy. She eventually showed up
with a list of medications that are not consistent with your medication
profile and you realize that there are many ways that treatment may fail
due to poor communication and lack of understanding or remembering. Our
patient increased her ACEI, yet continued to take her old dose in
addition. Even with good instructions and education a simplified regimen
can consist of multiple medications often taken 2-4 times a day - and we
need to consider that some medications are taken on an empty stomach
(lansoprazole) and others are taken after eating (aspirin); although
these medications are \"taken in the morning\" we already have two
dosing times that the patient must be aware of in order for the
medications to work safely and effectively.\
 \
\-\-\-\--\
Below is a summary of the plan developed after your first meeting with
the patient.\
 \
The plan so far:\
Need more information:\
A better understanding of her cognitive status.  The mini-cog (attached)
is a quick screening tool that can be easily used in the primary care
setting.\
 \
A better understanding of her emotional / psychological status.  The PHQ
2 screen for depression, followed by the PHQ 9 is supported by RPMS.
 While not specifically validated for the elderly or for the Native
population, these tools are in widespread use.  The PHQ 9 follows the
DSM diagnostic criteria for depression. (Health Factor and Exam Manual -
attached)\
 \
A better understanding of her home situation and risks (including
environmental fall risks -- Sue Arnold suggest a PHN referral.\
 \
Peter Stuart captures the need to understand her preferences for care
and her own, personal goals for health and health care.  That will
certainly help with the discussions around anticoagulation (risk of
stroke vs. risk and burden of warfarin), pain control (risk of adverse
events from pain meds vs. benefit in terms of relief of pain and
improvement of function), use of bisphosphonates, and other critical
discussions.\
 \
Further testing\
Some would like to see an echocardiogram; others don't feel that they
need it.  If the digoxin was started for rate control and she doesn't
have a history of CHF or symptoms suggestive of valvular heart disease,
an echo may be optional\
 \
A DEXA is mentioned but Tim Domer points out that with the history of a
fragility fracture, she already "earns" the diagnosis of osteoporosis
and should be offered treatment.  Is a DEXA helpful then for follow-up?
 Probably not....\
 \
More optimal management of chronic conditions:\
Improved HTN management.  Some readers suggested further tightening up
blood pressure control, others warn about the increased risk of
aggressive blood pressure control.  A landmark study published earlier
this year demonstrated the clear benefit of blood pressure control in
reduction of both morbidity and mortality in the very elderly, but used
160/90 as the trigger for treatment and treated to a target of 150 / 80.
 So she's okay. Treatment of Hypertension in Patients 80 Years of Age or
Older. Beckett N et al.  N Engl J Med. 2008 Mar 31\
 \
General consensus to treat lipids to target (LDL less than 100) in this
elderly diabetic woman.  This certainly makes sense given multiple
studies showing reduction in stroke as well as MI in high risk elderly
treated with statins.\
 \
Discussion about the risk / benefit of warfarin treatment in the setting
of paroxysmal a-fib.  This is a major topic for discussion with the
patient and her daughter.  As Tobe Probst points out, she is at risk of
stroke and that risk can be decreased by anticoagulation.\
 \
Discussion about whether she needs tighter control of her blood sugars.
 The geriatrics literature supports a target AIC in the range of 8% as a
comfortable middle ground, limiting the risk of hypoglycemia while
avoiding blood sugars over 200.  There are lots of ways to get
there...while hewing to the general principle that simpler is better.\
 \
Given that she does have osteoporosis (defined by her fragility
fracture) she is a candidate for bisphosphonates, either IV as suggested
by Tim Domer or weekly PO.  She would definitely benefit from vitamin D
and calcium.  Tim Domer suggests parenteral vitamin D; a combined Ca/Vit
D oral preparation is another option.\
 \
Agreement that she needs more rational approach to rate control, with a
general consensus that the beta blocker may be the best choice, to
eliminate the diltiazem and try to wean or eliminate the digoxin.\
 \
Several different strategies are discussed for pain control, generally
trying to avoid ibuprofen because of the risk of GI bleed, use low doses
of codeine if at all.  Another strategy not mentioned is to use low
doses of a stronger narcotic (e.g. π tab percocet 5/325) rather than
higher doses of a week narcotic (codeine), reducing the risk of nausea
and constipation.\
 \
Eliminate meds that put her at increased risk\
Alprazolam, Benadryl (Tylenol pm), ibuprofen, codeine.\
Folks seem generally comfortable with metformin, although she is at
increased risk for acidosis given her age and renal impairment.\
 \
Interventions to reduce the risk of fall.\
Robert McClelland points out the value of an eye exam as part of a fall
risk evaluation.  Because she has had a fall in the last year she
"screens in" as being at high risk for future falls.  This can be
documented using the exam code for fall risk screening (Health Factor
and Exam Manual).  Attached are the AGS Evidence-based guidelines for
fall risk screening and interventions\
 \
Tim Domer offers the strategy of a comprehensive geriatric assessment by
an interdisciplinary team as an efficient way to manage this older
woman's complicated social and medical condition.\
\
\-\-\-\-\-\-\-\--\
In conclusion, there are many issues associated with the treatment of
the elderly including disease states that occur more in the elderly and
the difficulties of medication management. We would like to thank you
all again for your participation and insights into this patient case and
wish you a wonderful Holiday season!\
Bruce, Chris, and Ann

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

**Recommendations for partner services programs for HIV infection,
syphilis, gonorrhea, and Chlamydia infection**

This report provides updated, integrated recommendations for services
provided to partners of persons with human immunodeficiency virus (HIV)
infection and three other sexually transmitted diseases (STDs) (i.e.,
syphilis, gonorrhea, and chlamydial infection) and replaces the CDC 2001
Program Operations Guidelines for STD Prevention\-\--Partner Services
and the 1998 HIV Partner Counseling and Referral Services Guidance.
These recommendations are intended for health department program
managers responsible for overseeing partner services programs for HIV
infection and the three other STDs at the state and local levels. The
recommendations also might be beneficial for HIV prevention community
planning groups, STD program advisory bodies, technical assistance
providers, community-based organizations, and clinical care providers.
The value of partner services in the control of syphilis and gonorrhea
is widely accepted. However, such services are underused among partners
of persons with HIV infection. On the basis of evidence of effectiveness
and cost-effectiveness of these services, CDC strongly recommends that
all persons with newly diagnosed or reported HIV infection or early
syphilis receive partner services with active health department
involvement. Persons with a diagnosis of, or who are reported with,
gonorrhea or chlamydial infection also are suitable candidates for
partner services; however, resource limitations and the numerous cases
of these infections might preclude direct health department involvement
in certain instances. Health departments might need to limit direct
involvement in partner services for gonorrhea and chlamydial infection
to selected high-priority cases and use other strategies for the
remainder (e.g., expedited partner therapy). These recommendations
highlight the importance of program collaboration and service
integration in the provision of partner services. Because coinfection
with HIV and one or more other STDs is common, all persons with a
diagnosis of HIV should be tested for other types of STDs, and vice
versa; rates of coinfection with HIV and syphilis have been particularly
high in recent years. Many persons at risk for these infections also are
at risk for other infectious diseases, such as tuberculosis and viral
hepatitis, as well as various other health conditions. STD and HIV
partner services offer STD, HIV, and other public health programs an
opportunity for collaboration to deliver comprehensive services to
clients, improve program efficiency, and maximize the positive effects
on public health.

  

Centers for Disease Control and Prevention, Recommendations for partner
services programs for HIV infection, syphilis, gonorrhea, and chlamydial
infection. MMWR Recomm Rep. 2008 Nov 7;57(RR-9):1-83; quiz CE1-4.
[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5709a1.htm](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5709a1.htm)

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

# QuickStats: Percentage of Large-for-Gestational-Age\* Births,^†^ by Race or Hispanic Ethnicity \-\-- United States, 2005

![](media/image4.png){width="5.873611111111111in"
height="4.115972222222222in"}

\* Birthweight at or above the 90th percentile for a given gestational
age.

† Includes only singleton live births.

§ Might be of any race.

Infants born large for their gestational age (LGA) are at increased risk
for birth complications, such as obstructed labor, and for obesity later
in life. Information from U.S. birth certificates for 2005 shows that a
greater percentage of American Indian/Alaska Native women gave birth to
an LGA infant (12%), followed by white (10%) and Hispanic women (9%).
Black and Asian/Pacific Islander women were least likely to have given
birth to an LGA infant (6%).

# Centers for Disease Control, MMWR Weekly, QuickStats: Percentage of Large-for-Gestational-Age\* Births,^†^ by Race or Hispanic Ethnicity \-\-- United States, 2005; November 21, 2008 / 57(46);1258 

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5746a4.htm?s_cid=mm5746a4_e>

####  {#section-40 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Women's Health Headlines Carolyn Aoyama, HQE {#womens-health-headlines-carolyn-aoyama-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**Please see the SART training announcement below** and the link which
takes you to the registration site (<http://www.sane-sart.com/>).  This
training is scheduled for May 28-29, 2009 and is the only national SART
training available.  This conference is relevant to any I/T/U facility
or Native community interested in building a coordinated community
response to sexual assault.

**FIFTH NATIONAL SEXUAL ASSAULT RESPONSE TEAM TRAINING CONFERENCE**\
**May 27 - 29, 2009; Seattle, Washington\
**The Sexual Assault Resource Service (SARS) office in Minneapolis, MN
is pleased to announce, in conjunction with the Office for Victims of
Crime, Department of Justice, that the Fifth National SART Training
Conference will be held in May of 2009 at the Westin Seattle in Seattle
Washington. Save the dates of May 27 - 29, 2009 for this exciting
training conference.\
\
The focus of the 2009 SART Training Conference will be to continue
expanding the capacity of SARTs to promote health and healing of sexual
assault victims, hold sex offenders accountable for their crimes, and
realize the hope of preventing further sexual violence in their
communities.\
\
Team scholarships of \$1,000 per team member will again be offered in
2009 to a limited number of SART teams comprised of four team members
representing four different SART disciplines; law enforcement
scholarships of \$1,000 per officer will also be offered. Applications
will be available from this website on November 1, 2008. Applications
will be accepted from November 1, 2008 to February 2, 2009. The
scholarships are designed to assist participants in covering air, hotel,
and the Conference Registration Fee.\
\
We will be repeating the interactive scenario which was well received in
2007. Teams representing four disciplines will be required for
participation in this interactive learning format. A limited number of
SARTs will work as teams, collecting evidence at the scene of the crime
through to testifying at the trial, with training by some of our top
trainers.\
\
The SART Conference Registration Fee will be \$425.00 if registered on
or before March 16, 2009. If registering after that date, the conference
fee will be \$475.00. The Registration Fee includes participation in six
Keynote addresses, eight workshops, entrance to the SART Exhibit Hall,
three continental breakfasts, three lunches, and printed conference
materials. All meetings will be held at the Westin Seattle. We are
holding rooms at the prevailing government per diem rate for 2009.

Website: <http://www.sane-sart.com/>

Questions: Direct to SART Conference Services at:
<admin@sartconference.com>

####  {#section-41 .Style-Heading-4-+-Arial-14-pt-Underline}

#### "What's new in PubMed on adolescent dating violence" {#whats-new-in-pubmed-on-adolescent-dating-violence-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Measuring sex differences in violence victimization and perpetration within date and same-sex peer relationships {#measuring-sex-differences-in-violence-victimization-and-perpetration-within-date-and-same-sex-peer-relationships .Style-Heading-4-+-Arial-14-pt-Underline}

This study examines sex differences in the patterns of repeated
perpetration and victimization of physical violence and psychological
aggression within dating relationships and same-sex peer relationships.
Data were obtained from the Youth Violence Survey: Linkages among
Different Forms of Violence, conducted in 2004, and administered to all
public school students enrolled in grades 7, 9, 11 and 12 (N = 4,131) in
a high-risk school district. Analyses of adolescents who dated in the
past year (n = 2,888) show that girls are significantly more likely than
boys to report physical violence and psychological aggression
perpetration within dating relationships. However, boys are
significantly more likely than girls to report physically injuring a
date. Boys are also significantly more likely than girls to report
physical violence victimization and perpetration within same-sex peer
relationships. Implications and directions for future research are
discussed.

Swahn MH, Simon TR, Arias I, Bossarte RM. Measuring sex differences in
violence victimization and perpetration within date and same-sex peer
relationships. J Interpers Violence. 2008 Aug;23(8):1120-38. Epub 2008
Mar 4. <http://www.ncbi.nlm.nih.gov/pubmed/18319366>

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

**Telluride Midwinter Conference on Maternal and Child Health**

-   January 30^th^ -- February 1^st^, 2009

-   Fun and inexpensive CME

-   Telluride, Colorado

-   [http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm?module=09&option=1#top](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm?module=09%26option=1%23top)

> (scroll down to date)

**First International Meeting on Indigenous Women's Health/Third
International Meeting on Indigenous Child Health Conference; Many Voices
into One Song**

-   Women's Health March 4-6, 2009

-   Child Health March 6-8, 2009

-   Albuquerque , NM

-   Joint conference of Women's Health and Children's Health Providers
    from Canada and the United States

-   <http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm?module=09&option=3#top>

**IHS Colposcopy Update & Refresher Course**

-   April 1-3, 2009

-   Albuquerque, NM

-   Contact: <AWaxman@salud.unm.edu>

 **Advances in Indian Health Conference**

-   April 21-24, 2009 in Albuquerque, NM 

-   Indian Health\'s conference for primary care providers and nurses

-   28 hours of CME/CE credit

-   Optional Diabetes track

-   Contact the Course Director, Dr. Ann Bullock, at
    <annbull@nc-cherokee.com> for more information.

**Indian Health Summit**

-   July 7-9, 2009, Hyatt Regency Hotel, Denver, Colorado

-   The Health Summit will be a national gathering of Indian Health
    professionals and administrative leadership, community health
    advocates and activists, and Tribal leadership. We will join
    together to build skills and share ideas and innovations

-   <http://conferences.thehillgroup.com/healthsummit/index.html>

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

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/index.cfm>

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

The **November 2008 CCC Corner** is available at:
<http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm>

#### [Abstract of the Month]{.underline} {#abstract-of-the-month-2 .Style-Heading-4-+-Arial-14-pt-Underline}

\- Effectiveness of maternal influenza immunization in mothers and
infants

#### [From your colleagues]{.underline} {#from-your-colleagues-2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Richard Church, IHS Headquarters {#richard-church-ihs-headquarters .Style-Heading-4-+-Arial-14-pt-Underline}

#### - CEO Brief -- Issue 7 {#ceo-brief-issue-7 .Style-Heading-4-+-Arial-14-pt-Underline}

**Joxel Garcia, U.S. Public Health Service**

\- Influenza Vaccination for Health Care Personnel

Scott Giberson, IHS Headquarters

\- Call for Abstracts -- Third Alaska Native Health Research Conference

**Paul Seligman, Food and Drug Administration**

## - FDA Creates Web Page with Drug Safety Information for Patients, Health Care Professionals 

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

##### Obstetrics

\- Alcohol Use Screening for FASD Prevention among a Cohort of American
Indian Women

\- Prevention of Diabetes in Women with a History of Gestational
Diabetes: Effects of Metformin and Lifestyle Interventions

\- Perinatal outcomes in low-risk term pregnancies: do they differ by
week of gestation?

\- Effect on birth outcomes of a formalised approach to care in hospital
labour assessment units: international, randomised controlled trial

\- Peripartum Clostridium difficile infection

**Gynecology**

\- Pregnancy outcome in women before and after cervical conisation

\- FDA Public Health Notification: Complications with Transvaginal
Placement of Surgical Mesh

\- The role of Lactobacillus in restoring the normal vaginal flora after
antibiotic treatment of bacterial vaginosis

\- Hormone therapy and the risk of breast cancer in BRCA1 mutation
carriers

**Child Health**

**-** [AAP Guidelines Recommend Doubling Children\'s Vitamin D
Intake](https://webmail.hhs.gov/exchange/Jean.Howe/reading 2/Vitamin D Guideline for Kids _x005F_xF8FF_ Stress Testing %26 PCI _x005F_xF8FF_ Episodic vs. Continuous Amiodarone.EML/#article1)

\- Interventions in primary care to promote breastfeeding

\- Use of a fan during sleep and the risk of sudden infant death
syndrome

**-** Support for Comprehensive Sexuality Education: Perspectives from
Parents of School-Age Youth **\
**- First-trimester maternal alcohol consumption and the risk of infant
oral clefts

**Chronic Illness and Disease**

\- Patients and Caregivers Benefit from End-of-Life Discussions

\- Comparative Effectiveness and Safety of Premixed Insulin Analogues in
Type 2 Diabetes

­- Smoking cessation interventions for hospitalized smokers

\- Patients with Coronary Heart Disease Benefit from Screening for
Depression

####  {#section-42 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Features]{.underline} {#features-2 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

\- Ultrasonography in Pregnancy

\- Use of Progesterone to Reduce Preterm Birth

\- Pregnant Women Reminded to Get Flu Vaccination

##### American Family Physician

\- Atypical Moles

\- Management of Mastitis

**Agency for Healthcare Research and Quality**

\- Behavioral Modification Programs Help Obese Children Manage Their
Weight

\- Task Force Finds Several Methods Equally Effective for Colorectal
Cancer Screening

**-** Behavioral Counseling to Prevent Sexually Transmitted Infections
** **

\- AHRQ's 2008 Guide to Clinical Preventive Services Now Available

**Ask a Librarian**

\- Medical Clinics of North America issue dedicated to Women's Health

**Behavioral Health Insights**

#### - Protecting urban American Indian young people from suicide {#protecting-urban-american-indian-young-people-from-suicide .Style-Heading-4-+-Arial-14-pt-Underline}

**Breastfeeding**

\- A Skinny Little Secret

**CCC Corner Digest**

**Domestic Violence**

#### - Health outcomes in women with physical and sexual intimate partner violence exposure {#health-outcomes-in-women-with-physical-and-sexual-intimate-partner-violence-exposure .Style-Heading-4-+-Arial-14-pt-Underline}

**Elder Care News**

\- Prescription drug misuse/abuse in the elderly

**Family Planning**

#### - Drospirenone for acne treatment {#drospirenone-for-acne-treatment .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

-The Immunization Action Coalition; free resources about vaccination for
everyone!

**Frequently asked questions**

-Q. Should we treat asymptomatic trichomonas found on a Pap smear?

-Q. Should we withhold contraception from a woman who is not 'current'
on her pap?

**Indian Child Health Notes**

\- Alcohol-Attributable Deaths and Years of Potential Life Lost Among
American Indians and Alaska Natives

­- Effectiveness of Maternal Influenza Immunization in Mothers and
Infants

**Information Technology**

\- Alpha Testing to Start on the EHR Version of the Well Child Module

International Health

\- Disease risks of premastication as an infant feeding practice

#### MCH Alert

-MCH Library Releases New Edition of Domestic Violence Knowledge Path

-Article Assesses Smoking Patterns and Use of Cessation Interventions
during Pregnancy

#### MCH Headlines

\- Native American Action Plan: Addressing Tobacco Abuse among Pregnant
and Postpartum Women

\- Cough and Cold Medications Not Recommended for Children Under 4 Years
of Age

\- Breastfeeding Mini-Grant Opportunity

#### Medical Mystery Tour

#### - Test your knowledge on Polycystic Ovarian Syndrome (PCOS) {#test-your-knowledge-on-polycystic-ovarian-syndrome-pcos .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

**Menopause Management**

\- Hot flashes and subclinical cardiovascular disease

**Midwives Corner**

**-** Centering Pregnancy ListServe Revived

**Navajo News**

#### - Navajo Area Women's Health Provider Meeting {#navajo-area-womens-health-provider-meeting .Style-Heading-4-+-Arial-14-pt-Underline}

**Nurses Corner**

\- Strategies to prevent healthcare-associated infections in acute care
hospitals

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

\- What Works to Promote Cancer Screening

Osteoporosis

\- Serum 25-hydroxyvitamin D and functional outcomes in the elderly

Patient Education

#### - Free Flu Materials from the CDC {#free-flu-materials-from-the-cdc .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

\- Cesarean delivery for the second twin

\- Accuracy of ultrasonographic fetal weight estimation in twin
pregnancies

\- Nicotine gum for pregnant smokers: a randomized controlled trial

\- Risk of development of diabetes mellitus after diagnosis of
gestational diabetes

Primary Care Discussion Forum

\- Geriatric Medication Issues

STD Corner

\- Innovative uses of technology that are being used to prevent STDs/HIV

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

-Postpartum screening after GDM affected pregnancies---room for
improvement

\- The association between low birth weight and type 2 diabetes

**Women's Health Headlines**

\- A web-based resource for oral health providers on screening for
domestic violence

The past CCC Corners are archived at:

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN02.cfm>

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 <jean.howe@ihs.gov> or
928-674-7422 (with voicemail).

\*The opinions expressed in the CCC Corner are strictly those of the
authors, and not necessarily those of the Indian Health System, or the
editor of this newsletter.