News Flashes

#### -Our International Health Columnist, Claire Wendland is on location..... in Malawi

#### -New CCC Corner Columnist: Judy Thierry -- MCH Headlines

![](media/image1.jpeg){width="5.992361111111111in"
height="1.1111111111111112in"}

OB/GYN Chief Clinical Consultant's Corner

Volume 5, No. 3, March 2007

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

#### Abstract of the Month page 5 {#abstract-of-the-month-page-5 .Style-Heading-4-+-Arial-14-pt-Underline}

**Healing words: The power of \'I\'m sorry\' in medical practice**

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

Amy Groom

Q&A vaccines, safety contraindications, allergies: Children's Hospital
of Philadelphia site

Burt Attico

Consumer Reports has withdrawn its study on infant safety seats

**Gordon Belcourt**

Cervical Cancer in America

**Scott Giberson**

Ryan White HIV / AIDS Treatment Modernization Act of 2006

March 21^st^: First Annual National Native HIV/AIDS Awareness Day

**Favian Kennedy**

Northern Plains Tobacco Policy Workshop March 8th and 9th, 2007

**Sunnah Kim**

-2007 Native American Child Health Advocacy Award

-Oral Health AIAN Preceptorship Award RFP

-Large data Catalog Available: Health / Well-Being of AI / AN, and Other
Native Americans

-Registration is now open for the 2nd International Meeting on
Indigenous Child Health

**Roberta Ward**

Common Skin Conditions During Pregnancy

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

##### Obstetrics page 12

-GDM Guidelines: Major discrepancies to identify GDM and predict
pregnancy outcome

-Benefit of cesarean for macrosomic infants weighing 4,000-4,999 g
questioned

-Amount of maternal smoking predicts the risk of spontaneous abortion

-First delivery by cesarean begins cascade of risks - obstetric and
perinatal outcomes

Brief motivational intervention decreased the risk of alcohol-exposed
pregnancy: RCT

and more...

**Gynecology page 16**

-Cystocoele Repair: The Mesh Controversy by John Heusinkveld, Shiprock

-Strong evidence for the efficacy of physical therapy for the treatment
for SUI in women

-Risk of preterm delivery increases after all treatment modalities for
CIN

-Report tracks state progress in cervical cancer prevention strategies

-The TVT and the TVT-O procedures perform equally

and more...

**Child Health page 19**

-Review and Comment: Newborn record form IHS-298 and its revision

-Importance of media in adolescent girls\' physical and emotional health
and weight loss

-Does Swaddling Reduce Excessive Crying in Infants?

-Autonomic function or dysfunction and its role in Sudden Infant Death
Syndrome

-Premature Infants Are Susceptible to SSRI, Venlafaxine Exposure In
Utero 

and more...

**Chronic Illness and Disease page 21**

-Does Delay in Diagnosis of Breast Cancer Impact Prognosis?

-Mammographic density and the risk and detection of breast cancer

-Estradiol showed benefit during menstrual migraine, but offset by
estrogen withdrawal

-Mental disorders among primiparous mothers increased several months
after childbirth

-Melanoma unabated: One-time melanoma screen at age 50 deemed cost
effective

and more...

#### Features page 23 {#features-page-23 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-ACOG Opposes Sex Selection for Family Planning Purposes

-Pelvic Organ Prolapse. ACOG Practice Bulletin

-Breastfeeding: Maternal and Infant Aspects. ACOG Committee Opinion

##### American Family Physician

-Role of Exercise in Patients with Type 2 Diabetes: Cochrane for
Clinicians

-Acute Uterine Bleeding: Progestin vs. Combination Therapy

**Agency for Healthcare Research and Quality**

-AI/AN are difficult to reach by mail for research or health care
reasons

-Women are more likely to suffer health problems and worse quality of
life due to obesity

-Missed opportunities: Few Americans are screened to prevent colorectal
cancer

-Physicians\' extended work shifts associated with of medical errors and
patient harm

-Extended resident work hours jeopardize both resident health and
patient safety

**Ask a Librarian**

Diet of Pregnant American Indians: Different than Whites?

**Breastfeeding**

-ACOG Calls on Employers for Increased Support for Breastfeeding

-Calcium Important for Nursing Mothers' Oral Health

-Call for Breastfeeding Abstracts: AAP

#### -Simple Antenatal Preparation Improves Breast-Feeding Practice: RCT {#simple-antenatal-preparation-improves-breast-feeding-practice-rct .Style-Heading-4-+-Arial-14-pt-Underline}

**CCC Corner Digest**

**February 2007 Highlights**

-Low hanging fruit: Promotion of healthy lifestyles during and after
pregnancy

-Teamwork Training: Decision to incision times significantly improved

-Outreach workers should follow women with the most severe PAP
abnormalities

-Are you interested in acquiring HPV vaccine to provide to 9 -- 18 year
olds?

-Sleepiness and sleep deprivation are associated with injury

-Guidelines Recommend Universal Screening for Down Syndrome: Regardless
of age

-Diet of Pregnant American Indians: Different than Whites?

-Supporting employee breastfeeding is easier than it sounds

-Continuous Contraceptive Therapy Safely Abolishes Menstrual Cycles

-Vaccine Preventable Diseases, IHS

-Are varicella titers necessary prior to immunization?

-What does the future hold in store?

-F/U: A boy has been born in Chile with a fetus in his stomach

-Local estrogen just as effective for vaginal atrophy in postmenopausal
women

-The Blessed Perineum: PubMed

-Getting Your Patient Back to Work: Return-to-Work Restrictions After
Illness / Injury

-I have to go really far just to exercise . . . er . . . actually no you
don't

-What do patients recall from our counseling?

-Planned cesarean delivery doubles rate of NICU and risk for pulmonary
disorders

-Adolescent with knee pain, Web M+M, Terry Cullen - Moderator

-First Indian Health Special Issue on Methamphetamine is now available
online

-Diabetic Moms\' Babies Have Impaired Sucking Reflexes

-What Causes Breast Cancer?

-Andy Narva moved to NIH, but is still our Renal CCC

-Year End Re-cap of Available Resources from CDC -- OWH

**Domestic Violence**

-Health Care-Based Interventions for Women Who Have Experienced Sexual
Violence

-Child Abuse: Approach and Management

**Elder Care News**

-Older American Indians often have a poorer view of their own health
than their doctors

-Selective Serotonin Reuptake Inhibitors Increase Fracture Risk in Older
Adults

-The decision to hospitalize nursing home residents

-Many nursing home residents suffer from poorly controlled pain

**Family Planning**

Abstinence counseling vs family planning: Which is more effective?

**Featured Website**

The MCH Coordinators Site has a clean new look, plus new functionality

**Frequently asked questions**

How many rubella vaccines does a mother really need to get?

**Indian Child Health Notes**

-A guest editorial for physicians who work with tribal child protective
services

-How will we roll out the new HPV vaccine? Who can we cover?

-Dr. Esposito gets passionate about poor data and unfounded conclusions

**Information Technology**

Have you visited the CRS Performance Improvement Toolbox web page
lately?

International Health

-Sexual behavior in context: A public health perspective

#### -Repair of obstetric vesicovaginal fistulas in Africa {#repair-of-obstetric-vesicovaginal-fistulas-in-africa .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Drugs for preventing malaria in pregnant women improve infant outcome {#drugs-for-preventing-malaria-in-pregnant-women-improve-infant-outcome .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Global struggle against poverty {#global-struggle-against-poverty .Style-Heading-4-+-Arial-14-pt-Underline}

#### MCH Alert

-First steps in implementing mental health screening in schools

-New Organization Focuses on Adolescent Health Care Reform

**MCH Headlines**

-Scrub Club

-Training Course in MCH Epidemiology

-New Child Health USA Report Released

-More on car seats, installment and safety on recheck

-CDC needs feedback on need for Educational resources HPV implementation

and more...

#### Medical Mystery Tour

#### Prolonged second stage with an epidural {#prolonged-second-stage-with-an-epidural .Style-Heading-4-+-Arial-14-pt-Underline}

#### 

#### Medscape

######### -HPV CEU\'s vaccine indications test your knowledge: 5 minute review

-Contraception for a Woman With a History of Fibroids

**Menopause Management**

-Physical Activity Improves Lipid Profile in Postmenopausal Women 

#### -Transdermal Estrogen Suggested for Women With Metabolic Syndrome {#transdermal-estrogen-suggested-for-women-with-metabolic-syndrome .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

Maternal positioning and pain relief measures: Pomoting effective
pushing

**Navajo News**

Clomiphene "bests" Metformin in a NEJM study

**Nurses Corner**

#### -A \"Small Fall\" and a Trip to the Emergency Department {#a-small-fall-and-a-trip-to-the-emergency-department .Style-Heading-4-+-Arial-14-pt-Underline}

-The REACH Program and Alzheimer\'s Caregivers

-Monthly Summaries of Nursing Research: Medscape

#### -Highlights of NPWH 9th Annual Conference \-- Women\'s Health in the New Millennium {#highlights-of-npwh-9th-annual-conference----womens-health-in-the-new-millennium .Style-Heading-4-+-Arial-14-pt-Underline}

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

Indian Health Surveillance Report---Sexually Transmitted Diseases 2004

Health, United States, 2006

**Oklahoma Perspective**

What do patients recall from our counseling?

Osteoporosis

-Early Postmenopausal Hormone Therapy Improves Postural Balance

-Repeat Bone Mineral Density Measurement May Not Predict Fractures in
Older Women 

Patient Education

#### -Tips for Using Medicines Wisely {#tips-for-using-medicines-wisely .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Parvovirus B19: What You Should Know {#parvovirus-b19-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Ultrasound is better at finding NTD than AFP

-Planned cesarean delivery doubles NICU rates and the risk for pulmonary
disorders

-Amniotic Fluid Promising Source of Stem Cells

-Formula that calculates the estimated risk of respiratory distress
syndrome is valid

-Pregnancy Loss After Amniocentesis and CVS

and more...

Primary Care Discussion Forum

Adolescent with knee pain -- Ongoing discussion

STD Corner

-A First: STD Rates Available by IHS Area

-Heterosexual Transmission of Community-Associated Methicillin-Resistant
Sttaph. aureus

-Research Seeks To Expand Understanding of Effects of Alcohol Use on
Developing Brain

-RCT comparing computer-assisted vs face-to-face sexual history taking

-CDC Releases Survey Results on STD Counseling in Adolescents

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

-Fertility rises as weight drops

-FDA Authorizes NovoLog for Pregnant Women With Type 1 Diabetes

#### -Mild Gestational Diabetes Raises Risk of Cryptorchidism {#mild-gestational-diabetes-raises-risk-of-cryptorchidism .Style-Heading-4-+-Arial-14-pt-Underline}

**Women's Health Headlines**

-Women\'s Health Week will be celebrated May 13-19, 2007

-Menstrual Cycle is a Vital Sign

\-[CDC reports decreasing mammogram rates
1999-2002](http://www.ihs.gov/MedicalPrograms/MCH/W/CanBr.cfm#DecrMammo)

-Vulvodynia: a state-of-the-art consensus on definitions, diagnosis and
management

###### Save the Dates: Upcoming events of interest page 50

#### What's new on the ITU MCH web pages page 50

-Second methamphetamine issue of the IHS Primary Care Provider now
available online!

-Check out new Indian Health STD website

-The History of Maternal Child Health in the United States

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

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

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

**Healing words: The power of \'I\'m sorry\' in medical practice**

In 'Healing Words: The Power of Apology in Medicine', Dr Michael Woods
addresses the intent of apology and disclosure programs. Dr. Woods later
stated \"I believe, and I\'m speaking from a very physician-centric
viewpoint, that we should be doing this because it\'s the right thing to
do, not because it\'s going to lower our liability.\"

Patients are passive observers of behavior in the environment of
care---in the clinics and the hospitals,\" he said. If an atmosphere of
respect and apology is fostered, even for seemingly inconsequential
matters, it becomes clear the provider really does care.

\"Apology and disclosure are of equal importance, but they accomplish
something very different. Both have to happen in the aftermath of an
unanticipated outcome.\" Dr Woods cites a reference from an Archives of
Internal Medicine article that said, \"Data indicate that the likelihood
of a lawsuit falls by 50% when an apology is offered and the details of
the medical error are disclosed immediately.\"

The point is, apology isn\'t about causality,\" Dr Woods said. \"Apology
is about empathy, and understanding what the patient is going through
and feeling badly for that. It\'s not about, \'Gee, I\'m sorry I caused
this.\'\"

\"The apology itself, which I consider to be the front-end piece of
maintaining the relationship and open communication, does not require
any sort of admission of guilt,\" he said. \"Even if there\'s a direct
causal relationship on the part of the physician.\"

\"Nobody needs to sue me to make me feel bad about a bad outcome. Every
physician, or provider at least, understands that.\"

\"The data,\" Dr Woods said, \"seems to be suggesting that it\'s
actually far greater than \[50%\]. \... \[The insurance\] program called
the three Rs \[regret, responsibility, and remedy,\] has shown dramatic
reductions in claims being filed in the group of people where they\'ve
had this process utilized. The number of patients who go through that
process \[of the three Rs\] who actually end up filing claims is just a
handful. It was essentially nothing, compared to the standard approach
to this problem.\" Dr Woods has expanded the three Rs to five---the
original regret, responsibility and remedy, plus recognition (of when an
apology is needed) and remain (engaged, meaning don\'t just issue a
quick apology and then disappear).

I\'ve become convinced, even more than I was, that the major driver of
medical malpractice \[lawsuits\] is not a litigious society, it is not
physician ineptitude, it\'s anger,\" he said. \"It\'s patient anger at
not being provided with the information that they feel they need, and/or
a sense that the physician is not respectful of them.\"

\"Healing Words: The Power of Apology in Medicine, Second Edition,\" is
published by Joint Commission Resources (JCR), an affiliate of Joint
Commission on Accreditation of Healthcare Organizations. To order, call
JCR customer service toll-free at 877-223- 6866, or
[www.jcrinc.com](http://www.jcrinc.com/)

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

**Full disclosure and compassion are important Indian Health tenets**

Our department has supported full disclosure with our patients for
years. Not only is it respectful, on a very basic human level, but it is
also the ethical approach. It may also be the most important
conversation you will ever have with that patient, or their family. It
will certainly be the one conversation you'll remember for the rest of
your career, or whole life for that matter, so please make the most of
it.

On a personal note, I had such conversations and they are the hardest
conversations I have ever had to initiate. I also wish I would have done
a better job. Perhaps if I had read \"Healing Words: The Power of
Apology in Medicine', prior that conversation, then I wouldn't have as
many things I wished I would have said.

**Other resources**

**American and Canadian error disclosure similar, despite malpractice
environments**

<http://www.ahrq.gov/research/jan07/0107RA9.htm>

**Ethical Decision Making in Obstetrics and Gynecology, ACOG**

<http://www.acog.org/from_home/publications/ethics/ethics003.pdf>

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

#### Amy Groom, Albuquerque {#amy-groom-albuquerque .Style-Heading-4-+-Arial-14-pt-Underline}

**Q&A vaccines, safety contraindications, allergies: Children's Hospital
of Philadelphia site**

The Vaccine Education Center - To provide complete, up-to-date and
reliable information about vaccines to parents and healthcare
professionals, The Children\'s Hospital of Philadelphia created the
Vaccine Education Center.  The Children\'s Hospital of Philadelphia, the
nation\'s first children\'s hospital, has been a center of vaccine
research and education for over 125 years. For example, the rubella
vaccine, a vaccine that prevents what was at one time the most common
cause of birth defects in the United States, was developed at The
Children\'s Hospital of Philadelphia and the Wistar Institute of Anatomy
and Biology.\
\
The Vaccine Education Center, through its Web site,
videos, [informational tear
sheets](http://www.chop.edu/consumer/jsp/division/generic.jsp?id=75763)
and speakers programs, provides [information on every
vaccine](http://www.chop.edu/consumer/jsp/division/generic.jsp?id=75692).  

The Center has also established the Parents PACK program to develop a
dialogue with parents, provide frequent vaccine information, and
establish a place for parents to get up-to-date information and answers
to questions about vaccines. Visit the Parents PACK site or sign up for
the monthly newsletter by going to [Parents PACK
home](http://www.chop.edu/consumer/jsp/division/generic.jsp?id=79354).

Other Resource:

Guide to Contraindications to Vaccinations, CDC
 <http://www.cdc.gov/nip/recs/contraindications.htm#Check>

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

#### Wonder what the status of HPV vaccine is in your state legislature? {#wonder-what-the-status-of-hpv-vaccine-is-in-your-state-legislature .Style-Heading-4-+-Arial-14-pt-Underline}

#### After Texas Gov. Rick Perry\'s executive order mandating that sixth-grade girls be vaccinated for the sexually transmitted human papillomavirus, Kaiser Daily Reports gives an update on the most active states entitled "State Politics & Policy \| HPV Vaccine Legislation Introduced in Colorado, Connecticut, Kansas, Michigan, Wisconsin; Maryland Bill To Be Withdrawn" {#after-texas-gov.-rick-perrys-executive-order-mandating-that-sixth-grade-girls-be-vaccinated-for-the-sexually-transmitted-human-papillomavirus-kaiser-daily-reports-gives-an-update-on-the-most-active-states-entitled-state-politics-policy-hpv-vaccine-legislation-introduced-in-colorado-connecticut-kansas-michigan-wisconsin-maryland-bill-to-be-withdrawn .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=42648**](http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=42648) {#httpwww.kaisernetwork.orgdaily_reportsrep_index.cfmdr_id42648 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Burt Attico, Phoenix {#burt-attico-phoenix .Style-Heading-4-+-Arial-14-pt-Underline}

**Consumer Reports has withdrawn its study on infant safety seats**

This story appeared in the Feb 2007 issue of the periodical and was
noted in the CCC Corner.  The CR press release states that a
"substantive issue" affecting results was brought to their attention by
NHTSA.  NHTSA reports that side impact tests conducted by Consumer
Reports did not simulate 38.5 mph as stated in the report, but instead
simulated speeds in excess of 70 mph. When NHTSA tested the same seats
at a simulated 38.5 mph, seats did not detach from their bases.  Both
Consumer Reports and NHTSA stress that car seats are the safest place
for infants in automobiles.
<http://www.consumerreports.org/cro/cu-press-room/pressroom/2007/2/0702_eng0702ccs.htm>

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

**Gordon Belcourt, Montana Wyoming Tribal Leaders**

**Cervical Cancer in America**

96 page national update on distribution of disease, economic burden, 1
page state-by-state reports, Women In Government is a national
501(c)(3), non-profit, bi-partisan organization of women state
legislators providing leadership opportunities, networking, expert
forums, and educational resources to address and resolve complex public
policy issues. Women In Government leads the nation with a bold,
courageous, and passionate vision that empowers and mobilizes all women
legislators to effect sound policy. Suggested Citation:

Women In Government. Partnering For Progress 2007: The "State" of
Cervical Cancer Prevention in America. Washington, DC, 2007.

To request free copies of this report or to send inquiries, contact:

Women In Government

HPV & Cervical Cancer Policy Resource Center

Toll free: 1.888.333.0164

E-mail: <resourcecenter@womeningovernment.org>

Web:
[www.womeningovernment.org/prevention](http://www.womeningovernment.org/prevention)

**Scott Giberson, HQE**

**Ryan White HIV / AIDS Treatment Modernization Act of 2006**

New Language may improve AI/AN opportunities and clarify linkages of
care

The Ryan White CARE Act (RWCA) was reauthorized (12/19/2006) as the
"Ryan White HIV/AIDS Treatment Modernization Act of 2006 (RWMA)". The
language is particularly remarkable for the Indian Health Service (IHS)
and AI/AN in that it establishes opportunity for more seamless access to
HIV/AIDS care and treatment. Although the intent of previous RWCA
language was to assist AI/AN in access and eligibility to treatment and
care of HIV/AIDS, this specific and reauthorized language certainly aims
and succeeds in augmenting that intent. 

 

The following RWCA provisions in the reauthorization affect the IHS and
AI/AN population:

1.  AI/AN individuals are/were always eligible for RWCA services if
    certain requirements were met (as any other person infected/affected
    by HIV/AIDS would need to meet various requirements -- dependent
    upon the State of residence).

```{=html}
<!-- -->
```
1.  IHS federally operated Health Facilities will now be eligible to
    apply for services under Title III and IV through the RWMA (in
    addition to previously authorized Urban Programs and 638 Tribal
    Facilities under RWCA):

> <http://hab.hrsa.gov/programs/CapacityDevelopment/>
>
> <http://hab.hrsa.gov/programs/PlanningGrant/>
>
> <http://hab.hrsa.gov/programs/EarlyIntervention/>
>
> <http://hab.hrsa.gov/programs/women/>

2.  IHS facilities are exempt from the "Payer of Last Resort"
    restriction for Titles I, II and III. Although RWCA grantees are the
    payer of last resort, this amendment exempts I/T/U facilities from
    reimbursement, regardless of referral. In the past, RWCA grantees
    were asked to coordinate reimbursement of such funds with the tribes
    and with the IHS.

3.  The new legislature supports access for all AI/AN under RWMA
    regardless of I/T/U utilization/affiliation or geographic
    location.  (Previously, HRSA Policy 00-01 stated that AI/AN could
    not be turned away from RWCA services, but still held RWCA grantees
    as Payers of Last Resort. So, if patients were referred from IHS,
    RWCA grantees could technically go back to IHS for funding (whether
    or not this actually happened). Now, the RWMA codifies (that IHS is
    exempt from the Payer of Last Resort restriction) this language into
    law.

4.  Planning council representation should include members from
    federally recognized Indian tribes as represented in the population.

5.  Language surrounding AIDS Education and Training Centers (AETCs) now
    specifically names "Native Americans" as person(s) to be trained.

**[Editorial Comment: IHS HIV/AIDS Principal Consultant]{.underline}**

It is a privilege to note that this revised language is due in large
part to the hard work, diligence, and passion of community members and
organizations that came from within our AI/AN communities. Some
additional explanation may be helpful:

-   The changes of eligibility as a grantee for Titles III and IV affect
    our IHS sites, but did not affect the eligibility that was already
    offered to Urban and 638 facilities. Here are links to services
    provided under Title III and IV

-   Although I/T/U sites are eligible for Titles III and IV, this does
    not mean I/T/U sites are automatically grantees; they must go
    through the application and approval process. I am gathering
    information as best possible including information about grant
    application process or timelines. For now, you may visit  
    <http://www.grants.gov/>

-   Previous RWCA language did not specify Native Americans or AI/AN
    when referring to AETCs ; however we have been working with the AETC
    leads at HQ for quite some time (prior to RWMA language) and are
    continuing this activity by integrating resources and ideas to
    maximize the benefit within our population.

We are working diligently with leadership from HRSA to discuss
ramifications and implementation of this language and to disseminate the
message of these changes to help with care of our AI/AN persons at risk
and living with HIV/AIDS. Additionally, we hope to focus current and
future initiatives and collaborations with HRSA around RWMA
opportunities and efficient models and linkages of care between our
clients, I/T/U facilities, and Ryan White grantees, service providers,
and services. We are in the process of renewing and enhancing a
Memorandum of Agreement (MOA) between IHS and HRSA that will speak to
any potential opportunities and care that may come with the new RWMA
Titles I, II, III, and IV. These 'services' (via RWMA) also include but
are not limited to, AETCs, Special Projects of National Significance
-SPNS, the AIDS Drug Assistance Program-ADAP, etc.).  We will also be
working with HRSA to identify and clarify each agency's comparative
advantage in collaborating on this language to best assist AI/AN.

Given these provisions, it is imperative that all AI/AN clients and
facilities eligible for these provisions are made aware and assisted in
removing any barriers to effective and seamless access and care. It may
be advisable for each health facility to contact a RWMA grantee in your
respective area/state to link this new language to an action plan and
discuss potential linkages or improve existing ones. If there are any
significant needs or anecdotal evidence (from the field) that
illuminates a specific challenge of implementation with RWMA grantees or
services, comments are welcome and appreciated. The HRSA RWMA grantee
website can be found at <http://careacttarget.org/community.htm> and
technical assistance center at <http://careacttarget.org/>. If you
would, please assist in passing this information along to appropriate
personnel

**Reference:**

The Library of Congress. December 19, 2006.

Found at: <http://thomas.loc.gov/cgi-bin/query/z?c109:h.r.6143.enr>

**March 21st marks the first annual observance of National Native
HIV/AIDS Awareness Day**

According to CDC data, over the past 6 years, prevalence of HIV/AIDS has
either continued to remain stable or has increased. When population size
is taken into account, the American Indian / Alaska Native (AI/AN)
population ranks third in the US (among all ethnicities) in rates of
HIV/AIDS cases. It is now present in both urban and rural populations.
We also do not use all of the opportunities we could to screen for HIV,
yielding a large portion of the population that remains untested. Given
these risks and trends, we must persevere even more diligently against
HIV/AIDS.

Some time ago, I found a quote (by Ralph Emerson, 1952) in a book that
said, "I am an invisible man. Invisible, understand, simply because you
refuse to see me." Although it seems to speak on the individual level,
it certainly could speak to the complacency sometimes observed over the
entire HIV/AIDS pandemic and epidemics within indigenous cultures,
minorities, and underserved populations. Let us make it a goal in our
population to avoid this. We are challenged to eliminate any potential
complacency, be proactive in the fight, continue our ongoing HIV/AIDS
initiatives and commence new programs that demonstrate this resolve.

It is necessary that each of us attempts to take on the role of an
advocate, supporter, facilitator, or provider of prevention and care
against arguably the most critical global healthcare issue of our time.
To mark this day, there are a number of AI/AN HIV/AIDS activities and
events in multiple geographic areas. In accordance with this and to mark
this day, it is a privilege to announce the March 21st release of our
first IHS HIV/AIDS website. Although still under development, it will
serve as another medium to gather information, share resources, provide
links and update personnel on the IHS HIV/AIDS program and its
activities. Additionally, this HIV/AIDS Listserv has now grown to
hundreds of members and serves as a way for this office to communicate
pertinent HIV/AIDS information to I/T/U personnel working in this and
related fields. I want to personally thank the Native communities who
advocated for this day. Please utilize the attached Save-the-Date
postcard and Awareness Day Toolkit to alert others and encourage people
to raise their awareness and have knowledge of their status. Without
perseverance against this particular virus, risk could turn to reality.

It is with much appreciation and thanks for prior and continued efforts
against HIV/AIDS that this email is distributed.

Sincerely,

 

CDR Scott Giberson

National IHS HIV/AIDS Consultant

More information on this Day can be found at
<http://www.happ.colostate.edu/> or
<http://www.ihs.gov/MedicalPrograms/hivaids/>

**Favian Kennedy, Northern Plains Tobacco Prevention Project**

**Northern Plains Tobacco Policy Workshop March 8th and 9th, 2007**

Dear Colleges,

The Aberdeen Area Tribal Chairmen's Health Board would like to invite
you to participate in a Northern Plains Tobacco Policy Workshop, March
8th and 9th, 2007. The Workshop is being co-sponsored by AATCHB and the
National Native Tobacco Prevention Network and will cover a variety of
topics from policy planning to enforcement. Anyone interested in
learning more about policy change is encouraged to attend.

There are a limited number of travel scholarships so register and
request a scholarship today. Registration forms can be faxed to the
attention of Terry Salway or completed online at
[www.tobaccoprevention.net](http://www.tobaccoprevention.net/). Click on
"whats new."

Favian Kennedy, MSW

Northern Plains Tobacco Prevention Project

Rapid City, SD

\(605\) 721- 1922  ext 112

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

**Sunnah Kim, American Academy of Pediatrics**

**2007 Native American Child Health Advocacy Award**

The AAP Committee on Native American Child Health will be accepting
nominations for the 2007 Native American Child Health Advocacy Award.
The award will be presented at the 2007 AAP National Conference and
Exhibition in San Francisco, CA to recognize an individual who has made
a major contribution to promoting Native American child health. If you
know of a health professional who merits this recognition, please submit
a letter of nomination, along with the candidate\'s contact information
to:

 

Committee on Native American Child Health

American Academy of Pediatrics

141 Northwest Point Blvd

Elk Grove Village, IL 60007

Fax: 847/434-8729

<indianhealth@aap.org>

Oral Health AIAN Preceptorship Award RFP

Partnership to Reduce Oral Health Disparities in Early Childhood
\-\--2007 American Indian/Alaska Native Preceptorship Program
Award\-\-\--Request for Proposals American Academy of Pediatrics

The award of up to \$2,000 will be given to cover expenses (eg travel,
meals, incidentals, training materials, etc). The preceptor will work
with AAP staff to arrange for their travel accommodations and training
material. The money will not be distributed directly to the practice
receiving the award. 

Preference will be given to practices/sites that:

-Are an IHS/Tribal/Urban Indian program

-Demonstrate willingness to train other health care professionals in
oral health risk assessment, conduct mother/caretaker interviews, and
apply fluoride varnish when appropriate

-Bring together community child health professionals for training (e.
g., family practitioners, physician assistants, dental hygienist,
dentists, etc)

Completed application should be sent ELECTRONICALLY to
[**wnelson@aap.org**](mailto:wnelson@aap.org) by March 9, 2007 as well
as signed copy of the application postmarked no later than March 16,
2007 to:

Wendy Nelson, Manager Oral Health Initiative

American Academy of Pediatrics

Department of Practice

AI/AN Preceptorship Awards

141 Northwest Point Blvd

Elk Grove Village, IL  60007-1098

**Large data Catalog Available: Health / Well-Being of AI / AN, and
Other Native Americans**

ASPE has recently completed a report entitled: *Data on Health and
Well-Being of American Indians, Alaska Natives, and Other Native
Americans: Data Catalogue.*  This report includes a description of 67
data sources that include AI/AN/NAs. 
[http://aspe.hhs.gov/hsp/06/Catalog%2DAI%2DAN%2DNA/](http://aspe.hhs.gov/hsp/06/Catalog-AI-AN-NA/)

**Registration is now open for the 2nd International Meeting on
Indigenous Child Health! **

The 2nd International Meeting on Indigenous Child Health will be held on
April 20-22, 2007 in Montreal, Quebec, Canada. Building upon the
successes of the first International Meeting held in April 2005, the
proposed conference will focus on the unique health needs and culturally
effective health care delivery models of the indigenous child
populations in the US and Canada.

 

The goal of this dissemination conference is to bring together
community-based practitioners involved in the health care of indigenous
children (ie. American Indian, Alaska Native, First Nations, Inuit, and
Métis) to focus on solutions, rather than problems. Solutions will be
specifically geared toward reducing health disparities that currently
exist, and providing community-based practitioners with practical tools
and strategies that can be implemented within their own communities. The
conference will have a strong emphasis on the identification of model
programs and research that have been successful at the community level,
and disseminating these findings to other professionals.

 

Please see the attached conference brochure for additional details, or
visit

[www.aap.org/nach/2InternationalMeeting.htm](http://www.aap.org/nach/2InternationalMeeting.htm)

 

For on-line registration, visit

<http://www.pedialink.org/cme/_coursefinder/CMEdetail.cfm?aid=32391&area=liveCME>

 

Hope to see you in Montreal!

**Roberta Ward, Anchorage**

**Wonder what that rash is?**

Here is an article with great pictures

**Common Skin Conditions During Pregnancy**

Common skin conditions during pregnancy generally can be separated into
three categories: hormone-related, preexisting, and pregnancy-specific.
Normal hormone changes during pregnancy may cause benign skin conditions
including striae gravidarum (stretch marks); hyperpigmentation (e.g.,
melasma); and hair, nail, and vascular changes. Preexisting skin
conditions (e.g., atopic dermatitis, psoriasis, fungal infections,
cutaneous tumors) may change during pregnancy. Pregnancy-specific skin
conditions include pruritic urticarial papules and plaques of pregnancy,
prurigo of pregnancy, intrahepatic cholestasis of pregnancy, pemphigoid
gestationis, impetigo herpetiformis, and pruritic folliculitis of
pregnancy. Pruritic urticarial papules and plaques of pregnancy are the
most common of these disorders. Most skin conditions resolve postpartum
and only require symptomatic treatment. However, there are specific
treatments for some conditions (e.g., melasma, intrahepatic cholestasis
of pregnancy, impetigo herpetiformis, pruritic folliculitis of
pregnancy). Antepartum surveillance is recommended for patients with
intrahepatic cholestasis of pregnancy, impetigo herpetiformis, and
pemphigoid gestationis. Am Fam Physician 2007;75:211-8.
<http://www.aafp.org/afp/20070115/211.html>

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

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

**GDM Guidelines: Major discrepancies to identify GDM and predict
pregnancy outcome**

CONCLUSIONS: The guidelines of the various professional committees,
being based on consensus and expert opinion, show major discrepancies in
their ability to identify women with GDM and their capacity to predict
adverse pregnancy outcome. Only evidence-based criteria derived from
reliable and consistent scientific data will eliminate the confusion
caused in clinical practice.

Agarwal MM et al Gestational diabetes: dilemma caused by multiple
international diagnostic criteria. [Diabet Med.  2005;
22(12):1731-6](http://www.medscape.com/medline/publicationbrowser/123?pmid=16401320) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16401320>

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

**If the criteria has shown improved outcome, then change to it**

Two different classification schemes of GDM based upon results of the
three-hour GTT results have been proposed. The Fourth International
Workshop-Conference on Gestational Diabetes GTT values cited above are
based upon the Carpenter and Coustan modification of earlier value. They
are lower than those proposed by the Expert Committee on the Diagnosis
and Classification of Diabetes Mellitus and the National Diabetes Data
Group (NDDG), which used cutoff values of 105, 190, 165, and 145 mg/dL
(5.8, 10.6, 9.2, and 9.1 mmol/L), respectively. The values are lower
because the thresholds derived from the older Somogyi-Nelson method of
glucose analysis were corrected to account for the enzymatic assays
currently in use.

However, Schwartz et al have suggested that this classification scheme
diagnosed more women with GDM at very little benefit and potentially
high cost. In this retrospective review of 8857 pregnant women screened
for GDM, 284 (3 percent) met the NDDG criteria while 438 (5 percent) met
the Fourth International Workshop criteria. Thus, application of the
more stringent Fourth International Workshop criteria to all women with
positive screening test results would at best have reduced the
prevalence of infants weighing
![](media/image2.png){width="8.333333333333333e-2in"
height="9.236111111111112e-2in"}4000 grams from 17.1 to 16.9 percent,
and the prevalence of infants weighing
![](media/image2.png){width="8.333333333333333e-2in"
height="9.236111111111112e-2in"}4500 grams from 3.0 to 2.9 percent.
Others have come to similar conclusions. (Ricart et al)

ACOG considers use of either the Fourth International Workshop or the
National Diabetes Data Group criteria acceptable for diagnosis of GDM.
The ADA recommends use of the Fourth International Workshop-Conference
on Gestational Diabetes criteria.

At this point Naylor et al reported that simply carrying the diagnosis
of diabetes in pregnancy has been shown to increase the rate of cesarean
delivery with no difference in pre-op clinical characteristics or
post-op improvement in outcome. Other factors to consider are the
increased fetal monitoring and blood testing associated with a diagnosis
of diabetes in pregnancy, e. g., 4 fingersticks / day for 6 months = 672
fingersticks.

Until the HAPO Study is complete the argument above is largely one of
conjecture. In the short term due to the increased morbidity just
associated with the diagnosis of diabetes in pregnancy should be made as
accurately as possible based on clinical outcome. Some would argue that
simply identifying a patient for potential glucose intolerance after
pregnancy is a benefit from public health standpoint. At this writing
there is no evidence of improved outcomes with the large number of extra
patients diagnosed by Carpenter and Coustan criteria.

As we use ACOG as our benchmark in Indian Country, either criteria is
acceptable. In Indian Country we suggest each center decide on one set
of criteria within that facility. At this point there is not clinical
benefit to either the mother or infant to the large increase in patients
diagnosed with diabetes in pregnancy by Carpenter and Coustan criteria.
Hence one would need some other compelling rationale to change from
those criteria.

**Resources:**

CONCLUSIONS: Replacing the National Diabetes Data Group criteria with
the Carpenter and Coustan criteria would increase by 54% the number of
pregnant women with a diagnosis of gestational diabetes mellitus and
would also increase costs, while only minimally affecting prevalence of
infant macrosomia. The medical literature does not provide compelling
evidence for adopting the Carpenter and Coustan criteria.
Standardization of both measurement of venous plasma glucose level and
diagnostic criteria for gestational diabetes mellitus is an important
goal. Parallel criteria for diagnosis and classification of diabetes
mellitus in pregnant and nonpregnant women should be developed.

Schwartz ML; Ray WN; Lubarsky SL. The diagnosis and classification of
gestational diabetes mellitus: is it time to change our tune? Am J
Obstet Gynecol 1999 Jun;180(6 Pt 1):1560-71.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=10368504>

CONCLUSIONS/INTERPRETATION: Use of the ADA criteria to identify GDM
would result in a 31.8% increase in prevalence compared with NDDG
criteria. However, as the contribution of these additionally diagnosed
cases to adverse GDM outcomes is not substantial, a change in diagnostic
criteria is not warranted in our setting.

Ricart W et al Potential impact of American Diabetes Association (2000)
criteria for diagnosis of gestational diabetes mellitus in Spain.
Diabetologia 2005 Jun;48(6):1135-41.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15889233>

[HAPO Study Cooperative Research
Group](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="HAPO+Study+Cooperative+Research+Group"%5BCorporate+Author%5D)
Integration of local and central laboratory functions in a worldwide
multicentre study: Experience from the Hyperglycemia and Adverse
Pregnancy Outcome (HAPO) Study. [Clin
Trials.](javascript:AL_get(this, 'jour', 'Clin Trials.');)
2006;3(4):397-407

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17060214>

[Naylor CD, Sermer M, Chen E, Sykora
K](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8609683&dopt=Abstract).
Cesarean delivery in relation to birth weight and gestational glucose
tolerance: pathophysiology or practice style? Toronto Trihospital
Gestational Diabetes Investigators. JAMA 1996 Apr 17;275(15):1165-70

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8609683&dopt=Abstract>

**Other**

**Benefit of cesarean for macrosomic infants weighing 4,000-4,999 g
questioned**

CONCLUSIONS: Although cesarean delivery may reduce the risk of death for
the heaviest infants (5,000+ g), the relative benefit of this
intervention for macrosomic infants weighing 4,000-4,999 g remains
debatable. Thus, policies in support of prophylactic cesarean delivery
for suspected fetal macrosomia may need to be reevaluated.

[Boulet
SL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Boulet+SL"%5BAuthor%5D),
et al Mode of delivery and the survival of macrosomic infants in the
United States, 1995-1999.
[Birth.](javascript:AL_get(this, 'jour', 'Birth.');) 2006
Dec;33(4):278-83

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17150065>

**Amount of maternal smoking predicts the risk of spontaneous abortion**

CONCLUSIONS: The amount of daily smoking prior to pregnancy seems to be
associated with an increased risk of spontaneous abortion, whereas the
duration of smoking does not seem to be related to an increased risk of
spontaneous abortion.

[Nielsen
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Nielsen+A"%5BAuthor%5D),
et al Maternal smoking predicts the risk of spontaneous abortion [Acta
Obstet Gynecol
Scand.](javascript:AL_get(this, 'jour', 'Acta Obstet Gynecol Scand.');)
2006;85(9):1057-65

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16929410>

**First delivery by cesarean begins cascade of risks - obstetric and
perinatal outcomes**

CONCLUSION: Cesarean delivery is associated with increased risks for
adverse obstetric and perinatal outcomes in the subsequent birth.
However, some risks may be due to confounding factors related to the
indication for the first cesarean. LEVEL OF EVIDENCE: II

[Kennare
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Kennare+R"%5BAuthor%5D)
et al Risks of adverse outcomes in the next birth after a first cesarean
delivery. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Feb;109(2 Pt 1):270-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17267823&dopt=Abstract>

**Brief motivational intervention decreased the risk of alcohol-exposed
pregnancy: RCT**

This randomized trial found that a brief motivational intervention
considerably decreased the risk of AEP \[alcohol-exposed pregnancy\] in
high risk women by altering the targeted behaviors of risky drinking and
ineffective contraception use. The authors found that

\* Across all three phases of follow-up (3, 6, and 9 months), the
unadjusted odds of being at reduced risk for an AEP were approximately
twofold greater in the information plus counseling (IPC) group than in
the information only (IO) group.

\* After controlling for confounders, odds ratios increased slightly,
with women in the IPC group again being significantly more likely to be
at reduced risk for an AEP, compared with women in the IO group.

This study demonstrated that a brief behavioral motivational
intervention produced significant reductions in risk for AEP among women
who met high-risk criteria prior to the study.\"

Floyd RL, Sobell M, Velasquez MM, Ingersoll K, et al. 2007. Preventing
alcohol-exposed pregnancies: A randomized controlled trial. American
Journal of Preventive Medicine 32(1):1-10.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17218187>

**Obese women: Increased risk of elective preterm deliveries / infant
disability**

CONCLUSIONS: Obese nulliparous women are at increased risk of elective
preterm deliveries. This in turn leads to an increased risk of perinatal
mortality and is likely to lead to increased risks of long-term
disability among surviving offspring.

[Smith
GC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Smith+GC"%5BAuthor%5D),
et al Maternal obesity in early pregnancy and risk of spontaneous and
elective preterm deliveries: a retrospective cohort study. [Am J Public
Health.](javascript:AL_get(this, 'jour', 'Am J Public Health.');) 2007
Jan;97(1):157-62.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17138924>

**Continued smoking in the next pregnancy after an adverse pregnancy**

CONCLUSION: A previous adverse pregnancy outcome has only a modest
influence on smoking habits in the successive pregnancy.

[Cnattingius
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Cnattingius+S"%5BAuthor%5D),
et al Will an adverse pregnancy outcome influence the risk of continued
smoking in the next pregnancy? [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Dec;195(6):1680-6

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17014811>

**TOLAC: Induction outcome depends on previous vaginal delivery and
cervical status**

CONCLUSION: Induction of labor in the study population is associated
with an increased risk of cesarean delivery in all women with an
unfavorable cervix, a statistically significant, albeit clinically
small, increase in maternal morbidity in women with no prior vaginal
delivery, and no appreciable increase in perinatal morbidity. LEVEL OF
EVIDENCE: II

[Grobman
WA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Grobman+WA"%5BAuthor%5D),
et al Outcomes of induction of labor after one prior cesarean. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Feb;109(2 Pt 1):262-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17267822&dopt=Abstract>

**Risk of Anal Sphincter Tear During Childbirth Can Be Reduced**

RESULTS: We included data from 797 primaparous women: 407 with a
recognized anal sphincter tear and 390 without. Based on univariable
analysis, a woman with a sphincter tear was more likely to be older, to
be white, to have longer gestation or prolonged second stage of labor,
to have a larger infant (birth weight/head circumference), or an infant
who was in occiput posterior position, or to have an episiotomy or
operative delivery. Logistic regression found forceps delivery (OR 13.6,
95% confidence interval \[CI\] 7.9-23.2) and episiotomy (OR 5.3, 95% CI
3.8-7.6) were strongly associated with a sphincter tear. The combination
of forceps and episiotomy was markedly associated with sphincter tear
(OR 25.3, 95% CI 10.2-62.6). The addition of epidural anesthesia to
forceps and episiotomy increased the OR to 41.0 (95% CI 13.5-124.4).
CONCLUSION: Our results highlight the existence of modifiable obstetric
interventions that increase the risk of anal sphincter tear during
vaginal delivery. Our results may be used by clinicians and women to
help inform their decisions regarding obstetric interventions.

[Fitzgerald
MP](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Fitzgerald+MP"%5BAuthor%5D),
et al Risk factors for anal sphincter tear during vaginal delivery.
[Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');)
2007 Jan;109(1):29-34 LEVEL OF EVIDENCE: II.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197584>

**Acupuncture good alternative to pharmacological methods in the effort
to facilitate birth**

CONCLUSION: Acupuncture may be a good alternative or complement to
pharmacological methods in the effort to facilitate birth and provide
normal delivery for women with prelabor rupture of membranes.

Gaudernack LC; et al Acupuncture administered after spontaneous rupture
of membranes at term significantly reduces the length of birth and use
of oxytocin. A randomized controlled trial. [Acta Obstet Gynecol Scand.
 2006;
85(11):1348-53](http://www.medscape.com/medline/publicationbrowser/123?pmid=17091416) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17091416>

**Be ready to treat maternal hypotension during spinal anaesthesia for
caesarean delivery**

AUTHORS\' CONCLUSIONS: While interventions such as colloids, ephedrine,
phenylephrine or lower leg compression can reduce the incidence of
hypotension, none have been shown to eliminate the need to treat
maternal hypotension during spinal anaesthesia for caesarean delivery.
No conclusions can be drawn regarding rare adverse effects due to the
relatively small numbers of women studied.

[Cyna
AM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Cyna+AM"%5BAuthor%5D),
et al Techniques for preventing hypotension during spinal anaesthesia
for caesarean delivery. [Cochrane Database Syst
Rev.](javascript:AL_get(this, 'jour', 'Cochrane Database Syst Rev.');)
2006 Oct 18;(4):CD002251

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17054153>

**Folic Acid May Prevent Cleft Lip and Palate**

A new study finds that women who take folic acid supplements early in
their pregnancy can substantially reduce their baby\'s chances of being
born with a facial cleft.

\"These findings provide further evidence of the benefits of folic acid
for women,\" said Allen J. Wilcox, M.D., Ph.D., lead NIEHS author on the
new study published online in the \"British Medical Journal.\" \"We
already know that folic acid reduces the risk of neural tube defects,
including spina bifida. Our research suggests that folic acid also helps
prevent facial clefts, another common birth defect.\" In the United
States, about one in every 750 babies is born with cleft lip and/or
palate.

The researchers examined the association between facial clefts and
mothers\' intake of folic acid supplements, multivitamins, and folates
in diet. The researchers found that folic acid supplementation of 400
micrograms or more per day reduced the risk of isolated cleft lip with
or without cleft palate by one-third, but had no apparent effect on the
risk of cleft palate alone.

\"A mother\'s nutrition during pregnancy is clearly an environmental
factor that can affect the health of her fetus,\" said NIEHS Director
David A. Schwartz, M.D. The NIEHS researchers are continuing to analyze
their data for evidence of other environmental exposures that increase
the risk of facial clefts. The researchers estimated that 22 percent of
isolated CLP cases in Norway could be averted if all pregnant women took
0.4 mg of folic acid per day.

Wilcox AJ, Lie RT, Solvoll K, Taylor J, McConnaughey DR, Abyholm F,
Vindenes H, Vollset SE, Drevon CA. \"Folic Acid Supplements and the risk
of facial clefts: A National population-based control study.\" \"British
Medical Journal\", 2007
[[http://www.nih.gov/news/pr/jan2007/niehs-26.htm]{.underline}](http://www.nih.gov/news/pr/jan2007/niehs-26.htm)

**Reducing caffeine intake has no effect on birth weight or length of
pregnancy**

CONCLUSION: A moderate reduction in caffeine intake in the second half
of pregnancy has no effect on birth weight or length of gestation.

[Bech
BH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Bech+BH"%5BAuthor%5D),
et al Effect of reducing caffeine intake on birth weight and length of
gestation: randomised controlled trial.
[BMJ.](javascript:AL_get(this, 'jour', 'BMJ.');) 2007 Jan 26\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17259189&dopt=Abstract>

**Clinical Presentations of Parvovirus B19 Infection (See Patient
Education)**

Although most persons with parvovirus B19 infection are asymptomatic or
have mild, nonspecific, cold-like symptoms, several clinical conditions
have been linked to the virus. Parvovirus B19 usually infects children
and causes the classic \"slapped-cheek\" rash of erythema infectiosum
(fifth disease). The virus is highly infectious and spreads mainly
through respiratory droplets. By the time the rash appears, the virus is
no longer infectious. The virus also may cause acute or persistent
arthropathy and papular, purpuric eruptions on the hands and feet
(\"gloves and socks\" syndrome) in adults. Parvovirus B19 infection can
trigger an acute cessation of red blood cell production, causing
transient aplastic crisis, chronic red cell aplasia, hydrops fetalis, or
congenital anemia. This is even more likely in patients with illnesses
that have already shortened the lifespan of erythrocytes (e.g., iron
deficiency anemia, human immunodeficiency virus, sickle cell disease,
thalassemia, spherocytosis). A clinical diagnosis can be made without
laboratory confirmation if erythema infectiosum is present. If
laboratory confirmation is needed, serum immunoglobulin M testing is
recommended for immunocompetent patients; viral DNA testing is
recommended for patients in aplastic crisis and for those who are
immunocompromised. Treatment is usually supportive, although some
patients may require transfusions or intravenous immune globulin
therapy. Most patients recover completely. Am Fam Physician
2007;75:373-6, 377 <http://www.aafp.org/afp/20070201/373.html>

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

**Cystocoele Repair: The Mesh Controversy by John Heusinkveld,
Shiprock**

After more than a century of improvements in pelvic surgery techniques,
the cystocoele continues to be one of the most vexing problems for
gynecologic surgeons. Recurrence rates for cystocoeles repaired with the
traditional fascial plication technique are reported as high as 40%,
with approximately half of the patients undergoing additional surgical
procedures. Several explanations have been proposed for the high
objective failure rate of the fascial plication as a treatment for
anterior compartment prolapse. The first is that connective issue that
has stretched or torn once is likely to do so again under the same
stresses. Proponents of this explanation point to relatively high
recurrence rates for other types of hernia when repaired using
traditional techniques.

Proponents of an alternative explanation for the high rate of cystocoele
recurrence believe that the primary defect responsible for cystocoeles
is not a central defect in the fascia supporting the bladder, but a
lateral detachment of this \"pubocervical fascia\" from the pelvic
sidewall. Members of this school of thought believe that plicating the
fascia centrally may ultimately do more harm than good, by drawing the
lateral edges of the fascia further away from their attachments and
thereby predisposing the patient to a larger cystocoele in the future.

In the early 1980s, the repair of inguinal and ventral hernias was
revolutionized by the introduction of artificial graft materials, which
drastically lowered the recurrence rate. To many gynecologic surgeons it
seemed logical that the same materials and techniques might be applied
to pelvic support surgery; however, early attempts to reinforce
cystocoele repairs with materials such as Goretex met with very limited
success and very high complication rates, mostly from infection and
extrusion of graft material into the vagina. At the same time,
improvements in abdominal techniques such as sacrocolpopexy provided
good alternatives for patients with recurrent prolapse.

Interest in vaginal mesh techniques was rekindled by the introduction of
the mid-urethral sling by Ulmsten and colleagues in the mid-1990s. Using
a sling made from monofilament, macroporous prolene mesh, these surgeons
were able to achieve excellent results in the treatment of urodynamic
stress incontinence associated with urethral hypermobility. Unlike
previous artificial materials used in the vagina, the prolene mesh was
well tolerated, and problems with infection and extrusion were rare.
Inspired by this success, other gynecologists began to attempt to use
the same material to reinforce cystocoele repairs. Almost immediately it
become apparent that the larger meshes required for cystocoele repair
were associated with significant rates of mesh exposure; in contrast to
earlier materials, however, the prolene meshes rarely needed to be
removed, as the erosions were generally small and relatively easily
treated with topical estrogen or minor surgical revisions. What was
lacking, however, was consistent evidence of a benefit in the form of a
reduction in the rate of cystocoele recurrence. A 2004 review by the
Cochrane group found no basis to recommend the use of artificial meshes
in the treatment of primary cystocoeles.

To many gynecologists, the lack of a consistent benefit from the use of
mesh was confirmation of the theory that the principal problem leading
to a cystocoele was lateral detachment rather than a central defect.
Impressed by the efficacy and safety of the transobturator route for
mid-urthral sling placement, a consortium of French surgeons attempted
to develop a similar procedure for cystocoele repair. The resulting
technique, often referred to as TVM or Transvaginal Mesh, utilizes a
double transobturator tension-free method of mesh fixation, with two
straps of mesh on each side passing through the obturator membrane to
recreate the lateral attachments of the pubocervical fascia; a larger,
central portion of the mesh supports the bladder. Another mesh is
sometimes placed posteriorly to support the vaginal vault, with
supporting straps passing through the sacrospinous ligaments. The
procedure can be performed with or without concurrent hysterectomy, and
many surgeons report a lower incidence of erosions if the uterus is left
in place.

Several kits based on the TVM technique are currently available in the
United States, and early data indicates a low recurrence risk for
cystocoeles repaired using these kits. The problem of mesh exposure,
however, continues to be significant with most centers reporting erosion
rates between 5 and 10%. A less common, but potentially more serious
problem which sometimes leads to mesh removal is dyspareunia,
occasionally accompanied by what Dr. Linda Brubaker of Loyola University
succinctly terms \"*his-*pareunia.\"

The need to find a balance between efficacy and potential complications
has led to a vigorous debate among pelvic sugeons, who seem to be
gathering into distinct pro-mesh and anti-mesh factions. This debate was
the lead topic of discussion at the 2006 meetings of both the American
Urogynecologic Society and the International Continence Society, with no
consensus emerging as of yet. In the abscence of such a concensus,
however, there are several situations in which the use of mesh seems
reasonable to consider:

[Recurrent cystocoele or vault prolapse]{.underline}*:* Most
urogynecologists feel that the gold standard for this condition is
abdominal sacrocolpopexy; however, this is a large abdominal operation
with significant morbidity, and many of the patients suffering from the
condition are older women who may welcome a less invasive option.

*Patients considering an obliterative procedure:* since these women are,
by definition, not expecting to be sexually active in the future, the
problem of possible dyspareunia is less of a consideration; the
transvaginal mesh technique avoids the psychological problems of vaginal
obliteration and also avoids potential complications associated with
displacement of the rectum and bladder. In addition, most TVM patients
will be able to resume sexual relations should their circumstances
change unexpectedly.

[Patients desiring uterine conservation]{.underline}: the problem of
mesh exposure seems to be closely tied to the size and orientation of
the vaginal incisions used to place the mesh. Multiple investigators
have reported that erosions are very rare when the uterus is left in
place and a small mucosal incision is used to place the mesh. Total
procidentia may be corrected via the placement of both anterior and
posterior meshes. Some mesh advocates believe that removal of a normal
uterus in order to facilitate the correction of pelvic support defects
may one day be viewed as archaic.

Other indications for the use of artificial mesh are the subject of
controversy and ongoing clinical trials. It should be noted that at
least one company has introduced a biological mesh (non-crosslinked
porcine dermis) which can be secured by the same tension-free methods
developed by the French group in an attempt to reduce the indicidence of
erosions and dyspareunia. This material may provide a more attractive
option for younger patients who wish to minimize the possibility of
dyspareunia. Several trials are also currently in progress to compare
the efficacy and total morbidity of the TVM technique with abdominal
sacrocolpopexy.

Stay tuned.

Here is a link to a Medscape CME that includes an extensive bibliography
on this topic

[[http://www.medscape.com/viewprogram/5513]{.underline}](http://www.medscape.com/viewprogram/5513)

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

**The Rest of the Story: Find out at the Albuquerque Meeting**

I would like to thank John Heusinkveld for this valuable contribution.
John will be giving an in depth presentation on this and related topics
at the National Indian Women's Health and MCH Conference August 15-17,
2007 in Albuquerque, NM. Please plan on attending

<http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07>

John welcomes correspondence with other IHS providers who are interested
in this subject.

<John.Heusinkveld@ihs.gov>

**Strong evidence for the efficacy of physical therapy for the treatment
for SUI in women**

Results: Twenty four studies, including 17 RCTs and seven non--RCTs, met
the inclusion criteria. The methodological quality of the studies varied
but lower quality scores did not necessarily indicate studies from lower
levels of evidence. This review found consistent evidence from a number
of high quality RCTs that PFMT alone and in combination with adjunctive
therapies is effective treatment for women with SUI with rates of
\'cure\' and \'cure/improvement\' up to 73% and 97% respectively. The
contribution of adjunctive therapies is unclear and there is limited
evidence about treatment outcomes in primary care settings.

CONCLUSION: There is strong evidence for the efficacy of physical
therapy for the treatment for SUI in women but further high quality
studies are needed to evaluate the optimal treatment programs and
training protocols in subgroups of women and their effectiveness in
clinical practice.

[Neumann
PB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Neumann+PB"%5BAuthor%5D),
et al Pelvic floor muscle training and adjunctive therapies for the
treatment of stress urinary incontinence in women: a systematic review.
[BMC Womens
Health.](javascript:AL_get(this, 'jour', 'BMC Womens Health.');) 2006
Jun 28;6:11.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16805910>

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

**Strongly consider a women's health physical therapist at your
facility**

Neumann et al confirm the previous data that greater than 70 % of
patients improve with pelvic physical therapy. Without proper training,
Kegel exercises are most frequently done incorrectly. I suggest that one
of your physical therapist get the extra training available in this
growing field.

In addition, many insurance companies now require formal physical
therapy before considering a patient to be a candidate for surgical
reimbursement. There are numerous special courses available for your
staff to choose from. For further questions <nmurphy@scf.cc>

**Here are two successful pelvic physical therapy stories from Indian
Country**

<http://www.ihs.gov/MedicalPrograms/MCH/W/MatPT.cfm>

**Risk of preterm delivery increases after all treatment modalities for
CIN**

CONCLUSION: Any treatment for CIN, including loop electrosurgical
excision procedure, increases the risk of preterm delivery. It is
important to emphasize this when treating young women with CIN. LEVEL OF
EVIDENCE: II.

[Jakobsson
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Jakobsson+M"%5BAuthor%5D),
et al Preterm delivery after surgical treatment for cervical
intraepithelial neoplasia. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Feb;109(2 Pt 1):309-13.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17267829&dopt=Abstract>

**Report tracks state progress in cervical cancer prevention
strategies**

Partnering for Progress 2007: The \"State\" of Cervical Cancer
Prevention in America shows how states are working with community
stakeholders in their efforts to eliminate cervical cancer and tracks
each state\'s performance in making cervical-cancer prevention a top
priority. The report is the third in a series of annual reports
published by Women in Government for the Challenge to Eliminate Cervical
Cancer Campaign. The campaign is designed to educate state legislators
about cervical cancer and the human papilloma virus and to advocate for
education and access to the most advanced and appropriate screening and
preventive technologies available. The campaign\'s 2007 report tracks
state-level cervical cancer incidence and mortality data, insurance
coverage, screening rates and coverage of advanced screening
technologies, and policy initiatives. Contents include an introduction,
findings, recommended actions, case studies, and
cervical-cancer-prevention facts.

[[http://www.womeningovernment.org/prevention/statereport/PDF/ExecutiveSummary.pdf]{.underline}](http://www.womeningovernment.org/prevention/statereport/PDF/ExecutiveSummary.pdf)

**The TVT and the TVT-O procedures perform equally**

CONCLUSION: The TVT and the TVT-O procedures perform equally in terms of
objective and subjective cure. The statistically significant higher
complication rate in the TVT-O group is not regarded as clinically
significant. LEVEL OF EVIDENCE: I.

Laurikainen E et al Retropubic compared with transobturator tape
placement in treatment of urinary incontinence: a randomized controlled
trial. [Obstet Gynecol.  2007;
109(1):4-11](http://www.medscape.com/medline/publicationbrowser/123?pmid=17197581)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197581>

**Laparoscopic occlusion of vessels and embolizaton of uterine leiomyoma
similar**

CONCLUSION: Both laparoscopic occlusion of uterine vessels and
embolizaton of uterine leiomyoma improved clinical symptoms in the
majority of patients. Participants with the laparoscopic procedure had
less postoperative pain but heavier menstrual bleeding 6 months after
treatment. A larger study and longer follow-up is necessary before a
definite conclusion can be made regarding the most effective treatment.
LEVEL OF EVIDENCE: I

Hald K; Laparoscopic occlusion compared with embolization of uterine
vessels: a randomized controlled trial. [Obstet Gynecol.  2007;
109(1):20-7](http://www.medscape.com/medline/publicationbrowser/123?pmid=17197583) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197583>

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

**Review and Comment: Newborn record form IHS-298 and its revision**

Diana Hu and pediatricians in the Navajo Area have developed a revised
newborn exam form.

We have included the old version (3/04) and the new version (8/06)
Please contact Diana directly\* The form revision process per the forms
chapter guidance is briefly as follows:

-   Clinical field review (2 to 4 weeks for sizeable response)

-   Trial use of the new form to work the 'bugs' out is also acceptable

-   Change title to IHS Newborn Form or

-   Route through originating area, etc....

Thanks to Diana for bringing this forward

\*Diana Hu, MD

Acting MCH Consultant: NAIHS, Pediatrics

Tuba City Regional Health Care Corporation

928-283-2406 [**diana.hu@tcimc.ihs.gov**](mailto:diana.hu@tcimc.ihs.gov)

**Importance of media in adolescent girls\' physical and emotional
health and weight loss**

The results indicate that frequency of \[reading magazine articles about
dieting or weight loss\] does, in fact, predict later weight-control
behavior in female adolescents.

The authors found that:

\* For female adolescents, the odds of engaging in healthy, unhealthy,
and extremely unhealthy weight-control behaviors at time 2 increased
with increasing frequency of time 1 magazine reading, after adjustment
for age, race/ethnicity, cohort (younger or older), time 1 BMI, time 1
weight importance, and time 1 levels of dependent variables.

\* Adolescent females who reported magazine reading had between 1.6 and
2.4 times the odds of engaging in unhealthy weight-control behaviors,
compared with nonreaders of magazine articles about dieting or weight
loss, in adjusted analyses.

\* For extremely unhealthy weight-control behaviors, frequency of
magazine reading among female adolescents had a strong positive
association with the odds of engaging in unhealthy behaviors at time 2.

\* A marginally significant, ordered association was found between binge
eating and magazine reading for female adolescents.

\* For male adolescents, the analysis revealed no consistent patterns
and no significant associations between magazine reading and any
weight-control behaviors or binge eating.

\* For both male and female adolescents, the relationship between
magazine reading at time 1 and measures of depression, self-esteem, and
body satisfaction at time 2 were nonsignificant.

The results of the current study highlight the importance of media in
influencing adolescent girls\'

physical and emotional health and suggest a need for interventions to
moderate this effect.

van den Berg P, Neumark-Sztainer D, Hannan PJ, et al. 2007. Is dieting
advice from magazines helpful or harmful? Five-year associations with
weight-control behaviors and psychological outcomes in adolescents.
Pediatrics Electronic Pages (119)1:e30-e37**.**
[[http://pediatrics.aappublications.org/cgi/content/abstract/119/1/e30]{.underline}](http://pediatrics.aappublications.org/cgi/content/abstract/119/1/e30)

Does Swaddling Reduce Excessive Crying in Infants?

CONCLUSION: For older babies, swaddling did not bring any benefit when
added to regularity and stimuli reduction in baby care, although
swaddling was a beneficial supplementation in excessively crying infants
\<8 weeks of age

[van Sleuwen
BE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="van+Sleuwen+BE"%5BAuthor%5D),
et al Comparison of behavior modification with and without swaddling as
interventions for excessive crying. [J
Pediatr.](javascript:AL_get(this, 'jour', 'J Pediatr.');) 2006
Oct;149(4):512-7

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17011324>

Autonomic function or dysfunction and its role in Sudden Infant Death
Syndrome

This from the SIDSIMPACT listserv - pediatric brainstem disorders
discussion of data from ongoing basic science neurochemical and tissue
studies of the brain stem is helping to clarify and define mechanisms
affecting autonomic function or dysfunction and its roll in Sudden
Infant Death Syndrome.

The serotonergic (5-HT) neurons of the medulla oblongata are postulated
to comprise a system that modulates homeostatic function in response to
metabolic imbalances in the internal milieu in a state-dependent manner.
The medullary 5-HTsystem began to form in the embryo, with the raphe
primordia appearing as early as 7 weeks (the earliest time-point
available). By 10-12 weeks, the lateral tegmental 5-HT neurons clustered
into the early primordia of extra-raphe subnuclei. By 20 weeks, the
\"adult-like\" topography of the medullary 5-HT system was in place,
with subtle (quantitative) changes occurring thereafter. Thus,
protracted changes occur from the prenatal period through infancy. These
data provide a foundation for 5-HTneuronal analysis in pediatric
brainstem disorders, as proposed in the sudden infant death syndrome

Kinney HC, Belliveau RA, Trachtenberg FL, Rava LA, Paterson DS. The
development of the medullary serotonergic system in early human life.
Auton Neurosci. 2007 Jan 19  

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17236817>

Full-text available at:
[**http://www.sciencedirect.com**](http://www.sciencedirect.com/)

**Premature Infants Are Susceptible to SSRI, Venlafaxine Exposure In
Utero** 

CONCLUSIONS: Neonatal behavioral signs were frequently found in exposed
newborns, but symptoms were transient and self-limited. Premature
infants could be more susceptible to the effects of selective serotonin
reuptake inhibitors and venlafaxine.

[Ferreira
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Ferreira+E"%5BAuthor%5D),
et al Effects of selective serotonin reuptake inhibitors and venlafaxine
during pregnancy in term and preterm neonates.
[Pediatrics.](javascript:AL_get(this, 'jour', 'Pediatrics.');) 2007
Jan;119(1):52-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17200271>

**Pediatric hospitalists are more likely than community pediatricians to
use evidence-based care for hospitalized children**

<http://www.ahrq.gov/research/jan07/0107RA11.htm>

Elevated lead levels: Lack of evidence for screening

CONCLUSIONS: There is no persuasive evidence that screening for elevated
lead levels in asymptomatic children will improve clinical outcomes. For
those children who are screened and found to have elevated levels, there
is conflicting evidence demonstrating the clinical effectiveness of
early detection and intervention.

Rischitelli G; et al Screening for elevated lead levels in childhood and
pregnancy: an updated summary of evidence for the US Preventive Services
Task Force. [Pediatrics.  2006;
118(6):e1867-95](http://www.medscape.com/medline/publicationbrowser/123?pmid=17142507) 

[**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17142507**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17142507)

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

Does Delay in Diagnosis of Breast Cancer Impact Prognosis?

[Background]{.underline}: Any delay in the diagnosis of breast cancer
may be distressing to patients, family members, and physicians. The
actual implications of a delayed diagnosis are not well understood.
Hardin and colleagues examined the records of women who experienced
delayed diagnoses and focused on physician-attributable delays,
excluding delays caused by patient or health care factors.

[The Study:]{.underline} They identified 40 patients diagnosed with
invasive breast cancer between 1995 and 2005 after
physician-attributable delays of three months or more. Data collected on
each patient included tumor diameter, pathologic stage, number of
positive axillary nodes, and death from breast cancer. Tumors are
believed to grow exponentially, so the natural log of tumor diameter was
calculated in each case and correlated with the delay in diagnosis.

[Results:]{.underline} The mean delay was 14.2 months with a range of
three to 36 months. The most common reason for delay in diagnosis was
failure to biopsy a palpable mass when mammography and or
ultrasonography results were negative. Pathology data were available for
39 of the women, and axillary node information was available for 38.

No significant correlations were demonstrated between the delay of
diagnosis, the natural log of tumor diameter, or the number of positive
axillary nodes. Diagnostic delay also did not correlate with tumor grade
or metastatic stage. Six patients died of breast cancer, and death was
associated with stage III or stage IV of the disease but not with the
length of diagnostic delay.

[Conclusion]{.underline}: Despite common fears that a diagnostic delay
enables the progression of the disease and signifies lost opportunities
for a better outcome, the authors conclude that delays in diagnosis of
36 months or less do not appear to worsen the prognosis of breast cancer
or patient survival.

[Hardin
C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Hardin+C"%5BAuthor%5D)
et al The relationships among clinician delay of diagnosis of breast
cancer and tumor size, nodal status, and stage. [Am J
Surg.](javascript:AL_get(this, 'jour', 'Am J Surg.');) 2006
Oct;192(4):506-8

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16978961>

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

**This is still the number one source of malpractice suits: Failure to
diagnose**

The authors do stress that delays are undesirable and negatively impact
patient and provider confidence. They also reference \"the triad of
error\" components of a young woman, a self-detected breast mass, and a
normal mammogram, which they describe as the patient most likely to be
associated with delay in diagnosis

**Mammographic density and the risk and detection of breast cancer**

CONCLUSIONS: Extensive mammographic density is strongly associated with
the risk of breast cancer detected by screening or between screening
tests. A substantial fraction of breast cancers can be attributed to
this risk factor.

Boyd NF et al Mammographic density and the risk and detection of breast
cancer.[N Engl J Med.  2007;
356(3):227-36](http://www.medscape.com/medline/publicationbrowser/123?pmid=17229950) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17229950>

**Estradiol showed benefit during menstrual migraine, but offset by
estrogen withdrawal**

CONCLUSION: Although perimenstrual percutaneous estradiol showed benefit
during treatment, this was offset by deferred estrogen withdrawal,
triggering post-dosing migraine immediately after the gel was stopped.
Further work could assess if this could be avoided by extending the
duration of treatment with estradiol.

MacGregor EA et al Prevention of menstrual attacks of migraine: a
double-blind placebo-controlled crossover study.[Neurology.  2006;
67(12):2159-63](http://www.medscape.com/medline/publicationbrowser/123?pmid=17190936) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17190936>

**Mental disorders among primiparous mothers increased several months
after childbirth**

CONCLUSION: In Denmark, the risk of postpartum mental disorders among
primiparous mothers is increased for several months after childbirth,
but among fathers there is no excess of severe mental disorders
necessitating admission or outpatient contacts.

Munk-Olsen T et al New parents and mental disorders: a population-based
register study.

[JAMA.  2006;
296(21):2582-9](http://www.medscape.com/medline/publicationbrowser/123?pmid=17148723) (ISSN:
1538-3598)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17148723>

**Melanoma unabated: One-time melanoma screen at age 50 deemed cost
effective**

Melanoma is the only cancer for which \[incidence and mortality\] are
rising unabated, while screening, the potential means for reducing the
burden of disease, continues to be underused.

CONCLUSIONS: One-time melanoma screening of the general population older
than 50 years is very cost-effective compared with other cancer
screening programs in the United States. Screening every 2 years in
siblings of patients with melanoma is also cost-effective.

[Losina
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Losina+E"%5BAuthor%5D),
et al Visual screening for malignant melanoma: a cost-effectiveness
analysis. [Arch
Dermatol.](javascript:AL_get(this, 'jour', 'Arch Dermatol.');) 2007
Jan;143(1):21-8

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17224538>

**Appropriate Prescribing of Medications: An Eight-Step Approach**

A systematic approach advocated by the World Health Organization can
help minimize poor-quality and erroneous prescribing. This six-step
approach to prescribing suggests that the physician should (1) evaluate
and clearly define the patient\'s problem; (2) specify the therapeutic
objective; (3) select the appropriate drug therapy; (4) initiate therapy
with appropriate details and consider nonpharmacologic therapies; (5)
give information, instructions, and warnings; and (6) evaluate therapy
regularly (e.g., monitor treatment results, consider discontinuation of
the drug). The authors add two additional steps: (7) consider drug cost
when prescribing; and (8) use computers and other tools to reduce
prescribing errors. These eight steps, along with ongoing self-directed
learning, compose a systematic approach to prescribing that is efficient
and practical for the family physician. Using prescribing software and
having access to electronic drug references on a desktop or handheld
computer can also improve the legibility and accuracy of prescriptions
and help physicians avoid errors. Am Fam Physician 2007;75:231-6, 239-40

<http://www.aafp.org/afp/20070115/231.html>

CDC Releases Data on Visual Impairment in Patients with Diabetes

Patients with diabetes are more likely to be visually impaired than
those who do not have the disease. However, few studies have examined
whether visual impairments in patients with diabetes can be corrected
with glasses or contact lenses. To estimate the proportion of patients
with diabetes who could benefit from such treatments, the Centers for
Disease Control and Prevention (CDC) published data from the National
Health and Nutrition Examination Study in the November 3, 2006, issue of
*Morbidity and Mortality Weekly Report.*

Patients with diabetes who had a severe infection in one or both eyes,
who were unable to see in either eye, or who were completely blind were
excluded from the analysis. Overall, the results suggested that 11
percent of American adults 20 years and older with self-reported
diabetes had visual impairments, 65.5 percent of which were correctable.
Additionally, 9.7 percent of U.S. adults with diabetes had mild visual
impairment, and 1.4 percent of those had a severe visual impairment
before correction; after correction, 2.9 percent had mild impairment,
and 1 percent of those had severe impairment.

As a result, optimal correction could have restored vision in 73.4
percent of adults with diabetes with mild visual impairments and 9.1
percent of adults with severe impairment. Therefore, health care
professionals who care for patients with diabetes should be aware that
poor vision often can be corrected, and that doing so can reduce the
patient\'s risk for injury and improve the quality of life.

Correctable Visual Impairment Among Persons with Diabetes \-\-- United
States, 1999---2004

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5543a2.htm>

National Diabetes Awareness Month \-\-- November 2006

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5543a1.htm>

**AGA Reviews the Use of Corticosteroids, Immunomodulators, and
Infliximab in IBD**

Summary

Although the use of corticosteroids, immunomodulators, and infliximab
for treating IBD is supported by well-designed clinical trials, many of
the data are insufficient, and additional research is needed. Physicians
who use these medications should clearly understand their benefits and
risks so they can provide the best possible care.

<http://www.gastrojournal.org/article/PIIS0016508506000734/fulltext>

**Depressive symptoms, not hostility or anxiety, linked to coronary
artery disease**

CONCLUSION: Our findings suggest that the somatic-vegetative features of
depression, but perhaps not anxiety and hostility/anger, may play an
important role in the earlier stages of the development of coronary
artery disease.

[Stewart
JC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Stewart+JC"%5BAuthor%5D),
et al Negative emotions and 3-year progression of subclinical
atherosclerosis. [Arch Gen
Psychiatry.](javascript:AL_get(this, 'jour', 'Arch Gen Psychiatry.');)
2007 Feb;64(2):225-33

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17283290>

**Update on Helicobacter pylori Treatment**

One half of the world\'s population has Helicobacter pylori infection,
with an estimated prevalence of 30 percent in North America. Although it
is unclear whether eradication of H. pylori improves symptoms in
patients with nonulcer dyspepsia, there is strong evidence that
eradication of this bacteria improves healing and reduces the risk of
recurrence or rebleeding in patients with duodenal or gastric ulcer. A
\"test-and-treat\" strategy is recommended for most patients with
undifferentiated dyspepsia. With this approach, patients undergo a
noninvasive test for H. pylori infection and, if positive, are treated
with eradication therapy. This strategy reduces the need for
antisecretory medications as well as the number of endoscopies. The urea
breath test or stool antigen test is recommended. Until recently, the
recommended duration of therapy for H. pylori eradication was 10 to 14
days. Shorter courses of treatment (i.e., one to five days) have
demonstrated eradication rates of 89 to 95 percent with the potential
for greater patient compliance. A one-day treatment course consists of
bismuth subsalicylate, amoxicillin, and metronidazole, all given four
times with a one-time dose of lansoprazole. In children with documented
H. pylori infection, however, all regimens should continue to be
prescribed for seven to 14 days until short-course treatment is studied
and its effectiveness has been established in this population. Am Fam
Physician 2007;75:351-8.

<http://www.aafp.org/afp/20070201/351.html>

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

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

**ACOG Opposes Sex Selection for Family Planning Purposes**

ABSTRACT: In this Committee Opinion, the American College of
Obstetricians and Gynecologists' Committee on Ethics presents various
ethical considerations and arguments relevant to both prefertilization
and postfertilization techniques for sex selection. The principal
medical indication for sex selection is known or suspected risk of
sex-linked genetic disorders. Other reasons sex selection is requested
are personal, social, or cultural in nature. The Committee on Ethics
supports the practice of offering patients procedures for the purpose of
preventing serious sex-linked genetic diseases. However, the committee
opposes meeting requests for sex selection for personal and family
reasons, including family balancing, because of the concern that such
requests may ultimately support sexist practices. Because a patient is
entitled to obtain personal medical information, including information
about the sex of her fetus, it will sometimes be impossible for health
care professionals to avoid unwitting participation in sex selection.

Sex Selection. ACOG Committee Opinion No. 360. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2007;109:245--8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17267863>

**Pelvic Organ Prolapse. ACOG Practice Bulletin**

Summary of Recommendations and Conclusions

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

-   The only symptom specific to prolapse is the awareness of a vaginal
    bulge or protrusion. For all other pelvic symptoms, resolution with
    prolapse treatment cannot be assumed.

-   Pessaries can be fitted in most women with prolapse, regardless of
    prolapse stage or site of predominant prolapse.

-   Cadaveric fascia should not be used as graft material for abdominal
    sacral colpopexy because of a substantially higher risk of recurrent
    prolapse than with synthetic mesh.

-   Stress-continent women with positive stress test results (prolapse
    reduced) are at higher risk for developing postoperative stress
    incontinence after prolapse repair alone compared with women with
    negative stress test results (prolapse reduced).

-   For stress-continent women planning abdominal sacral colpopexy,
    regardless of the results of preoperative stress testing, the
    addition of the Burch procedure substantially reduces the likelihood
    of postoperative stress incontinence without increasing urgency
    symptoms or obstructed voiding.

-   For women with positive prolapse reduction stress test results who
    are planning vaginal prolapse repair, TVT midurethral sling (rather
    than suburethral fascial plication) appears to offer better
    prevention from postoperative stress incontinence.

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

-   Clinicians should discuss the option of pessary use with all women
    who have prolapse that warrants treatment based on symptoms. In
    particular, pessary use should be considered before surgical
    intervention in women with symptomatic prolapse.

-   Alternative operations for uterine preservation in women with
    prolapse include uterosacral or sacrospinous ligament fixation by
    the vaginal approach, or sacral hysteropexy by the abdominal
    approach.

-   Hysteropexy should not be performed by using the ventral abdominal
    wall for support because of the high risk for recurrent prolapse,
    particularly enterocele.

-   Round ligament suspension is not effective in treating uterine or
    vaginal prolapse.

-   Compared with vaginal sacrospinous ligament fixation, abdominal
    sacral colpopexy has less apical failure and less postoperative
    dyspareunia and stress incontinence, but is also associated with
    more complications.

-   Transvaginal posterior colporrhaphy is recommended over transanal
    repair for posterior vaginal prolapse.

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

-   Clinicians should discuss with women the potential risks and
    benefits in performing a prophylactic antiincontinence procedure at
    the time of prolapse repair.

-   Women with prolapse who are asymptomatic or mildly symptomatic can
    be observed at regular intervals, unless new bothersome symptoms
    develop.

-   For women who are at high risk for complications with reconstructive
    procedures and who no longer desire vaginal intercourse,
    colpocleisis can be offered.

-   Cystoscopy should be performed intraoperatively to assess for
    bladder or ureteral damage after all prolapse or incontinence
    procedures during which the bladder or ureters may be at risk of
    injury.

Pelvic Organ Prolapse. ACOG Practice Bulletin No. 79. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2007;109:461--73.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17267862>

**Breastfeeding: Maternal and Infant Aspects. ACOG Committee Opinion**

ABSTRACT: Evidence continues to mount regarding the value of
breastfeeding for both women and their infants. The American College of
Obstetricians and Gynecologists strongly supports breastfeeding and
calls on its Fellows, other health care professionals caring for women
and their infants, hospitals, and employers to support women in choosing
to breastfeed their infants. Obstetrician--gynecologists and other
health care professionals caring for pregnant women should provide
accurate information about breastfeeding to expectant mothers and be
prepared to support them should any problems arise while breastfeeding.

Breastfeeding: Maternal and Infant Aspects. ACOG Committee Opinion No.
361. American College of Obstetricians and Gynecologists. Obstet Gynecol
2007;109:279--80.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17267864>

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

The Role of Exercise in Patients with Type 2 Diabetes: Cochrane for
Clinicians

Clinical Scenario

A 65-year-old woman with new-onset type 2 diabetes and an A1C level of 8
percent wants to know if she can control her diabetes without taking
medications or insulin.

Clinical Question

What should physicians tell patients with type 2 diabetes about the role
of exercise?

Evidence-Based Answer

Regular exercise reduces A1C levels, adiposity, and triglyceride levels.
However, no research has definitively proved a benefit of exercise on
patient-oriented outcomes such as diabetes-related morbidity and
mortality. <http://lyris.aafp.org/t/1050775/16249464/518993/0/>

Tips from other Journals

Acute Uterine Bleeding: Progestin vs. Combination Therapy

**Results:** The 20 women in each group did not differ significantly in
any important variable, although the mean duration of bleeding before
randomization was 15.5 days in the progestin group compared with eight
days in the combination group. The average age of participants was about
43 years, the mean body mass index was about 30 kg per m2, and the mean
hemoglobin concentration was 12.4 to 12.8 g per dL (124 to 128 g per L).
At four weeks, complete data were available for 17 women (85 percent) in
the progestin group and for 16 women (80 percent) in the combination
group. In both groups, the median time to cessation of bleeding was
three days. At the two-week visit, 76 percent of women treated with the
progestin and 88 percent treated with the combination oral contraceptive
reported cessation of bleeding. The only surgery performed was dilation
and curettage in one patient in the combination group. The groups did
not differ in symptom scores for nausea, cramping, or bloating or in
overall patient satisfaction scores.

**Conclusion:** Although this small study had some difficulties with
compliance and follow-up, the authors conclude that both regimens
provided effective and acceptable therapy for acute uterine bleeding in
stable, nonpregnant patients. The incidence and severity of adverse
effects were low, and surgical interventions were avoided. The authors
call for larger randomized studies to confirm their results.

Munro MG, et al. Oral medroxyprogesterone acetate and combination oral
contraceptives for acute uterine bleeding: a randomized controlled
trial. Obstet Gynecol October 2006;108:924-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17012455>

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

**American Indians and Alaska Natives are difficult to reach by mail for
research or health care reasons**

<http://www.ahrq.gov/research/jan07/0107RA4.htm>

**Women are more likely than men to suffer health problems and worse
quality of life due to obesity**

<http://www.ahrq.gov/research/jan07/0107RA19.htm>

**Missed opportunities: Too few Americans are being screened or
counseled to prevent colorectal cancer, obesity, and other conditions**

<http://www.ahrq.gov/research/jan07/0107RA1.htm>

**Physicians\' extended work shifts are associated with increased risks
of medical errors that harm patients**

<http://www.ahrq.gov/research/jan07/0107RA6.htm>

**Extended resident work hours jeopardize both resident health and
patient safety**

<http://www.ahrq.gov/research/jan07/0107RA7.htm>

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

**Diet of Pregnant American Indians: Different than Whites?**

A pregnant woman's diet can influence the outcome of her pregnancy. Is
the diet of pregnant American Indians different than whites? A Harvard
team sought to find the answer using data from the North Dakota WIC
(Women, Infants and Children) program.

They found that the diets of the two groups were not much different.
There was a statistical difference in the sample of over 5,000 women,
but it was "minimal." Both groups needed improvement, the researchers
said. Increases in iron and folate intake were specially recommended.
And, as expected, both groups would benefit from eating less fat and
more grains and vegetables. AI women had "greater diet diversity," which
was a plus.

[Comment:]{.underline} The conclusions were flawed because the study did
not include the effect of dietary supplements such as prenatal vitamins.
Iron and folate are usually in prenatal supplements. Generalizability is
weak since the sample was limited to one state. While the study was
published in December, 2006, the data reach back to 1996, another reason
results are not generalizable. A finding that may be more important was
that smoking among AI women was much higher than whites: 46% vs. 28%.

Watts V, et al.: Assessing Diet Quality in a population of low-income
pregnant women. Maternal Child Health Journal, 2006; Dec 27 Epub ahead
of print.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17191147>

\*"Informationists help find the information you need."

##### 

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

**ACOG Calls on Ob-Gyns, Health Care Professionals, Hospitals and
Employers for Increased Support for Breastfeeding**

Washington, DC \-- In an effort to help increase the rate of
breastfeeding in the US, today The American College of Obstetricians and
Gynecologists (ACOG) issued a Committee Opinion, \"Breastfeeding:
Maternal and Infant Aspects,\" emphasizing ACOG\'s strong support for
breastfeeding and urging ob-gyns, other health care professionals,
hospitals, and employers to support women in choosing to breastfeed
their infants.

Breastfeeding is the preferred method of feeding for newborns and
infants, and nearly every woman can breastfeed her child, according to
ACOG. ACOG continues to recommend exclusive breastfeeding of infants
until approximately 6 months of age, with longer periods being
beneficial. Some exceptions to breastfeeding include women who take
illegal drugs, have high alcohol intake, have HIV, have an infant with
galactosemia, or have certain other infections.

Research that shows the many health benefits of breastfeeding to
infants, women, families, and society continues to accumulate. Education
and support for breastfeeding can improve breastfeeding rates for all
women and would be a positive economic investment for both health plans
and employers because there are lower rates of illness among infants who
are breastfed.

Committee Opinion #361, \"Breastfeeding: Maternal and Infant Aspects,\"
is published in the February 2007 issue of Obstetrics & Gynecology. More
detailed information on breastfeeding can be found in ACOG Clinical
Review (Vol. 12, Issue 1 (supplement), Jan-Feb 2007) \"Special Report
from ACOG, Breastfeeding: Maternal and Infant Aspects\" available to
Fellows online at [www.acog.org](http://www.acog.org/) and to nonmembers
by emailing <jbrenner@acog.org>.

<http://www.acog.com/from_home/publications/press_releases/nr02-01-07-1.cfm>

**Calcium Important for Nursing Mothers' Oral Health**

Conclusions: Lactation could be a risk factor for alveolar bone loss,
especially under conditions of calcium insufficiency. Increased systemic
demand for calcium and an insufficient supply of calcium might enhance
the development of alveolar bone loss in periodontitis.

[Shoji
K](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Shoji+K"%5BAuthor%5D),
et al Effects of Lactation on Alveolar Bone Loss in Experimental
Periodontitis. [J
Periodontol.](javascript:AL_get(this, 'jour', 'J Periodontol.');) 2007
Jan;78(1):152-156

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17199552>

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

**Call for Breastfeeding Abstracts: AAP**

The AAP Call for Abstracts for the 2007 National Conference & Exhibition
is underway. Authors may submit their research on the website belos
until April 13, 2007.

The AAP Section on Breastfeeding welcomes abstracts that pertain to
breastfeeding. A \$100.00 award will be given to the best abstract and
the top two abstracts will be presented at the Annual Section
Educational Session at the NCE in San Francisco. Other accepted
abstracts will be invited to present a poster during our poster session
on the same day (this session has been moved from the evening to mid-day
to encourage more participation - so this is the year to submit!).
[[http://www.call4abstracts.com/aap]{.underline}](http://www.call4abstracts.com/aap)

If you have any questions, please contact Lauren F. Kotch
<lkotch@aap.org>

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

#### Simple Antenatal Preparation Improves Breast-Feeding Practice: RCT {#simple-antenatal-preparation-improves-breast-feeding-practice-rct-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Where breastfeeding practices are suboptimal, simple one-encounter antenatal education and counseling significantly improve breastfeeding practice up to 3 months after delivery. Provision of printed or audiovisual educational material is not enough. Health care workers should make every effort to have one face-to-face encounter to discuss breastfeeding with expectant mothers before they deliver. LEVEL OF EVIDENCE: I {#conclusion-where-breastfeeding-practices-are-suboptimal-simple-one-encounter-antenatal-education-and-counseling-significantly-improve-breastfeeding-practice-up-to-3-months-after-delivery.-provision-of-printed-or-audiovisual-educational-material-is-not-enough.-health-care-workers-should-make-every-effort-to-have-one-face-to-face-encounter-to-discuss-breastfeeding-with-expectant-mothers-before-they-deliver.-level-of-evidence-i .Style-Heading-4-+-Arial-14-pt-Underline}

[Mattar
CN](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Mattar+CN"%5BAuthor%5D),
et al Simple antenatal preparation to improve breastfeeding practice: a
randomized controlled trial. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Jan;109(1):73-80

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197590**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197590) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17197590 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-9 .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}

#### February 2007 Highlights include  {#february-2007-highlights-include .Style-Heading-4-+-Arial-14-pt-Underline}

Low hanging fruit: Promotion of healthy lifestyles during and after
pregnancy

-Teamwork Training: Decision to incision times significantly improved

-Outreach workers should follow women with the most severe PAP
abnormalities

-Are you interested in acquiring HPV vaccine to provide to 9 -- 18 year
olds?

-Sleepiness and sleep deprivation are associated with injury

-Guidelines Recommend Universal Screening for Down Syndrome: Regardless
of age

-Diet of Pregnant American Indians: Different than Whites?

-Supporting employee breastfeeding is easier than it sounds

-Continuous Contraceptive Therapy Safely Abolishes Menstrual Cycles

-Vaccine Preventable Diseases, IHS

-Are varicella titers necessary prior to immunization?

-What does the future hold in store?

-F/U: A boy has been born in Chile with a fetus in his stomach

-Local estrogen just as effective for vaginal atrophy in postmenopausal
women

-The Blessed Perineum: PubMed

-Getting Your Patient Back to Work: Return-to-Work Restrictions After
Illness / Injury

-I have to go really far just to exercise . . . er . . . actually no you
don't

-What do patients recall from our counseling?

-Planned cesarean delivery doubles rate of NICU and risk for pulmonary
disorders

-Adolescent with knee pain, Web M+M, Terry Cullen - Moderator

-First Indian Health Special Issue on Methamphetamine is now available
online

-Diabetic Moms\' Babies Have Impaired Sucking Reflexes

-What Causes Breast Cancer?

-Andy Narva moved to NIH, but is still our Renal CCC

-Year End Re-cap of Available Resources from CDC -- OWH

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_02.pdf>

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

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

**Health Care-Based Interventions for Women Who Have Experienced Sexual
Violence**

Thirty publications that evaluated health care-based interventions for
women who experienced sexual violence were reviewed. The findings
highlight that clinicians often need training in the provision sexual
assault care, and that not all emergency departments have sexual assault
care protocols. Studies examining effectiveness found that Sexual
Assault Nurse Examiner programs are very helpful, that health care-based
sexual assault treatment settings attract more women than do
forensic-based settings, that sexual assault survivors often prefer a
combination of medication and counseling treatment, and that preexam
administration of a video explaining the collection of forensic evidence
may reduce women\'s stress during the procedure. Studies on postexposure
HIV prophylaxis found that many women did not complete the treatment
regimen, often because of side effects. Emergency contraception to
prevent postrape pregnancy is not consistently offered to women. Only
one study reported on abortion as part of the range of sexual assault
services. (Forwarded by Carolyn Aoyama <Carolyn.Aoyama@ihs.gov> )

Martin, Sandra L., Young, Siobhan K., Billings, Deborah L., Bross, C.
Christopher Health Care-Based Interventions for Women Who Have
Experienced Sexual Violence: A Review of the Literature. Trauma Violence
Abuse, Jan 2007; vol. 8: pp. 3-18

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17204597>

**Child Abuse: Approach and Management**

Child abuse is a common diagnosis in the United States and should be
considered any time neglect or emotional, physical, or sexual abuse is a
possibility. Although home visitation programs have been effective in
preventing child maltreatment, much of the approach to and management of
child abuse is directed by expert opinion or legal mandate. Any
suspicion of abuse must be reported to Child Protective Services. A
multidisciplinary approach is recommended to adequately evaluate and
treat child abuse victims; however, the responsibility often lies with
the family physician to recognize and treat these cases at first
presentation to prevent significant morbidity and mortality. Am Fam
Physician 2007;75:221-8.

<http://www.aafp.org/afp/20070115/221.html>

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

**Older American Indians often have a poorer view of their own health
than their doctors**

<http://www.ahrq.gov/research/dec06/1206RA2.htm>

**Selective Serotonin Reuptake Inhibitors Increase Fracture Risk in
Older Adults**

CONCLUSIONS: Daily SSRI use in adults 50 years and older remained
associated with a 2-fold increased risk of clinical fragility fracture
after adjustment for potential covariates. Depression and fragility
fractures are common in this age group, and the elevated risk attributed
to daily SSRI use may have important public health consequences.

[Richards
JB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Richards+JB"%5BAuthor%5D),
et al Effect of selective serotonin reuptake inhibitors on the risk of
fracture. [Arch Intern
Med.](javascript:AL_get(this, 'jour', 'Arch Intern Med.');) 2007 Jan
22;167(2):188-94

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17242321>

**The decision to hospitalize nursing home residents is driven primarily
by residents\' preference and quality of life**

<http://www.ahrq.gov/research/dec06/1206RA7.htm>

**A pain medication appropriateness scale reveals that many nursing home
residents suffer from poorly controlled pain**

<http://www.ahrq.gov/research/dec06/1206RA8.htm>

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

**Abstinence counseling vs family planning: Which is more effective?**

Adolescent pregnancy rates in the United States declined by 27% from
1991 to 2000. Our data suggest that declining adolescent pregnancy rates
in the United States between 1995 and 2002 were primarily attributable
to improved contraception use.

\* Rates of sexual activity did not decline significantly among
adolescents ages 15-19 or among those ages 18-19; the decline in sexual
activity among adolescents ages 15-17 was of borderline significance.

\* The contraceptive risk index declined by 34% among adolescents ages
15-19, by 46% among those ages 15-17, and by 27% among those ages 18-19.

\* Pregnancy risk declined by 38% among adolescents ages 15-19, by 55%
among those ages 15-17, and by 27% among those ages 18-19.

\* Fourteen percent of the change in pregnancy risk among adolescents
ages 15-19 was attributable to a decrease in the percentage of sexually
active young women, while 86% was attributable to changes in
contraceptive method use; among adolescents ages 15-17, the
corresponding percentages were 23% and 77%, respectively. All of the
change in pregnancy risk among adolescents ages 18-19 was the result of
increased contraceptive use.

In comparison with our school-based study, this analysis of the NSFG
showed a larger contribution of contraceptive use to declines in
adolescent pregnancy rates. Our findings raise questions about current
US government policies that promote abstinence from sexual activity as
the primary strategy to prevent adolescent pregnancy.

#### Santelli JS, Lindberg LD, Finer LB, et al. 2007. Explaining recent declines in adolescent pregnancy in the United States: The contribution of abstinence and improved contraceptive use. American Journal of Public Health 97(1):150-156. [[http://www.ajph.org/cgi/content/abstract/97/1/150?etoc]{.underline}](http://www.ajph.org/cgi/content/abstract/97/1/150?etoc) {#santelli-js-lindberg-ld-finer-lb-et-al.-2007.-explaining-recent-declines-in-adolescent-pregnancy-in-the-united-states-the-contribution-of-abstinence-and-improved-contraceptive-use.-american-journal-of-public-health-971150-156.-httpwww.ajph.orgcgicontentabstract971150etoc .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**The MCH Coordinators Site has a clean new look, plus new
functionality**

The MCH Coordinators Site now has a wide open approachable format that
streamlines the reader's navigation to get to the important links. To
that end, there is now a schematic map of Indian Country so that one can
simply click on the area of the country you want to learn more about.

In addition, there is an easy to read MCH Headlines box at the top of
the page which gives you access to all the recent headlines generated by
Judy Thierry's new MCH Headlines Column in the monthly CCC Corner
Newsletter. The combination of these two items increases the user
friendly nature of the page, plus makes it timely.
<http://www.ihs.gov/MedicalPrograms/MCH/F/MCHC01.cfm>

What has not changed is the encyclopedic nature of the resources
available especially through the National MCH Coordinator's 'More Links
of Interest' site. This page serves in many ways as a resource for Child
Health links missing after the demise of the Indian Child Health page.

<http://www.ihs.gov/MedicalPrograms/MCH/F/MCHC03.cfm>

Please contact <Judith.Thierry@ihs.gov> for questions or additions.

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

**Q. How many rubella vaccines does a mother really need to get?**

**A.** If negative, then revaccination with one dose of MMR, and no
further serologic testing

What is the current recommendation from CDC for post partum women who
are non-immune and who have had 2 previous document MMR\'s?  At my past
facility we didn\'t give any further vaccine but at my new facility, it
seems to be a mystery.  Can you point me in the right direction?  Thanks

**Answer**

The CDC \"Pink Book\", in the section on Rubella, p. 165\* the CDC
briefly addresses the issue of a patient who has a documented
vaccination for rubella, but still has a negative serum IgG by ELISA. In
this case, they recommend revaccination with one dose of MMR, and do not
recommend further serologic testing. It seems that if you don\'t have an
immune response after two doses of MMR, you do not need to administer
another dose.

 

(\*p. 11 of the  pdf at
<http://www.cdc.gov/nip/publications/pink/rubella.pdf>)

**Background**

In reality the \'titer\' is more like a \"+ or -\", depending on whether
it\'s \>1:10 or \<1:10, getting a repeat titer is often
unhelpful\.... Most women nowadays have been vaccinated in childhood,
and the booster we give them in pregnancy should provoke a
satisfactory anamnestic response. It\'s a good question, but more of a
hassle issue at present when the disease is so rare! Even women from
Mexico and Central America usually get immunized in childhood now,
mostly because measles is such a big public health problem as a cause of
childhood mortality, but the vaccine currently comes as MMR, so they
get covered for all 3.

The Redbook states on page 578 that "routine prenatal screening for
rubella immunity should be undertaken. If a women is found to be
susceptible than rubella vaccine should be administered in the
postpartum period."

 

However, on page 576 of the Redbook it states "some people in whom
antibody has been absent by hemagglutination inhibition testing have
been found to be immune when more sensitive testing has been done."

 

So the practical answer is that his patient is immune for all practical
purposes. In theory each vaccine administration is 95% effective so
after two vaccines the chance of being truly non-immune is 0.05 X 0.05 =
0.0025 or 2.5/1,000 women with two MMR on record.

For more information, you could send this question to CDC at
<NIPINFO@cdc.gov>, and get access to other resources.

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

**February 2007**

-A guest editorial for physicians who work with tribal child protective
services

-How will we roll out the new HPV vaccine? Who can we cover?

-Dr. Esposito gets passionate about poor data and unfounded conclusions

[[http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN207.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN207.doc)

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

**Have you visited the CRS Performance Improvement Toolbox web page
lately?**

This valuable and informative page features comprehensive powerpoint
presentations on clinical GPRA measures. Each presentation provides
extensive clinical background information, including best practice
recommendations, for individual GPRA measures. Full citations and
references are included in the \"notes\" section on individual slides.
These slides are available as PDF files, and can be downloaded for
training purposes. Presentations on behavioral health topics (Depression
Screening and DV/IPV Screening) also include detailed instructions on
how to document behavioral health screening in RPMS.

Current topics available include:

•  Colorectal Cancer Screening Information for Providers

•  Comprehensive CVD Screening Information for Providers

•  Depression Screening Information for Providers

•  Domestic (Intimate Partner) Violence Screening Information for
Providers

•  Mammography Screening Information for Providers

•  Prenatal HIV Screening Information for Providers

•  Tobacco Screening and Cessation Intervention Information for
Providers

The Toolbox page also includes other useful resources for providers,
including screening tools and \"cheat sheets,\" standards and procedures
documents, reporting templates, and case studies. 

Keep checking the CRS Toolbox page for new information and new
presentations.

<http://www.ihs.gov/cio/crs/crs_performance_improvement_toolbox.asp>

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

**Sexual behavior in context: A public health perspective**

Here\'s the international health column, sent to you from a very green,
very rainy, very mosquito-abundant Malawi. Cheers, Claire

Since the 1980s, and especially since the recognition of sex as an
important route of HIV transmission, research into sexual behavior has
flourished nearly worldwide. (The Middle East and some parts of Asia
represent exceptions where proposed research on sexual behavior is
rarely approved or funded, while there is a disproportionate amount of
data from Africa.) In a recent Lancet article, Kaye Wellings and
international colleagues analyze datasets from 59 countries' surveys on
sexual behavior, using research conducted 1996-2006. When possible, they
compare this data with reports from the 1970s. Most datasets were part
of the standard Demographic and Health Surveys, conducted by trained
interview teams in developing countries on a regular basis, so the
comparability of data is unusually good. The resulting report busts some
myths about sexual behavior while leaving other questions unanswered.

Contrary to popular opinion, there is no overall trend toward earlier
intercourse. Though considerable intraregional and some inter-gender
variability exists, worldwide first intercourse continues to be
typically between ages 15 and 19. Premarital sex has increased; however,
it appears that this trend is linked to later marriage in many countries
and not to increased early sex. Most people are married (in this report
cohabitation was counted as marriage since legal standards of marriage
vary substantially). Single people have much less sex than married
people, especially in Africa, and marriage is not protective against
acquisition of HIV; for women in much of Africa and Asia, it is actually
a risk factor. The proportion of people using a condom at most recent
sexual encounter was higher for men than women worldwide, and this
difference appears to be because women were having sex with their
husbands and were unwilling or unable to negotiate safe sex. Overall
condom use at last intercourse was low worldwide, particularly in
developing countries. It is encouraging to note, however, a substantial
increase in condom use in both sexes over the past decade, especially
dramatic in much of Africa and among women in the US. Ten to fifty
percent of women worldwide report they cannot always say no to sex, and
first intercourse in young girls was forced in about a third of cases.
Multiple partnerships are more common in industrialized countries, and
globally more common among men than women. They were especially common
where the distance between work and home was substantial. Nonetheless,
monogamy remains the dominant pattern worldwide.

This fascinating report has several serious limitations. Data on use of
sex workers was so poor, in part due to vexing variations in the
definition of sex work, that it cannot be compared properly. Data on
same-sex behavior, similarly, is minimal -- entirely absent in some
regions -- and when it exists at all addresses men only. The authors did
not correlate sexual risk with socioeconomic status (though they do
refer to other studies that have done so). Probably most seriously,
sexual health surveys are of course even more vulnerable than other
surveys to reporting bias: respondents may tend to report what they
think is acceptable behavior, rather than what they actually do. The
authors suggest that male over-reporting and female under-reporting may
contribute to the substantial gender differences seen here.

Despite its limitations, however, the report is also useful from a
public health perspective. On the positive side, it reassures us that
there is no pandemic of adolescent promiscuity to worry about. However,
it also shows that self-reported sexual behavior does not seem to
correlate well with HIV: with the exception of patterns of condom use,
sexual behaviors in high-transmission areas are, if anything, less risky
than those in low-transmission areas.

Wellings K et al. Sexual behaviour in context: a global perspective. The
Lancet 368:1706-28, November 2006

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17098090>

(Also available online with free registration at
[[www.thelancet.com]{.underline}](../www.thelancet.com))

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

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

#### Repair of obstetric vesicovaginal fistulas in Africa {#repair-of-obstetric-vesicovaginal-fistulas-in-africa-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: The initial repair of vesicovaginal fistulas has the highest probability of success. The successful closure is dependent on size, site, and associated scarring  {#conclusion-the-initial-repair-of-vesicovaginal-fistulas-has-the-highest-probability-of-success.-the-successful-closure-is-dependent-on-size-site-and-associated-scarring .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Roenneburg ML](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Roenneburg+ML"%5BAuthor%5D), et al Repair of obstetric vesicovaginal fistulas in Africa {#roenneburg-ml-et-al-repair-of-obstetric-vesicovaginal-fistulas-in-africa .Style-Heading-4-+-Arial-14-pt-Underline}

[Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Dec;195(6):1748-52

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17132477**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17132477) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17132477 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Drugs for preventing malaria in pregnant women improve infant outcome {#drugs-for-preventing-malaria-in-pregnant-women-improve-infant-outcome-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### AUTHORS\' CONCLUSIONS: Chemoprophylaxis or IPT reduces antenatal parasite prevalence and placental malaria when given to women in all parity groups. They also have positive effects on birthweight and possibly on perinatal death in low-parity women. {#authors-conclusions-chemoprophylaxis-or-ipt-reduces-antenatal-parasite-prevalence-and-placental-malaria-when-given-to-women-in-all-parity-groups.-they-also-have-positive-effects-on-birthweight-and-possibly-on-perinatal-death-in-low-parity-women. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Garner P](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Garner+P"%5BAuthor%5D), et al Drugs for preventing malaria in pregnant women. {#garner-p-et-al-drugs-for-preventing-malaria-in-pregnant-women. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Cochrane Database Syst Rev.](javascript:AL_get(this, 'jour', 'Cochrane Database Syst Rev.');) 2006 Oct 18;(4):CD000169 {#cochrane-database-syst-rev.-2006-oct-184cd000169 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17054128**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17054128) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17054128 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Global struggle against poverty {#global-struggle-against-poverty-1 .Style-Heading-4-+-Arial-14-pt-Underline}

America is a land of such vast opportunity and advancement that many of
us take it for granted. Yet ironically, in this country, there have
always been people living at bare subsistence levels. For them, the land
of opportunity is harder to define. The poverty-stricken have fewer
educational opportunities, limited access to health care, and certainly
less of a reason to feel that upward economic mobility is just around
the corner. They have been around countless corners that have led to too
many dead ends and are often trapped with no discernable escape.

The stories of people living in poverty, whether a single mother, a
Native American family on a reservation, a worker earning minimum wage
and struggling to support four children, or some other real-life
situation, all portray heartbreaking struggles. Government agencies,
nongovernmental organizations, and church groups all make a difference
in assisting those in need, and many find opportunity through education
and job training. But for others, the oppression of poverty makes
working through the morass so improbable that those families flail and
experience second- and third-generation poverty. This is a particular
tragedy because the United States has the resources to eliminate poverty
over time in most cases.

As bad as these situations are in the United States, they pale in
comparison with those in other parts of the world. In many
poverty-stricken areas, such as Bangladesh, starvation is the major
concern, with disease and shelter close behind. As an obstetrician, it
is particularly wrenching to see mothers holding starving babies with
sunken eyes, swollen bellies, skeletal limbs, and flies all over their
bodies. Their primary challenge is to beat the odds and stay alive.
Issues like education or employment are far-off dreams. Their problems
are so dire that they often must rely on outside help to survive.

In countries like Sudan, the misery of poverty is compounded by war,
genocide, and rape. Families lose homes, are stricken with disease, and
struggle to survive. Victims of rape are no longer accepted by their
families. Such desperate situations generally cannot be solved
internally. Trade is limited, so the only hope lies in foreign aid and
outside pressure on their government to reform.

Other countries like India and China have stable governments and
infrastructures, so the prospects of people emerging from poverty are
quite good. Because China has a wealth of manpower and productivity, aid
is not as valuable as trade. Some areas in China, such as Beijing and
Shanghai, enjoy such success that now a mounting concern is the
disparity between the well-off and the many poor
people.[1](http://www.greenjournal.org/cgi/content/full/109/2/248#R1-2%23R1-2)

In this issue, a chapter from Dr. Jean Chamberlain Froese's book, Where
Have All the Mothers Gone?, illustrates some of the hardships
experienced by women living in poverty (page 441). Dr. Chamberlain
Froese, a Canadian obstetrician--gynecologist, is executive president of
Save the Mothers. She has worked in Zambia, Zimbabwe, Uganda, Pakistan,
and Ecuador. In the chapter, \"Breech: The Tragic Story of One African
Mother,\" she relates the tragedy of a mother losing her two daughters
in childbirth. In many African countries, motherhood is revered, yet
there is no system in place to ensure safety in childbirth.

The enormous efforts on the part of government agencies, nongovernmental
organizations, and church groups are critical and valuable, but their
efforts comprise only a fraction of what is needed. When concerned
people become involved, the chance of a turnaround increases. Hence, the
answer to poverty seems to be involving everyone in some appropriate way
to support the struggle. As physicians, we are privileged and have
special capabilities to help this plight, and in my opinion, we are
obliged to contribute in some fashion.

In October 2007, medical journals from around the world will
simultaneously publish content on poverty and human development.
Organized by the Council of Science Editors, the intent of the Global
Theme Issue on Poverty and Human Development is to \"raise awareness,
stimulate interest, and stimulate research into poverty and human
development.\"[2](http://www.greenjournal.org/cgi/content/full/109/2/248#R2-2%23R2-2)
As editors of Obstetrics & Gynecology, we are proud to be a part of this
important initiative, and I encourage you to contact the editorial
office (<obgyn@greenjournal.org>
![](media/image3.png){width="0.20833333333333334in" height="0.15625in"})
if you are interested in submitting content on this theme for
consideration.

In Obstetrics & Gynecology, we seek to publish clinically relevant
articles. Clinical relevance takes on an urgent and critical meaning
when applied to women and children who lack basic necessities. Our
research and our editorials cannot immediately eliminate the problems of
poverty, but they can raise awareness and stimulate action to enhance
health and living conditions worldwide.

#### [Queenan JT](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Queenan+JT"%5BAuthor%5D) Global struggle against poverty. [Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007 Feb;109(2 Pt 1):248-9. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17267819&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17267819&dopt=Abstract) {#queenan-jt-global-struggle-against-poverty.-obstet-gynecol.-2007-feb1092-pt-1248-9.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids17267819doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**First steps in implementing mental health screening in schools**

Mental health screening in schools has the potential to be a cornerstone
of a transformed mental health system. The authors found:

-Inclusive Planning \-- Planning should involve all significant
stakeholders and should begin with a policy review.

-Collaborative Relationships \-- Ideally, a memorandum of agreement
should be established between schools and collaborating community
agencies and supported by state systems.

-Logistics \-- The optimal time to conduct screenings must be
determined, based on the adequacy of resources necessary to provide
needed follow-up services after screenings.

-Training, Supervision, and Support \-- Staff will require adequate
training and supervision to coordinate a screening program; select
age-appropriate and culturally sensitive measurement tools; manage
associated technology for administering, scoring, and interpreting data;
and establish and sustain relationships with the school and the
community. Professional development will also be required to raise
awareness about and increase knowledge of child and adolescent mental
health needs, factors that promote healthy development and those that
contribute to mental health problems, specific signs of mental health
problems, and strategies to assist children and adolescents with mental
health problems in obtaining help.

-Integration \-- Mental health screening should be one aspect of a
complete continuum of effective mental health programs and services in
schools that includes a full partnership between families, schools, and
child-serving systems; quality assessment and improvement; empirically
supported practice; and outcome evaluations.

The authors conclude that \"consideration of the issues outlined in this
article should help schools and communities determine whether they are
ready to include screening in schools as part of their SMH program.\"

Weist MD, Rubin M, Moore E, et al. 2007. Mental health screening in
schools. Journal of School Health 77(2):53-58.

[[http://www.blackwell-synergy.com/doi/abs/10.1111/j.1746-1561.2007.00167.x]{.underline}](http://www.blackwell-synergy.com/doi/abs/10.1111/j.1746-1561.2007.00167.x)

**New Organization Focuses on Adolescent Health Care Reform**

Incenter Strategies, a new affiliate of the Maternal and Child Health
Policy Research Center, has announced the availability of the following
four new publications on adolescent health and health care:

\* Racial and Ethnic Disparities in Adolescent Health and Access to Care
provides new national information on disparities in health status and
access to care among Hispanic, Black, and White adolescents ages 12-17.

The fact sheet addresses racial and ethnic disparities for a broad set
of indicators and also examines the impact of income, insurance, and
mother\'s or household education on these indicators. The fact sheet is
available at
[[http://www.incenterstrategies.org/jan07/factsheet1.pdf]{.underline}](http://www.incenterstrategies.org/jan07/factsheet1.pdf)

\* Racial and Ethnic Disparities in Health and Access to Care Among
Older Adolescents presents new national information on disparities and
health status and access to care among Hispanic, Black, and White
adolescents ages 18-21. A set of five widely used indicators were
selected to assess whether income, insurance, and mother\'s education
explain racial and ethnic differences. The fact sheet is available at
[[http://www.incenterstrategies.org/jan07/factsheet2.pdf]{.underline}](http://www.incenterstrategies.org/jan07/factsheet2.pdf)

\* Making the Case for Addressing Adolescent Health Care draws on data
from multiple studies and national surveys to document the failings of
the current system of health care financing and delivery in addressing
the unique needs of adolescents. The authors argue for more effective
health care in which intensive health-promotion interventions are
available; health care for physical and behavioral conditions is
integrated; and the unique needs, perspectives, and vulnerabilities of
adolescents are understood.
[[http://www.incenterstrategies.org/jan07/factsheet3.pdf]{.underline}](http://www.incenterstrategies.org/jan07/factsheet3.pdf)

\* Preliminary Thoughts on Restructuring Medicaid to Promote Adolescent
Health proposes an enhanced set of health-promotion and primary-care
benefits designed specifically for adolescents that can be offered
through the Early and Periodic Screening, Diagnostic and Treatment
program, or as an alternative benefit package under the Deficit
Reduction Act. The issue brief also suggests possible changes to payment
policies to support comprehensive preventive and primary-care-service
delivery for adolescents.
[[http://www.incenterstrategies.org/jan07/issuebrief1.pdf]{.underline}](http://www.incenterstrategies.org/jan07/issuebrief1.pdf)

#### \* Incenter Strategies will be focusing on building partnerships and promoting interdisciplinary models of health care to improve the accessibility and availability of health care for adolescents. More information is available at [[http://www.incenterstrategies.org]{.underline}](http://www.incenterstrategies.org/) {#incenter-strategies-will-be-focusing-on-building-partnerships-and-promoting-interdisciplinary-models-of-health-care-to-improve-the-accessibility-and-availability-of-health-care-for-adolescents.-more-information-is-available-at-httpwww.incenterstrategies.org .Style-Heading-4-+-Arial-14-pt-Underline}

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

**MCH Headlines Judy Thierry HQE**

**Scrub Club**

Scrub Club is a KID friendly website and as the name implies it gets
kids to wash their hands and think about why this is important. IT is
also for health care providers and definitely for teachers who must
engage students (K to 5th grade) and those in early childhood settings
and their administrators in having a healthy environment, halting spread
of disease, URI, influenza -- starting with effective hand washing.
<http://www.scrubclub.org/home.php?fuseaction=main>

**Training Course** **in MCH** **Epidemiology**

-   Albuquerque, New Mexico

-   June 10 - 15, 2007

-   Sponsored by HRSA / MCHB and CDC

<http://www.crpcorp.info/mchtraining2007.htm>

**New Child Health USA Report Released**

A recently published HRSA report indicates that prenatal care and
breastfeeding rates are improving, but that low birth weight rates are
increasing and the U.S. infant mortality rate remains high compared to
other developed nations.

Key findings from Child Health USA 2005, the 16th annual assessment of
the health status and service needs of America\'s children, include:

-   The rate of first-trimester prenatal care has been increasing
    steadily since the early 1990s. The proportion of non-Hispanic
    black, Hispanic and American Indian women receiving early prenatal
    care has increased by 20 percent or more since 1990, and 84.1
    percent of pregnant women received early prenatal care in 2003.
    Non-Hispanic white women had the highest rates of prenatal care at
    89.0 percent, followed by Asian-Pacific Islander women at 85.4
    percent, Hispanic women at 77.5 percent, non-Hispanic black women at
    75.9 percent, and American Indian women at 70.8 percent.

-   Breastfeeding, which enhances the health of mothers and infants, has
    been steadily on the rise since the beginning of the 1990s. In 2003,
    70.9 percent of mothers started breastfeeding when their babies were
    born, the highest rate yet recorded. While 36.2 percent of mothers
    were still breastfeeding their infants at 6 months, only 14.2
    percent were breastfeeding their 6-month-olds without any other form
    of nourishment. Many government and international initiatives
    promote breastfeeding as the best way to feed a baby.

-   A 2002-03 CDC survey shows that 80.5 percent of children ages 19 to
    35 months received the recommended series of vaccines. As a result
    of increased immunization, the number of reported cases of
    vaccine-preventable diseases continues to decrease. In 2003, there
    were no reported cases of diphtheria, tetanus, rubella or polio
    among children under 5 years of age, and very few cases of hepatitis
    B, measles and mumps. HHS' Healthy People 2010 objective is to
    immunize at least 90 percent of children in this age group.

-   Despite improved rates of prenatal care, the rate of
    low-birth-weight births (less than 2,500 grams or 5 pounds, 8
    ounces) is currently at the highest level in the past three decades.
    In 2003, 7.9 percent of all births were considered low birth weight,
    rising steadily from a low of 6.7 percent in 1984. Very low birth
    weight (less than 1,500 grams or 3 pounds 4 ounces) is also
    increasing, representing 1.4 percent of all live births in 2003,
    compared to approximately 1 percent in 1980. Low birth weight babies
    are significantly more likely to die in the first year of life than
    babies of normal birth weight, and those who survive are at risk for
    severe physical, developmental and cognitive problems.

-   Although rates of maternal and infant mortality have dropped in the
    past century, the U.S. still has one of the higher rates of infant
    death in the industrialized world. Seven out of every 1,000 babies
    born alive in 2003 died in their first year, according to the
    report.

Child Health USA 2005 provides the most current information available
for public health professionals, policy makers and others on more than
50 health and health care indicators. Data are drawn mainly from 2003-04
surveys and reports supported by federal agencies and non-profit
organizations, and are depicted in easy-to-use bar graphs and pie
charts, with trend analyses, when applicable.

The current edition of Child Health USA 2005 and previous editions are
available online at
<http://www.mchb.hrsa.gov/mchirc/chusa_05/index.htm>. Copies can be
ordered on the HRSA Information Center Web site
[www.ask.hrsa.gov](http://www.ask.hrsa.gov/), by calling 1-888-ASK-HRSA,
or by e-mailing Stephanie Toomer at <stoomer@hrsa.gov>.

**More on car seats, installment and safety on recheck**

At a second child safety seat checkup, 45 percent more seats were
properly installed by the parents than at the first instructional
event.\
Correctly used child safety seats decrease the risk of death by 71
percent for infants and 54 percent for toddlers. Injury risks for
children using belt- positioning booster seats are reduced by 59
percent. Typically, more than 70 percent of child safety seats are
improperly installed.

<http://www.prnewswire.com/usnewswire/>

<http://www.usa.safekids.org/tier3_cd.cfm?content_item_id=24130&folder_id=301>

**CDC needs feedback on need for Educational resources HPV
implementation**

As you begin work on implementing use of the new HPV vaccine among
providers who may not have previously administered vaccines, CDC would
like to assist in your efforts by providing educational tools or
resources that would be useful to your program or to the providers who
will be administering this vaccine.  Following is a short list of
potential resources as well as an opportunity for you to identify other
items that would be of use to you. 

If there is someone else in your program who is better able to provide
input on your program's HPV vaccine educational resources needs, please
ask that person to respond.

Thank you; your input is greatly appreciated.

 

Providers need more information about (check all that apply and put an
asterisk by the most needed item):

\_\_\_\_HPV infection and associated diseases (epidemiology, natural
history, transmission, prevention)

\_\_\_\_HPV vaccination recommendations

\_\_\_\_How to talk to parents/adolescents abut HPV vaccine

\_\_\_\_Other adolescent vaccines such as hepatitis B, Tdap, and MCV4)

\_\_\_\_General vaccine and vaccination recommendations

\_\_\_\_Beginning a vaccine program in a provider setting (including
education on vaccine storage and handling, vaccine administration
techniques, required documentation, immunization information systems,
vaccine management and other related issue)

 

We would prefer to receive this information in the following formats
(note all that apply):

\_\_\_\_\_Information/fact sheets for providers

\_\_\_\_\_\_Information/fact sheets for potential vaccine recipients
(parents of pre-teens/adolescents and women)

\_\_\_\_\_Posters for providers and other settings to raise awareness of
the disease and vaccine for the target population

\_\_\_\_\_DVD or PowerPoint media programmed instruction sets  

\_\_\_\_\_Web-based training for state program staff including online
information and training, DVD, podcasts, archived webcasts 

\_\_\_\_\_Web-based training for providers including online information,
DVD, podcasts, webcasts (live and archived)

Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

PLEASE REPLY TO:    Duane Kilgus**        **<dgk9@cdc.gov>

**Interventional Kit to Prevent Fetal Alcohol Spectrum Disorders**

Drinking and Reproductive Health: A Fetal Alcohol Spectrum Disorders
 Prevention Tool Kit presents strategies to help health professionals
 identify women who drink at risky levels and engage them in changing
 behavior to reduce their risk for an alcohol-exposed pregnancy. The
continuing education activity, sponsored by the American College of
Obstetricians and Gynecologists with support from the Centers for
Disease Control and Prevention, is designed to help health professionals
who care for women prevent fetal alcohol spectrum disorders (FASD) when
they encounter risky drinking, regardless of the woman\'s pregnancy
status. A brief guide provides information on FASD, screening and
intervention guidelines, frequently asked questions, a blueprint for
putting screening and intervention into practice, the Surgeon General's
Advisory on Alcohol Use in Pregnancy, resources, and references. Other
 materials include handouts for patients about drinking and reproductive

health, additional screening tools and counseling tips for health
 professionals, and a pocket card illustrating standard-sized drinks.
<http://www.acog.org/from_home/misc/dept_pubs.cfm>

**Two webcasts that you may want to review:**

1.) Contrast traditional prenatal care with a group model of prenatal
care

Describe the three components of prenatal care

Discuss the strengths and challenges of providing prenatal care through
the Centering Pregnancy® model
<http://www.cdnetwork.org/NewCDN/LibraryView.aspx?ID=cdn337>

2.) Understand "bundling" as a heuristic for the redesign of healthcare.

Provide brief clinical overview of group prenatal care.

Show evidence to support a variety of positive clinical outcomes of
group prenatal care.

Invite participation in new clinical study in 14 community health
centers in the New York metro area.
<http://www.cdnetwork.org/NewCDN/LibraryView.aspx?ID=cdn338>

**Ontario PE in High schools: \"\... more focused intervention is
needed..."**\
excerpt from this MMWR study:   \"\... more focused intervention is
needed to address the participation of youths, particularly females and
older youths. The findings also underscore the need for development of
strategies to ensure that PE is appealing and available\...  

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5603a2.htm?s_cid=mm5603a2_e>

**Oral Health Care during Pregnancy and Early Childhood Practice
Guidelines**

Produced by the NY State Health Department these guidelines are ideal
introduction and way to focus on local initiatives with science based
discussion - I sent out a link on this recently.

SEND me your mailing address if you are interested in a HARD COPY and
moving forward on implementing these guidelines locally.
<Judith.Thierry@ihs.gov>

**School Based Health Care**

 ![](media/image4.png){width="4.364583333333333in"
height="2.2395833333333335in"}

[http://www.nasbhc.org/Jan07/07kellogg-natio_s%20f%20rev0131.pdf](http://www.nasbhc.org/Jan07/07kellogg-natio_s f rev0131.pdf)
 

# Developmental delays: SSA Early Identification and Intervention Demonstration 

The Social Security Administration (SSA) is making cooperative agreement
funding available to support a project that will design and implement
effective, replicable, and sustainable models which will increase the
number of children (birth to age 5) who receive developmental screening
and improve the early identification of children with developmental
delays and/or disabilities.

Current Closing Date for Applications: Mar 14, 2007   Applications are
to be submitted through www.grants.gov by the Close Date.

# [**http://www.grants.gov/search/search.do?mode=VIEW&oppId=12418**](http://www.grants.gov/search/search.do?mode=VIEW&oppId=12418)

**Health Disparities Among Minority and Underserved Women**\
SOURCE: National Institute of Nursing Research (NINR), National
Institute of Child Health and Human Development (NICHD), National
Institute of Drug Abuse (NIDA), National Institute of Diabetes and
Digestive and Kidney Diseases (NIDDK), Office of Research on Women\'s
Health (ORWH)

APPLICATION DEADLINE: 2/5, 6/5, 10/5. Expires 8/28/07.\
\$ AVAILABLE: Awards issued under this announcement are contingent upon
the availability of funds and the submission of a sufficient number of
meritorious applications.

ELIGIBILITY: Public/state/private controlled institutions of higher
education, nonprofits with and without 501(c)(3) IRS status (other than
institutions of higher education), small businesses, for-profit
organizations (other than small businesses), state governments, U.S.
territories or possessions, Indian/Native American tribal government
(federally recognized and other than federally recognized),
Indian/Native American tribally designated organizations, non-domestic
(non-U.S.) entities, Hispanic-serving institutions, Historically Black
Colleges and Universities (HBCUs), Tribally Controlled Colleges and
Universities (TCCUs), Alaska native and native Hawaiian serving
institutions, regional organizations, eligible agencies of the federal
government, and faith-based or community-based organizations.

PURPOSE: The purpose of this initiative is to stimulate research aimed
at reducing health disparities among racial/ethnic minority and
underserved women. More specifically, this initiative seeks applications
for: (1) research related to health promotion or risk reduction among
minority and underserved women age 21 and older; and, (2) intervention
studies that show promise for improving the health profile of minority
and underserved women. Investigators responding to this announcement
should focus on enhancing the body of knowledge of a variety of factors
(e.g., social, economic, demographic, community, societal, personal,
cultural) influencing the health promoting and health compromising
behaviors of racial and ethnic minority women and underserved women and
their subpopulations. The focus of this program announcement is on women
age 21 and older, but investigators may also focus on the childhood
antecedents of adult health disparities.\
CONTACT: Yvonne Bryan, (301) 594-6908, fax: (301) 480-8260, e-mail:
[bryany@mail.nih.gov]{.underline}

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

#### Prolonged second stage with an epidural {#prolonged-second-stage-with-an-epidural-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### A primigravid at 41 3/7 weeks presented after 2 days of outpatient vaginal misoprostol cervical ripening 1 hour after spontaneous rupture of membranes. The patient's past history was significant for polycystic ovarian syndrome. The patient had a 41 lb. weight gain through 8 visits and one abnormal result on a 3 hour glucose tolerance test.  {#a-primigravid-at-41-37-weeks-presented-after-2-days-of-outpatient-vaginal-misoprostol-cervical-ripening-1-hour-after-spontaneous-rupture-of-membranes.-the-patients-past-history-was-significant-for-polycystic-ovarian-syndrome.-the-patient-had-a-41-lb.-weight-gain-through-8-visits-and-one-abnormal-result-on-a-3-hour-glucose-tolerance-test. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The patient was contracting every 1 -- 4 minutes was noted to be 2 cm dilated, and 80% effaced with an estimated fetal weight of "9 + lbs" and reassuring fetal heart tones in cephalic presentation. Initially the patient was managed expectantly, but after 4 hours of no progress, oxytocin augmentation was begun. The patient was beta strep positive and received IV penicillin IV. The patient subsequently received epidural anesthesia.  {#the-patient-was-contracting-every-1-4-minutes-was-noted-to-be-2-cm-dilated-and-80-effaced-with-an-estimated-fetal-weight-of-9-lbs-and-reassuring-fetal-heart-tones-in-cephalic-presentation.-initially-the-patient-was-managed-expectantly-but-after-4-hours-of-no-progress-oxytocin-augmentation-was-begun.-the-patient-was-beta-strep-positive-and-received-iv-penicillin-iv.-the-patient-subsequently-received-epidural-anesthesia. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Stage I lasted 8 hours. At 5-6 cm dilation the patient was noted to have temperature of 100.6 F and started on intravenous gentamicin and ampicillin. {#stage-i-lasted-8-hours.-at-5-6-cm-dilation-the-patient-was-noted-to-have-temperature-of-100.6-f-and-started-on-intravenous-gentamicin-and-ampicillin. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### In Stage II the patient was noted to have 'labored down' due a dense epidural status without active pushing for some of Stage II. The patient ultimately regained the sensation to push and the caput descended to +2. As Stage II neared 4 hours the risks and benefits of vacuum assistance were discussed with the patient and it was agreed to proceed. The vacuum extractor was placed during 3 contractions. Subsequently, the fetal presenting part descended to +3/5 with the scalp visible without pushing. The fetal heart tones were reassuring throughout. The patient is noticeably beginning to tire and subjectively seems to be pushing less effectively. {#in-stage-ii-the-patient-was-noted-to-have-labored-down-due-a-dense-epidural-status-without-active-pushing-for-some-of-stage-ii.-the-patient-ultimately-regained-the-sensation-to-push-and-the-caput-descended-to-2.-as-stage-ii-neared-4-hours-the-risks-and-benefits-of-vacuum-assistance-were-discussed-with-the-patient-and-it-was-agreed-to-proceed.-the-vacuum-extractor-was-placed-during-3-contractions.-subsequently-the-fetal-presenting-part-descended-to-35-with-the-scalp-visible-without-pushing.-the-fetal-heart-tones-were-reassuring-throughout.-the-patient-is-noticeably-beginning-to-tire-and-subjectively-seems-to-be-pushing-less-effectively. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### What do you want to do now? {#what-do-you-want-to-do-now .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Allow the patient to push for 30 minutes more and re-evaluate {#allow-the-patient-to-push-for-30-minutes-more-and-re-evaluate .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Notify the OR team and discuss cesarean delivery  {#notify-the-or-team-and-discuss-cesarean-delivery .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Wait for the epidural to completely wear off {#wait-for-the-epidural-to-completely-wear-off .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Apply the vacuum for a second trial {#apply-the-vacuum-for-a-second-trial .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Add clindamycin {#add-clindamycin .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

######### HPV CEU\'s vaccine indications test your knowledge: 5 minute review

<http://www.medscape.com/viewarticle/551247?src=mp>

######### 

######### Contraception for a Woman With a History of Fibroids: An Interactive Case CME/CE

<http://www.medscape.com/viewprogram/6582?sssdmh=dm1.244144&src=nlcmealert>

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

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

######### 

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

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

**Clinical Discussion Board Index, Medscape**

Hundreds of ongoing clinical discussions available

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

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

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

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

**Menopause Management**

**Physical Activity Improves Lipid Profile in Postmenopausal Women **

CONCLUSIONS: Physical activity was significantly related to some
lipoprotein subclasses regardless of HT; however, several key
lipoprotein subclasses were associated with higher levels of activity
only among non-HT users.

[Pettee
KK](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Pettee+KK"%5BAuthor%5D),
et al The relationship between physical activity and lipoprotein
subclasses in postmenopausal women: the influence of hormone therapy.
[Menopause.](javascript:AL_get(this, 'jour', 'Menopause.');) 2006 Oct 3

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17023874**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17023874) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17023874 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Transdermal Estrogen Suggested for Women With Metabolic Syndrome {#transdermal-estrogen-suggested-for-women-with-metabolic-syndrome-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION(S): This short-term study suggests that oral E(2) may worsen IR and adipocytokine parameters, worsening cardiovascular risk. Transdermal E(2) had minimal effects on IR and resulted in higher adiponectin. Although these data may not reflect alterations that occur with estrogen therapy in more metabolically normal postmenopausal women or with longer term therapy, the findings suggest that tE(2) may be a preferable treatment for obese women with MBS. Long-term studies are needed to make any recommendations {#conclusions-this-short-term-study-suggests-that-oral-e2-may-worsen-ir-and-adipocytokine-parameters-worsening-cardiovascular-risk.-transdermal-e2-had-minimal-effects-on-ir-and-resulted-in-higher-adiponectin.-although-these-data-may-not-reflect-alterations-that-occur-with-estrogen-therapy-in-more-metabolically-normal-postmenopausal-women-or-with-longer-term-therapy-the-findings-suggest-that-te2-may-be-a-preferable-treatment-for-obese-women-with-mbs.-long-term-studies-are-needed-to-make-any-recommendations .Style-Heading-4-+-Arial-14-pt-Underline}

[Chu
MC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Chu+MC"%5BAuthor%5D),
et al A comparison of oral and transdermal short-term estrogen therapy
in postmenopausal women with metabolic syndrome. [Fertil
Steril.](javascript:AL_get(this, 'jour', 'Fertil Steril.');) 2006
Dec;86(6):1669-75

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17074346>

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

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

**Maternal positioning and pain relief measures and promoting effective
pushing technique**

CONCLUSIONS: The primary findings of our review indicated that most of
the studies are flawed and do not answer the important questions for
maternity caregivers to safely manage prolonged second stage. Meanwhile,
approaches for promoting a normal second stage of labor are available to
caregivers, such as maternal positioning and pain relief measures and
also promoting effective pushing technique.

Altman MR; Lydon-Rochelle MT Prolonged second stage of labor and risk of
adverse maternal and perinatal outcomes: a systematic review. [Birth.
 2006;
33(4):315-22](http://www.medscape.com/medline/publicationbrowser/123?pmid=17150071) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17150071>

**Navajo News Jean Howe, Chinle**

**Clomiphene "bests" Metformin in a NEJM study**

This and similar headlines were used to describe the results of a recent
multicenter study published in The New England Journal of Medicine. As
the treatment of anovulatory infertility is a routine part of our
clinical practice, it seemed worthwhile to find out more...

The study, titled "Clomiphene, Metformin, or Both for Infertility in the
Polycystic Ovary Syndrome", enrolled women with polycystic ovarian
syndrome and infertility. A total of 626 women were enrolled and
randomized to one of 3 groups: clomiphene + placebo, metformin +
placebo, and clomiphene + metformin. Each woman received the assigned
treatment until pregnancy was achieved or for up to 6 cycles or 30
weeks. The live birth rates were as follows: clomiphene 22.5% (47/209),
metformin 7.2% (15/208), and clomiphene plus metformin 26.8% (56/209).
Although the highest absolute live birth rate was in the group receiving
combination therapy, the difference between combination therapy and
clomiphene alone was not statistically significant. The study used live
births (appropriately) as the primary outcome measure; however the
secondary outcome measures are also of interest. The mean number of
ovulations per subject was 2.2 in the clomiphene group, 1.4 in the
metformin group, and 2.8 in the group receiving combination therapy. The
conception rates were 39.5% with clomiphene, 21.7 with metformin, and
46.0 with combination therapy. The multiple gestation rate was 6.0% with
clomiphene, 0% with metformin, and 3.1% with combination therapy.
Additional material included on-line provided stratification by BMI.
Those with a BMI \<30 had live birth rates of 36.8% (clomiphene), 8.8%
(metformin), and 36.9% (combination therapy). This decreased to 16.4%
(clomiphene), 3.8% (metformin), and 22.9% (combination therapy) for
those with a BMI \>35. BMI was noted to increase during the course of
the study in women treated with clomiphene alone but decreased in those
receiving metformin, either alone or in combination with clomiphene. The
study population included many women with high BMI and longstanding
infertility (40 months on average, with over half having previously
received one or both study drugs in the past). Over 10% of the study
participants were American Indian or Alaska Native.

Polycystic ovarian syndrome (PCOS) is a common cause of female
infertility. PCOS is characterized by the formation of multiple small
ovarian cysts, high androgen levels, high LH levels, and insulin
resistance. Obesity is a common finding. It has been proposed that
correcting the underlying metabolic abnormalities of PCOS may lead to
improved fertility. This premise, and success in small trials, has led
to the widespread use of metformin for the treatment of PCOS-related
infertility. This study is the first large-scale attempt to rigorously
examine this approach. It is important because it demonstrates that
clomiphene is actually more effective than metformin in treatment of
PCOS-related infertility. What is less clear is if there is still a role
for metformin use in combination with clomiphene; although the overall
live birth rate was higher with combination therapy the difference
achieved was not statistically significant. A review of the treatment of
anovulatory infertility by Up to Date Online describes a sequential
approach to infertility treatment, with weight loss as the first
intervention, followed by clomiphene, then a course of metformin if
clomiphene is unsuccessful, followed by resumption of clomiphene after 8
-- 12 weeks of metformin use. An update to these recommendations is
anticipated later this month.

As I review this literature, I am struck by the central role of weight
issues in the treatment of anovulatory infertility. Up to Date Online
cites several studies about PCOS and weight loss and concludes that, in
women with PCOS and a BMI over 27, loss of 5-10 percent of body weight
will restore ovulation in over half of women within six months. Women
who can achieve this goal benefit from improved fertility without the
increased risk of multiple gestation associated with clomiphene use. For
those unable to achieve this weight loss or still requiring treatment,
the efficacy of treatment remains higher for those with healthier BMIs.
Addressing weight issues is challenging for both patients and health
care providers. Attention to healthy diet and increased physical
activity remain the core interventions in this endeavor. It will be
interesting to see if metformin is abandoned completely in the treatment
of PCOS-related infertility or if its use will continue, not necessarily
as a primary therapy for ovulation induction, but in an effort to combat
the metabolic abnormalities and obesity associated with PCOS.

**Resources:**

Legro RS, Barnhart HX, Schlaff WD, et al., Clomiphene, Metformin, or
Both for Infertility in Polycystic Ovarian Syndrome, The New England
Journal of Medicine, February 8, 2007; 356(6)551-566.
<http://content.nejm.org/cgi/content/short/356/6/551>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17287476&dopt=Abstract>

 

Guzick DS, Treating the Polycystic Ovary Syndrome the Old-Fashioned Way,
The New England Journal of Medicine, February 8, 2007; 356(6)622-624.
<http://content.nejm.org/cgi/content/full/356/6/622>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17287483&dopt=Abstract>

**Overview of the treatment of female infertility, UpToDate**
<http://www.utdol.com/utd/content/topic.do?topicKey=gen_gyne/25217&type=A&selectedTitle=4~72>

**Review of metformin for the treatment of PCOS by UpToDate**

<http://www.utdol.com/utd/content/topic.do?topicKey=r_endo_f/20044>

**Nurses Corner, Sandra Haldane, HQE**

#### A \"Small Fall\" and a Trip to the Emergency Department {#a-small-fall-and-a-trip-to-the-emergency-department-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### \"Prepare yourself: this is the beginning of the end \-- your mother will go through a gradual decline and, most likely, never regain her previous level of function.\" {#prepare-yourself-this-is-the-beginning-of-the-end----your-mother-will-go-through-a-gradual-decline-and-most-likely-never-regain-her-previous-level-of-function. .Style-Heading-4-+-Arial-14-pt-Underline}

#### The above sentence, with infinite variations, was repeated many times during the past year as my family attempted to cope with the sudden transition of my mother\'s health from that of a 91-year-old, independent, New England woman, living by herself and driving her car in a city where there were no family members living, to a dependent ward of the healthcare system. The transition began one day as I listened to my voice mail and heard the small voice of my mother saying that she had suffered a \"small fall\" and that the \"nice men in the ambulance\" had taken her to an unspecified emergency department. I stared at my phone, unable to internalize the message for a moment. I was then flooded with terror as I contemplated what she (and we) would have to endure. {#the-above-sentence-with-infinite-variations-was-repeated-many-times-during-the-past-year-as-my-family-attempted-to-cope-with-the-sudden-transition-of-my-mothers-health-from-that-of-a-91-year-old-independent-new-england-woman-living-by-herself-and-driving-her-car-in-a-city-where-there-were-no-family-members-living-to-a-dependent-ward-of-the-healthcare-system.-the-transition-began-one-day-as-i-listened-to-my-voice-mail-and-heard-the-small-voice-of-my-mother-saying-that-she-had-suffered-a-small-fall-and-that-the-nice-men-in-the-ambulance-had-taken-her-to-an-unspecified-emergency-department.-i-stared-at-my-phone-unable-to-internalize-the-message-for-a-moment.-i-was-then-flooded-with-terror-as-i-contemplated-what-she-and-we-would-have-to-endure. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### For the rest of this story of elders in the 21^st^ century, go here {#for-the-rest-of-this-story-of-elders-in-the-21st-century-go-here .Style-Heading-4-+-Arial-14-pt-Underline}

#### The Cycle of Relocation: One Family\'s Experience With Elder Care {#the-cycle-of-relocation-one-familys-experience-with-elder-care .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/549625**](http://www.medscape.com/viewarticle/549625) {#httpwww.medscape.comviewarticle549625 .Style-Heading-4-+-Arial-14-pt-Underline}

**The REACH Program and Alzheimer\'s Caregivers**

Family members who provide care for someone with Alzheimer\'s disease
often experience constant demands and role strain that can lead to a
broad range of personal, social, and health consequences. The Resources
for Enhancing Alzheimer\'s Caregiver Health (REACH) project was the
first to study an intervention for these caregivers in a clinical trial.
The first phase, REACH I, found that active skills training
interventions were more effective at relieving caregiver burden and
depression than more passive techniques, such as providing information.
These preliminary findings were used to develop REACH II, which provided
a series of 12 training sessions (9 in-home and 3 by telephone)
delivered by trained interventionists over 6 months to teach caregivers
about Alzheimer\'s disease and the skills to manage troublesome
behaviors, along with strategies to maintain social support, reframe
negative emotions, manage stress, and enhance their own healthy
behaviors. The sessions used role-playing, problem solving, skills
training, and relaxation techniques tailored to the needs of each
individual caregiver to address quality-of-life (QOL) issues. The
intervention was available in both English and Spanish.

Researchers tested REACH II with 323 caregivers of an elder diagnosed
with Alzheimer\'s disease. The caregivers averaged 60 years of age; over
80% were women; about half were the spouse of the care recipient; and
the ethnic composition was roughly one third white, one third black, and
one third Hispanic. Over 75% of the participants received at least 9 of
the training sessions, with 60% receiving all 12, and 90% reported that
they found the sessions helpful. The caregivers completed a series of
questionnaires on depression, burden, self-care, social support, and
problem behaviors of the care recipient to measure overall QOL. Compared
with a nonintervention control group, the REACH caregivers were only
half as likely to have signs of clinical depression, whereas Hispanic
and white caregivers, along with black spouse caregivers, reported
significant improvements in their QOL. These findings indicated that the
REACH II intervention helped caregivers of Alzheimer\'s patients reduce
their risk for depression and improve their QOL.

Belle SH, Burgio L, Burns R, et al. Enhancing the quality of life of
dementia caregivers from different ethnic or racial groups: a
randomized, controlled trial. Annals of Internal Medicine.
2006;145:727-738.

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17116917**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17116917) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17116917 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Monthly Summaries of Nursing Research: Medscape**

#### [**http://www.medscape.com/viewarticle/549758?src=mp**](http://www.medscape.com/viewarticle/549758?src=mp) {#httpwww.medscape.comviewarticle549758srcmp .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Highlights of NPWH 9th Annual Conference \-- Women\'s Health in the New Millennium CE {#highlights-of-npwh-9th-annual-conference----womens-health-in-the-new-millennium-ce .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/6275?src=mp**](http://www.medscape.com/viewprogram/6275?src=mp) {#httpwww.medscape.comviewprogram6275srcmp .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-29 .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}

**Indian Health Surveillance Report---Sexually Transmitted Diseases
2004**

This report presents statistics and trends for sexually transmitted
diseases (STDs) among American Indians and Alaska Natives (AI/AN) in the
United States. This inaugural report represents a unique collaboration
and partnership between CDC and the Indian Health Service (HIS). Most of
the AI/AN-specific data provided in this report are the result of a new
surveillance methodology, whereby existing nationally notifiable STD
data reported to CDC were analyzed using standard IHS populations and
methods. In 2004, reported rates of chlamydia, gonorrhea, and primary
and secondary syphilis among AI/AN were 2 to 6 times higher than
comparable rates for whites.
<http://www.cdc.gov/std/stats-ihs-2004/toc.htm>

**Health, United States, 2006**

The report includes 147 detailed trend tables organized around four
subject areas: health status and determinants, health-care use,
health-care resources, and health-care expenditures. Many of the trend
tables provide information on racial, ethnic, and socioeconomic
disparities in health. The report also includes the 2006 Chartbook on
Trends in the Health of Americans, which assesses the current state of
the nation\'s health and how it is changing, both positively and
negatively, by presenting trends and information on selected
determinants and measures of health status.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5603a3.htm>

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

#### Oklahoma Perspective Greggory Woitte -- Hastings Indian Medical Center {#oklahoma-perspective-greggory-woitte-hastings-indian-medical-center .Style-Heading-4-+-Arial-14-pt-Underline}

**What do patients recall from our counseling?**

In scanning over the journals this month I ran across this article from
the British Medical Journal

Quick synopsis was that providing mothers of babies in the neonatal ICU
audiotaped conversations between the mothers and the neonatalogists
helped improve the mother's recall of the diagnosis, treatment plan and,
prognosis.

Although we certainly can not provide every patient with a tape recorded
conversation, it is important to remember that despite us as providers
giving a clear description and recommendations for treatment plans,
there are times of stress that the patients do not understand our plan.
Fetal demise and missed abortions are two prominent examples where it is
probably better to inform the patient of your findings and schedule
follow up appointment when the patient can have their social support
system available and have had time to let the diagnosis register.

[Koh
TH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Koh+TH"%5BAuthor%5D),
et al Provision of taped conversations with neonatologists to mothers of
babies in intensive care: randomised controlled trial.
[BMJ.](javascript:AL_get(this, 'jour', 'BMJ.');) 2007 Jan 6;334(7583):28

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17142256>

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

**Early Postmenopausal Hormone Therapy Improves Postural Balance**

CONCLUSIONS: Initiation of HT soon after menopause rapidly improved
postural balance to levels normally seen in young women. We suggest that
improved postural balance can contribute to the protection against
fractures associated with HT and explain the more substantial reduction
in hip fracture risk after HT initiated sooner, compared with later,
after menopause. Further study is required to confirm these results.

[Naessen
T](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Naessen+T"%5BAuthor%5D),
et al Early postmenopausal hormone therapy improves postural balance.
[Menopause.](javascript:AL_get(this, 'jour', 'Menopause.');) 2006 Nov 3

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17091024>

**Repeat Bone Mineral Density Measurement May Not Predict Fractures in
Older Women **

CONCLUSION: In healthy, older, postmenopausal women, repeating a
measurement of BMD up to 8 years later provides little additional value
besides the initial BMD measurement for predicting incident fractures.

[Hillier
TA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Hillier+TA"%5BAuthor%5D)
et al Evaluating the value of repeat bone mineral density measurement
and prediction of fractures in older women: the study of osteoporotic
fractures. [Arch Intern
Med.](javascript:AL_get(this, 'jour', 'Arch Intern Med.');) 2007 Jan
22;167(2):155-60

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17242316>

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

#### Tips for Using Medicines Wisely {#tips-for-using-medicines-wisely-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20070115/239ph.html**](http://www.aafp.org/afp/20070115/239ph.html) {#httpwww.aafp.orgafp20070115239ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Parvovirus B19: What You Should Know {#parvovirus-b19-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://lyris.aafp.org/t/1050775/16249464/518988/0/**](http://lyris.aafp.org/t/1050775/16249464/518988/0/) {#httplyris.aafp.orgt1050775162494645189880 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Perinatology Picks George Gilson, MFM, ANMC {#perinatology-picks-george-gilson-mfm-anmc .Style-Heading-4-+-Arial-14-pt-Underline}

**Ultrasound is better at finding NTD than AFP**

For instance, if one performs 1st trimester screening, then one does not
also need to obtain a 2nd trimester AFP if you have obtained an
ultrasound in the interim

CONCLUSION: Standard ultrasound improved NTD detection over AFP
screening alone, by improving AFP test sensitivity and identifying NTDs
in low-risk pregnancies

[Dashe
JS](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Dashe+JS"%5BAuthor%5D),
et al Alpha-fetoprotein detection of neural tube defects and the impact
of standard ultrasound [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Dec;195(6):1623-8

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16769022>

**Planned cesarean delivery doubles NICU rates and the risk for
pulmonary disorders**

RESULTS: Compared with planned vaginal deliveries, planned cesarean
delivery increased transfer rates to the neonatal intensive care unit
from 5.2% to 9.8% (P \< .001).

CONCLUSION: A planned cesarean delivery doubled both the rate of
transfer to the neonatal intensive care unit and the risk for pulmonary
disorders, compared with a planned vaginal delivery.

[Kolas
T](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Kolas+T"%5BAuthor%5D),
et al Planned cesarean versus planned vaginal delivery at term:
comparison of newborn infant outcomes. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Dec;195(6):1538-43

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16846577>

**Amniotic Fluid Promising Source of Stem Cells**

Stem cells capable of differentiating to multiple lineages may be
valuable for therapy. We report the isolation of human and rodent
amniotic fluid-derived stem (AFS) cells that express embryonic and adult
stem cell markers. Undifferentiated AFS cells expand extensively without
feeders, double in 36 h and are not tumorigenic. Lines maintained for
over 250 population doublings retained long telomeres and a normal
karyotype. AFS cells are broadly multipotent. Clonal human lines
verified by retroviral marking were induced to differentiate into cell
types representing each embryonic germ layer, including cells of
adipogenic, osteogenic, myogenic, endothelial, neuronal and hepatic
lineages. Examples of differentiated cells derived from human AFS cells
and displaying specialized functions include neuronal lineage cells
secreting the neurotransmitter L-glutamate or expressing G-protein-gated
inwardly rectifying potassium channels, hepatic lineage cells producing
urea, and osteogenic lineage cells forming tissue-engineered bone.

[De Coppi
P](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="De+Coppi+P"%5BAuthor%5D),
et al Isolation of amniotic stem cell lines with potential for therapy.
[Nat Biotechnol.](javascript:AL_get(this, 'jour', 'Nat Biotechnol.');)
2007 Jan;25(1):100-6

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17206138>

**Formula that calculates the estimated risk of respiratory distress
syndrome is valid**

CONCLUSION: Our previously derived logistic regression model formula
incorporating TDx-FLM II results and gestational age to predict risk of
neonatal respiratory distress syndrome was robust and stable over time
in an independent data set. The results suggest that the equation can be
implemented clinically to assist physicians and patients and used by
other institutions after their own internal validation. LEVEL OF
EVIDENCE: III.

[Melanson
SE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Melanson+SE"%5BAuthor%5D),
et al Validation of a formula that calculates the estimated risk of
respiratory distress syndrome. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Dec;108(6):1471-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17138782>

Pregnancy Loss After Amniocentesis and CVS

**Conclusions:** The authors conclude that the danger of fetal loss
following amniocentesis or CVS has declined in recent years, and that
the loss rate for CVS is no longer significantly higher than that for
amniocentesis. The authors believe these results will assist families
and health care professionals in making difficult decisions about
antenatal diagnoses, especially during the first trimester.

Caughey AB, et al. Chorionic villus sampling compared with amniocentesis
and the difference in the rate of pregnancy loss. Obstet Gynecol
September 2006;108:612-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16946222>

**Complicated first births are associated with an increased risk of
unexplained stillbirth**

The authors conclude that complicated first births of liveborn infants
are associated with an increased risk of unexplained stillbirth in the
next pregnancy.

Smith GC; et al Previous preeclampsia, preterm delivery, and delivery of
a small for gestational age infant and the risk of unexplained
stillbirth in the second pregnancy: a retrospective cohort study,
Scotland, 1992-2001. [Am J Epidemiol.  2007;
165(2):194-202](http://www.medscape.com/medline/publicationbrowser/123?pmid=17065276) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17065276>

**Nitroglycerin during premature labour improves babies' health**

The improvement is most marked in babies who are born very prematurely
(at 24 to 28 weeks).

Until now, no drug to stop pre-term labour has demonstrated an improved
outcome from a baby's point of view. CONCLUSION: Transdermal
nitroglycerin may reduce neonatal morbidity and mortality as a result of
decreased risk of birth before 28 weeks.

[Smith
GN](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Smith+GN"%5BAuthor%5D),
et al Randomized double-blind placebo-controlled trial of transdermal
nitroglycerin for preterm labor. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
Jan;196(1):37

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17240225>

## Antenatal Corticosteroids for Fetal Lung Maturation for Women at Risk of Preterm Birth 

REVIEWERS\' CONCLUSION: The evidence from this new review supports the
continued use of a single course of antenatal corticosteroids to
accelerate fetal lung maturation in women at risk of preterm birth. A
single course of antenatal corticosteroids should be considered routine
for preterm delivery with few exceptions. Further information is
required concerning optimal dose-to-delivery interval, optimal
corticosteroid to use, and effects in multiple pregnancies and to
confirm the long-term effects into adulthood.

CLINICAL IMPLICATIONS

A single course of corticosteroids, such as betamethasone 12 mg
intramuscularly twice at a 24-hour interval, should be given to women
between 24 and 34 weeks in whom there is reason to anticipate early
delivery, including women:

-   with ruptured membranes,

-   with preeclampsia,

-   with multiple pregnancies, and

-   in whom delivery is likely in less than 24 hours.

**COMMENTARY**

Separate Cochrane reviews address the related issues of the
effectiveness and safety of multiple doses of prenatal corticosteroids
(still controversial---but may be beneficial), the adjunctive use of
thyroid-releasing hormone with corticosteroids (does not help), and the
use of corticosteroids before planned cesarean delivery at term (review
pending).

Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal
lung maturation for women at risk of preterm birth. Cochrane Database of
Systematic Reviews 2006, Issue 3. Art. No.: CD004454. DOI:
10.1002/14651858. CD004454.pub2

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17233108>

**Ischemic placental disease may serve as an important pathway to
preterm birth**

CONCLUSION: Preeclampsia, fetal distress, small-for-gestational-age, and
placental abruption, conditions that are associated with ischemic
placental disease, are implicated in well over half of all medically
indicated preterm births. Although the etiology of preterm birth is
heterogeneous, it is reasonable that ischemic placental disease may
serve as an important pathway to preterm birth.

[Ananth
CV](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Ananth+CV"%5BAuthor%5D),
et al Maternal-fetal conditions necessitating a medical intervention
resulting in preterm birth. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Dec;195(6):1557-63

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17014813>

**Elevated prenatal homocysteine levels as a risk factor for
schizophrenia**

CONCLUSIONS: These findings indicate that elevated third-trimester
homocysteine levels may be a risk factor for schizophrenia. Elevated
third-trimester homocysteine levels may elevate schizophrenia risk
through developmental effects on brain structure and function and/or
through subtle damage to the placental vasculature that compromises
oxygen delivery to the fetus. If future studies both replicate this
association and support a causal link, then the use of folic acid
supplementation would merit evaluation as a strategy for prevention of
schizophrenia in

Brown AS et al Elevated prenatal homocysteine levels as a risk factor
for schizophrenia [Arch Gen Psychiatry.  2007;
64(1):31-9](http://www.medscape.com/medline/publicationbrowser/123?pmid=17199052) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17199052>

**Induction of labor isosorbide mononitrate plus dinoprostone**

CONCLUSION: Vaginally administered isosorbide mononitrate does not play
a role in promoting delivery in term pregnancy if given at the same time
as dinoprostone. This might reflect its relaxant effect on the uterine
fundus, which may overcome its cervical softening effect.

[Wolfler
MM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Wolfler+MM"%5BAuthor%5D),
et al Induction of labor at term using isosorbide mononitrate
simultaneously with dinoprostone compared to dinoprostone treatment
alone: a randomized, controlled trial. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Dec;195(6):1617-22.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16723101>

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

**Adolescent with knee pain**

February 1, 2007

Moderator: Terry Cullen, MD

Web M + M

We will explore these issues

-A 12 year old male presents to a busy outpatient clinic complaining of
knee pain after football practice

-How do you approach the provision of patient care with limited access
to services and consultants?

-Is medical diagnostic decision making different in a rural setting? Do
we tolerate increased ambiguity?

-When do you 'start over' to find a different diagnosis?

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

Subscribe to the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26>

Unsubscribe from the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26>

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

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

**A First: STD Rates Available by IHS Area**

A new STD surveillance report is the first to present STD rates by IHS
Area. The report---a collaborative effort between IHS and CDC---uses an
innovative methodology, whereby existing nationally notifiable STD data
reported to CDC were analyzed using standard IHS populations and
methods. The plan is to update this report every two years.

Report Highlights:

-   Despite their small numbers, AI/AN are disproportionately affected
    by STDs

-   Chlamydia:

    -   Chlamydia remains the most commonly reported STD for all races
        and ethnicities

    -   There are large disparities between IHS and US chlamydia rates:
        2.3 times greater for AI/AN than US

    -   3 IHS Areas---Aberdeen, Alaska, and Billings---had chlamydia
        rates 4.9 to 6 times higher than the US rate

    -   Compared to men, chlamydia rates are higher among women and
        reflect the fact that women are far more likely to be screened

```{=html}
<!-- -->
```
-   Gonorrhea:

    -   Gonorrhea rates for the overall IHS population are stable and
        similar to US rates

    -   3 IHS Areas---Aberdeen, Alaska, and Phoenix---were 1.6 to 2.4
        times higher than the US rate

    -   IHS gonorrhea rates were higher for women than for men

-   Primary & Secondary Syphilis (P&S)

    -   Both the US and IHS have experienced increases in P&S in the
        past 4 years, however increases have been greater in AI/AN

    -   IHS P&S cases are primarily occurring in 3 Areas in the
        southwest: Albuquerque, Navajo, and Phoenix

    -   IHS P&S cases are evenly distributed between men and women (this
        is in contrast to US cases, where many more cases are among men
        than women)

Electronic copies of this report are available at
<http://www.cdc.gov/std/stats-ihs-2004/toc.htm>

Hard copies are available upon request from the IHS National STD Program
<lori.deravello@ihs.gov>

**Heterosexual Transmission of Community-Associated
Methicillin-Resistant Sttaph. aureus**

Heterosexual transmission of community-associated methicillin-resistant
Staphylococcus aureus has not been documented. As part of a survey
conducted in northern Manhattan, we encountered 3 households in which
heterosexual transmission was responsible for new community-associated
methicillin-resistant S. aureus infection. The vaginal and inguinal
isolates obtained from the sexual partners were USA 300. This report
documents an important and previously unrecognized means of
community-associated methicillin resistant S. aureus colonization and
transmission for these potentially invasive strains.

Cook H, et al Heterosexual Transmission of Community-Associated
Methicillin-Resistant Staphylococcus aureus CID 2007:44 (1 February)

<http://www.journals.uchicago.edu/CID/journal/issues/v44n3/40836/brief/40836.abstract.html>

**Research Seeks To Expand Understanding of Effects of Alcohol Use on
Developing Brain**

As part of a two-phase Funding Opportunity Announcement (FOA), the
[National Institutes of Health](http://www.nih.gov/)\'s [National
Institute on Alcohol Abuse and Alcoholism](http://www.niaaa.nih.gov/) is
seeking [research grant
applications](http://www.grants.gov/search/search.do?mode=VIEW&oppId=12110)
to further its understanding of the effects of child and adolescent
alcohol use on the developing human brain.\
\
It is known that the brain continues to develop into a person\'s
twenties with dramatic changes in structure and function coincident with
a period of life during which most youth initiate and escalate their
consumption of alcohol. This FOA calls for applications to propose and
test the feasibility of research study designs addressing the following
fundamental questions about the impact of child and adolescent alcohol
consumption on the developing brain:

1.  What are the effects (both long and shorter-term) of alcohol
    exposure on the developing brain?

```{=html}
<!-- -->
```
1.  What is the effect of timing, dose, and duration of alcohol exposure
    on brain development?

2.  To what extent do these effects resolve or persist?

As noted, this is a two phase FOA. Phase I, which is addressed in this
FOA, is the study design and feasibility testing phase. Phase II, which
will be the subject of a future FOA, will involve conducting the
full-fledged study. The application deadline for this phase is March 29,
2007.

To obtain further information about this funding opportunity, including
an application form, visit
<http://www.grants.gov/search/search.do?mode=VIEW&oppId=12110>

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

# Risk reduction counseling for prevention of STIs: how it works and how to make it work 

Prevention research in the past decade has proved the efficacy of risk
reduction counseling in reducing the risks for sexually transmitted
infections (STIs). The question currently facing STI service providers
is therefore not so much whether counseling should be part of the
standard of STI care but rather how this intervention can be implemented
given the logistical and resource constraints of a busy practice
setting. After a brief introduction of the history and an overview of
the models for risk reduction counseling and their theoretical and
scientific underpinnings, the focus of this paper will be on the extent
to which individual prevention models have been adopted in different
clinical settings, the impediments to implementation and suggestions for
improvement.

Rietmeijer, CA Risk reduction counseling for prevention of sexually
transmitted infections: how it works and how to make it work [Sex Transm
Infect.](javascript:AL_get(this, 'jour', 'Sex Transm Infect.');) 2007
Feb;83(1):2-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17283359>

Full text available at: <http://sti.bmj.com/cgi/reprint/83/1/2>

**RCT comparing computer-assisted vs face-to-face sexual history
taking**

Results: During the study period, of 713 patients approached, 611 agreed
to participate in the study; 356 were randomised to FTFI and 255 to
CASI. Overall, the responses to questioning using CASI and FTFI were
similar except that women undertaking the CASI reported a significantly
higher median number of male partners for the preceding 12 months (3 v
2, p = 0.05) and the CASI participants reported previous hepatitis B
vaccination more often (50% v 37%, p = 0.01). Most participants found
the CASI either easy (31; 13%) or very easy (193; 82%) to complete; 83
(35%) were comfortable and 121 (51%) were very comfortable with it.

Conclusions: CASI may be a reliable, efficient and highly acceptable
method for the screening of sexual risk in clinical sexual health
settings and could be used routinely to improve the efficiency of
clinical services.

Tideman R L et al A randomised controlled trial comparing
computer-assisted with face-to-face sexual history taking in a clinical
setting. Sexually Transmitted Infections,  Feb. 2007, Vol.83 ,1, p. 
52-56.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17098771>

Full text available at: <http://sti.bmj.com/cgi/reprint/83/1/52>

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

CDC Releases Survey Results on STD Counseling in Adolescents

In 2000, persons 15 to 24 years of age represented 48 percent of the
18.9 million new cases of sexually transmitted diseases (STDs), despite
being only one quarter of the sexually active population. The most
common sexually transmitted infection in persons younger than 24 years
is human papillomavirus (HPV). To assess the risk of STDs and the
education and counseling practices of health care professionals, the
Centers for Disease Control and Prevention (CDC) surveyed physicians who
care for adolescents.

The survey results found that 95 percent of health care professionals
thought monogamy or limiting the number of sex partners was effective in
preventing the spread of HPV, and 81 percent thought these practices
were worth recommending to patients. Although 91 percent of respondents
considered abstinence to be highly effective, only 45 percent said they
would recommend it. Family physicians and other physicians who treat
adolescents were more likely to recommend abstinence compared with other
health care professionals.

Although 89 percent of those surveyed said that consistent and correct
condom use would be worthwhile to recommend to their patients, only 78
percent felt that correct condom use was an effective prevention.
Another 23 percent of health care professionals expected consistent
condom use to be adopted for long-term use by patients, compared with 21
percent for monogamy and limiting sex partners, and 6 percent for
abstinence.

Among health care professionals who treat mostly adolescents, 97 percent
said they always or usually remind patients to use condoms for STD
prevention; 62 percent recommend monogamy or limiting the number of sex
partners; and 51 percent recommend abstinence. Ninety-three percent said
they routinely provide STD-prevention education to their patients, and
another 69 percent said they routinely provide education about genital
HPV infection to their adult or adolescent patients who they think are
sexually active.

STD-Prevention Counseling Practices and Human Papillomavirus Opinions
Among Clinicians with Adolescent Patients \-\-- United States, 2004
Morbidity and Mortality Weekly Report October 20, 2006
<http://www.aafp.org/afp/20070201/practice.html>

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

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

**Fertility rises as weight drops**

Weight loss surgery could have surprising results for some women - as
the pounds melt off, the chance of becoming pregnant increases.

Dr. Vadim Sherman, assistant professor of surgery at Baylor College of
Medicine, said obese women who thought they could not have children
regained their fertility during the months following gastric bypass or
lap-band procedures.

\"Weight affects how hormones act in the body,\" Sherman said. \"Body
fat helps to convert certain hormones such as estrogen into other
hormones. If there is extra body fat, healthy hormonal changes are
thrown off. Hormonal imbalances can lead to irregular menstrual cycles
and other reproductive problems. As women begin to lose weight, their
fertility returns to normal. For bariatric patients, the weight comes
off rapidly, and some are surprised by how quickly pregnancy can occur.
In some cases women become pregnant within six months of surgery.

\"We recommend waiting a year, when weight stabilizes, before having a
child,\" Sherman said. \"But women who become pregnant sooner can still
have healthy children.\"

On average more than half of excess body weight is lost during the year
following surgery. One fear is that the dramatic change in weight will
affect the fetus\'s health.

\"Some worry the weight will continue to come off and be harmful to the
pregnancy,\" Sherman said. \"Weight loss usually stops and some women
even gain up to 20 pounds.\"

Sherman said if nutritional needs are met, including all the usual
vitamin guidelines for bariatric surgeries, a woman can expect a healthy
pregnancy. <http://www.bcm.tmc.edu/>

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

**FDA Authorizes NovoLog for Pregnant Women With Type 1 Diabetes**\
NovoLog has now been given a pregnancy category B rating, indicating
that adequate studies in pregnant women with type 1 diabetes have
demonstrated that NovoLog does not increase risk to the unborn baby.

As a safety precaution, the FDA classifies prescription drugs with
specific category ratings to provide guidelines for physicians treating
pregnant women.

Previously, NovoLog was classified as a category C rating, which
indicates that adverse effects on the fetus have been demonstrated in
animal reproduction studies, and that studies in pregnant women have not
been conducted to demonstrate safety.

The FDA category change was based on a review of a trial using an
insulin analog in pregnant women with type 1 diabetes. The study
compared the safety and efficacy of NovoLog versus human regular insulin
(HRI). Data demonstrated that changes in HbA1c and rates of maternal
hypoglycemia were comparable with NovoLog compared to HRI. The study was
not large enough to evaluate the risk of congenital malformations.

Compared to HRI, the trial with NovoLog showed improved outcomes for
both mother and child in terms of fewer preterm deliveries, reduced risk
of neonatal hypoglycemia requiring treatment, consistently low rates of
major hypoglycemia and reduced risks to the fetus.\
FDA: [http://www.fda.gov](http://www.fda.gov/)

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

#### Mild Gestational Diabetes Raises Risk of Cryptorchidism {#mild-gestational-diabetes-raises-risk-of-cryptorchidism-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Mildly abnormal glucose metabolism during pregnancy was associated with an increased risk for congenital cryptorchidism. The mechanism remains to be elucidated. {#conclusions-mildly-abnormal-glucose-metabolism-during-pregnancy-was-associated-with-an-increased-risk-for-congenital-cryptorchidism.-the-mechanism-remains-to-be-elucidated. .Style-Heading-4-+-Arial-14-pt-Underline}

[Virtanen
HE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Virtanen+HE"%5BAuthor%5D),
et al Mild gestational diabetes as a risk factor for congenital
cryptorchidism

[J Clin Endocrinol
Metab.](javascript:AL_get(this, 'jour', 'J Clin Endocrinol Metab.');)
2006 Dec;91(12):4862-5.

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17032715**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17032715) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17032715 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Women's Health Headlines, Carolyn Aoyama {#womens-health-headlines-carolyn-aoyama .Style-Heading-4-+-Arial-14-pt-Underline}

**Women\'s Health Week will be celebrated May 13-19, 2007**\
This year\'s theme is \"It\'s Your Time.\"

Check back here soon for information on 2007 activities and programs.

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

**Menstrual Cycle is a Vital Sign**

NIH will convene a workshop or conference to facilitate public and
professional education about menses in girls and women, keeping in mind
the \"Menstrual Cycle is a Vital Sign\" as what will probably be the
theme.  The summary of a previous workshop that he helped to organize on
this topic with the Society for Menstrual Cycle Research and the New
York Academy of Sciences in NYC can be seen at: 
<http://www.medicalnewstoday.com/medicalnews.php?newsid=13805>

[**CDC reports decreasing mammogram rates
1999-2002**](http://www.ihs.gov/MedicalPrograms/MCH/W/CanBr.cfm#DecrMammo)

<http://www.ihs.gov/MedicalPrograms/MCH/W/CanBr.cfm#DecrMammo>

**Vulvodynia: a state-of-the-art consensus on definitions, diagnosis and
management**

Vulvodynia is a chronic pain syndrome affecting up to 18% of the female
population. Despite its high prevalence and associated distress, the
etiology, diagnosis and clinical management of the disorder have not
been clearly delineated. This \"white paper\" describes the findings and
recommendations of a consensus conference panel based on a comprehensive
review of the published literature on vulvodynia in addition to expert
presentations on research findings and clinical management approaches.
The consensus panel also identified key topics and issues forfurther
research, including the role of inflammatory mechanisms and genetic
factors and psychosexual contributors.

[Bachmann
GA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Bachmann+GA"%5BAuthor%5D),
et al. Vulvodynia: a state-of-the-art consensus on definitions,
diagnosis and management. [J Reprod
Med.](javascript:AL_get(this, 'jour', 'J Reprod Med.');) 2006
Jun;51(6):447-56.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16846081>

#### [Editorial comment:]{.underline} Carolyn Aoyama

NIH will be initiating a workshop next fall that will generate
recommended standard classification of uterine fibroids in order to have
consistency in standards of diagnosis, characterization and treatment
protocols.  Dr. Segars at NICHD describes the purpose and date of this
meeting:

Progress of both clinical and translational research on uterine fibroids
is impeded by the lack of a classification system that enables results
from one team to be compared to those from another center. In accordance
with a summary recommendation that arose from the 2nd NIH International
Congress on Uterine Leiomyoma Research, we are planning a meeting at NIH
to devise a classification system for uterine fibroids that may be used
by investigators conducting studies on leiomyoma.

NIH plans to assemble leading investigators from around the world and
interested stakeholders at an NIH workshop in September 2007. The
meeting will include clinicians, surgeons, radiologists, clinical and
basic researchers. Following brief presentations that will highlight
possible elements needed in the classification system, there will be an
effort to arrive at a consensus. The proceedings of the meeting will be
published and subject to peer-review. The one and one-half day meeting
is planned for Thursday September 20th to Friday noon on September 21st.
Please consider this an invitation to participate in this meeting.\"

Contact Carolyn Aoyama <Carolyn.Aoyama@ihs.gov>

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

**TeenScreen Conference: Second Annual**

-   March 14 and 15, 2007

-   Washington D.C.

-   Contact <TSConference@childpsych.columbia.edu>

**IHS Colposcopy Update & Refresher Course**

-   April 16-18, 2007

-   Albuquerque, NM

-   Save the Dates Brochure available

-   Contact <AWaxman@salud.unm.edu>

**2nd** **International Meeting on Indigenous Child Health**

-   April 20-22, 2007

-   Montreal, Quebec, Canada

-   Solutions, not Problems

-   Joint meeting of IHS, AAP-CONACH, First Nations and several other
    stakeholders

-   <http://www.aap.org/nach/2InternationalMeeting.htm>

**2007 IHS APN/PA Meeting**

-   May 21-25, 2007

```{=html}
<!-- -->
```
-   Scottsdale, AZ

-   Nearly 20 hours of credit

<http://www.ihs.gov/MedicalPrograms/clinicalSupportCenter/training.cfm#paapn>

**Training Course** **in MCH** **Epidemiology**

-   Albuquerque, New Mexico

-   June 10 - 15, 2007

-   Sponsored by HRSA / MCHB and CDC

<http://www.crpcorp.info/mchtraining2007.htm>

**2007 Indian Health MCH and Women's Health National Conference**

-   August 15 -17, 2007

-   Albuquerque, NM

-   Internationally recognized speakers

-   Save the dates. Details to follow

-   Want a topic discussed? Contact <nmurphy@scf.cc>

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

**Second methamphetamine issue of the IHS Primary Care Provider now
available online!**

Note that we received more articles than anticipated so some of them
will appear in a third issue to come out later this Spring.

Thanks again for your collaboration and support -- Lori de Ravello

<http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV0107.pdf>

**Check out new Indian Health STD website**

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

**The History of Maternal Child Health in the United States**

<http://www.ihs.gov/MedicalPrograms/MCH/F/pdr.cfm#History>

There are several upcoming **Conferences**

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

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

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

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

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

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

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

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

#### The February 2007 OB/GYN CCC Corner is available at: {#the-february-2007-obgyn-ccc-corner-is-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0207.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0207.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn0207.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

####  Abstract of the Month page 5 {#abstract-of-the-month-page-5-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Low hanging fruit: Promotion of healthy lifestyles during and after
pregnancy- less DM**

#### From your colleagues page 9 {#from-your-colleagues-page-9 .Style-Heading-4-+-Arial-14-pt-Underline}

Steve Holve

#### New Children\'s Health Services Fellowship available {#new-childrens-health-services-fellowship-available .Style-Heading-4-+-Arial-14-pt-Underline}

Sunnah Kim

2nd International Meeting on Indigenous Child Health in Montreal

Judy Thierry

-How do you manage STI treatment for partners? AIAN and non beneficiary?

-Training and course work on epidemiology summer-institute

-Consumer Reports: Only 2 out of 12 infant car seats tested performed
well in crash tests

-AI / AN SIDS kits from CJ foundation available   

-Overweight in toddlers breastfeeding protective dose dependent effect

-New Child Health USA Report Released

and more.....

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

##### Obstetrics page 14

#### -Teamwork Training: Decision to incision times significantly improved {#teamwork-training-decision-to-incision-times-significantly-improved .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Physical activity in pregnancy: Important determinant of birth weight  {#physical-activity-in-pregnancy-important-determinant-of-birth-weight .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Fetal injury and death twice as likely to have been born from 11 pm to 8 am {#fetal-injury-and-death-twice-as-likely-to-have-been-born-from-11-pm-to-8-am .Style-Heading-4-+-Arial-14-pt-Underline}

-VBAC is safer

#### -Induction of labor at 41 completed weeks improves birth outcomes: Cochrane {#induction-of-labor-at-41-completed-weeks-improves-birth-outcomes-cochrane .Style-Heading-4-+-Arial-14-pt-Underline}

and more.....

**Gynecology page 17**

-Outreach workers should follow women with the most severe PAP
abnormalities

-Pelvic Floor Muscle Therapy May Be Best Option for Urinary Incontinence

-Closing the vaginal cuff vertically is superior to horizontal closure
for vaginal length

-TVT and the transobturator tension- free vaginal tape procedures
perform equally

-Prophylactic Oophorectomy in Young Women Carries Increased Mortality
Risk

and more.....

**Child Health page 19**

-Are you interested in acquiring HPV vaccine to provide to 9 -- 18 year
olds?

-South Dakota becomes 2nd State in the Nation to Offer Girls Free Cancer
Vaccine  

-Rapid flu test trims further tests, treatment

-Training Available: The Stanford Pediatric Weight Control Program

-Hepatitis B Vaccine for Infants of HBsAg-Positive Mothers: Cochrane
Briefs

and more.....

**Chronic Illness and Disease page 21**

-Sleepiness and sleep deprivation are associated with injury

-Discourage scheduled work beyond 16 consecutive hours

-Making and Keeping New Year\'s Resolutions: Nine Modifiable Cancer Risk
Factors

-High blood glucose is a leading cause of cardiovascular mortality in
most world regions

-Meta-Analysis Confirms Red Meat Consumption Linked to Colorectal Cancer
Risk

and more.....

#### Features page 27 {#features-page-27 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-Universal Screening for Down Syndrome: Regardless of age

-Hemoglobinopathies in Pregnancy

-Commercial Enterprises in Medical Practice

-Professional Responsibilities in Obstetric--Gynecologic Education

##### American Family Physician

Childhood and Adolescent Depression

**Agency for Healthcare Research and Quality**

-Women\'s self-report of mammography use conflicts with verified reports
using claims data

-Free blood glucose monitors for patients with diabetes encourages
self-management

**Ask a Librarian**

Diet of Pregnant American Indians: Different than Whites?

**Breastfeeding**

-Supporting employee breastfeeding is easier than it sounds

-Simple antenatal intervention improves breastfeeding until 6 months
postpartum

**CCC Corner Digest**

-Organizational silence threatens patient safety

-The 2nd International Meeting on Indigenous Child Health

-Shoulder dystocia: Only 43% participants could achieve delivery before
training

-HPV vaccine is effective: Why do we not provide it to most AI/AN?

-Why do disparities in infant mortality persist between AIAN and white
infants?

\-[Firearm Safety in Homes with
Adolescents](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1206_HT.cfm#chrIll)

\-[Treatment With Selective Serotonin Reuptake Inhibitors During
Pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1206_Feat.cfm#acog)

\-[Levothyroxine Reduces Preterm Birth in Euthyroid
Women](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1206_Feat.cfm#afp)

\-[Flu season and
Breastfeeding](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1206_Feat.cfm#breast)

\-[Improving the Health Care Response to Domestic Violence in AI/AN
Communities](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1206_Feat.cfm#dv)

\-[Bone Loss With Use of Depot Medroxyprogesterone Acetate Slows After 2
Years](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1206_Feat.cfm#fp)

\-[The IHS Breastfeeding Home Page is
live!](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1206_Feat.cfm#webSite)

\-[Patent Wellness
Handout](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1206_Feat.cfm#it)

\-[A nurse, a doctor, and an epidemiologist were standing by the
river......](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1206_Feat.cfm#ih)

\-[A boy has been born in Chile with a fetus in his
stomach](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1206_Feat.cfm#mmtour)

\-[Start 'Em Young for Future Success and Maybe No One Will Be Left
Behind](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1206_Feat.cfm#MidWives)

\-[GYN Spotlight: Endometrial
ablation](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1206_Feat.cfm#navajo)

\-[Nurses less satisfied than physicians or nurse managers: Perceptions
of
teamwork](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1206_Feat.cfm#nurseCorner)

\-[Reduction in Teen
Pregnancies](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1206_Feat.cfm#okie)

\-[97 cesarean deliveries (NNT) prevent serious morbidity / mortality in
second
twins](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1206_Feat.cfm#periPicks)

\-[Less than half of parents with HIV tell their children about the
diagnosis](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1206_Feat.cfm#std)

\-[Diabetes Prevention Study: Participants Still Benefiting Three Years
Later](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1206_Feat.cfm#stillW)

**Domestic Violence**

-Measuring Intimate Partner Violence Victimization and Perpetration: A
Compendium

-Physical Dating Violence Among High School Students -- United States,
2003

**Elder Care News**

Risk of Poor Outcomes From Bariatric Surgery May Be Greater in Elderly

**Family Planning**

#### -Continuous Contraceptive Therapy Safely Abolishes Menstrual Cycles {#continuous-contraceptive-therapy-safely-abolishes-menstrual-cycles .Style-Heading-4-+-Arial-14-pt-Underline}

-FDA Questions and Answers: Ortho Evra

-Access to emergency contraceptive enhances use but not reduce
unintended pregnancy

**Featured Website**

Vaccine Preventable Diseases

**Frequently asked questions**

Are varicella titers necessary prior to immunization?

**Indian Child Health Notes**

-Needle size: "less is more" versus "more is less"

-2007 Childhood and Adolescent Immunization Schedules: Evolution or
Intelligent Design?

-Embracing a Common Destiny: Health for All.

**Information Technology**

Computerized Public Health Activity Data System, Version 1.0
Announcement

International Health

What does the future hold in store?

#### MCH Alert

School based care: 3 articles - Obesity, exercise, and vaccinations

#### Medical Mystery Tour

#### A boy has been born in Chile with a fetus in his stomach {#a-boy-has-been-born-in-chile-with-a-fetus-in-his-stomach .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

**Menopause Management**

Local estrogen just as effective for vaginal atrophy in postmenopausal
women

Life After WHI: Postmenopausal Symptoms and Use of Alternative Therapies
After HRT

Conjugated Equine Estrogen Treatment May Not Increase Breast Cancer Risk

**Midwives Corner**

The Blessed Perineum: PubMed

**Navajo News**

GYN Spotlight: Endometrial ablation

#### Nurses Corner 

#### Getting Your Patient Back to Work: Return-to-Work Restrictions After Illness or Injury

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

#### -I have to go really far just to exercise.....er.... actually no you don't {#i-have-to-go-really-far-just-to-exercise..er.-actually-no-you-dont .Style-Heading-4-+-Arial-14-pt-Underline}

#### -OWH - Year End Re-cap of Available Resources from CDC {#owh---year-end-re-cap-of-available-resources-from-cdc .Style-Heading-4-+-Arial-14-pt-Underline}

**Oklahoma Perspective**

What do patients recall from our counseling?

Osteoporosis

-Steroidal contraceptives influence fracture risk cannot be determined
from existing data

-Strontium ranelate decreases fractures in the spine and slightly
decreases other fractures

Patient Education

#### -Health literacy and depression: Literacy education improves self-efficacy scores {#health-literacy-and-depression-literacy-education-improves-self-efficacy-scores .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Depression in Children and Teens {#depression-in-children-and-teens .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Fish Oil Supplements During Pregnancy Are Safe and Beneficial 

### -Planned cesarean delivery doubles rate of NICU and the risk for pulmonary disorders

#### -Health of children born as a result of IVF was worse than that of singletons {#health-of-children-born-as-a-result-of-ivf-was-worse-than-that-of-singletons .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Preterm birth is significantly associated with antenatal depression {#preterm-birth-is-significantly-associated-with-antenatal-depression .Style-Heading-4-+-Arial-14-pt-Underline}

-Hydroxychloroquine in lupus pregnancy: continuation recommended

Primary Care Discussion Forum

Adolescent with knee pain February 1, 2007

STD Corner

-First Indian Health Special Issue on Methamphetamine is now available
online

# -Key Trainers for Rural HIV Providers

-How do you manage STI treatment for partners? AIAN and non beneficiary?

#### -Routine HIV Screening Deemed Cost-Effective in Average-Risk Populations {#routine-hiv-screening-deemed-cost-effective-in-average-risk-populations .Style-Heading-4-+-Arial-14-pt-Underline}

-Genital Warts: Best Practices for Diagnosis and Management CME/CE

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

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

-Diabetic Moms\' Babies Have Impaired Sucking Reflexes

-HbA1c Early in Diabetic Pregnancy Predicts Outcomes

-Prenatal Multivitamins for Undernourished Women May Reduce Risk of Low
Birth Weight

**Women's Health Headlines**

-What Causes Breast Cancer?

-Women's History Month: March 2007

-Hormone replacement therapy and survival after colorectal cancer
diagnosis

\- New Report on the Detection and Treatment of Ovarian Cancer

-ACOG Releases Revised Recommendations for Women\'s Health Screenings
and Care

###### Save the Dates: Upcoming events of interest page 54

#### What's new on the ITU MCH web pages page 55

-Andy Narva moved to NIH, but is still our Renal CCC

-Diabetes: Understandings About the Causes of Type 2 - Old / New

The past CCC Corners are archived at:

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

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

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

or 907 729 3154 (with voicemail)

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

2/12/07njm