New Feature Columnist

Carolyn Aoyama -- Women's Health Headlines

![](media/image1.png){width="5.992361111111111in"
height="1.3020833333333333in"}

 

OB/GYN Chief Clinical Consultant's Corner

Volume 5, No. 2, February 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}

**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 .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 .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

**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}

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

Gestational diabetes mellitus (GDM) affects approximately 2% to 4% of
all pregnant women in the United States each year. Women who have had
GDM are at high risk for developing nongestational diabetes. The
objective of this study was to assess the prevalence of modifiable risk
factors for developing diabetes among women with previous GDM only.

[Methods]{.underline} Cross-sectional data for nonpregnant women from
the 2003 Behavioral Risk Factor Surveillance System were used to
estimate and compare the prevalence of modifiable risk factors among
three groups: nonpregnant women with previous GDM only, nonpregnant
women with current diabetes, and nonpregnant women without diabetes.

[Results]{.underline} In 2003, 7.6% of nonpregnant women aged 18 years
and older in the United States had current self-reported
physician-diagnosed diabetes, and 1.5% had previous GDM only. Compared
with women without diabetes, women with previous GDM only had higher
prevalence of no leisure-time physical activity (32.0% vs 25.7%),
overweight (62.2% vs 49.0%), and obesity (29.4% vs 20.0%). After
adjusting for sociodemographic variables, women with previous GDM only
were more likely to have no leisure-time physical activity (prevalence
odds ratio \[POR\], 1.4; 95% confidence interval \[CI\], 1.2--1.7) and
more likely to be overweight (POR, 1.8; 95% CI, 1.6--2.2) or obese (POR,
1.7; 95% CI, 1.4--2.1), compared with women with no diabetes.   

[Conclusion]{.underline} Women with previous GDM are more likely to have
modifiable risk factors for developing diabetes than women without
diabetes. More attention to this issue is needed from health care
providers and public health officials to encourage the promotion of
healthy lifestyles during and after pregnancy.

Yun s et al Modifiable risk factors for developing diabetes among women
with previous gestational diabetes. [Prev Chronic
Dis.](javascript:AL_get(this, 'jour', 'Prev Chronic Dis.');) 2007
Jan;4(1):A07

Full Text
<http://www.cdc.gov/pcd/issues/2007/jan/06_0028.htm?s_cid=pcd41a07_e>

Abstract
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17173715>

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

**Women with previous GDM more likely to have modifiable risk factors
for developing DM**

In GDM, many times the chance to make changes in postpartum life style
is squandered. Russell et al, below, report that the glucose often goes
unchecked. One successful model has been the utilization of intense case
management. Here is a model to consider.

[Exercise counseling]{.underline} consists of aerobic activities such as
walking or stationary cycling. Frequency: 3 days per week. Duration:
20-45 minutes per session. Moderate intensity: The "talk-sing test" may
be used (the patient should be able to talk while exercising but not
sing) or rating of perceived exertion (RPE) of "fairly light" to
"somewhat hard".

[Initial exercise consult:]{.underline} Assessment of current physical
activities and level of readiness for exercise education/information on
exercise and GDM, and individualized exercise plan.

**Goals**

The goals of the currently proposed program are to improve maternal and
fetal outcomes of patients with diabetes in pregnancy through more
effective use of existing resources. One key element to maximizing the
utilization of those resources is the coordination by effective Diabetes
in Pregnancy case management.

**Methods**

Key elements that are currently available, but in some cases under
utilized

-Exercise counseling and follow-up

-Diet counseling and follow-up

Additional element often not currently utilized

-Group care sessions / Support groups

**The Program**

There will be pre-assessment of dietary and exercise levels with
standardized dietary and exercise evaluation instruments. If there is
glucose intolerance then all patients will be counseled on monitoring
blood sugar, diet, and exercise.  The program will involve voluntary
enrollment and approval by a prenatal healthcare provider. Candidates
will be excluded if they have medical, obstetric, skeletal, or muscular
disorders that would contraindicate physical exercise in pregnancy.

**Exercise Intervention**

Participants in the lifestyle intervention could receive instruction in
group-session exercises and in home based exercise. In addition to
counseling, patient education and equipment, patients will receive an
appointment with an Exercise Physiologist.   Blood glucose is tested at
the start of each session.   Each woman then exercises for 5-20 minutes
under supervision culminating in post-exercise blood sugar tests.  
Painful movements are addressed by Physical Therapy.   Blood glucose
continues to be monitored at prenatal appointments.  

Recommended activities include walking, swimming, mild aerobics, and
strength exercise (such as lifting a 500 g food can in each hand). Group
sessions will be held weekly. Floor aerobics, stretching, and strength
exercises will be led by professional trainers for \~45 minutes /
session. The participants will be instructed to use a pedometer, self
monitor their heart rate, and record daily activities in a diary before
and after the sessions. Exercise 3-5 times per week for 30 -45 minutes
per session will be recommended for AI participants. The AI participants
will also be given videos and DVD(s) for exercise instruction to assist
in home based exercise. Daily diary information will be gathered,
collected, and analyzed.

The supervised exercise component will include:

Measurement of blood glucose pre- and post exercise

Exercise on treadmill and/or recumbent cycle

Monitored perceived exertion

Monitored blood pressure and/or heart rate

**Dietary intervention**

After the initial dietary assessment, dieticians will provide a
personalized diet plan for participants including recommended changes in
food choice, frequency, portion size, and pattern of intake.
Participants will be evaluated weekly for body weight, total energy
intake, and macronutrient intake in interviews with dieticians.

**Follow-up and data collection**

The post-gestation visit will consist of an evaluation of the general
health of the mothers and infants. Additional information on delivery
mode, gestational weeks, newborn weight, and birth weight related
obstetric interventions (induction, maneuvers, operative vaginal
deliveries, or cesarean delivery) will be obtained from the patient
charts after delivery. Diagnosis of gestational diabetes mellitus (GDM)
or impaired glucose tolerance (one abnormal 3 hr OGTT result) will be
made by both NDDG criteria. Excess weight gain will be assessed based on
pre-pregnant body mass index (BMI).

**Other Background**

Gestational diabetes is highly associated with subsequent glucose
intolerance. After the index pregnancy, the cumulative incidence of
diabetes ranged to over 70% in studies up to 28 years postpartum. (Kim
2002) Differences in rates of progression between ethnic groups was
reduced by adjustment for various lengths of follow-up and testing
rates, so that women appeared to progress to type 2 diabetes at similar
rates after a diagnosis of GDM. Cumulative incidence of type 2 diabetes
increased markedly in the first 5 years after delivery and appeared to
plateau after 10 years. An elevated fasting glucose level during
pregnancy was the risk factor most commonly associated with future risk
of type 2 diabetes. Adjustment for these differences reveals rapid
increases in the cumulative incidence occurring in the first 5 years
after delivery for different racial groups.

Data from an intervention in primary care practices randomized to
intervention and control groups in a large-staff model health
maintenance organization (HMO) revealed that periodic primary care
sessions organized to meet the complex needs of diabetic patients
improved the process of diabetes care and were associated with better
outcomes. (Wagner 2001) There is also randomized data which evaluated
whether in women with previous gestational diabetes chronic amelioration
of insulin resistance would preserve pancreatic beta-cell function and
delay or prevent the onset of type 2 diabetes in high-risk Hispanic
women. In that case the protective effect was associated with the
preservation of pancreatic beta-cell function and appeared to be
mediated by a reduction in the secretory demands placed on beta-cells by
chronic insulin resistance. (Buchanan 2002)

Various risk factors have been suggested. The incidence of diabetes
among Danish women with previous diet-treated GDM was very high and had
more than doubled over a 10-year period. This seems to be due to a
substantial increase in BMI in women with GDM. (Lauenborg 2004)
Targeting women with elevated fasting glucose levels during pregnancy
may prove to have the greatest effect for the effort required. (Kim
2002)

Does diabetes disease management save money and improve outcomes?
Sidorov et al reported simultaneous short-term savings and quality
improvement associated with a health maintenance organization-sponsored
disease management program among patients fulfilling health employer
data and information set criteria. (Sidorov 2002) In this HMO, an opt-in
disease management program appeared to be associated with a significant
reduction in health care costs and other measures of health care use.
There was also a simultaneous improvement in HEDIS measures of quality
care. These data suggest that disease management may result in savings
for sponsored managed care organizations and that improvements in HEDIS
measures are not necessarily associated with increased medical costs.

**After Gestational Diabetes, Postpartum Glucose Goes Unchecked**\
Only 45% women in the cohort underwent postpartum glucose testing, as
recommended.

CONCLUSION: Although persistent abnormal glucose tolerance was common in
our cohort, less than half of the women were tested for it. Our data
suggest that to increase rates of postpartum glucose testing, improved
attendance at the postpartum visit with greater attention to testing and
better continuity between antenatal and postpartum care are required.
LEVEL OF EVIDENCE: II-2. [Russell
MA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Russell+MA"%5BAuthor%5D),
et al Rates of postpartum glucose testing after gestational diabetes
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Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Dec;108(6):1456-62

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17138780>

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

#### Steve Holve, Tuba City {#steve-holve-tuba-city .Style-Heading-4-+-Arial-14-pt-Underline}

#### New Children\'s Health Services Fellowship available {#new-childrens-health-services-fellowship-available-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### This was forwarded by David Grossman. The fellowship includes a stipend and other support {#this-was-forwarded-by-david-grossman.-the-fellowship-includes-a-stipend-and-other-support .Style-Heading-4-+-Arial-14-pt-Underline}

#### More information [**http://www.ichsr.org/Fellowship**](http://www.ichsr.org/Fellowship) E-mail contact [**fellowship@ichsr.org**](mailto:fellowship@ichsr.org) {#more-information-httpwww.ichsr.orgfellowship-e-mail-contact-fellowshipichsr.org .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Sunnah Kim, AAP {#sunnah-kim-aap .Style-Heading-4-+-Arial-14-pt-Underline}

**2nd International Meeting on Indigenous Child Health in Montreal**

Do you plan to attend the 2nd International Meeting on Indigenous Child
Health in Montreal on April 20-22, 2007?  If so, and if you are an
IHS/federal employee, an important deadline is approaching. . .

 

Due to the Canadian location, all US federal employees will need to
obtain a travel order and a federal passport (ie. red passport) to
receive reimbursement. It is noted that one requirement for obtaining a
federal passport is to have a current US passport. The IHS has developed
resource materials outlining the necessary steps to obtain the special
federal passport. While the process is not difficult, it does take about
3 months to process (meaning the deadline is January
20!!). Therefore, federal employees are encouraged to begin this process
ASAP, if you plan to attend!  For instructions on obtaining this
passport and a travel order, see the attached Word document or visit
[www.aap.org/nach/2InternationalMeeting.htm](http://www.aap.org/nach/2InternationalMeeting.htm)

 

FOR ALL US ATTENDEES:  As of January 1, 2007, those traveling by air or
sea to and from Canada will be required to have a passport or other
secure, accepted document to enter or re-enter the United
States. Therefore, it is strongly recommended that all potential
International Meeting attendees obtain a US passport if they do not
already have one. Additional information on obtaining a US passport,
including application materials, can be found at the link above. 

 

The International Meeting will be a great opportunity for health
professionals working with or interested in AI/AN child health to learn
from the experiences of others who work with indigenous populations in
both the US and Canada. The theme of this conference will be
\"Solutions, Not Problems\". Additional information about the conference
will be forthcoming via a conference brochure which will be sent to all
IH-SIG members. Information can also be found on the conference Web
pages (via the link above). 

We hope to see you in Montreal!

Sunnah

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

#### Judy Thierry, HQE {#judy-thierry-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**How do you manage STI treatment for partners? AIAN and non
beneficiary?**

Partner Management: Once cases are found, they must be interviewed to
identify recent sex partners so that those partners can also be treated.
Partner management services such as this are usually handled by the
state department of health Disease Intervention Specialist (DIS) and
sometimes in collaboration with the Public Health Nursing (PHN) staff,
or tribal STD/HIV program staff. How are they managed at your facility?
How can they be managed better?

Contact <Judith.Thierry@ihs.gov>

**Training and course work on epidemiology summer-institute**

Thinking of summertime ? Oregon ???

The Summer institute curriculum is designed to meet the needs of
professionals who work in diverse areas of American Indian and Alaska
Native health, from administrators to community health workers,
physicians, nurses, researchers, and program managers.

Courses are presented in a modular one-week format for three weeks.\
Courses will be held on two campuses in downtown Portland, Oregon.  Most
courses will meet on the campus of Oregon Health & Science University in
Portland, Oregon. A few courses will be hosted nearby at The Northwest
Portland Area Indian Health Board, located on the campus of Portland
State University. The registration deadline is May 15th, 2006.

<http://www.ohsu.edu/summer-institute/>

**Consumer Reports: Only 2 out of 12 infant car seats tested performed
well in crash tests**

Consumer's Union, publisher of Consumer Reports, conducted crash tests
on 12 infant car seats at 35 mph (frontal crash) and 38 mph (side-impact
crash), the speeds currently used to crash test most new cars and
minivans.  Base-mounted, rear-facing seats, suitable for children under
one year and 22 lbs according to the manufacturers, were found to detach
from their bases or twist violently, damaging test dummies in some
cases.  While the federal New Car Assessment Program scores crash safety
in the form of highly publicized "star" ratings, no similar for score is
used to rate infant and child safety seats.  Manufacturers have improved
car designs based on star ratings but there is no such incentive for car
seat manufacturers.   The tests also highlighted on-going problems with
the federally-mandated LATCH system, where most car seats performed less
well using LATCH than when attached with vehicle safety belts.   A NHTSA
report issued late last month stated that 40% of parents use safety
belts instead of the LATCH system because of confusion about the
system. 

Press release from Consumer's Union:

<http://www.consumerreports.org/cro/babies-kids/child-car-booster-seats/car-seats-2-07/overview/0207_seats_ov.htm>

NHTSA report, Child Restraint Use Survey: LATCH Use and Misuse:

[http://www.nhtsa.gov/staticfiles/DOT/NHTSA/Communication%20&%20Consumer%20Information/Articles/Associated%20Files/LATCH_Report_12-2006.pdf](http://www.nhtsa.gov/staticfiles/DOT/NHTSA/Communication & Consumer Information/Articles/Associated Files/LATCH_Report_12-2006.pdf)

American Academy of Pediatrics Jan 2007 posting AAP infant passenger
seat -- guide to parents:

<http://www.aap.org/family/infantpassengersafety.htm>

SEAT sold in Europe top performer in crash tests:

<http://www.consumerreports.org/cro/babies-kids/child-car-booster-seats/car-seats-2-07/european-models/0207_seats_euro.htm>

**AI / AN SIDS kits from CJ foundation available   **

Produced by the CJ foundation in collaboration with Aberdeen Area Tribal
Chairman\'s Health Board (AATCHB) and the Great Lakes Inter Tribal
Council (GLITC) these kits provide videos, posters, pamphlets for
patient and community education.  Training materials, PSA's are
included.  Kits focus on sensitive risk reduction messages for moms,
cover infant sleep positioning and 'back to sleep' messaging, use
intergenerational messages, integrate parent and father focus, cover
teen pregnancy psycho-social aspects.  Materials are based on stages of
change theory.  Materials are derived from the communities themselves
and can be adapted (with acknowledgement of CJfoundation).
 Katproductions provided the technical aspects of production, filming
and hard print materials.

A mass mail-out in 2003 to distributed kits to all tribes, federal and
urban programs. 

KITS WILL ONLY BE AVAILABLE THROUGH JANUARY 2007!            

The American Indian & Alaska Native SIDS Risk Reduction Resource Kit -
order in as small or large a quantity as needed (and while supplies
last). To place your order, please email: [David
Mayer](mailto:dmayer@katproductions.com) with subject line: AI KITS.
 Include name, complete mailing address and the number of kits to be
delivered. Emails with incomplete mailing addresses will not be
processed. The kits and shipping are offered free of charge through the
CJ Foundation for SIDS.  Please allow 3-4 weeks for delivery.
<http://www.cjsids.com/>

**Overweight in toddlers breastfeeding protective dose dependent
effect**

Like the chicken and the egg -- the question of when does obesity start
and where to tackle it is provoking.  This Medscape/ article/cme is a
great 10 to 15 minute read taking you through the evidence behind
toddler obesity and what WIC, health care workers of all professions and
parents need to do.  -- Medscape CEU -- integrates interview, history,
and measures to address healthy weight and age appropriate activities
for children.  I highly recommend reading this!

A few excerpts to wet your appetite:

... Recent meta-analysis...studies on breast-feeding effects on future
weight outcome ... breast-feeding is significantly related to a lower
risk for the development of obesity and that there is a dose-dependent
effect. That is, for each month of breast-feeding, there is an
associated 4% decrease in the risk of developing obesity. The odds ratio
(OR) for obesity in infants breast-fed longer than 9 months was 0.68,
indicating a decrease in the likelihood of being obese if an infant was
breast-fed for more than 9 months. 

Harder T, Bergmann R, Kallischnigg G, Plagemann A. Duration of
breastfeeding and risk of overweight: A meta-analysis. J Epidemiol.
2005; 162:397-403.

AND

... intake patterns during toddlerhood foreshadow shortcomings of
children\'s diets noted in later developmental periods in that fruit and
vegetable intake is notably low, even absent in some children. Among
toddlers aged 1 year and older, 18% to 23% consumed no vegetables, and
between 25% to 33% consumed no fruit. By the age 15 months, french fries
were the most commonly consumed vegetable and 44% of toddlers consumed a
sweetened beverage daily. Skinner JD, Ziegler P, Pac S, DeVaney B. Meal
and snack patterns of infants and toddlers. J Am Diet Assoc. 2004;
104:S65-S70.

AND

... children learn to prefer the familiar, so that the foods caregivers
purchase for the home and send in prepared lunches, and the types of
foods children consume outside the home, provide a foundation for
children\'s later food preferences. In one study, preschool-aged
children were given either a sweet, salty or plain version of a novel
food as a series of snacks. Regardless of their assigned version, over
time children showed higher preference for the food they were repeatedly
served (5 to 10 times) as compared to the unfamiliar versions.

Sullivan SA, Birch LL. Pass the sugar, pass the salt: experience
dictates preference. Dev Psychol. 1990;26:546-551.

AND

Pressuring children to eat can also undermine the child\'s own sense of
fullness as the sign to stop eating. Birch and colleagues also found
that focusing children on the amount of food remaining on the plate, the
time on the clock, or rewarding for finishing the food on their plate
disrupted the child\'s ability to self-regulate energy intake at a meal.

Birch LL, McPhee L, Shoba BC, Steinberg L, Krehbiel R. \"Clean up your
plate\": effects of child feeding practices on the conditioning of meal
size. Learning and motivation. Learning Motivation. 1987;18:301-317.

[http://www.medscape.com/viewarticle/520834?sssdmh=dm1.237155&src=top10#](http://www.medscape.com/viewarticle/520834?sssdmh=dm1.237155&src=top10)

**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.  \[initiation,
    exclusivity, duration- Thierry\]

-   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. \[see Kay
    Tomashek et al. article in Dec 06 APHA AIAN low birth weight -- also
    mentioned in the Chief Clinical Consultant Corner\*\]

-   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.
<http://www.mchb.hrsa.gov/mchirc/chusa_05/index.htm>

\* Kay Tomashek et al. article in Dec 06 APHA AIAN low birth weight in
December CCC Corner

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1206_HT.cfm#child>

**The infant mortality rate for 2004 was 6.79 infant deaths per 1,000
live births**

The 10 leading causes of infant mortality for 2004

![](media/image2.png){width="0.3333333333333333in"
height="8.333333333333333e-2in"}Congenital malformations, deformations
and chromosomal abnormalities (congenital malformations);

![](media/image2.png){width="0.3333333333333333in"
height="8.333333333333333e-2in"}Disorders related to short gestation and
low birth weight, not elsewhere classified (low birthweight);

![](media/image2.png){width="0.3333333333333333in"
height="8.333333333333333e-2in"}Sudden infant death syndrome (SIDS);

![](media/image2.png){width="0.3333333333333333in"
height="8.333333333333333e-2in"}Newborn affected by maternal
complications of pregnancy (maternal complications);

![](media/image2.png){width="0.3333333333333333in"
height="8.333333333333333e-2in"}Accidents (unintentional injuries);

![](media/image2.png){width="0.3333333333333333in"
height="8.333333333333333e-2in"}Newborn affected by complications of
placenta, cord and membranes (cord and placental complications);

![](media/image2.png){width="0.3333333333333333in"
height="8.333333333333333e-2in"}Respiratory distress of newborn;

![](media/image2.png){width="0.3333333333333333in"
height="8.333333333333333e-2in"}Bacterial sepsis of newborn;

![](media/image2.png){width="0.3333333333333333in"
height="8.333333333333333e-2in"}Neonatal hemorrhage; and

![](media/image2.png){width="0.3333333333333333in"
height="8.333333333333333e-2in"}Diseases of the circulatory system

<http://www.cdc.gov/nchs/products/pubs/pubd/hestats/finaldeaths04/finaldeaths04.htm>

**Genomics: study of gene to gene and gene to environment interactions**

Genomics is the study of the entire genome, including all genes and
their interactions with each other and with the environment. The scope
of public health genomics is even broader, encompassing genetic
variation in populations, both human and microbial. Molecular typing of
pathogens\-\--a mainstay of infectious disease surveillance, prevention,
and control\-\--already is used to trace epidemics, provide information
for vaccine development, and monitor drug resistance. Now genomic
research is producing powerful new tools for public health; for example,
a newly described, microchip-based method promises to diagnose influenza
infection, distinguish among viruses of human or animal origin, and
detect mutations that suggest increasing virulence\-\--all in a matter
of hours .\
\
Until recently, public health applications of human genetics were
limited largely to state-mandated programs that screened newborn infants
and ensured access to genetic services for affected children and
families. Now genomic research and technology have generated new
molecular targets and new tests for newborn screening, kindling renewed
debate on their relative benefits, risks, and costs. Public health
investigations of diseases with infectious and environmental causes also
are beginning to evaluate the contribution of human genetic variation to
susceptibility and natural history.\
\
Most population-based research in genetic epidemiology has focused on
common, chronic diseases, as reflected in approximately 22,000
scientific publications during the last 5 years (9). The results point
to complex interactions among multiple genes and environmental factors,
which remain poorly understood. However, small successes in translation
illustrate the potential for public health genomics in three areas:

-   stratifying risk to guide multilevel interventions,

-   understanding environmental causes of disease, and

-   identifying new opportunities for prevention.

Family health history, which captures information about shared inherited
and environmental factors, is a simple and inexpensive genomic tool for
identifying persons and families at high risk. For example, a Utah study
indicated that the 14% of families with positive family histories for
coronary heart disease (CHD) accounted for 48% of all persons with CHD
and for 72% of CHD events occurring before age 55 years.
Population-based data and careful cost-effectiveness analysis are needed
to determine whether combining traditional, population-level prevention
strategies with more intensive interventions for families at increased
risk will improve the return on investment in prevention.\
\
Public health interventions are based on understanding and modifying
environmental risk factors. For example, recognition of inadequate
folate status as a cause of neural tube defects led to an effective
public health intervention to increase folic acid intake among
reproductive-aged women. A systematic review of epidemiologic data on
birth defects in relation to folic acid intake and variation in the
methylenetetrahydrofolate reductase (MTHFR) gene illustrates \"Mendelian
randomization\", in which the effects of specific environmental
exposures, such as dietary elements, drugs or toxins, are either
accentuated or mitigated in persons with different variants of genes
involved in physiologic response. Because genotype is \"randomized\" at
birth, biologic information thus can strengthen evidence obtained from
traditional environmental risk factor studies and provide a less biased
framework for interpreting data on gene-environment interactions.\
\
Public health genomics can provide information about population-level
interventions that do not depend on knowledge of individual genotypes.
For example, a study in Mexico of children with asthma found that
supplementation with the antioxidant vitamins C and E improved lung
function in children with a common polymorphism of glutathione
S-transferase M1 (GSTM1) who are exposed to ozone. If confirmed by other
studies, this finding might suggest a simple
intervention\-\--antioxidant vitamin supplementation\-\--for children
with asthma who are exposed to ozone. Without genotype-specific
analysis, a potentially important population-level intervention could
have been overlooked.\
\
Just as genomics will enhance the knowledge base for public health
research and practice, public health principles and methods can provide
information for genomics research and translation. Rigorous application
of population-based methods for collecting, evaluating, and interpreting
the evidence on genetic variation in relation to health and disease will
improve research quality, promote knowledge synthesis, and help identify
research gaps. By keeping the focus on population-level implications,
the public health perspective helps ensure the entire population
benefits from public investment in genomics research.

[[http://www.cdc.gov/mmwr/preview/mmwrhtml/su5502a8.htm?s_cid=su5502a8_e]{.underline}](http://www.cdc.gov/mmwr/preview/mmwrhtml/su5502a8.htm?s_cid=su5502a8_e)

# 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}

#### Teamwork Training: Decision to incision times significantly improved {#teamwork-training-decision-to-incision-times-significantly-improved-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Training, as was conducted and implemented, did not transfer to a detectable impact in this study. The Adverse Outcome Index could be an important tool for comparing obstetric outcomes within and between institutions to help guide quality improvement. LEVEL OF EVIDENCE: I. {#conclusion-training-as-was-conducted-and-implemented-did-not-transfer-to-a-detectable-impact-in-this-study.-the-adverse-outcome-index-could-be-an-important-tool-for-comparing-obstetric-outcomes-within-and-between-institutions-to-help-guide-quality-improvement.-level-of-evidence-i. .Style-Heading-4-+-Arial-14-pt-Underline}

[Nielsen
PE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Nielsen+PE"%5BAuthor%5D),
et al Effects of Teamwork Training on Adverse Outcomes and Process of
Care in Labor and Delivery: A Randomized Controlled Trial. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Jan;109(1):48-55

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197587>

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

**Put innovation into motion:** **National Indian Health MCH and Women's
Health meeting**

Another successful example is the 100,000 Lives Campaign, which is an
initiative to engage US hospitals in a commitment to implement changes
in care proven to improve patient care and prevent avoidable deaths. The
Institute for Healthcare Improvement estimates that the lives saved as
of June 14, 2006 was 122,300.

To that end, the **National Indian Health MCH and Women's Health
meeting**, August 15-17, 2007 in Albuquerque will highlight speakers
from the Institute for Healthcare Improvement and others that have
evaluated and treated various health care systems. The meeting has
individual facility program review as well as many hours of CME/CEUs.

Your facility should send a team of staff to the above meeting, e. g.,
you and 2-3 other colleagues from different disciplines should start
planning now.

**National Indian Health MCH and Women's Health meeting**

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

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

#### Infants born to women in the highest quartile of physical activity weighed 608 g less than infants born to women in the lowest quartile. The inverse relationship between physical activity and fetal growth ratio was moderated by maternal height; virtually all the effect was seen in mothers taller than the sample median (1.65 m). Similar relationships were found across methods of physical activity measurement. [CONCLUSION]{.underline}: Aerobic physical activity in pregnancy may be an important determinant of birth weight within the normal range, especially in taller mothers. LEVEL OF EVIDENCE: II. [Perkins CC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Perkins+CC"%5BAuthor%5D), et al Physical Activity and Fetal Growth During Pregnancy. [Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007 Jan;109(1):81-87 {#infants-born-to-women-in-the-highest-quartile-of-physical-activity-weighed-608-g-less-than-infants-born-to-women-in-the-lowest-quartile.-the-inverse-relationship-between-physical-activity-and-fetal-growth-ratio-was-moderated-by-maternal-height-virtually-all-the-effect-was-seen-in-mothers-taller-than-the-sample-median-1.65-m.-similar-relationships-were-found-across-methods-of-physical-activity-measurement.-conclusion-aerobic-physical-activity-in-pregnancy-may-be-an-important-determinant-of-birth-weight-within-the-normal-range-especially-in-taller-mothers.-level-of-evidence-ii.-perkins-cc-et-al-physical-activity-and-fetal-growth-during-pregnancy.-obstet-gynecol.-2007-jan109181-87 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197591**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197591) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17197591 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-5 .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-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Fetuses sustaining injuries resulting in death were more than twice as likely as controls to have been born from 11 pm to 8 am. Further studies are needed to determine the factors that affect this association and what changes might need to be made to optimize care regardless of time of day or night {#conclusion-fetuses-sustaining-injuries-resulting-in-death-were-more-than-twice-as-likely-as-controls-to-have-been-born-from-11-pm-to-8-am.-further-studies-are-needed-to-determine-the-factors-that-affect-this-association-and-what-changes-might-need-to-be-made-to-optimize-care-regardless-of-time-of-day-or-night .Style-Heading-4-+-Arial-14-pt-Underline}

[Urato
AC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Urato+AC"%5BAuthor%5D),
et al The association between time of birth and fetal injury resulting
in death. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Dec;195(6):1521-6.

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16723102**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16723102) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids16723102 .Style-Heading-4-+-Arial-14-pt-Underline}

**VBAC is safer**

Among VBAC candidates who have had a prior vaginal delivery, those who
attempt a VBAC trial have decreased risk for overall major maternal
morbidities, as well as maternal fever and transfusion requirement
compared with women who elect repeat cesarean delivery. Physicians
should make this more favorable benefit-risk ratio explicit when
counseling this patient subpopulation on a trial of labor.

[Cahill
AG](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Cahill+AG"%5BAuthor%5D),
et al Is vaginal birth after cesarean (VBAC) or elective repeat cesarean
safer in women with a prior vaginal delivery? [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Oct;195(4):1143-7

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16846571>

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

#### Induction of labor at 41 completed weeks improves birth outcomes: Cochrane {#induction-of-labor-at-41-completed-weeks-improves-birth-outcomes-cochrane-1 .Style-Heading-4-+-Arial-14-pt-Underline}

[Authors\' conclusions]{.underline}: A policy of labour induction after
41 completed weeks or later compared to awaiting spontaneous labour
either indefinitely or at least one week is associated with fewer
perinatal deaths. However, the absolute risk is extremely small. Women
should be appropriately counselled on both the relative and absolute
risks.

#### Gülmezoglu AM, Crowther CA, Middleton P. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004945. DOI: 10.1002/14651858.CD004945.pub2. {#gülmezoglu-am-crowther-ca-middleton-p.-induction-of-labour-for-improving-birth-outcomes-for-women-at-or-beyond-term.-cochrane-database-of-systematic-reviews-2006-issue-4.-art.-no.-cd004945.-doi-10.100214651858.cd004945.pub2. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions**](http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions) {#httpwww.ihs.govmedicalprogramscirindex.cfmmodulecir_answering_clinical_questions .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Conservative management for pregnant women with carcinoma in situ of the uterine cervix {#conservative-management-for-pregnant-women-with-carcinoma-in-situ-of-the-uterine-cervix .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: We recommend conservative management for women with carcinoma in situ of the uterine cervix. We found no difference for the route of delivery regarding postpartum regression and recommend a postpartum evaluation after the puerperium. Colposcopic guided biopsy should rule out an invasive process during pregnancy. Cesarean section as the mode of delivery should be considered, if invasion is suspected. {#conclusions-we-recommend-conservative-management-for-women-with-carcinoma-in-situ-of-the-uterine-cervix.-we-found-no-difference-for-the-route-of-delivery-regarding-postpartum-regression-and-recommend-a-postpartum-evaluation-after-the-puerperium.-colposcopic-guided-biopsy-should-rule-out-an-invasive-process-during-pregnancy.-cesarean-section-as-the-mode-of-delivery-should-be-considered-if-invasion-is-suspected. .Style-Heading-4-+-Arial-14-pt-Underline}

[Ackermann
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Ackermann+S"%5BAuthor%5D),
et al Management and course of histologically verified cervical
carcinoma in situ during pregnancy. [Acta Obstet Gynecol
Scand.](javascript:AL_get(this, 'jour', 'Acta Obstet Gynecol Scand.');)
2006;85(9):1134-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16929422>

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

#### Cerebral Palsy Linked With Preterm Birth, Maternal Age and Other Factors {#cerebral-palsy-linked-with-preterm-birth-maternal-age-and-other-factors .Style-Heading-4-+-Arial-14-pt-Underline}

#### Even if it is recognized that most cases of CP are due to antenatal events, our study revealed associations between various perinatal factors and cerebral palsy. CONCLUSION: Preterm birth entails a high risk for CP, but 65% of these children are born at term. Several obstetric factors and low Apgar scores are associated with CP. LEVEL OF EVIDENCE: II-2. {#even-if-it-is-recognized-that-most-cases-of-cp-are-due-to-antenatal-events-our-study-revealed-associations-between-various-perinatal-factors-and-cerebral-palsy.-conclusion-preterm-birth-entails-a-high-risk-for-cp-but-65-of-these-children-are-born-at-term.-several-obstetric-factors-and-low-apgar-scores-are-associated-with-cp.-level-of-evidence-ii-2. .Style-Heading-4-+-Arial-14-pt-Underline}

[Thorngren-Jerneck
K](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Thorngren-Jerneck+K"%5BAuthor%5D),
et al Perinatal factors associated with cerebral palsy in children born
in Sweden. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Dec;108(6):1499-505

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17138786>

#### Controlled-release misoprostol effectively induced labor in parous women at term {#controlled-release-misoprostol-effectively-induced-labor-in-parous-women-at-term .Style-Heading-4-+-Arial-14-pt-Underline}

#### OBJECTIVE: To assess the ability of a controlled-release misoprostol vaginal insert to induce labor using dose reservoirs of 25, 50, 100, and 200 microg. CONCLUSION: Misoprostol vaginal inserts effectively induced labor in pregnant parous women at term. LEVEL OF EVIDENCE: I. {#objective-to-assess-the-ability-of-a-controlled-release-misoprostol-vaginal-insert-to-induce-labor-using-dose-reservoirs-of-25-50-100-and-200-microg.-conclusion-misoprostol-vaginal-inserts-effectively-induced-labor-in-pregnant-parous-women-at-term.-level-of-evidence-i. .Style-Heading-4-+-Arial-14-pt-Underline}

Ewert K et al Controlled-release misoprostol vaginal insert in parous
women for labor induction: a randomized controlled trial. Obstet
Gynecol.  2006; 108(5):1130-7

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17077234**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17077234) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17077234 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### No evidence to show regional anesthesia is superior for maternal or neonatal outcomes {#no-evidence-to-show-regional-anesthesia-is-superior-for-maternal-or-neonatal-outcomes .Style-Heading-4-+-Arial-14-pt-Underline}

#### AUTHORS\' CONCLUSIONS: There is no evidence from this review to show that RA is superior to GA in terms of major maternal or neonatal outcomes. Further research to evaluate neonatal morbidity and maternal outcomes, such as satisfaction with technique, will be useful. {#authors-conclusions-there-is-no-evidence-from-this-review-to-show-that-ra-is-superior-to-ga-in-terms-of-major-maternal-or-neonatal-outcomes.-further-research-to-evaluate-neonatal-morbidity-and-maternal-outcomes-such-as-satisfaction-with-technique-will-be-useful. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Afolabi BB, Lesi FEA, Merah NA. Regional versus general anaesthesia for caesarean section. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004350. DOI: 10.1002/14651858.CD004350.pub2. {#afolabi-bb-lesi-fea-merah-na.-regional-versus-general-anaesthesia-for-caesarean-section.-cochrane-database-of-systematic-reviews-2006-issue-4.-art.-no.-cd004350.-doi-10.100214651858.cd004350.pub2. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions**](http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions) {#httpwww.ihs.govmedicalprogramscirindex.cfmmodulecir_answering_clinical_questions-1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### National recommendations for preconception care: Essential role of primary care {#national-recommendations-for-preconception-care-essential-role-of-primary-care .Style-Heading-4-+-Arial-14-pt-Underline}

#### The Centers for Disease Control and Prevention have published national recommendations for improving preconception health and health care in response to unfavorable aspects of the health status of women and children in the United States. The publication explains that the national recommendations are part of a strategic plan for improving preconception health through the provision of clinical care as well as the promotion of changes in individual behaviors, health policy, and public health strategies. The concept of preconception care has been articulated for well over a decade but has not become part of the routine practice of family medicine. Because all women of reproductive age presenting to the primary care setting are candidates for preconception care, the essential and critical role of family physicians in the provision of preconception care is apparent. As a specialty, we are now challenged to devise ways to effectively translate the concept of preconception care into clinical reality. {#the-centers-for-disease-control-and-prevention-have-published-national-recommendations-for-improving-preconception-health-and-health-care-in-response-to-unfavorable-aspects-of-the-health-status-of-women-and-children-in-the-united-states.-the-publication-explains-that-the-national-recommendations-are-part-of-a-strategic-plan-for-improving-preconception-health-through-the-provision-of-clinical-care-as-well-as-the-promotion-of-changes-in-individual-behaviors-health-policy-and-public-health-strategies.-the-concept-of-preconception-care-has-been-articulated-for-well-over-a-decade-but-has-not-become-part-of-the-routine-practice-of-family-medicine.-because-all-women-of-reproductive-age-presenting-to-the-primary-care-setting-are-candidates-for-preconception-care-the-essential-and-critical-role-of-family-physicians-in-the-provision-of-preconception-care-is-apparent.-as-a-specialty-we-are-now-challenged-to-devise-ways-to-effectively-translate-the-concept-of-preconception-care-into-clinical-reality. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Dunlop AL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Dunlop+AL"%5BAuthor%5D), [Jack B](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Jack+B"%5BAuthor%5D), [Frey K](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Frey+K"%5BAuthor%5D). National recommendations for preconception care: the essential role of the family physician. [J Am Board Fam Med.](javascript:AL_get(this, 'jour', 'J Am Board Fam Med.');) 2007 Jan-Feb;20(1):81-4. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17204739&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17204739&dopt=Abstract) {#dunlop-al-jack-b-frey-k.-national-recommendations-for-preconception-care-the-essential-role-of-the-family-physician.-j-am-board-fam-med.-2007-jan-feb20181-4.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids17204739doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

Maternal Oxygen Affects Nonreassuring FHR Patterns

**Results:** The mean increase in fetal oxygen saturation was 4.9
percent for 40 percent Fio2 and 6.5 percent for 100 percent Fio2. In
fetuses with an initial oxygen saturation of 30 to 40 percent, the
increases in saturation were 7.0 percent for 40 percent Fio2 and 12.6
percent for 100 percent Fio2. Fetuses with the lowest initial oxygen
saturation had the greatest improvement in their oximetry readings. All
of these increases were statistically significant compared with room air
oximetry levels. These results were consistent regardless of which of
the five nonreassuring FHR patterns were present.

**Conclusion:** The authors conclude that providing supplemental oxygen
to women in labor significantly increases fetal oxygen saturation in
fetuses with nonreassuring FHR patterns. They add that those with the
lowest oxygen saturation seem to benefit the most from maternal oxygen
supplementation.

#### Haydon ML, et al. The effect of maternal oxygen administration on fetal pulse oximetry during labor in fetuses with nonreassuring fetal heart rate patterns. Am J Obstet Gynecol September 2006;195:735-8. [**http://www.aafp.org/afp/20070101/tips/5.html**](http://www.aafp.org/afp/20070101/tips/5.html) {#haydon-ml-et-al.-the-effect-of-maternal-oxygen-administration-on-fetal-pulse-oximetry-during-labor-in-fetuses-with-nonreassuring-fetal-heart-rate-patterns.-am-j-obstet-gynecol-september-2006195735-8.-httpwww.aafp.orgafp20070101tips5.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Fetal death remains a significant and understudied problem {#fetal-death-remains-a-significant-and-understudied-problem .Style-Heading-4-+-Arial-14-pt-Underline}

#### The death of a formed fetus is one of the most emotionally devastating events for parents and clinicians. With improved care for conditions such as RhD alloimmunization, diabetes, and preeclampsia, the rate of fetal death in the United States decreased substantially in the mid twentieth century. However, the past several decades have seen much greater reductions in neonatal death rates than in fetal death rates. As such, fetal death remains a significant and understudied problem that now accounts for almost 50% of all perinatal deaths. The availability of prostaglandins has greatly facilitated delivery options for patients with fetal death. Risk factors for fetal death include African American race, advanced maternal age, obesity, smoking, prior fetal death, maternal diseases, and fetal growth impairment. There are numerous causes of fetal death, including genetic conditions, infections, placental abnormalities, and fetal--maternal hemorrhage. Many cases of fetal death do not undergo adequate evaluation for possible causes. Perinatal autopsy and placental examination are perhaps the most valuable tests for the evaluation of fetal death. Antenatal surveillance and emotional support are the mainstays of subsequent pregnancy management. Outcomes may be improved in women with diabetes, hypertension, red cell alloimmunization, and antiphospholipid syndrome. However, there is considerable room for further reduction in the fetal death rate. {#the-death-of-a-formed-fetus-is-one-of-the-most-emotionally-devastating-events-for-parents-and-clinicians.-with-improved-care-for-conditions-such-as-rhd-alloimmunization-diabetes-and-preeclampsia-the-rate-of-fetal-death-in-the-united-states-decreased-substantially-in-the-mid-twentieth-century.-however-the-past-several-decades-have-seen-much-greater-reductions-in-neonatal-death-rates-than-in-fetal-death-rates.-as-such-fetal-death-remains-a-significant-and-understudied-problem-that-now-accounts-for-almost-50-of-all-perinatal-deaths.-the-availability-of-prostaglandins-has-greatly-facilitated-delivery-options-for-patients-with-fetal-death.-risk-factors-for-fetal-death-include-african-american-race-advanced-maternal-age-obesity-smoking-prior-fetal-death-maternal-diseases-and-fetal-growth-impairment.-there-are-numerous-causes-of-fetal-death-including-genetic-conditions-infections-placental-abnormalities-and-fetalmaternal-hemorrhage.-many-cases-of-fetal-death-do-not-undergo-adequate-evaluation-for-possible-causes.-perinatal-autopsy-and-placental-examination-are-perhaps-the-most-valuable-tests-for-the-evaluation-of-fetal-death.-antenatal-surveillance-and-emotional-support-are-the-mainstays-of-subsequent-pregnancy-management.-outcomes-may-be-improved-in-women-with-diabetes-hypertension-red-cell-alloimmunization-and-antiphospholipid-syndrome.-however-there-is-considerable-room-for-further-reduction-in-the-fetal-death-rate. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197601**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197601) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17197601 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

A health care system in which many women fail to get follow-up care for
an abnormal Pap smear, outreach workers were more effective than usual
care (mail or telephone reminders) at increasing follow-up rates. The
results suggest that outreach workers should manage their effort based
on the degree of abnormality; most effort should be placed on women with
the most severe abnormality (high-grade squamous intraepithelial
lesion).

Wagner TH, Engelstad LP, McPhee SJ, Pasick RJ. The costs of an outreach
intervention for low-income women with abnormal Pap smears. Prev Chronic
Dis 2007 Jan <http://www.cdc.gov/pcd/issues/2007/jan/06_0058.htm>

**Pelvic Floor Muscle Therapy May Be Best Option for Urinary
Incontinence**

CONCLUSIONS: In women who have already had simple behavioural therapies
(including advice on PFM exercises) for urinary dysfunction, the
continuation of these behavioural therapies can lead to further
improvement. The addition of vaginal cone therapy or intensive PFMT does
not seem to contribute to further improvement. The improvement in pelvic
floor function was significantly greater in the PFMT arm than in the
control arm although this did not translate into changes in urinary
symptoms.

[Williams
KS](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Williams+KS"%5BAuthor%5D),
et al A randomized controlled trial of the effectiveness of pelvic floor
therapies for urodynamic stress and mixed incontinence. [BJU
Int.](javascript:AL_get(this, 'jour', 'BJU Int.');) 2006
Nov;98(5):1043-50

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17034605>

**Closing the vaginal cuff vertically is superior to horizontal closure
for vaginal length**

RESULTS: Preoperatively mean vaginal lengths in the horizontal and
vertical groups were statistically similar (7.76 +/- 1.23 cm versus 8.28
+/- 1.39 cm, respectively; P = .21). Postoperatively the groups
statistically differed (6.63 +/- 1.02 cm versus 7.93 +/- 1.18 cm, P \<
.001). The mean change in vaginal length was -1.13 +/- 1.15 cm and -0.35
+/- 0.91 cm, respectively (P = .01). CONCLUSION: Closing the vaginal
cuff vertically is superior to horizontal closure for the purpose of
preserving vaginal length.

Vassallo BJ et al A randomized trial comparing methods of vaginal cuff
closure at vaginal hysterectomy and the effect on vaginal length Am J
Obstet Gynecol.  2006; 195(6):1805-8

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17132483>

**TVT and the transobturator tension- free vaginal tape 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](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Laurikainen+E"%5BAuthor%5D),
et al Retropubic Compared With Transobturator Tape Placement in
Treatment of Urinary Incontinence: A Randomized Controlled Trial.
[Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');)
2007 Jan;109(1):4-11.

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

**Prophylactic Oophorectomy in Young Women Carries Increased Mortality
Risk**

We aimed to investigate survival patterns in a population-based sample
of women who had received an oophorectomy and compare these with women
who had not received an oophorectomy. CONCLUSION: Although prophylactic
bilateral oophorectomy undertaken before age 45 years is associated with
increased mortality, whether it is causal or merely a marker of
underlying risk is uncertain.

[Rocca
WA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Rocca+WA"%5BAuthor%5D),
et al Survival patterns after oophorectomy in premenopausal women: a
population-based cohort study. [Lancet
Oncol.](javascript:AL_get(this, 'jour', 'Lancet Oncol.');) 2006
Oct;7(10):821-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17012044>

**Less complications for transobturator tape than TVT**

### [Conclusion]{.underline} Transobturator tape is associated with a lower rate of bladder injury, a decreased incidence of postoperative anticholinergic medication use, and fewer urethrolyses for postoperative voiding dysfunction or urinary urgency than tension-free vaginal tape. 

[Barber
MD](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Barber+MD"%5BAuthor%5D),
et al Perioperative complications and adverse events of the MONARC
transobturator tape, compared with the tension-free vaginal tape. [Am J
Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Dec;195(6):1820-5
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17027591>

**The VI-SENSE-vaginal discharge self-test to facilitate management of
vaginal symptoms**

OBJECTIVE: This study was undertaken to evaluate a diagnostic panty
liner (VI-SENSE) (Common Sense, Caesarea, Israel) developed to
facilitate diagnosis of vaginal infections by detecting disordered
acidity level. CONCLUSION: The VI-SENSE test was found to be superior to
traditional individual tests in facilitating preliminary diagnosis of
vaginal infections.

[Geva
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Geva+A"%5BAuthor%5D),
et al The VI-SENSE-vaginal discharge self-test to facilitate management
of vaginal symptoms. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Nov;195(5):1351-6

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16769019>

**Age-Based Ovarian Stimulation Yields High Pregnancy Rates**

CONCLUSION(S): Women with diminished ovarian reserve, if treated with an
ovarian age-based rather than chronological age-based ovarian
stimulation protocols, will demonstrate surprisingly good pregnancy rate
with IVF in comparison to women with normal ovarian function.

[Gleicher
N](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Gleicher+N"%5BAuthor%5D),
[Barad
D](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Barad+D"%5BAuthor%5D).
\"Ovarian age-based\" stimulation of young women with diminished ovarian
reserve results in excellent pregnancy rates with in vitro
fertilization. [Fertil
Steril.](javascript:AL_get(this, 'jour', 'Fertil Steril.');) 2006
Dec;86(6):1621-5

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17074322>

**Specific Symptoms May Assist in Early Detection of Ovarian Cancer **

RESULTS.: Symptoms that were associated significantly with ovarian
cancer were pelvic/abdominal pain, urinary urgency/frequency, increased
abdominal size/bloating, and difficulty eating/feeling full when they
were present for \<1 year and occurred \>12 days per month. In a
logistic regression analysis, symptoms that were associated
independently with cancer were pelvic/abdominal pain (P \< .001),
increased abdominal size/bloating (P\<.001), and difficulty
eating/feeling full (P = .010). A symptom index was considered positive
if any of those 6 symptoms occurred \>12 times per month but were
present for \<1 year. In the confirmatory sample, the index had a
sensitivity of 56.7 for early-stage disease and 79.5% for advanced-stage
disease. Specificity was 90% for women age \>50 years and 86.7% for
women age \<50 years. CONCLUSIONS.: Specific symptoms in conjunction
with their frequency and duration were useful in identifying women with
ovarian cancer. A symptom index may be useful for identifying women who
are at risk.

[Goff
BA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Goff+BA"%5BAuthor%5D),
et al Development of an ovarian cancer symptom index: possibilities for
earlier detection.
[Cancer.](javascript:AL_get(this, 'jour', 'Cancer.');) 2006 Dec 11

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17154394>

**Intravaginal slingplasty effective for stress incontinence, but 9%
removed for erosions**

CONCLUSION: Both procedures were effective for stress incontinence, but
9% of women treated with the IVS required removal of the tape for
erosions.

Meschia M et al Tension-free vaginal tape (TVT) and intravaginal
slingplasty (IVS) for stress urinary incontinence: a multicenter
randomized trial. Am J Obstet Gynecol.  2006; 195(5):1338-42

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16769016>

**Vulvar vestibulitis: Electromyographic biofeedback and topical
lidocaine both effective**

CONCLUSIONS: Four months\' treatment with electromyographic biofeedback
and topical lidocaine gave statistically significant improvements on
vestibular pain measurements, sexual functioning, and psychosocial
adjustments at the 12-month follow-up. No differences in outcome between
the two treatments were observed but a larger sample may be needed to
obtain significance. The treatments were well tolerated but the
compliance to the electromyographic biofeedback training program was
low. A combination of both treatments could potentially benefit many
women with vulvar vestibulitis.

Danielsson I et al EMG biofeedback versus topical lidocaine gel: a
randomized study for the treatment of women with vulvar vestibulitis.
[Acta Obstet Gynecol Scand.  2006;
85(11):1360-7](http://www.medscape.com/medline/publicationbrowser/123?pmid=17091418)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17091418>

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

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

Please see note below from CDC regarding the entitlement for all VFC
eligible females 9 -- 18 years of age to receive HPV vaccine. This email
was sent to all state immunization program managers and IHS Immunization
coordinators.

If your Area/facilities are interested in acquiring HPV vaccine to
provide to 9 -- 18 year olds, but you are unable to get the vaccine
through your state VFC program or are limited to certain age groups,
please let Amy Groom <amy.groom@ihs.gov> ** **know so she can follow up
with CDC. Please cc Judy Thierry. <Judith.Thierry@ihs.gov>

Response requested: From Amy Groom, IHS Immunization Program Manager /
CDC Field Assignee:   As you begin planning for implementation of the
new HPV vaccine, please keep in mind that VFC is an entitlement
program.  In the case of HPV vaccine, this means that all VFC-eligible
females 9 through 18 years of age are entitled to the vaccine.  It also
means that VFC-enrolled providers must have access to the vaccine and
may provide it to all VFC-eligible females between 9 through 18 years of
age.  While you may target your outreach efforts to certain age groups
or types of providers, requests for the vaccine from VFC-enrolled
providers must be honored.  A copy of the VFC resolution is attached for
your reference.

**South Dakota becomes 2nd State in the Nation to Offer Girls Free
Cancer Vaccine  **

Governor Rounds his plan to provide the HPV vaccine, Gardasil to every
girl in South Dakota between the ages of 11-18. SOUX FALLS, SD. --
January 9, 2007 -- The Women's Cancer Network -- the breast and cervical
cancer statewide coalition \-- applauded the Governor's decision today
to make South Dakota the 2nd state in the nation to offer the new
cervical-cancer vaccine free to girls.  The vaccine against the human
papilloma virus, or HPV, will be available to all girls ages 11 through
18 as part of a state program that offers immunizations to youth at no
cost. FOR MORE INFORMATION, COTACT: Jill Ireland, Women\'s Cancer
Network\
<Jill.Ireland@cancer.org>

**Rapid flu test trims further tests, treatment**

CONCLUSIONS: The inclusion of rapid influenza testing for the evaluation
of febrile young infants without signs of focal infection during
influenza season decreases the need for additional studies and reduces
the length of stay in the ED, the use of antibiotic treatment and
unnecessary hospitalizations. [Benito-Fernandez
J](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Benito-Fernandez+J"%5BAuthor%5D),
et al Impact of rapid viral testing for influenza A and B viruses on
management of febrile infants without signs of focal infection. [Pediatr
Infect Dis
J.](javascript:AL_get(this, 'jour', 'Pediatr Infect Dis J.');) 2006
Dec;25(12):1153-7

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17133161>

Training Available: The Stanford Pediatric Weight Control Program

What is the Training Institute?

The Training Institute is a four-day program at Stanford University to
train and certify you to deliver the Stanford Pediatric Weight Control
Program at your own organization.  Successful completion of the
Institute will certify your organization to use the Stanford Pediatric
Weight Control Program and materials.

What is the Stanford Pediatric Weight Control Program? The Stanford
Pediatric Weight Control Program is available in versions for families
with 8-12 year old children (English and culturally-tailored Spanish
versions) or 13-15 year old teens (English only). The Program is
extremely well received by participating families. More than 400
families have completed the program to date at Stanford Medical School
and Lucile Packard Children's Hospital. The Program is not designed for
large, rapid, short-term weight loss.  

Successful completion of the Institute will provide initial
certification as a Stanford Pediatric Weight Control Program provider.

Training Institute for the Stanford Pediatric Weight Control Program --
cost \$5,000 for first participant and 1250 for subsequent persons. 

<krissy.connell@stanford.edu>

Hepatitis B Vaccine for Infants of HBsAg-Positive Mothers: Cochrane
Briefs

[Clinical Question]{.underline}

Do hepatitis B vaccine and immune globulin prevent hepatitis B infection
in newborns of mothers who are positive for hepatitis B surface antigen
(HBsAg)?

[Evidence-Based Answer]{.underline}

Hepatitis B vaccine, hepatis B immune globulin, and the combination of
both reduce the risk of transmission of hepatitis B virus from mother to
newborn, especially in newborns of mothers positive for hepatitis B e
antigen (HBeAg). The combination of vaccine and immune globulin is more
effective than vaccine alone.

[Practice Pointers]{.underline}

Without intervention, 70 to 90 percent of infants born to women who are
positive for both HBsAg and HBeAg will have chronic hepatitis B
infection by six months of age.1 This Cochrane review of 29 clinical
trials demonstrates that vaccine and immune globulin each are effective
in preventing infection and that they are more effective in combination.

The reviewers found that compared with no intervention, hepatitis B
immune globulin alone and the combination of immune globulin and vaccine
reduced transmission of hepatitis B virus by 50 percent. The combination
of vaccine and hepatitis B immune globulin also reduced transmission
compared with vaccine alone (relative risk = 0.54; 95% confidence
interval \[CI\], 0.41 to 0.73; 10 trials). Recombinant and
plasma-derived vaccines were comparable in effectiveness, as were
high-dose and low-dose vaccines.

Most of the trials included only mothers who tested positive for HBsAg
and HBeAg. The number needed to treat to prevent transmission of
hepatitis B from mothers who are positive for HBsAg but negative for
HBeAg is likely to be much lower, but data for this population are
limited.

The Advisory Committee on Immunization Practices recommends that all
pregnant women be screened for HBsAg during routine prenatal care and
that they be reevaluated and the results recorded when they report to
the hospital in labor. Patients with positive results should be reported
to local or state prenatal hepatitis B prevention programs and
case-management tracking programs. Women who present in labor who are at
high risk of infection or do not have HBsAg results should be tested as
soon as possible. Newborns of mothers who are positive for HBsAg should
receive single-antigen hepatitis B vaccine and hepatitis B immune
globulin within 12 hours of birth. Thimerosal has been removed from
vaccines, so neonatal vaccination can be performed.

Infants of mothers whose HBsAg status is unknown should receive
single-antigen hepatitis B vaccine within 12 hours of birth. If the
results of subsequent HBsAg testing of the mother are positive, the
infant should receive hepatitis B immune globulin within seven days of
birth. A complete hepatitis B vaccine series should be completed on all
infants regardless of newborn vaccinations. At the end of the
vaccination series at nine to 18 months, the infant should be tested for
HBsAg and hepatitis B surface antibody.2

Lee C, et al. Hepatitis B immunisation for newborn infants of hepatitis
B surface antigen-positive mothers. Cochrane Database Syst Rev
2006;(2):CD004790.

<http://www.aafp.org/afp/20070101/cochrane.html>

**2007 Childhood and Adolescent Immunization Schedules: Evolution or
Intelligent Design?**

The recent expansion of the recommended vaccines includes 14 additional
vaccine doses as follows:

-Meningococcal vaccine (one dose at 11 or 12 years of age)

-Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis
(Tdap) vaccine (one dose at 11 or 12 years of age)

-Hepatitis A vaccine (two doses six months apart at one to two years of
age)

-Three additional doses of influenza vaccine (starting at six months of
age; two doses in the first

season, then one dose annually through 59 months of age)

-Rotavirus vaccine (three doses at two, four, and six months of age)

-Human papillomavirus vaccine (three doses at 11 or 12 years of age)

-Second dose of varicella vaccine (at four to six years of age)

Such changes present a challenge to the clinically active primary care
provider; the complicated array of antigens and timing for
administration can make one\'s head swim. Fortunately, this expansion
also has shaped the evolution of the recommended schedules. This is
where the recommended immunization schedules become essential clinical
tools.

<http://www.aafp.org/afp/20070101/practice.html>

Size Does Matter: Childhood Immunization Needle

[Results:]{.underline} Of the 696 infants enrolled, 240 were randomized
to wide, long needles; 230 to narrow, short needles; and 226 to narrow,
long needles. The infants in each group did not differ in any
significant variables. Although immunogenicity was not significantly
different, the average immune response was higher in infants in the
wide, long needle group, and it was lowest in the narrow, short needle
group. The differences in immunogenicity were greatest for the
meningococcal C vaccine. Overall, local reactions at the injection site
were reported for 61 percent of infants. Significantly fewer local
reactions were reported in the wide, long needle group. Over the
three-dose series, the relative reduction ranged from 22 to 54 percent.
The size of the reaction also was smaller, but this difference was not
statistically significant. Differences in reactivity were only apparent
for the first vaccine dose. Eleven infants were withdrawn from the study
because they had injection site reactions; 10 of these infants were in
the narrow, short needle group.

The three groups of infants did not differ in reported systemic
reactions or use of analgesics, and the infants in the long needle
groups did not differ significantly in immunogenicity. The narrow, long
needle was associated with lower local reactivity compared with the
wide, long needle; however, both had similar systemic reactivity.
[Conclusion:]{.underline} The authors conclude that local reactions from
routine childhood immunizations are significantly reduced with no change
in immunogenicity or increase in systemic reactions when wide, long
needles are used. This may be because the longer needle more
consistently reaches the muscle layer.

Diggle L, et al. Effect of needle size on immunogenicity and
reactogenicity of vaccines in infants: randomised controlled trial. BMJ
September 16, 2006; 333:571-4.

<http://www.aafp.org/afp/20070101/tips/3.html>

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

**Sleepiness and sleep deprivation are associated with injury**

Results: Better sleep quality in the past 7 days was associated with a
lower risk of injury (odds ratio (OR) 0.88, 95% confidence interval (CI)
0.80 to 0.97). Self-reported sleepiness just before injury compared with
control time was associated with a lower risk of injury, with ORs of
0.82 per unit on a 0-to-12 scale (95% CI 0.78 to 0.86) in case-control
analysis and 0.76 (0.73 to 0.80) in case-crossover analysis. In
case-crossover analysis, additional sleep in the 24 hours before injury
compared with the 24 hours before that was associated with an increased
risk of injury (OR 1.06 per hour, 95% CI 1.03 to 1.09), but this effect
disappeared when we controlled for activity, location, and recent
alcohol consumption. Conclusions: Better recent sleep quality was
associated with a lower risk of injury, but surprisingly, feeling sleepy
was also.

[Edmonds
JN](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Edmonds+JN"%5BAuthor%5D),
[Vinson
DC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Vinson+DC"%5BAuthor%5D).Three
measures of sleep, sleepiness, and sleep deprivation and the risk of
injury: a case-control and case-crossover study. [J Am Board Fam
Med.](javascript:AL_get(this, 'jour', 'J Am Board Fam Med.');) 2007
Jan-Feb;20(1):16-22.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17204730&dopt=Abstract>

**Discourage scheduled work beyond 16 consecutive hours**

Companies today glorify the executive who logs 100-hour workweeks, the
road warrior who lives out of a suitcase in multiple time zones, and the
negotiator who takes a red-eye to make an 8 A.M. meeting. But to Dr.
Charles A. Czeisler, the Baldino Professor of Sleep Medicine at Harvard
Medical School, this kind of corporate behavior is the antithesis of
high performance. In fact, he says, it endangers employees and puts
their companies at risk. In this interview, Czeisler describes four
neurobiological functions that affect sleep duration and quality as well
as individual performance. When these functions fall out of alignment
because of sleep deprivation, people operate at a far lower level of
performance than they would if they were well rested. Czeisler goes on
to observe that corporations have all kinds of policies designed to
protect employees- rules against smoking, sexual harassment, and so
on-but they push people to the brink of self-destruction by expecting
them to work too hard, too long, and with too little sleep. The negative
effects on cognitive performance, Czeisler says, can be similar to those
that occur after drinking too much alcohol: \"We now know that 24 hours
without sleep or a week of sleeping four or five hours a night induces
an impairment equivalent to a blood alcohol level of .1%. We would never
say, \'This person is a great worker! He\'s drunk all the time!\' yet we
continue to celebrate people who sacrifice sleep for work.\" Czeisler
recommends that companies institute corporate sleep policies that
discourage scheduled work beyond 16 consecutive hours as well as working
or driving immediately after late-night or overnight flights. A sidebar
to this article summarizes the latest developments in sleep research.

[Czeisler
CA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Czeisler+CA"%5BAuthor%5D).
Sleep deficit: the performance killer. [Harv Bus
Rev.](javascript:AL_get(this, 'jour', 'Harv Bus Rev.');) 2006
Oct;84(10):53-9, 148

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17040040>

**Making and Keeping New Year\'s Resolutions: Nine Modifiable Cancer
Risk Factors**

More Than One Third of Cancer Deaths May Be Attributable to Nine
Modifiable Risk Factors

INTERPRETATION: Reduction of exposure to key behavioural and
environmental risk factors would prevent a substantial proportion of
deaths from cancer.

[Danaei
G](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Danaei+G"%5BAuthor%5D),
et al Causes of cancer in the world: comparative risk assessment of nine
behavioural and environmental risk factors.
[Lancet.](javascript:AL_get(this, 'jour', 'Lancet.');) 2005 Nov
19;366(9499):1784-93

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16298215>

**High blood glucose is a leading cause of cardiovascular mortality in
most world regions**

INTERPRETATION: Higher-than-optimum blood glucose is a leading cause of
cardiovascular mortality in most world regions. Programmes for
cardiovascular risk and diabetes management and control at the
population level need to be more closely integrated.

[Danaei
G](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Danaei+G"%5BAuthor%5D),
et al Global and regional mortality from ischaemic heart disease and
stroke attributable to higher-than-optimum blood glucose concentration:
comparative risk assessment.
[Lancet.](javascript:AL_get(this, 'jour', 'Lancet.');) 2006 Nov
11;368(9548):1651-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17098083>

**Meta-Analysis Confirms Red Meat Consumption Linked to Colorectal
Cancer Risk**

Consumption of red meat and processed meat was positively associated
with risk of both colon and rectal cancer, although the association with
red meat appeared to be stronger for rectal cancer. In 3 studies that
reported results for subsites in the colon, high consumption of
processed meat was associated with an increased risk of distal colon
cancer but not of proximal colon cancer. The results of this
meta-analysis of prospective studies support the hypothesis that high
consumption of red meat and of processed meat is associated with an
increased risk of colorectal cancer

[Larsson
SC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Larsson+SC"%5BAuthor%5D),
[Wolk
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Wolk+A"%5BAuthor%5D).
Meat consumption and risk of colorectal cancer: a meta-analysis of
prospective studies. [Int J
Cancer.](javascript:AL_get(this, 'jour', 'Int J Cancer.');) 2006 Dec
1;119(11):2657-64

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16991129>

Mastectomy vs. Breast-Conserving Therapy for DCIS

[Background:]{.underline} The incidence of ductal carcinoma in situ
(DCIS) of the breast has dramatically increased over the past 25 years.
Most cases initially were treated with mastectomy; however,
breast-conserving therapy (with or without radiation) has become more
common. Although breast-conserving therapy provides a better cosmetic
result, it is associated with a higher rate of local recurrence, distant
spread, and cancer-related mortality. Lee and colleagues studied
outcomes in women treated for DCIS between 1972 and 2005 and compared
the outcomes of mastectomy versus breast-conserving treatment
strategies. [Conclusion:]{.underline} The authors emphasize that
patients with DCIS have a good prognosis regardless of treatment
strategy. They also note that treatments have evolved considerably since
their data collection, and the current prognosis may be better than
reported. Although breast preservation treatment strategies were
associated with somewhat worse outcomes in this series, many of the
differences were not statistically significant and there was no survival
advantage following mastectomy. The authors encourage physicians to
remind their patients that the breast cancer survival rates for DCIS
are\
99 percent or more. Lee LA, et al. Breast cancer-specific mortality
after invasive local recurrence in patients with ductal
carcinoma-in-situ of the breast. Am J Surg October 2006;192;416-9.

<http://www.aafp.org/afp/20070101/tips/4.html>

**Delay in Diagnosis of Diabetes Mellitus Due to Inaccurate Use of
Hemoglobin A1C Levels**

Testing of hemoglobin A1C (HbA1C) levels has become widespread in the
management of patients with diabetes mellitus. Since the 1980s, it has
proven to be an invaluable tool correlating with a patient's average
blood glucose levels as well as with their disease morbidity. Clinicians
often base treatment decisions and make adjustments depending on a
patient's HbA1C level. As useful as the HbA1C is, it does have notable
limitations. A number of conditions can lead to a falsely elevated or a
falsely low HbA1C level. When one of these conditions is present, it is
important to recognize the inaccuracy of the HbA1C test to prevent a
delay or error in the diagnosis or care of patients with diabetes
mellitus. It is also important to be aware of alternative methods of
monitoring a patient's diabetes such as a fructosamine assay or home and
office blood glucose measurements. Presented is the case of a patient
with diabetes mellitus and hereditary spherocytosis, a condition that
interfered with her HbA1C value and resulted in a delay in her care.

[Arnold
JG](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Arnold+JG"%5BAuthor%5D),
[McGowan
HJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="McGowan+HJ"%5BAuthor%5D).
Delay in Diagnosis of Diabetes Mellitus Due to Inaccurate Use of
Hemoglobin A1C Levels. [J Am Board Fam
Med.](javascript:AL_get(this, 'jour', 'J Am Board Fam Med.');) 2007
Jan-Feb;20(1):93-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17204741&dopt=Abstract>

**New Guidelines Issued for Tdap Vaccine for Adults**

The Advisory Committee on Immunization Practices (ACIP) has issued
guidelines for tetanus toxoid, reduced diphtheria toxoid and acellular
pertussis (Tdap) vaccine for adults which are published in the December
15, 2006, issue of the Morbidity and Mortality Weekly Report.

ACIP recommendations to reduce pertussis morbidity among adults, to
maintain the standard of care for tetanus and diphtheria prevention, and
to reduce the transmission of pertussis to infants and in healthcare
settings are as follows:

-   Adults aged 19 to 64 years should receive a single dose of Tdap to
    replace Td for booster immunization against tetanus, diphtheria, and
    pertussis if they received their last dose of Td more than 10 years
    earlier and if they have not previously received Tdap.

-   For booster protection against pertussis, intervals shorter than 10
    years since the last Td may be used.

-   To reduce the risk for transmitting pertussis, adults who have or
    who anticipate having close contact with an infant younger than 12
    months, such as parents, grandparents younger than 65 years, child
    care providers, and healthcare personnel, should receive a single
    dose of Tdap. The guidelines suggest an interval as short as 2 years
    from the last Td, but shorter intervals can be used. Whenever
    possible, women should receive Tdap before becoming pregnant, but
    women who have not previously received Tdap should receive a dose of
    Tdap in the immediate postpartum period.

-   Healthcare personnel who have direct patient contact working in
    hospitals or ambulatory care settings should receive a single dose
    of Tdap as soon as possible if they have not previously received
    Tdap. The guidelines recommend an interval as short as 2 years from
    the last dose of Td, but shorter intervals may be used. HICPAC
    supports these recommendations for use of Tdap in healthcare
    personnel.

In addition to recommendations for the use of Tdap among adults aged 19
to 64 years, other issues highlighted in this ACIP report include a
review of US pertussis, tetanus, and diphtheria vaccination policy, of
the clinical features and epidemiology of pertussis in adults, and of
immunogenicity, efficacy, and safety data for Tdap.

Safety considerations for adult vaccination with Tdap include the proper
spacing and administration sequence of vaccines containing tetanus
toxoid, diphtheria toxoid, and pertussis antigens. Potential adverse
neurologic and systemic events related to use of vaccines with pertussis
or tetanus toxoid components may include Guillain-Barré syndrome,
encephalopathy, or Arthus reaction.

The guidelines also discuss economic considerations for adult Tdap use
and suggestions for implementing these recommendations for routine adult
Tdap vaccination, vaccination of adults in contact with infants,
vaccination of pregnant women, and vaccination of healthcare personnel.

Also highlighted are contraindications and precautions for use of Tdap,
special situations for Tdap use, reporting of adverse events after
vaccination, vaccine injury compensation, and areas of future research
related to Tdap and adults.

Tdap is contraindicated for people with a history of serious allergic
reaction, defined as anaphylaxis, to any component of the vaccine. These
individuals should be referred to an allergist to determine whether they
have a specific allergy to tetanus toxoid and whether they can safely
receive tetanus toxoid vaccinations.

Tdap is contraindicated for adults with a history of encephalopathy,
defined as coma or prolonged seizures, not attributable to an
identifiable cause within 7 days of administration of a vaccine with
pertussis components. These adults should receive Td instead of Tdap.

\"Progressive neurological disorders are not considered a
contraindication as indicated in the package insert, and unstable
neurological disorders (e.g., cerebrovascular events, acute
encephalopathic conditions) are considered precautions and a reason to
defer Tdap and/or Td,\" the authors conclude. \"Tdap may be used as part
of the primary series for tetanus and diphtheria.\"

CDC, their planners, and their content experts have disclosed that they
have no financial relationships with the makers of commercial products,
suppliers of commercial services, or commercial supporters. Morbid
*Mortal Wkly Rep*. 2006;55(RR-17):1-33.

<http://www.cdc.gov/mmwr/weekcvol.html>

What are the effects of surgical interventions for hip fracture?

unlikely to be beneficial

**Conservative vs. Operative Treatment for Most Types of Hip Fracture.**
One small randomized controlled trial (RCT) identified by a systematic
review showed limited evidence that conservative treatment of
undisplaced intracapsular fractures increased the risk of nonunion
compared with internal fixation of the fracture. The review provided
limited evidence that, compared with operative treatment, conservative
treatment of extracapsular fractures increased the proportion of persons
who remained hospitalized after 12 weeks and the occurrence of leg
shortening and varus deformity. The review identified no RCTs including
persons with displaced intracapsular fracture. The review provided
insufficient evidence to assess whether significant differences exist
between conservative and operative treatment in medical complications,
mortality, long-term pain, or loss of independence.

**Short Cephalocondylic Nail (e.g., Gamma Nail) vs. Sliding Hip Screw
for Extracapsular Hip Fracture.** One systematic review showed no
significant difference between intramedullary fixation with a short
cephalocondylic nail (e.g., Gamma nail) and extramedullary fixation with
a sliding hip screw in mortality, pain at follow-up, ability to return
to a previous residence, and ability to walk after three to 12 months.
The review also showed no significant difference between treatments in
wound infection or cutout of the implant, but the review showed that
cephalocondylic intramedullary fixation increased intraoperative and
later femoral fractures and reoperation rates.

likely to be ineffective or harmful

**Older Fixed Nail Plates vs. Sliding Hip Screws for Extramedullary
Fixation of Extracapsular Fracture.** One systematic review showed no
significant difference between older fixed nail plates and sliding hip
screws in mortality, pain at follow-up, or mobility. The review showed
that sliding hip screws reduced the risk of fixation failure in persons
with extracapsular hip fracture.

**Intramedullary Fixation with Condylocephalic Nails (e.g., Ender Nails)
vs. Extramedullary Fixation for Extracapsular Fracture.** One systematic
review showed that intramedullary fixation with condylocephalic nails
increased reoperation rates and the incidence of leg shortening and
external rotation deformity compared with extramedullary fixation.
However, the review showed that condylocephalic nails reduced length of
surgery, the incidence of deep wound sepsis, and operative blood loss.

trade-off between benefits and harms

**Internal Fixation vs. Arthroplasty for Intracapsular Hip Fracture.**
Two systematic reviews and two subsequent RCTs including older persons
with displaced intracapsular fractures showed that internal fixation
increased the need for subsequent revision surgery compared with
arthroplasty. Internal fixation, however, was associated with less
operative trauma, including reduced operative blood loss and transfusion
requirements, and reduced deep wound sepsis. There were no clear
differences in mortality or long-term functional outcome.

unknown effectiveness

**Choice of Implant for Internal Fixation of Intracapsular Hip
Fracture.** One systematic review provided insufficient evidence to
determine the best implant for internal fixation of intracapsular
fracture.

**Different Types of Arthroplasty for Intracapsular Hip Fracture.** One
systematic review provided insufficient evidence to determine the best
type of arthroplasty (cemented and uncemented prostheses; unipolar and
bipolar hemiarthroplasty; or hemiarthroplasty and total hip replacement)
for persons with intracapsular fracture.

**Arthroplasty vs. Internal Fixation for Extracapsular Fracture.** One
RCT with weak methods identified by a systematic review provided
insufficient evidence to compare arthroplasty with internal fixation in
persons with extracapsular fracture.

**Extramedullary Implants Other Than Older Fixed Nail Plates vs. Sliding
Hip Screw for Extracapsular Fracture.** One systematic review provided
insufficient evidence on the relative effects of sliding and fixed
extramedullary implants other than older fixed nail plates in persons
with extracapsular hip fracture.

**External Fixation for Extracapsular Fracture.** One RCT identified by
a systematic review provided insufficient evidence on the relative
effects of external fixation compared with the sliding hip screw in
persons with extracapsular hip fracture.

What are the effects of perioperative medical interventions on surgical
outcome and prevention of complications?

beneficial

**Perioperative Prophylaxis with Antibiotics.** One systematic review
showed that multiple-dose perioperative and single-dose preoperative
antibiotic prophylaxis reduced deep and superficial wound infection
after hip surgery compared with control or no antibiotics.

likely to be beneficial

**Perioperative Prophylaxis with Antiplatelet Agents.** One systematic
review and one subsequent large RCT showed that perioperative and
postoperative antiplatelet prophylaxis reduced the incidence of deep
venous thrombosis (DVT) and pulmonary embolism compared with placebo or
no prophylaxis. There was no significant effect on mortality. The review
and subsequent RCT showed that more persons who received antiplatelet
treatment had bleeding complications.

**Cyclical Compression of the Foot or Calf to Reduce Venous
Thromboembolism.** One systematic review showed that cyclical
compression devices (i.e., foot or calf pumps) reduced DVT and pulmonary
embolism compared with no compression. However, compression devices were
associated with noncompliance to therapy and skin abrasion.

**Oral Multinutrient Feeds as Nutritional Supplementation After Hip
Fracture.** One systematic review including persons who had had hip
fracture surgery showed limited evidence that nutritional
supplementation consisting of oral protein and energy feeds reduced
unfavorable outcomes (i.e., postoperative complications or death)
compared with control.

unlikely to be beneficial

**Preoperative Traction to the Injured Leg.** One systematic review
showed no significant difference in preoperative pain relief or
subsequent ease and fracture reduction at the time of surgery between
routine preoperative traction and control.

trade-off between benefits and harms

**Perioperative Prophylaxis with Heparin to Reduce Venous
Thromboembolism.** One systematic review showed that perioperative
prophylaxis with unfractionated heparin or low-molecular-weight heparin
(LMWH) reduced the incidence of DVT compared with placebo or no
treatment. The review provided insufficient evidence to determine
whether heparin reduced pulmonary embolism risk or mortality. It also
provided insufficient evidence to determine whether heparin increased
bleeding and other complications, although another systematic review of
unfractionated heparin in persons undergoing general, orthopedic, and
urologic surgery showed that, overall, heparin increased excessive
bleeding or the need for transfusion compared with control.

unknown effectiveness

**Regional vs. General Anesthesia for Hip Fracture Surgery.** One
systematic review of persons after hip fracture surgery provided limited
evidence that regional anesthesia reduced the risk of acute
postoperative confusion compared with general anesthesia. The review
provided insufficient evidence to draw conclusions about mortality or
other outcomes.

**Nerve Blocks for Pain Control Before and After Hip Fracture.** One
systematic review of small RCTs showed that nerve blocks reduced total
analgesic intake compared with no nerve block.

**Operative Day (Less Than 24 Hours) vs. Extended Multiple-Dose
Antibiotic Regimens.** Two systematic reviews provided limited evidence,
from two and three RCTs, respectively, that there is no significant
difference in wound infection between operative day and extended
multiple-dose antibiotic regimens in persons undergoing hip fracture
surgery.

**Single-Dose (Long-Acting) vs. Multiple-Dose Antibiotic Regimens.** Two
systematic reviews provided limited evidence that there is no
significant difference in wound infection between some single- and some
multiple-dose antibiotic regimens in persons undergoing hip fracture
surgery.

**LMWH vs. Unfractionated Heparin to Reduce Venous Thromboembolism After
Hip Fracture Surgery.** Five weak RCTs identified by a systematic review
provided insufficient evidence to establish whether LMWH reduced DVT
compared with unfractionated heparin. A second systematic review
including persons undergoing orthopedic surgery provided no evidence
that there is a difference in bleeding complications between LMWH and
unfractionated heparin.

**Graduated Elastic Compression to Prevent Venous Thromboembolism.** We
found no RCTs of thromboembolism stockings for prevention of thrombotic
complications in persons with hip fracture. Two systematic reviews of
persons undergoing surgery, including elective total hip replacement,
showed that graduated elastic compression reduced the risk of DVT
compared with control.

**Nasogastric Feeds for Nutritional Supplementation After Hip
Fracture.** One systematic review provided no evidence that nasogastric
feeding tubes for nutritional supplementation reduced mortality compared
with control. However, the four RCTs were small, had flawed methods, and
included persons with differing nutritional status. There was
insufficient evidence to assess other outcomes.

What are the effects of rehabilitation interventions and programs after
hip fracture?

likely to be beneficial

**Coordinated Multidisciplinary Approaches for Inpatient Rehabilitation
of Older Persons.** One systematic review comparing coordinated
multidisciplinary care for inpatient rehabilitation with usual care
(often orthopedic) in older persons showed no significant difference in
mortality or the combined outcomes of death or institutional care, death
or deterioration in functional status, or death or rehospitalization.
However, more persons receiving multidisciplinary care tended to have
better outcomes, and there was limited evidence that multidisciplinary
care resulted in fewer complications. It was not possible to define the
best method of multidisciplinary care from the various models assessed
in the review.

unknown effectiveness

**Mobilization Strategies Initiated Soon After Hip Fracture Surgery.**
One systematic review and one subsequent RCT provided insufficient
evidence to determine the effects of various mobilization strategies
initiated soon after hip fracture surgery.

**Early Supported Discharge Followed by Home-Based Rehabilitation.** Two
RCTs showed no significant difference in overall quality of life,
mortality, falls, or rehospitalization between early supported discharge
(followed by home-based rehabilitation) and hospital-based
rehabilitation in less-disabled persons with a favorable home situation.
One RCT showed that early supported discharge reduced caregiver burden
at 12 months compared with hospital-based rehabilitation. Both RCTs
showed that early supported discharge reduced length of hospital stay
but increased the overall length of rehabilitative care.

**Systematic, Multicomponent Home-Based Rehabilitation.** One RCT
comparing a systematic, multicomponent home-based rehabilitation program
with usual care showed no significant difference in recovery to
prefracture self-care levels, home management, social activity, balance,
or lower extremity strength after 12 months.
<http://www.aafp.org/afp/20070101/bmj.html>

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

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

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

**Summary of Recommendations and Conclusions**

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

-   First-trimester screening using both nuchal translucency measurement
    and biochemical markers is an effective screening test for Down
    syndrome in the general population. At the same false-positive
    rates, this screening strategy results in a higher Down syndrome
    detection rate than does the second-trimester maternal serum triple
    screen and is comparable to the quadruple screen.

-   Measurement of nuchal translucency alone is less effective for
    first-trimester screening than is the combined test (nuchal
    translucency measurement and biochemical markers).

-   Women found to have increased risk of aneuploidy with
    first-trimester screening should be offered genetic counseling and
    the option of CVS or second-trimester amniocentesis.

-   Specific training, standardization, use of appropriate ultrasound
    equipment, and ongoing quality assessment are important to achieve
    optimal nuchal translucency measurement for Down syndrome risk
    assessment, and this procedure should be limited to centers and
    individuals meeting these criteria.

-   Neural tube defect screening should be offered in the second
    trimester to women who elect only first-trimester screening for
    aneuploidy.

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

-   Screening and invasive diagnostic testing for aneuploidy should be
    available to all women who present for prenatal care before 20 weeks
    of gestation regardless of maternal age. Women should be counseled
    regarding the differences between screening and invasive diagnostic
    testing.

-   Integrated first- and second-trimester screening is more sensitive
    with lower false-positive rates than first-trimester screening
    alone.

-   Serum integrated screening is a useful option in pregnancies where
    nuchal translucency measurement is not available or cannot be
    obtained.

-   An abnormal finding on second-trimester ultrasound examination
    identifying a major congenital anomaly significantly increases the
    risk of aneuploidy and warrants further counseling and the offer of
    a diagnostic procedure.

-   Patients who have a fetal nuchal translucency measurement of 3.5 mm
    or higher in the first trimester, despite a negative aneuploidy
    screen, or normal fetal chromosomes, should be offered a targeted
    ultrasound examination, fetal echocardiogram, or both.

-   Down syndrome risk assessment in multiple gestation using first- or
    second-trimester serum analytes is less accurate than in singleton
    pregnancies.

-   First-trimester nuchal translucency screening for Down syndrome is
    feasible in twin or triplet gestation but has lower sensitivity than
    first-trimester screening in singleton pregnancies.

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

-   After first-trimester screening, subsequent second-trimester Down
    syndrome screening is not indicated unless it is being performed as
    a component of the integrated test, stepwise sequential, or
    contingent sequential test.

-   Subtle second-trimester ultrasonographic markers should be
    interpreted in the context of a patient's age, history, and serum
    screening results.

Screening for fetal chromosomal abnormalities. ACOG Practice Bulletin
No. 77. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2007;109:217--27.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197615>

**Hemoglobinopathies in Pregnancy**

**Summary of Recommendations and Conclusions**

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

-   Individuals of African, Southeast Asian, and Mediterranean descent
    are at increased risk for being carriers of hemoglobinopathies and
    should be offered carrier screening and, if both parents are
    determined to be carriers, genetic counseling.

-   A complete blood count and hemoglobin electrophoresis are the
    appropriate laboratory tests for screening for hemoglobinopathies.
    Solubility tests alone are inadequate for screening because they
    fail to identify important transmissible hemoglobin gene
    abnormalities affecting fetal outcome.

-   Couples at risk for having a child with sickle cell disease or
    thalassemia should be offered genetic counseling to review prenatal
    testing and reproduction options. Prenatal diagnosis of
    hemoglobinopathies is best accomplished by DNA analysis of cultured
    amniocytes or chorionic villi.

Hemoglobinopathies in pregnancy. ACOG Practice Bulletin No. 78. American
College of Obstetricians and Gynecologists. Obstet Gynecol
2007;109:229--37.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197616>

**Commercial Enterprises in Medical Practice**

ABSTRACT: Increasing numbers of physicians sell and promote both medical
and nonmedical products as part of their practices. Physicians always
have rendered advice and treatment for a fee, and this practice is
appropriate. It is unethical under most circumstances, however, for
physicians to sell or promote medical or nonmedical products or services
for their financial benefit. The following activities are considered
unethical: sale of prescription drugs to be used at home, sale or
promotion of nonprescription medicine, sale or promotion of
presumptively therapeutic agents that generally are not accepted as part
of standard medical practice, sale or promotion of non--health-related
items, recruitment of patients or other health care professionals into
multilevel marketing arrangements, and sale or promotion of any product
in whose sale the physician has a significant financial interest. It is
ethical and appropriate, however, to sell products to patients as
follows: sale of devices or drugs that require professional
administration in the office setting; sale of therapeutic agents, when
no other facilities can provide them at reasonable convenience and at
reasonable cost; sale of products that clearly are external to the
patient--physician relationship, when such a sale would be considered
appropriate in an external relationship; and sale of low-cost products
for the benefit of community organizations. A rationale is provided for
both the prohibited activities and exceptions.

Commercial enterprises in medical practice. ACOG Committee Opinion No.
359. American College of Obstetricians and Gynecologists. Obstet Gynecol
2007;109:243--5.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197617>

**Professional Responsibilities in Obstetric--Gynecologic Education**

ABSTRACT: Physicians must learn new skills in a manner consistent with
their ethical obligations to benefit the patient, to do no harm, and to
respect a patient\'s right to make informed decisions. Patients should
be given the opportunity to consent to or refuse treatment by students.
Students must hold in confidence any information they learn about
patients. The relationship between teacher and student involves an
imbalance of power and the risk of exploitation of a student for the
benefit of the teacher. Students should not be placed in situations
where they must provide care or perform procedures for which they are
not qualified and not adequately supervised. Students have the
obligation to be honest, conscientious, and respectful in their
relationships with their teachers. They should act in ways that preserve
the dignity of patients and do not undermine relationships between
patients and their physicians. If a student observes unethical behavior
or incompetent conduct by a teacher, the appropriate institutional
authority should be informed. Institutions have an obligation to provide
a work environment that enhances professional competence by ensuring
that students and residents work reasonable hours, helping them balance
education and patient care responsibilities; providing adequate support
services; and, in the case of residents, providing reasonable salaries
and benefits. With increasing numbers of women in education programs,
special attention must be given to the parallel demands of pregnancy and
career goals.

Education of health care professionals is essential to maintain
standards of competent and beneficial practice. Inherent in the
education of health professionals is the problem of disparity in power
and authority, including the power of teachers over students and the
power of practitioners over
patients[†](http://www.acog.org/publications/committee_opinions/co358.cfm#cross%23cross)
(1). It is therefore important to clarify both the professional
responsibilities to those patients whose care provides educational
opportunities and the responsibilities of teachers and students toward
one another. Students in the context of this Committee Opinion include
both medical students and residents. However, residents have a dual
responsibility as teacher and student and must be aware of that in
understanding their ethical responsibilities to the students they teach
and the patients they care for.

Professional responsibilities in obstetric--gynecologic education. ACOG
Committee Opinion No. 358. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2007;109:239--42.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197618>

## American Family Physician {#american-family-physician-1 .Style-Heading-2-+-14-pt}

**Childhood and Adolescent Depression**

Major depression affects 3 to 5 percent of children and adolescents.
Depression negatively impacts growth and development, school
performance, and peer or family relationships and may lead to suicide.
Biomedical and psychosocial risk factors include a family history of
depression, female sex, childhood abuse or neglect, stressful life
events, and chronic illness. Diagnostic criteria for depression in
children and adolescents are essentially the same as those for adults;
however, symptom expression may vary with developmental stage, and some
children and adolescents may have difficulty identifying and describing
internal mood states. Safe and effective treatment requires accurate
diagnosis, suicide risk assessment, and use of evidence-based therapies.
Current literature supports use of cognitive behavior therapy for mild
to moderate childhood depression. If cognitive behavior therapy is
unavailable, an antidepressant may be considered. Antidepressants,
preferably in conjunction with cognitive behavior therapy, may be
considered for severe depression. Tricyclic antidepressants generally
are ineffective and may have serious adverse effects. Evidence for the
effectiveness of selective serotonin reuptake inhibitors is limited.
Fluoxetine is approved for the treatment of depression in children eight
to 17 years of age. All antidepressants have a black box warning because
of the risk of suicidal behavior. If an antidepressant is warranted, the
risk/benefit ratio should be evaluated, the parent or guardian should be
educated about the risks, and the patient should be monitored closely
(i.e., weekly for the first month and every other week during the second
month) for treatment-emergent suicidality. Before an antidepressant is
initiated, a safety plan should be in place. This includes an agreement
with the patient and the family that the patient will be kept safe and
will contact a responsible adult if suicidal urges are too strong, and
assurance of the availability of the treating physician or proxy 24
hours a day to manage emergencies. (see Patient Education)

Am Fam Physician 2007;75:73-80, 83-4.
<http://www.aafp.org/afp/20070101/73.html>

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

**Women\'s self-report of mammography use conflicts with verified
reports using claims data**

<http://www.ahrq.gov/research/nov06/1106RA7.htm>

**Free blood glucose monitors for patients with diabetes encourages
self-management**

<http://www.ahrq.gov/research/nov06/1106RA6.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}

**Supporting employee breastfeeding is easier than it sounds**

The Indian Health Services" Lactation Support Circular is part of a new
national wave of improvements to the work environment. Establishing
guidelines that support moms to work and breastfeed benefits many parts
of the work environment.

-   When new moms can keep breastfeeding their infants, their children
    have half the clinic visits for diarrhea and otitis media and
    dramatically lower rates of hospitalizations rates for lung and
    gastrointestinal illnesses. (1,2,3)

-   Breastfeeding moms need less leave for sick infants, reducing the
    burden to their co-workers for unexpected absences.

-   Breastfed babies are cheaper to care for medically. Ball et al found
    significantly less health care/insurance dollars spent for illness
    with breastfed babies compared to formula fed babies.

-   Aetna Life and Casualty, Hartford CT is a forerunner in supporting
    breastfeeding. They established a employee breastfeeding center in
    the 1996s because those families required employee sick leave and
    lower insurance claims. Their return on investment is \$2.18 for
    every \$1.00 spent. (5)

-   Research on employee and management satisfaction indicates that
    supporting the choice to breastfed improves job satisfaction and
    productivity. (6)

So what is the easy part about supporting employee breastfeeding ?

-   It is mom-driven. Once the work place adapts the Circular's
    suggestions that fit the local needs, it is almost a turn-key
    operation. Moms use the available resources to continue
    breastfeeding. Available resource will vary depending on the
    location -- for example, in some work environments, this may mean
    more flexible schedules, in others it could mean using existing
    hospital electric breast pumps or encouraging employees to rent
    their own.

Want some ideas/options about pumps, tips for employees to store their
milk, ideas for breastfeeding room etiquette, policy and procedures,
etc?

-   Watch for Tool Kit to be released soon.

-   For more information, check the I.H.S. MCH Breastfeeding website
    sections, Going back to work or school and Staff Resources.

The Lactation Support Circular can be found at
[www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm](http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm)

1\. Policy Statement: Breastfeeding and the Use of Human Milk.
*Pediatrics*, Vol. 115 No. 2 February 2005, pp. 496-506.

2\. Benefits of breastfeeding. Department of Health and Human Service
Office on Women\'s Health. *Nutr Clin Care*. 2003 Oct-Dec;6(3):125-31.

3\. Dewey KG, Heinig MJ, Nommsen-Rivers LA. Differences in morbidity
between breast-fed and formula-fed infants. *J Pediatr.* 1995;126 :696
--702

4\. Ball TM, Wright AL. Health care cost of formula-feeding in the first
year of life. *Pediatrics*. 1999;103 :870 --876.

5\. Danyliw NC, *US News and World Report*, Dec 15, 1997, pp 79-81

6\.
[www.wicworks.ca.gov/breastfeeding/EmployerResources/bf_bestinvestment.pdf](http://www.wicworks.ca.gov/breastfeeding/EmployerResources/bf_bestinvestment.pdf)

**Other**

**Simple antenatal intervention improves breastfeeding practice until 6
months postpartum**

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.

[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>

####  {#section-15 .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}

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

-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)

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_01.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_01.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocumentscccc_v5_01.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

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

**Measuring Intimate Partner Violence Victimization and Perpetration: A
Compendium**

<http://www.cdc.gov/ncipc/dvp/Compendium/Measuring_IPV_Victimization_and_Perpetration.htm>

**Physical Dating Violence Among High School Students -- United States,
2003**

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5519a3.htm>

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

**Risk of Poor Outcomes From Bariatric Surgery May Be Greater in
Elderly**

CONCLUSIONS: Age, male sex, electrolyte disorders, and congestive heart
failure were independent risk factors for bariatric surgical mortality.
Limiting bariatric surgical procedures to those younger than 65 years is
warranted because of the high morbidity and mortality associated with
these operations in older patients.

[Livingston
EH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Livingston+EH"%5BAuthor%5D),
[Langert
J](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Langert+J"%5BAuthor%5D).
The impact of age and Medicare status on bariatric surgical outcomes.
[Arch Surg.](javascript:AL_get(this, 'jour', 'Arch Surg.');) 2006
Nov;141(11):1115-20; discussion 1121

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17116805>

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

#### Continuous Contraceptive Therapy Safely Abolishes Menstrual Cycles {#continuous-contraceptive-therapy-safely-abolishes-menstrual-cycles-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Continuous daily regimen of levonorgestrel (LNG) 90 mug/ethinyl estradiol (EE) 20 mug demonstrated a good safety profile and efficacy similar to cyclic OCs. The regimen continuously inhibited menses, increased the incidence of amenorrhea over time and, except for a subset of women, decreased the number of bleeding and spotting days. {#conclusions-continuous-daily-regimen-of-levonorgestrel-lng-90-mugethinyl-estradiol-ee-20-mug-demonstrated-a-good-safety-profile-and-efficacy-similar-to-cyclic-ocs.-the-regimen-continuously-inhibited-menses-increased-the-incidence-of-amenorrhea-over-time-and-except-for-a-subset-of-women-decreased-the-number-of-bleeding-and-spotting-days. .Style-Heading-4-+-Arial-14-pt-Underline}

[Archer
DF](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Archer+DF"%5BAuthor%5D),
et al Evaluation of a continuous regimen of levonorgestrel/ethinyl
estradiol: phase 3 study results.
[Contraception.](javascript:AL_get(this, 'jour', 'Contraception.');)
2006 Dec;74(6):439-45

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17157099>

**FDA Questions and Answers: Ortho Evra** (norelgestromin/ethinyl
estradiol)

Ortho-McNeil and FDA notified healthcare professionals and patients
about revisions to the prescribing information to inform them of the
results of two separate epidemiology studies that evaluated the risk of
developing a serious blood clot in women using Ortho Evra compared to
women using a different oral contraceptive. The first study found that
the risk of non-fatal venous thromboembolism (VTE) associated with the
use of Ortho Evra contraceptive patch is similar to the risk associated
with the use of oral contraceptive pills containing 35 micrograms of
ethinyl estradiol and norgestimate.The second study found an approximate
two-fold increase in the risk of medically verified VTE events in users
of Ortho Evra compared to users of norgestimate-containing oral
contraceptives containing 35 micrograms of estrogen. Although the
results of the two studies differ, the results of the second study
support FDA\'s concerns regarding the potential for Ortho Evra use to
increase the risk of blood clots in some women.\
Prescribing information for Ortho Evra continues to recommend that women
with concerns or risk factors for thromboembolic disease talk with their
healthcare professionals about using Ortho Evra versus other
contraceptive options.

#### [**http://www.fda.gov/cder/drug/infopage/orthoevra/qa20060920.htm**](http://www.fda.gov/cder/drug/infopage/orthoevra/qa20060920.htm) {#httpwww.fda.govcderdruginfopageorthoevraqa20060920.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Access to emergency contraceptive enhances use but not reduce unintended pregnancy  {#access-to-emergency-contraceptive-enhances-use-but-not-reduce-unintended-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Increased access to emergency contraceptive pills enhances use but has not been shown to reduce unintended pregnancy rates. Further research is needed to explain this finding and to define the best ways to use emergency contraception to produce a public health benefit. {#conclusion-increased-access-to-emergency-contraceptive-pills-enhances-use-but-has-not-been-shown-to-reduce-unintended-pregnancy-rates.-further-research-is-needed-to-explain-this-finding-and-to-define-the-best-ways-to-use-emergency-contraception-to-produce-a-public-health-benefit. .Style-Heading-4-+-Arial-14-pt-Underline}

[Raymond
EG](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Raymond+EG"%5BAuthor%5D),
et al Population Effect of Increased Access to Emergency Contraceptive
Pills: A Systematic Review. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Jan;109(1):181-188.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197603>

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

**Featured Website David Gahn, IHS Women's Health Web Site Content
Coordinator**

**Vaccine Preventable Diseases**

The IHS National Immunization Program is a partnership between CDC and
IHS, working with IHS and tribal immunization programs across the
country.\
\
The program is based in the IHS Division of Epidemiology & Disease
Prevention in Albuquerque, NM. IHS National Immunization Program staff
are assigned from the CDC Immunization Services Division. Each IHS Area
also has a designated Immunization Coordinator.

<http://www.ihs.gov/medicalprograms/epi/index.cfm?module=health_issues&option=immunizations&cat=sub_2>

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

**Are varicella titers necessary prior to immunization?**

Some providers and/or nurses are ordering varicella titers on patients
during pregnancy, if they do not have a clear history of having had the
disease, with the purpose of vaccinating those with negative titers
postpartum.  Is that is a reasonable approach?  Or would it be better to
assume that all without a history of the disease are susceptible and
immunize them postpartum without doing titers?

**Answer**

For individuals with a reliable history of varicella, it can be assumed
that they are immune and vaccination is unnecessary. The vast majority
of adults (70 to 90 percent) without a reliable history of varicella are
also immune. In light of these data, the American Academy of Pediatrics
has suggested that it may be cost effective to perform serologic testing
on persons 13 years of age and older and immunize those who are
seronegative. This requires that serologic results will be tracked and
susceptible patients will be immunized. However, serologic testing is
not required because the vaccine is well tolerated in patients with
immunity; thus in some situations, universal immunization may be more
practical and preferable.

Health care and child care workers who do not have a history of
varicella should be tested serologically, and those who are
seronegative, and without a contraindication, should be immunized. (more
Background below)

....so.... my suggestion is that unless you want to develop a specific
tracking system for this issue

#1 ask the patient if she has had chickenpox or been immunized

#2 if not, then treat with vaccine

...if you have a robust infrastructure, then

#1 ask the patient if she has had chickenpox or been immunized

#2 if not, then test and vaccinate the sero-negative patients postpartum

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

**The Perinatology Corner offers a module on this topic**

The Chickenpox (varicella) in Pregnancy module presents other resources,
as well as free CME / CEUs if desired

<http://www.ihs.gov/MedicalPrograms/MCH/M/VC01.cfm>

**Other references:**

Perinatal Viral and Parasitic Infections, ACOG Practice Bulletin, No.
20, American College of Obstetricians and Gynecologists, September 2000

American Academy of Pediatrics. Committee on Infectious Diseases.
Varicella vaccine update. Pediatrics 2000; 105:136. (Updated May 16,
2006).

Treatment and prevention of chickenpox, UpToDate

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=viral_in/11333&type=A&selectedTitle=2~43>

Centers for Disease Control and Prevention. Prevention of varicella:
recommendations of the Advisory Committee on Immunization Practices
(ACIP). MMWR Morb Mortal Wkly Rep 1996;45(RR-11):1--36 (Level III)

Glantz JC, Mushlin AI. Cost-effectiveness of routine antenatal varicella
screening. Obstet Gynecol 1998;91:519--528 (Level III)

Rouse DJ, Gardner M, Allen SJ, Goldenberg RL. Management of the presumed
susceptible varicella (chickenpox)-exposed gravida: a
cost-effectiveness/cost-benefit analysis. Obstet Gynecol
1996;87:932--936 (Level III)

McGregor JA, Mark S, Crawford GP, Levin MJ. Varicella zoster antibody
testing in the care of pregnant women exposed to varicella. Am J Obstet
Gynecol 1987; 157:281--284 (Level II-3)

**More Background**

Nonpregnant women of childbearing age should be questioned about
previous infection with varicella preconceptionally and offered
vaccination if no report of chickenpox is elicited. Varicella vaccine is
approved for use in healthy susceptible persons 12 months or older.
Conception should be delayed until 1 month after the second vaccination
dose is given.

Among women who do not recall a history of varicella, 70--90% have
detectable antibodies. Antenatal VZV screening of all pregnant women
with negative or indeterminate varicella histories is not believed to be
cost-effective by some. However, others argue that from a
cost-effectiveness/cost-benefit standpoint, management based on immune
testing is preferable to universal VZIG administration when caring for
pregnant women exposed to VZV with a negative or indeterminate infection
history. Patients known to be nonimmune to VZV should be counseled to
avoid contact with individuals who have chickenpox.

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

**February 2007**

-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.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN107.doc>

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

**Computerized Public Health Activity Data System, Version 1.0
Announcement**

The Portland Area and OIT are pleased to announce the release the
Computerized Public Health Activity Data System, Version 1.0.  The
package was tested at:  Chinle Comprehensive Health Care Facility, Warm
Springs Health and Wellness Center, Cherokee Indian Hospital and
Stillaguamish Tribal.              

The Indian Health Service (IHS) Computerized Public Health Activity Data
System (CPHAD) application provides for the entry of public health
activity being performed by clinicians or other providers of public
health activities. This software application will work in conjunction
with the existing Resource and Patient Management (RPMS) applications.

Please contact Mary Brickell  <mary.brickell@ihs.gov>

IHS Web page
<http://www.ihs.gov/Cio/RPMS/index.cfm?module=home&option=software>

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

**What does the future hold in store?**

Important news in the world of international health is the recent update
of the Global Burden of Disease (GBD) study. The original and
groundbreaking 1990 GBD project gathered data from around the world to
provide the first truly global estimates of morbidity and mortality due
to various causes. Researchers at Harvard University and the WHO, funded
by the World Bank, also used their data to make projections of global
death rates through 2020. These GBD projections have been used
extensively by policymakers at national and international levels to
guide resource allocation; however, some of the predictions have already
proven to be badly off. In particular, the original report gravely
underestimated the impact of HIV/AIDS.

The researchers used 2002 WHO disease prevalence data to model patterns
of illness and death under three scenarios of socioeconomic change: a
baseline scenario, a pessimistic scenario (in which economic growth is
less than expected) and an optimistic scenario (projecting a faster rate
of economic growth). In all three cases, they predict that the risk of
death for children below 5 will drop substantially by 2030. Life
expectancy at birth will rise in all regions, and the disparity between
life expectancies in rich and poor countries will narrow somewhat,
though in both baseline and pessimistic scenarios the gap will remain
very large. Death due to non-communicable disease -- particularly
ischemic heart disease -- will rise, as will death from HIV/AIDS and
from road traffic accidents, even in the most optimistic projections.
(In fact, greater economic growth is expected to result in more road
traffic fatalities.) Diabetes and cancer will increase while measles,
malaria, and lower-respiratory conditions are projected to decline. By
2015, tobacco will be responsible for 10% of deaths worldwide. The three
leading causes of disability are projected to be HIV/AIDS, depression,
and coronary artery disease.

Of course it is too much to expect that any such projections can truly
accurately forecast the future, and no model, however well constructed,
can account for unpredictable events like a world war, pandemic
influenza, or the discovery of antibiotics. Two serious and potentially
preventable flaws in the study concern me, however. First, the
mathematical models assume that future mortality trends in poor
countries will respond to economic growth in the same way that they did
historically for now-rich countries. There is already evidence to
suggest this rosy prediction may not hold true, as overall economic
growth in poor countries has in a number of cases been associated with
worsening internal inequalities and worsening population health. The
second flaw is the failure to address issues of climate change, which
researchers believe will have a profound effect on both infectious
disease and nutrition. Including some of the climate and disease change
models would have added a new level of complexity to an already
complicated problem, but omitting them entirely has probably hurt the
accuracy of these projections. Even with these two serious caveats,
though, this study will be useful and interesting for people who work in
health policy, and represents an important update of the now outdated
1990 GBD figures.

Mathers CD, Loncar D. Projections of global mortality and burden of
disease from 2002 to 2030. PLoS Medicine 3(11):e442, November 2006

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17132052>

or

Available at [www.plosmedicine.org](http://www.plosmedicine.org/)

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

**School based care: 3 articles - Obesity, exercise, and vaccinations**

**Physical activity and sedentary behavior during adolescence**

Findings indicate that adolescents are experiencing unfavorable shifts
in activity patterns, such as longitudinal decreases in MVPA \[moderate
to vigorous physical activity\], coupled with longitudinal and secular
increases in sedentary behaviors that are attributable specifically to
computer use. Low levels of MVPA and high levels of sedentary behavior
have been shown to be associated with obesity. Project EAT-1 (Eating
Among Teens) and Project Eat II (a follow-up study) follow a large
cohort of individuals longitudinally through various stages of the
adolescent transition to young adulthood. The authors found that:

\* MVPA among female adolescents declined dramatically from 5.9 to 3.9
hours per week during the transition from early to mid-adolescence and
from 5.1 to 3.5 hours per week during the transition from mid- to late
adolescence.

\* Computer use significantly increased among older female adolescents
during the transition from mid- to late adolescence.

\* MVPA among male adolescents did not decline during the transition
from early to mid-adolescence but did decline significantly from mid- to
late adolescence (from 6.5 to 5.1 hours per week). Leisure-time computer
use increased substantially from both early to mid-adolescence (from
11.4 to 14.2 hours per week) and from mid- to late adolescence (from
10.4 to

14.2 hours per week).

\* Television viewing time did not change among adolescent males across
the adolescent transition period.

\* Between 1999 and 2004, secular trends during mid-adolescence indicate
further striking increases in computer use. Mid-adolescent males engaged
in 10.4 hours of use in 1999, compared with 15.2 hours in 2004.

Mid-adolescent females engaged in 2.3 more hours of use per week in 2004
than in 1999.

\* There was no evidence of a secular decline in MVPA between 1999 and
2004 for either female or males adolescents.

As the prevalence of obesity continues to rise in this and other age
groups, we need to continue to advance our understanding of dynamic
population-wide trends in behavior patterns, so as to inform effectively
a broad array of health promotion strategies and public policies that
aim to prevent obesity.

Nelson MC, Neumark-Stzainer D, Hannan PJ, et al. 2006. Longitudinal and
secular trends in physical activity and sedentary behavior during
adolescence. Pediatrics Electronic Pages 118:1627-1634
[[http://pediatrics.aappublications.org/cgi/content/abstract/118/6/e1627]{.underline}](http://pediatrics.aappublications.org/cgi/content/abstract/118/6/e1627)

**School bases obesity research, challenges, and recommendations**

Choosing which obesity prevention components to include in a curriculum
should be based on the evidence.

The authors found that two types of programs have potential for reducing
childhood obesity:

\* For older students, classroom instruction and physical education can
promote moderate to vigorous physical activity both in and out of
school, especially for adolescent girls.

\* Younger students benefit from behavior-change programs that reduce
sedentary behavior.

Based on the findings, the authors offer the following conclusions:

\* Classroom programming should provide behavior-modification strategies
to help students and their families reduce the amount of fast food,
high-sugar drinks, and high-fat foods they consume and increase fruit
and vegetable consumption. In addition, food service must be involved in
obesity-prevention initiatives, and sales of unhealthy foods for
fundraising purposes should be restricted.

\* Physical education that promotes at least 30 minutes of vigorous
activity three to five times a week is the goal. Achieving this with a
cumulative approach through physical education classes, intramural
sports, and before- and after-school programs is recommended.

\* Schools must consider the reduction of sedentary behavior as a
separate issue from increasing physical activity. Classroom programs for
reducing sedentary behavior should use a behavior-change approach, start
in the early grades, and be repeated every few years.

Budd GM, Volpe SL. 2006. School-based obesity prevention: Research,
challenges, and recommendations. Journal of School Health
76(10):485-495.

[[http://www.blackwell-synergy.com/doi/abs/10.1111/j.1746-1561.2006.00149.x]{.underline}](http://www.blackwell-synergy.com/doi/abs/10.1111/j.1746-1561.2006.00149.x).

**School based influenza vaccination is effective**

This school-based vaccination intervention resulted in a reduction in
influenza-related outcomes in household members of children attending
intervention schools.

The authors found that

\* A total of 2,717 of 5,840 students (47%) in intervention schools
received the vaccine after parental consent had been granted.

\* The number of reported episodes of influenza-like illness during the
predicted peak influenza week was significantly lower in
intervention-school households than in control-school households.

\* Compared with children in control-school households, children in
intervention-school households had fewer visits to doctors or clinics
for influenza-like illness, and adults in these households had a trend
toward fewer such visits.

\* Compared with control-school households, intervention-school
households reported significantly lower absentee rates for
influenza-like illness among students in elementary school and
significantly fewer workdays missed by parents to care for their own, or
someone else\'s, influenza-like illness.

\* Both intervention and control schools had increased rates of overall
absenteeism during the influenza outbreak. Within intervention schools,
unvaccinated students had a significantly greater increase in absentee
rates over baseline than did vaccinated students for the predicted peak
week, the intense influenza outbreak period, and the influenza outbreak
period.

Conclusion: Our multicenter study . . . demonstrates that school-based
immunization influenza directly and indirectly reduces outcomes related
to influenza-like illness.

King JC, Stoddard JJ, Gaglani MJ, et al. 2006. Effectiveness of
school-based influenza vaccination. The New England Journal of Medicine
355(24):2523-2532.
[[http://content.nejm.org/cgi/reprint/355/24/2523.pdf]{.underline}](http://content.nejm.org/cgi/reprint/355/24/2523.pdf)

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

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

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

To recap from last month...

A boy had been born in Chile with a fetus in his stomach in what doctors
said was a rare case of \"fetus in fetu\" in which one twin becomes
trapped inside another during pregnancy and continues to grow inside it.

Doctors noticed the 4-inch-long fetus inside the boy\'s abdomen. It had
limbs and a partially developed spinal cord but no head and stood no
chance of survival, doctors said.

After the birth, doctors operated and removed the fetus from the boy\'s
stomach. The boy, who has not been named, was recovering at Temuco\'s
Hernan Henriquez hospital.

**Background**

Fetus in fetu is a malformed parasitic monozygotic diamniotic twin that
is found inside the body of the living child or adult. Thirty one cases
have been published before 1900 and only 11 have been published from
1900 to 1956. This pathology is rare and the incidence is 1 per 500 000
births.

The living children with fetus in fetu were \<18 months except in
11 cases: 20 months (1 case), 5 years (2 cases), 7 years (1 case),
9 years (2 cases), 10 years (1 case), 12 years (1 case) and \>15 years
(3 cases). Sex ratio was 47 boys to 35 girls (the sex of 5 other cases
was undetermined). In 70% of cases, the chief complaint was an abdominal
mass. As far as location was concerned, it was predominantly
retroperitoneal in 80% of cases, but could be atypical including the
skull as in 6 cases, the sacrum as in 6 cases, the scrotum as in 1 case,
and the mouth as in 1 case.

In almost all cases (88%), there was a single parasitic fetus apart from
5 reports in which the number of the fetus ranged from 2 to 5. The size
and weight of the fetus varied, from 4 cm to 24.5 cm, respectively, and
from 1.2 g to 1.8 kg, respectively.

The organs present in the fetus in fetu were as follows: vertebral
column, 91%; limbs, 82.5% (number varied from 1 to 4); central nervous
system, 55.8%; gastrointestinal tract, 45%; vessels, 40%; and
genitourinary tract, 26.5%.

The fetus was always anencephalic, the vertebral column and the limbs
were present in the fetus in fetu in almost all cases (91% and 82.5%,
respectively). The lower limbs were more developed than the upper limbs.
Fetus in fetu was rarely found in the central nervous system,
gastrointestinal tract, vessels, or the genitourinary tract; however, it
was found in 55.8%, 45%, 40% and 26.5% of cases, respectively. It was
rarer still to find fetus in fetu in the lungs, adrenal glands,
pancreas, spleen, and lymph nodes. The heart was very rarely found in
fetu.

The absence of cardiovascular system almost led to misdiagnosis of
acardiac fetus in 1 case as the morphology is otherwise similar with
findings of anencephaly, absent or rudimentary limbs, absent lungs,
short intestine, and single umbilical artery. However, in the case of
acardiac twin fetus, the karyotype is abnormal in at least 50% of cases
including both trisomy or triploidy whereas the karyotype of fetus in
fetu is normal and similar to his host\'s.

Eighty-nine per cent of fetus in fetu lesions were noted before
18 months of age. In reviewing literature most case reports up to
1980 showed the preoperative diagnosis of fetus in fetu was made only in
16.7% of cases because CT scan was not performed. Nowadays, CT scan has
proven very helpful in suggesting the preoperative diagnosis. Magnetic
resonance imaging was also used in 4 cases.

The differential radiologic diagnoses were teratoma and meconium
pseudocyst. Indeed, these masses often had calcified components, so they
were sometimes difficult to differentiate with fetus in fetu.

Treatment was complete resection of the mass except when it was adherent
to the host\'s organs. Relapse was observed in 1 case (out of 87 cases)
with recurrent right abdominal mass 4 months after surgery. This was a
teratoma, which contained cystic, solid, and calcified components. It
measured 13 cm in diameter and 5% of the tumor was yolk sac carcinoma.
After surgical excision, the patient was treated with chemotherapy and
recovered at 2 years of age.

PS:

Which venerable medical resource was the original source of this story?

While I did not spend enough time in the grocery check out line this
month to definitively say if the venerable medical journal, the National
Enquirer, also covered this story, I did ask our readers who regularly
subscribe the National Enquirer to peruse their personal subscription to
National Enquirer. 'Hearing few replies, I will say I first saw this
story on Reuters, before I launched my literature review in Pediatrics,
PubMed, Journal of Pediatric Surgery, etc....though the Yeti who ate
Portland article sounded quite promising when I was standing in line to
buy milk.

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

#### References: {#references .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Hoeffel CC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Hoeffel+CC"%5BAuthor%5D), et al. Fetus in fetu: a case report and literature review. [Pediatrics.](javascript:AL_get(this, 'jour', 'Pediatrics.');) 2000 Jun;105(6):1335-44. {#hoeffel-cc-et-al.-fetus-in-fetu-a-case-report-and-literature-review.-pediatrics.-2000-jun10561335-44. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=10835078&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=10835078&dopt=Abstract) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids10835078doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

[Brand
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Brand+A"%5BAuthor%5D)
et al Fetus in fetu\--diagnostic criteria and differential diagnosis\--a
case report and literature review. [J Pediatr
Surg.](javascript:AL_get(this, 'jour', 'J Pediatr Surg.');) 2004
Apr;39(4):616-8

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15065040>

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

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

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

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

######### 

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

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

**Clinical Discussion Board Index, Medscape**

Hundreds of ongoing clinical discussions available

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

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

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

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

**Menopause Management**

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

[Authors\' conclusions]{.underline} Creams, pessaries, tablets and the
oestradiol vaginal ring appeared to be equally effective for the
symptoms of vaginal atrophy. One trial found significant side effects
following cream (conjugated equine oestrogen) administration when
compared to tablets causing uterine bleeding, breast pain and perineal
pain. Another trial found significant endometrial overstimulation
following use of the cream (conjugated equine oestrogen) when compared
to the ring. As a treatment choice women appeared to favour the
oestradiol-releasing vaginal ring for ease of use, comfort of product
and overall satisfaction.

#### Suckling J, Lethaby A, Kennedy R. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD001500. DOI: 10.1002/14651858.CD001500.pub2. {#suckling-j-lethaby-a-kennedy-r.-local-oestrogen-for-vaginal-atrophy-in-postmenopausal-women.-cochrane-database-of-systematic-reviews-2006-issue-4.-art.-no.-cd001500.-doi-10.100214651858.cd001500.pub2. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions**](http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions) {#httpwww.ihs.govmedicalprogramscirindex.cfmmodulecir_answering_clinical_questions-2 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Life After WHI: Postmenopausal Symptoms and Use of Alternative Therapies After HRT {#life-after-whi-postmenopausal-symptoms-and-use-of-alternative-therapies-after-hrt .Style-Heading-4-+-Arial-14-pt-Underline}

#### RESULTS: Reasons why the women discontinued therapy and any nonhormonal alternative therapies that they may have used to manage subsequent menopausal symptoms were recorded. The primary investigator contacted the 78 women to complete a telephone survey. In most women, at least one menopausal symptom recurred. Vasomotor symptoms (hot flashes) were most common and occurred in 41 (53%) women. In addition, 59 (76%) women reported using nonhormonal alternative therapies, and 40 (68%) of this group deemed the alternatives helpful. CONCLUSION: We strongly believe that health care providers, including pharmacists, must continue to communicate with and educate women regarding treatment options for menopausal symptoms. Clinical pharmacists are ideally suited to contribute to ongoing research in this area. {#results-reasons-why-the-women-discontinued-therapy-and-any-nonhormonal-alternative-therapies-that-they-may-have-used-to-manage-subsequent-menopausal-symptoms-were-recorded.-the-primary-investigator-contacted-the-78-women-to-complete-a-telephone-survey.-in-most-women-at-least-one-menopausal-symptom-recurred.-vasomotor-symptoms-hot-flashes-were-most-common-and-occurred-in-41-53-women.-in-addition-59-76-women-reported-using-nonhormonal-alternative-therapies-and-40-68-of-this-group-deemed-the-alternatives-helpful.-conclusion-we-strongly-believe-that-health-care-providers-including-pharmacists-must-continue-to-communicate-with-and-educate-women-regarding-treatment-options-for-menopausal-symptoms.-clinical-pharmacists-are-ideally-suited-to-contribute-to-ongoing-research-in-this-area. .Style-Heading-4-+-Arial-14-pt-Underline}

[Shrader
SP](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Shrader+SP"%5BAuthor%5D),
[Ragucci
KR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Ragucci+KR"%5BAuthor%5D).
Life after the women\'s health initiative: evaluation of postmenopausal
symptoms and use of alternative therapies after discontinuation of
hormone therapy.
[Pharmacotherapy.](javascript:AL_get(this, 'jour', 'Pharmacotherapy.');)
2006 Oct;26(10):1403-9

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16999650**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16999650) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids16999650 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Conjugated Equine Estrogen Treatment May Not Increase Breast Cancer Risk {#conjugated-equine-estrogen-treatment-may-not-increase-breast-cancer-risk .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Treatment with CEE alone for 7.1 years does not increase breast cancer incidence in postmenopausal women with prior hysterectomy. However, treatment with CEE increases the frequency of mammography screening requiring short interval follow-up. Initiation of CEE should be based on consideration of the individual woman\'s potential risks and benefits. {#conclusions-treatment-with-cee-alone-for-7.1-years-does-not-increase-breast-cancer-incidence-in-postmenopausal-women-with-prior-hysterectomy.-however-treatment-with-cee-increases-the-frequency-of-mammography-screening-requiring-short-interval-follow-up.-initiation-of-cee-should-be-based-on-consideration-of-the-individual-womans-potential-risks-and-benefits. .Style-Heading-4-+-Arial-14-pt-Underline}

[Stefanick
ML](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Stefanick+ML"%5BAuthor%5D),
et al Effects of conjugated equine estrogens on breast cancer and
mammography screening in postmenopausal women with hysterectomy.
[JAMA.](javascript:AL_get(this, 'jour', 'JAMA.');) 2006 Apr
12;295(14):1647-57

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16609086>

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

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

**The Blessed Perineum: PubMed**

As I went hunting for an article to review for this month, I started
playing around on PubMed and found an amazing array of articles about
the blessed perineum. I encourage you to go looking when you have a
spare moment at a computer. However, for the reality that you may only
read this, here is a smattering of what I found:

-   Leah Albers, et al, our esteemed sisters at UNM, did an awesome
    study (N=1211) of perineal techniques and found that it made no
    difference if the midwives used warm compresses, perineal massage,
    or hands off 'til crowning. But they did find that a sitting upright
    position and delivering the head between contractions did lower the
    risk of perineal trauma.

-   Terry, et al, (N=198) found that nonsupine positions (defined as
    sitting, squatting, or kneeling/hands and knees) led to less
    perineal tearing, less vulvar edema, and less blood loss. They also
    found that the length of second stage was shorter in nonsupine
    positions, but this wasn't statistically significant.

-   Soong and Barnes (N=3756) found that the semi-recumbent position was
    associated with more need for perineal suturing and all-fours with
    less, especially with first births and babies over 3500g. With
    regional anesthesia they again found the semi-recumbent position
    associated with more suturing and found that the lateral position
    caused less need for perineal suturing. The authors suggest that
    women be given the choice to find the most comfortable position to
    give birth in and that providers should inform women of the
    likelihood of perineal trauma in the preferred birth position.

-   Shorten, et al, (N=2891) found that the lateral position was the
    best (66.6% intact perineums) and squatting the worst (42% intact),
    especially for primiparas. They also found a difference by
    accoucheur. Intact perineum was achieved by 56-61% of women attended
    by midwives and 31.9% of women attended by obstetricians, who also
    had a five times higher rate of episiotomies. (OK I'm bragging for
    us just a little...)

-   Aikins and Feinland (N=1068) studied planned home births and found
    69.6% of the women gave birth with an intact perineum! (Way to go
    home birth midwives and mothers!) In multiparous women, low
    socioeconomic status and higher parity were associated with intact
    perineum, whereas older age (\>/= 40 yr), previous episiotomy,
    weight gain of over 40 pounds, prolonged second stage, and the use
    of oils or lubricants were associated with perineal trauma. Among
    primiparas, low socioeconomic status, kneeling or hands-and-knees
    position at delivery, and manual support of the perineum at delivery
    were associated with intact perineum, whereas perineal massage
    during delivery was associated with perineal trauma.

So, from the research it sounds like getting women up on their knees,
hands and knees, sitting, or lying on their sides is probably a good
idea and using the oils and massage for other parts of the body rather
than the perineum may be good, too. Soong and Barnes' suggestion to talk
with women about the relationship between birth positions and perineal
trauma risk is a great suggestion, but starting the conversation during
prenatal care or birth classes would be advisable rather than waiting
until second stage.

Over the years I have noticed that my previous enthusiasm for perineal
massage and stretching has waned greatly---now I rarely do more than a
little pressure just inside the introitus to help the woman focus where
to push, if she needs that. I only use warm compresses if I can tell the
perineum is so taut that it needs any help I can give it to melt. Most
of the time, though, I have noticed that if I can help the whole woman
(and everyone else in the room, too) relax, then her perineum melts just
fine (I figure that hormone relaxin is doing it's thing!) I also have
noticed that I don't say much at all anymore about how she should push
and I have noticed the absolute brilliance of women shine through---they
push perfectly---letting up when I would have suggested it and pushing
when I would have said push.....women know how to give birth in the best
way for themselves and their babies---have faith.

**Reference:**

[Albers
LL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Albers+LL"%5BAuthor%5D),
[Sedler
KD](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Sedler+KD"%5BAuthor%5D),
[Bedrick
EJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Bedrick+EJ"%5BAuthor%5D),
[Teaf
D](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Teaf+D"%5BAuthor%5D),
[Peralta
P](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Peralta+P"%5BAuthor%5D).
Midwifery care measures in the second stage of labor and reduction of
genital tract trauma at birth: a randomized trial. [J Midwifery Womens
Health.](javascript:AL_get(this, 'jour', 'J Midwifery Womens Health.');)
2005 Sep-Oct;50(5):365-72

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16154062>

[Terry
RR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Terry+RR"%5BAuthor%5D),
[Westcott
J](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Westcott+J"%5BAuthor%5D),
[O\'Shea
L](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="O'Shea+L"%5BAuthor%5D),
[Kelly
F](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Kelly+F"%5BAuthor%5D).
Postpartum outcomes in supine delivery by physician vs nonsupine
delivery by midwives. [J Am Osteopath
Assoc.](javascript:AL_get(this, 'jour', 'J Am Osteopath Assoc.');) 2006
Apr;106(4):199-202

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16627774>

[Soong
B](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Soong+B"%5BAuthor%5D),
[Barnes
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Barnes+M"%5BAuthor%5D).
Maternal position at midwife-attended birth and perineal trauma: is
there an association?
[Birth.](javascript:AL_get(this, 'jour', 'Birth.');) 2005
Sep;32(3):164-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16128969>

[Shorten
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Shorten+A"%5BAuthor%5D),
[Donsante
J](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Donsante+J"%5BAuthor%5D),
[Shorten
B](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Shorten+B"%5BAuthor%5D).
Birth position, accoucheur, and perineal outcomes: informing women about
choices for vaginal birth.
[Birth.](javascript:AL_get(this, 'jour', 'Birth.');) 2002
Mar;29(1):18-27

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11843786>

[Aikins Murphy
P](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Aikins+Murphy+P"%5BAuthor%5D),
[Feinland
JB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Feinland+JB"%5BAuthor%5D).
Perineal outcomes in a home birth setting.
[Birth.](javascript:AL_get(this, 'jour', 'Birth.');) 1998
Dec;25(4):226-34

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=9892890>

**Navajo News Tomekia Strickland, Chinle**

**GYN Spotlight: Endometrial ablation**

Pre-menopausal dysfunctional uterine bleeding unrelated to malignancy
continues to be a significant problem for women wrought with social
embarrassment, disruption of daily activities, and morbidity associated
with anemia. Not only is it a challenging condition for the patient but
dysfunctional uterine bleeding usually requires lengthy and frequent
outpatient visits for appropriate evaluation and management. Many times,
patients have suffered for years with the condition and often present
discouraged after a series of failed hormonal regimens. Hysterectomy,
the only procedure that is 100% effective in eliminating abnormal
uterine bleeding, is often less acceptable to Native American women than
other populations, both for cultural reasons and because of a general
reluctance to undergo major surgery. Thus endometrial ablation has risen
as an ideal treatment option for women who have completed child bearing,
failed conservative management, and desire uterine conservation.

The Department of Gynecology at Chinle Service Unit is now offering
endometrial ablation to appropriate candidates, as are some other I.H.S.
sites. There are several global endometrial ablation techniques that
have become available nationally over the past few years. Global
endometrial ablation refers to a series of FDA approved newer generation
technologies that do not require an operative hysteroscope. These
include Thermachoice (hot liquid filled balloon), hydrothermal ablation
(circulating hot water), Novasure (bipolar desiccation), Her Option
(cryoablation)and Microwave ablation. This is in contrast to the
standard technique which uses monopolar energy via a rollerball, roller
barrel, or resectoscope requiring operative hysteroscopy. There is also
increased risk of uterine perforation and fluid overload with the
standard techniques. We have started using the Novasure system which is
a global ablative technique that utilizes a three dimensional bipolar
gold mesh that when inserted conforms to the shape of the uterine
cavity. The average ablation time for Novasure® is 90 seconds.\*It also
has the advantage of not requiring hormonal pretreatment to thin the
endometrial lining. When

used correctly, the global ablative techniques are considered safe,
effective, fast, simple to perform, painless and cost effective to both
physician and patient. Many of these procedures can also be performed as
office based procedures.

Like the standard technique, global ablation techniques are considered
successful not so much according to amenorrhea rates, but by reduction
in menstrual flow. Hypomenorrhea correlates with high rates of
subjective patient satisfaction usually greater than 80-90%. The
amenorrhea rates for some of the devices are as follows: Thermachoice
14% at 12-24 months; Microwave 38% at 3 years; and Novasure 51% at 1
year.

In conclusion, global endometrial ablation will most likely continue to
become an increasingly popular and primary minimally invasive surgical
treatment option for women who have completed childbearing and continue
to suffer for abnormal uterine bleeding despite medical therapy. Like
all medical and surgical interventions, care must be taken to evaluate
each patient carefully and individualize their treatment plan
accordingly. "Endometrial Ablation" by UpToDate
[www.uptodate.com](http://www.uptodate.com/) provides a detailed
discussion on the indications, contraindications and safety profiles for
each ablative procedure. If you would like more information about our
exciting but still new experience with Novasure, please feel free to
contact me at <tomekia.strickland@ihs.gov>

**Nurses Corner, Sandra Haldane, HQE**

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

Getting the patient back to work after an illness or injury is a major
goal for clinicians. How to write back-to-work restrictions and
instructions so that they are both understood and implemented by both
the employee and employer is important for patient safety. It is also
often a complicated process. The healthcare provider has the
responsibility to determine when and under what restrictions an employee
should return to work.

Recovery from injury and illness is influenced by many conditions:
pre-existing medical conditions, workers\' compensation issues, surgical
or medical complications, and emotional or family stress associated with
recovery from illness and injury.

Employees should be encouraged to return to work as soon as they are
able. Research has suggested that the longer the recovery time, the less
the chance that individuals will return to work. Effective
return-to-work programs can decrease medical costs, improve outcomes,
and decrease the recovery time. Some individuals may develop a
\"disability mindset\" as soon as 2 weeks after an injury, so a plan for
return to work needs to be in place as soon as it is feasible and begins
with the first employee visit.

Who gets injured? The top 10 jobs that are responsible for 30% of job
injuries are topped by truck drivers and then followed by laborers,
nurses aides, construction laborers, janitors and cleaners, assemblers,
carpenters, cooks, registered nurses, and stock handlers or baggers. Men
have 65% of the injuries, people between the ages and 20 and 44 years
have more injuries, and 42% of injuries occur within the first year of
work. It is often this later group of individuals who recover and then
move on to another job to avoid re-injury.

The standard process followed in getting employees back to work involves
4 distinct tasks: gathering data, assessing expectations, performing the
physical examination, and writing restrictions.

Gathering data helps establish the diagnosis and clarify any problems
that might arise. It will also rule out any serious medical conditions.
In order to determine a back-to-work plan, the clinician should collect
a description of the injury, the past and current status of symptoms,
medications being taken, allergies, and work history. A visit to the
workplace to meet with safety and management personnel is important,
particularly if the work site is associated with many injuries or they
have requested your input about return-to-work issues.

Part of talking with the patient should include assessing their
expectations for recovery and return to work. Assessing the patient\'s
perceived ability to do the work involved, as well as psychological and
financial issues, should be explored. The patient who is able to return
quickly to work is likely to have more financial security, positive
self-image, and reinforcement of other efforts for recovery. Injury or
illness may surface or aggravate other problems such as substance abuse,
somatoform or personality disorders, depression, or anxiety. Personnel
issues with others at work may also influence the desire of the patient
to return to work. Discussing and dealing with these issues are
important if the patient is going to be willing to cooperate in going
back to work.

The physical examination is important in determining the physical
fitness of the individual and their ability to do the specific work of
their job. In addition to the relevant musculoskeletal, neurologic,
cardiac, or respiratory examinations, mood, pain behaviors, gait, vital
signs, and preinjury limitations all impact current ability to work.

Work restrictions should then be crafted in a way that is clear and
meaningful. Functional activity requires comparing job demands and the
patient\'s abilities. This is a step-by-step process facilitated by a
treatment plan to promote recovery. The conditions under which the
employee can work need to be stated in a way that management can
understand and apply. Based on the physical evaluation, functional
limitations should be based on an assessment of the stamina, strength,
and cognitive function that will affect the patient\'s ability to do the
job. This will involve looking at what the patient must physically and
cognitively do on the job and writing specific restrictions that the
patient must face as they initially return to work. The clinician may
make a table indicating what physical activity is required for a job
using the neck, shoulders, elbow, back, or knees and then writing any
restrictions the patient may have in those areas. For example, the
patient may be unable to squat or kneel, climb stairs, or stand for long
periods of time. The employer may be required to offer some
accommodation or modification of the job for the employee to return to
work. This requires that all levels of management support the employee
in their gradual resumption of work activities.

Sometimes it is required that the work environment be modified so that a
patient could sit or avoid turning in a particular direction. Based upon
the clinician\'s recommendations, the patient may also return to work
for reduced hours. The progress in returning to work should be monitored
frequently and consistently and the restrictions gradually removed as
the patient improves.

#### Majerus SI, Miller SK, Asp KM  Getting Your Patient Back to Work: Writing Return-to-Work Restrictions After Illness or Injury Journal for Nurse Practitioners.  2006;2(10):533-538

#### Other Medscape case studies, here: {#other-medscape-case-studies-here .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/547779?src=mp**](http://www.medscape.com/viewarticle/547779?src=mp) {#httpwww.medscape.comviewarticle547779srcmp .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-28 .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}

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

#### [Results]{.underline} No statistically significant relationships were found between activity and perceived or objectively measured proximity to parks. Pearson correlation coefficients for perceptions of distance and objectively measured distance to physical activity resources ranged from 0.40 (gyms, schools) to 0.54 (parks). Perceived distance to gyms and objective number of schools within 1-mile buffers were negatively associated with activity. No statistically significant relationships were found between activity and perceived or objectively measured proximity to parks {#results-no-statistically-significant-relationships-were-found-between-activity-and-perceived-or-objectively-measured-proximity-to-parks.-pearson-correlation-coefficients-for-perceptions-of-distance-and-objectively-measured-distance-to-physical-activity-resources-ranged-from-0.40-gyms-schools-to-0.54-parks.-perceived-distance-to-gyms-and-objective-number-of-schools-within-1-mile-buffers-were-negatively-associated-with-activity.-no-statistically-significant-relationships-were-found-between-activity-and-perceived-or-objectively-measured-proximity-to-parks .Style-Heading-4-+-Arial-14-pt-Underline}

#### Jilcott SB, Evenson KR, Laraia BA, Ammerman AS. Association between physical activity and proximity to physical activity resources among low-income, midlife women. Prev Chronic Dis 2007 Jan [**http://www.cdc.gov/pcd/issues/2007/jan/06_0049.htm**](http://www.cdc.gov/pcd/issues/2007/jan/06_0049.htm) {#jilcott-sb-evenson-kr-laraia-ba-ammerman-as.-association-between-physical-activity-and-proximity-to-physical-activity-resources-among-low-income-midlife-women.-prev-chronic-dis-2007-jan-httpwww.cdc.govpcdissues2007jan06_0049.htm .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-29 .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-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Guidelines and Recommendations**

**2006 Sexually Transmitted Disease Treatment Guidelines**

<http://www.cdc.gov/std/treatment/default.htm>

**Immunization Strategy to Eliminate Transmission of Hepatitis B Virus
Infection**

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5516a1.htm?s_cid=rr5516a1_e>

**HIV Testing in Health-Care Settings**

<http://www.cdc.gov/hiv/topics/testing/healthcare/index.htm>

**HPV Vaccine**

<http://www.cdc.gov/std/HPV/default.htm#vaccine>

**Recommendations to Improve Preconception Health and Health Care-
United States**

[www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm](http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm)

**Revised Recommendations for HIV Testing of Adults, Adolescents, and
Pregnant Women**

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm>

**Sexual Violence Prevention: Beginning the Dialogue**

<http://www.cdc.gov/ncipc/dvp/SVPrevention.htm>

**Successful Business Strategies to Prevent Heart Disease and Stroke
Toolkit**

<http://www.cdc.gov/dhdsp/library/toolkit/index.htm>

**Science and Research**

**2003 Assisted Reproductive Technology Success Rates**

<http://www.cdc.gov/ART/ART2003/preface.htm>

**2004 Chlamydia Prevalence Monitoring Project Annual Report**

<http://www.cdc.gov/std/Chlamydia2004/default.htm>

**2004 STD Surveillance Report**

<http://www.cdc.gov/std/stats/toc2004.htm>

**Birth and Fertility Rates for States by Hispanic Origin Subgroups:
1990 and 2000**

[www.cdc.gov/nchs/data/series/sr_21/sr21_057.pdf](http://www.cdc.gov/nchs/data/series/sr_21/sr21_057.pdf)

**Chronic Fatigue Syndrome**

<http://www.cdc.gov/cfs/>

**Contraceptive Use: United States and Territories, BRFSS, 2002**

<http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5406a1.htm>

**Critical Needs in Caring for Pregnant Women during Times of Disaster**

<http://www.bt.cdc.gov/disasters/pregnantdisasterhcp.asp>

**Disability and Health State Chartbook -- 2006 Profiles of Health for
Adults with Disabilities**

<http://www.cdc.gov/ncbddd/dh/chartbook/default.htm>

**Fatalities and Injuries from Falls Among Older Adults -- 1993-2003 and
2001-2005**

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5545a1.htm>

**Fertility, Family Planning, and Reproductive Health of U.S. Women:
2002**
[www.cdc.gov/nchs/data/series/sr_23/sr23_025.pdf](http://www.cdc.gov/nchs/data/series/sr_23/sr23_025.pdf)

**Genomic Tests for Ovarian Cancer Detection & Management**

<http://www.cdc.gov/genomics/gtesting/EGAPP/docs/announcement2006-10-26.htm>

**HIV/AIDS Among Women**

<http://www.cdc.gov/hiv/topics/women/index.htm>

**Identifying Best Practices for WISEWOMAN Programs Using a
Mixed-Methods Evaluation**

<http://www.cdc.gov/pcd/issues/2006/jan/05_0133.htm>

**Lymphocytic Choriomeningitis Virus (LCMV) and Pregnancy: Facts and
Prevention**

<http://www.cdc.gov/ncbddd/bd/lcmv.htm>

**Measuring Intimate Partner Violence Victimization and Perpetration: A
Compendium**

<http://www.cdc.gov/ncipc/dvp/Compendium/Measuring_IPV_Victimization_and_Perpetration.htm>

**Physical Dating Violence Among High School Students -- United States,
2003**

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5519a3.htm>

**Racial and Socioeconomic Disparities in Breastfeeding - United States,
2004**

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5512a3.htm?s_cid=mm5512a3_e>

**Recent Trends in Teenage Pregnancy in the United States, 1990-2002**

<http://www.cdc.gov/nchs/products/pubs/pubd/hestats/teenpreg1990-2002/teenpreg1990-2002.htm>

**Smoking Among Women: Cardiovascular Disease and Stroke**

<http://www.cdc.gov/tobacco/factsheets/Cardiovascular.htm>

**The Health Consequences of Involuntary Exposure to Tobacco Smoke:
Surgeon General**

<http://www.cdc.gov/tobacco/sgr/sgr_2006/index.htm>

**U.S. Cancer Statistics: 2002 Incidence and Mortality Report**

<http://www.cdc.gov/cancer/npcr/uscs/index.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}

**Steroidal contraceptives influence fracture risk cannot be determined
from existing data**

AUTHORS\' CONCLUSIONS: Whether steroidal contraceptives influence
fracture risk cannot be determined from existing information. Due to
different interventions, no trials could be combined for meta-analysis.
Many trials had small numbers of participants and some had large losses
to follow up. Health care providers and women should consider the costs
and benefits of these effective contraceptives. For example, injectable
contraceptives and implants provide effective, long-term birth control
yet do not involve a daily regimen. Progestin-only contraceptives are
considered appropriate for women who should avoid estrogen due to
medical conditions.

Lopez LM, Grimes DA, Schulz KF, Curtis KM. Steroidal contraceptives:
effect on bone fractures in women. Cochrane Database of Systematic
Reviews 2006, Issue 4. Art. No.: CD006033. DOI:
10.1002/14651858.CD006033.pub2.

<http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions>

**Strontium ranelate decreases fractures in the spine and slightly
decreases other fractures**

[Authors\' conclusions]{.underline} There is silver level evidence
(www.cochranemsk.org) to support the efficacy of strontium ranelate for
the reduction of fractures (vertebral and to a lesser extent
non-vertebral) in postmenopausal osteoporotic women and an increase in
BMD in postmenopausal women with/without osteoporosis. Diarrhea may
occur however, adverse events leading to study withdrawal were not
significantly increased with taking 2 g of strontium ranelate daily.
Potential vascular and neurological side-effects need to be further
explored.

O\'Donnell S, Cranney A, Wells GA, Adachi JD, Reginster JY. Strontium
ranelate for preventing and treating postmenopausal osteoporosis.
Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.:
CD005326. DOI: 10.1002/14651858.CD005326.pub3

<http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions>

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

#### Health literacy and depression: Literacy education improves self-efficacy scores {#health-literacy-and-depression-literacy-education-improves-self-efficacy-scores-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: The results of this preliminary study suggest that among persons with low literacy and symptoms of depression, depression symptoms lessen as self-efficacy scores improve during participation in adult basic literacy education. {#conclusion-the-results-of-this-preliminary-study-suggest-that-among-persons-with-low-literacy-and-symptoms-of-depression-depression-symptoms-lessen-as-self-efficacy-scores-improve-during-participation-in-adult-basic-literacy-education. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Francis L](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Francis+L"%5BAuthor%5D), [Weiss BD](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Weiss+BD"%5BAuthor%5D), [Senf JH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Senf+JH"%5BAuthor%5D), et al Does Literacy Education Improve Symptoms of Depression and Self-efficacy in Individuals with Low Literacy and Depressive Symptoms? A Preliminary Investigation. [J Am Board Fam Med.](javascript:AL_get(this, 'jour', 'J Am Board Fam Med.');) 2007 Jan-Feb;20(1):23-7. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17204731&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17204731&dopt=Abstract) {#francis-l-weiss-bd-senf-jh-et-al-does-literacy-education-improve-symptoms-of-depression-and-self-efficacy-in-individuals-with-low-literacy-and-depressive-symptoms-a-preliminary-investigation.-j-am-board-fam-med.-2007-jan-feb20123-7.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids17204731doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Depression in Children and Teens {#depression-in-children-and-teens-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20070101/83ph.html**](http://www.aafp.org/afp/20070101/83ph.html) {#httpwww.aafp.orgafp2007010183ph.html .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}

**Fish Oil Supplements During Pregnancy Are Safe and Beneficial **

CONCLUSION: Maternal fish oil supplementation during pregnancy is safe
for the fetus and infant, and may have potentially beneficial effects on
the child\'s eye and hand coordination. Further studies are needed to
determine the significance of this finding.

[Dunstan
JA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Dunstan+JA"%5BAuthor%5D),
et al Cognitive assessment at 21/2 years following fish oil
supplementation in pregnancy: a randomized controlled trial.

[Arch Dis Child Fetal Neonatal
Ed.](javascript:AL_get(this, 'jour', 'Arch Dis Child Fetal Neonatal Ed.');)
2006 Dec 21

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17185423>

### 

### **Planned cesarean delivery doubles rate of NICU and the risk for pulmonary disorders**

### [Results]{.underline} 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). The risk for pulmonary disorders (transient tachypnea of the newborn infant and respiratory distress syndrome) rose from 0.8% to 1.6% (P = .01). There were no significant differences in the risks for low Apgar score and neurologic symptoms. [Conclusion]{.underline} 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**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16846577) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids16846577 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### Perinatal outcomes of in vitro fertilization children were worse and hospital episodes were more common than among control children. Risks for cerebral palsy and psychological and developmental disorders were increased. Among in vitro fertilization singletons, worse results for perinatal outcomes and hospitalizations, but no increased risk for specific diseases, were found. The health of in vitro fertilization multiple births was comparable to the health of control multiple births. CONCLUSIONS: Reducing the number of transferred embryos would improve the health of in vitro fertilization children. Klemetti R et al Health of children born as a result of in vitro fertilization. [Pediatrics.  2006; 118(5):1819-27](http://www.medscape.com/medline/publicationbrowser/123?pmid=17079550) {#perinatal-outcomes-of-in-vitro-fertilization-children-were-worse-and-hospital-episodes-were-more-common-than-among-control-children.-risks-for-cerebral-palsy-and-psychological-and-developmental-disorders-were-increased.-among-in-vitro-fertilization-singletons-worse-results-for-perinatal-outcomes-and-hospitalizations-but-no-increased-risk-for-specific-diseases-were-found.-the-health-of-in-vitro-fertilization-multiple-births-was-comparable-to-the-health-of-control-multiple-births.-conclusions-reducing-the-number-of-transferred-embryos-would-improve-the-health-of-in-vitro-fertilization-children.-klemetti-r-et-al-health-of-children-born-as-a-result-of-in-vitro-fertilization.-pediatrics.-2006-11851819-27 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17079550&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17079550&dopt=Abstract) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids17079550doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Preterm birth is significantly associated with antenatal depression {#preterm-birth-is-significantly-associated-with-antenatal-depression-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: These findings provide evidence that antenatal depression is significantly associated with spontaneous preterm birth in a population of European women receiving early and regular care. Dayan J et al Prenatal depression, prenatal anxiety, and spontaneous preterm birth: a prospective cohort study among women with early and regular care.[Psychosom Med.  ; 68(6):938-46](http://www.medscape.com/medline/publicationbrowser/123?pmid=17079701) {#conclusions-these-findings-provide-evidence-that-antenatal-depression-is-significantly-associated-with-spontaneous-preterm-birth-in-a-population-of-european-women-receiving-early-and-regular-care.-dayan-j-et-al-prenatal-depression-prenatal-anxiety-and-spontaneous-preterm-birth-a-prospective-cohort-study-among-women-with-early-and-regular-care.psychosom-med.-686938-46 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17079701**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17079701) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17079701 .Style-Heading-4-+-Arial-14-pt-Underline}

**Hydroxychloroquine in lupus pregnancy: continuation recommended**

CONCLUSION: We recommend the continuation of HCQ treatment during
pregnancy. Our findings are consistent with prior reports of the absence
of fetal toxicity. Similar to studies of nonpregnant women, the
cessation of HCQ treatment during pregnancy increases the degree of
lupus activity.

Clowse ME et al Hydroxychloroquine in lupus pregnancy. [Arthritis Rheum.
 2006;
54(11):3640-7](http://www.medscape.com/medline/publicationbrowser/123?pmid=17075810) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17075810>

#### 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=51>

Unsubscribe from the Primary Care listserv

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

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

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

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

The Indian Health Service Primary Care Provider's December 2006 issue is
dedicated to the problems and solutions for Methamphetamine abuse in
Indian Country. There are 2-3 more planned installments. If you have
questions, or want to contribute contact <Lori.deRavello@ihs.gov>

# [**http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV1206.pdf**](http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV1206.pdf)

# Key Trainers for Rural HIV Providers

The National Rural Health Association (NRHA) has developed several new
documents on delivery of HIV care in rural settings.  The first two
documents listed below identify AIDS EDUCATION & TRAINING CENTERS
(AETCs) as crucial resources for training providers on delivery of HIV
care.  NRHA's work was sponsored by the HHS Office of HIV/AIDS Policy,
with input from HRSA/HAB and other Federal agencies.

"Provider Training Techniques" discusses barriers to training providers
in rural areas and offers strategies on how to effectively train rural
providers.

<http://nrharural.org/opporty/pdf/HIV_Provider_Training.pdf>

Resources on HIV services in rural areas are available at:
<http://nrharural.org/opporty/sub/rural_HIV.html#Resources>

Transportation and HIV Care" includes best practices for providing
transportation services such as conducting a needs assessment, use of
vouchers, and shuttle services.

<http://nrharural.org/opporty/pdf/HIV_Transportation.pdf>

 

# Webcast Explores Partnerships between Community Health Centers and AIDS SERVICE ORGANIZATIONS (ASO)

A Web-Based In-Service Training, sponsored by the AETC Network, HRSA's
Bureau of Primary Health Care (BPHC), and the National Association of
Community Health Centers, explores opportunities and strategies for
partnership across community health centers and other providers of
HIV-related care.  BPHC-supported health centers are a major component
of America\'s health care safety net. Community health centers care for
people regardless of their ability to pay and status of health insurance
coverage.  They provide primary and preventive health care, as well as
services such as transportation and translation. Many community health
centers also offer dental, mental health, and substance abuse care.  The
training provides an overview of the community health centers role in
HIV care and treatment.  It also discusses the capacity of health
centers in HIV prevention and testing.
<http://www.aidsetc.org/aetc/aetc?page=cf-bphc-info>

### **Presentation**

#### Bureau of Primary Health Care (BPHC), Community Health Centers, and the AETC Network: Opportunities and Strategies for Partnership

View the web conference

(Link to TARGET Center Web site)
<http://www.careacttarget.org/media.htm>

### **Supplemental Resources and Materials**

HRSA Bureau of Primary Health Care

National Association of Community Health Centers, Inc.

Putting Patients First: Health Centers as Leaders in HIV Prevention and
Testing

# New Website Links to All Federal HIV Information and Resources

The Federal Government has launched a new website, AIDS.gov, designed to
link users to Federal domestic HIV/AIDS information and resources.  The
goal is to ease access to information on Federal HIV/AIDS prevention,
testing, treatment, and research programs, policies, and resources.  It
provides comprehensive government-wide information on HIV/AIDS for the
general public, Federal agencies, state staff/public health departments,
Federal grantees, medical institutions, research institutions, and
HIV/AIDS-related organizations. <http://www.aids.gov/> 

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

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

#### Routine HIV Screening Deemed Cost-Effective in Average-Risk Populations {#routine-hiv-screening-deemed-cost-effective-in-average-risk-populations-1 .Style-Heading-4-+-Arial-14-pt-Underline}

CONCLUSIONS: Routine, rapid HIV testing is recommended for all adults
except in settings where there is evidence that the prevalence of
undiagnosed HIV infection is below 0.2%.

[Paltiel
AD](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Paltiel+AD"%5BAuthor%5D),
et al Expanded HIV screening in the United States: effect on clinical
outcomes, HIV transmission, and costs. [Ann Intern
Med.](javascript:AL_get(this, 'jour', 'Ann Intern Med.');) 2006 Dec
5;145(11):797-806

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17146064>

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

**Genital Warts: Best Practices for Diagnosis and Management CME/CE**

This Medscape CME combines a visual discussion of genital warts (effects
of low risk HPV strains) and reinforces also our continued focus on high
risk strains.  The photos themselves are worth the quick 20 minute
review.  The session is more reinforcement for the HPV vaccine as well.
<http://www.medscape.com/viewprogram/6385?src=mp> from
[Judith.Thierry@ihs.gov]{.underline}

####  {#section-38 .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}

**Diabetic Moms\' Babies Have Impaired Sucking Reflexes**\
Immature sucking patterns are often seen in infants whose mothers
developed diabetes during pregnancy and had to be treated with insulin,
new research indicates.\
On the other hand, babies of mothers with diabetes that was managed with
a careful diet do not seem to have impaired sucking reflexes. The
findings suggest that the nervous system of newborns of insulin-treated
diabetic mothers is less mature than that of babies born to healthy
mothers. CONCLUSION: Poorer sucking patterns were found among infants of
insulin-managed mothers with diabetes. The present findings indicate
some degree of neurologic immaturity during the early neonatal period.
[Bromiker
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Bromiker+R"%5BAuthor%5D),
et al Immature sucking patterns in infants of mothers with diabetes. [J
Pediatr.](javascript:AL_get(this, 'jour', 'J Pediatr.');) 2006
Nov;149(5):640-3
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17095335>

**HbA1c Early in Diabetic Pregnancy Predicts Outcomes**

CONCLUSIONS: Starting from a first-trimester A1C level slightly \<7%,
there is a dose-dependent association between A1C and the risk of
adverse pregnancy outcome without indication of a plateau, below which
the association no longer exits. A1C, however, seems to be of limited
value in predicting outcome in the individual pregnancy.

[Nielsen
GL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Nielsen+GL"%5BAuthor%5D),
[Moller
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Moller+M"%5BAuthor%5D),
[Sorensen
HT](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Sorensen+HT"%5BAuthor%5D).
HbA1c in early diabetic pregnancy and pregnancy outcomes: a Danish
population-based cohort study of 573 pregnancies in women with type 1
diabetes. [Diabetes
Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');) 2006
Dec;29(12):2612-6

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17130193>

**Prenatal Multivitamins for Undernourished Women May Reduce Risk of Low
Birth Weight**

Undernourished women who take a vitamin and mineral supplement while
pregnant may be less likely than women taking only iron and folic acid
supplements to have babies weighing less than 2,500 grams, and their
newborns may be less likely to have morbidity in the first seven days of
life. CONCLUSION: Compared with iron and folic acid supplementation, the
administration of multimicronutrients to undernourished pregnant women
may reduce the incidence of low birth weight and early neonatal
morbidity [Gupta
P](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Gupta+P"%5BAuthor%5D),
et al Multimicronutrient Supplementation for Undernourished Pregnant
Women and the Birth Size of Their Offspring: A Double-blind, Randomized,
Placebo-Controlled Trial. [Arch Pediatr Adolesc
Med.](javascript:AL_get(this, 'jour', 'Arch Pediatr Adolesc Med.');)
2007 Jan;161(1):58-64.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17199068>

#### Women's Health Headlines, Carolyn Aoyama, HQE {#womens-health-headlines-carolyn-aoyama-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**What Causes Breast Cancer?**

The Sister Study must enroll 20,000 more women in 2007 to help find the
answers.

You can help get these 20,000 sisters in 2007 by:

-Forwarding this to everyone in your contact address list

-Taking Sister Study materials to places where eligible women may be
such as doctors' offices, beauty salons, churches/synagogues, meetings,
workplaces, conferences, events, etc.

-Make a pledge to personally find 5 eligible women to enroll in the
study

-Write a letter to your newspaper editor with a personal story

Help the Sister Study now! Let's put a stop to Breast Cancer!

For questions or more information:

Call toll-free telephone number 1-877-474-7837

Or log on to [www.sisterstudy.org](http://www.sisterstudy.org/)

A woman is eligible to join this landmark national breast cancer study
which looks at how environment and genes may affect the chances of
getting breast cancer if -

Your sister (living or deceased), related to you by blood, had breast
cancer

You are between the ages of 35 and 74

You have never had breast cancer yourself

You live in the United States or Puerto Rico

Conducted by National Institute of Environmental Health Sciences one of
the  National Institutes of Health  of the U.S. Department of Health and
Human Services

**Women's History Month: March 2007**

National Women's History Month's roots go back to March 8, 1857, when
women from New York City factories staged a protest over working
conditions. International Women's Day was first observed in 1909, but it
wasn't until 1981 that Congress established National Women's History
Week during the second week of March. In 1987, Congress expanded the
week to a month. Every year since, Congress has passed a resolution for
Women's History Month, and the president has issued a proclamation.

152 million

The number of females in the United States as of Nov. 1, 2006. That
exceeds the number of males (148 million).
[[http://www.census.gov/popest/national/asrh/2005_nat_res.html]{.underline}](http://www.census.gov/popest/national/asrh/2005_nat_res.html)

As of July 1, 2005, males outnumbered females in every five-year age
group through the

35 to 39 age group. Starting with the 40 to 44 age group, women
outnumbered men. At 85 and over, there were more than twice as many
women as men.

[[http://www.census.gov/popest/national/asrh/NC-EST2005-sa.html]{.underline}](http://www.census.gov/popest/national/asrh/NC-EST2005-sa.html)

Motherhood

82.5 million

Estimated number of mothers of all ages in the United States. (From
unpublished data.)

1.9

Average number of children that women 40 to 44 had given birth to as of
2004, down from

3.1 children in 1976, the year the Census Bureau began collecting such
data. Likewise, the percentage of women in this age group who were
mothers was 81 percent in 2004, down from 90 percent in 1976.

[[http://www.census.gov/population/www/socdemo/fertility.html]{.underline}](http://www.census.gov/population/www/socdemo/fertility.html)

Earnings

\$32,168

The median annual earnings of women 16 or older who worked year-round,
full time, in 2005. Women earned 77 cents for every \$1 earned by men.
(Source: American Community Survey at

<http://www.census.gov/PressRelease/www/releases/archives/>[income_wealth/007419.html]{.underline}

91 cents

The amount women in the District of Columbia, who worked year-round,
full time, earned for every \$1 their male counterparts earned in 2005.
Among all states or state equivalents, the district was where women were
closest to earnings parity with men. Maryland and Connecticut were the
only states where median earnings for women were above \$40,000, as was
the District of Columbia. (Source: American Community Survey at

<http://www.census.gov/PressRelease/www/releases/archives/income_wealth/007419.html>

\$58,906

Median earnings of women working in computer and mathematical jobs, the
highest for women among the 22 major occupational groups. Among these
groups, community and social services was the only group where women's
earnings as a percentage of men's earnings were higher than 90 percent.
(Source: American Community Survey
<http://www.census.gov/PressRelease/www/releases/archives/income_wealth/007419.html>

Education

32%

Percent of women 25 to 29 who had attained a bachelor's degree or higher
in 2005, which exceeded that of men in this age range (25 percent).

Eighty-seven percent of women and 85 percent of men in this same age
range had completed high school.
<http://www.census.gov/PressRelease/www/releases/archives/education/007660.html>

85.4%

Percent of women 25 or older who had completed high school as of 2005.
High school graduation rates for women continued to exceed those of men
(84.9 percent).

<http://www.census.gov/PressRelease/www/releases/archives/education/007660.html>

26.1 million

Number of women 25 or older with a bachelor's degree or more education
in 2005, more than double the number 20 years earlier.

<http://www.census.gov/PressRelease/www/releases/archives/education/007660.html>

27%

Percent of women 25 or older who had obtained a bachelor's degree as of
2005. This rate was up 10.5 percentage points from 20 years earlier

<http://www.census.gov/PressRelease/www/releases/archives/education/007660.html>

870,000

The projected number of bachelor's degrees that will be awarded to women
in the

2006-07 school year. Women also are projected to earn 369,000 master's
degrees during this period. Women would, therefore, earn 58 percent of
the bachelor's and 61 percent of the master's degrees awarded during
this school year. (Source: National Center for Education Statistics,
Projections of Education Statistics to 2015, at
<http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2006084>

Businesses

More than \$939 billion

Revenue for women-owned businesses in 2002, up 15 percent from 1997.
There were 116,985 women-owned firms with receipts of \$1 million or
more.

Nearly 6.5 million

The number of women-owned businesses in 2002, up 20 percent from 1997.
(The increase was twice the national average for all businesses.) Women
owned 28 percent of all non-farm businesses.

More than 7.1 million

Number of people employed by women-owned businesses. There were 7,231
women-owned firms with 100 or more employees, generating \$274 billion
in gross receipts.

• Nearly one in three women-owned firms operated in health care and
social assistance, and other services such as personal services, and
repair and maintenance. Women owned 72 percent of social assistance
businesses and just over half of nursing and residential care
facilities. Wholesale and retail trade accounted for 38.2 percent of
women-owned business revenue.

43%

Rate of growth in the number of women-owned firms in Nevada between 1997
and 2002, which led the nation. Georgia (35 percent), Florida (29
percent) and New York (28 percent) followed.

Source for the statements in this section:

[[http://www.census.gov/prod/ec02/sb0200cswmnt.pdf]{.underline}](http://www.census.gov/prod/ec02/sb0200cswmnt.pdf)

[[http://www.census.gov/prod/ec02/sb0200cscosumt.pdf]{.underline}](http://www.census.gov/prod/ec02/sb0200cscosumt.pdf)

Voting

65%

Percentage of women citizens who reported voting in the 2004
presidential election, higher than the 62 percent of their male
counterparts who cast a ballot

<http://www.census.gov/PressRelease/www/releases/archives/voting/004986.html>

Jobs

59%

Percent of women 16 or older who participated in the labor force in
2005.

This amounted to 69.3 million women. More than 35 million women in 2005
had worked year-round, full time, in the past 12 months. Men in this age
range had a participation rate of 73 percent. (Sources:
[[http://www.bls.gov/cps/cpsaat2.pdf]{.underline}](http://www.bls.gov/cps/cpsaat2.pdf)
and 2005 American Community Survey via American FactFinder.)

37%

Percent of women 16 or older who work in management, professional and
related occupations, compared with 31 percent of men. (Source: 2005
American Community Survey via American FactFinder)

21.1 million

Number of female workers in educational services, health care and social
assistance industries. More women work in this industry group than in
any other. Within this industry group, 10.7 million work in the health
care industry and 8 million in educational services. (Source: 2005
American Community Survey via American FactFinder)

Military

203,000

Total number of active duty women in the military, as of Sept. 30, 2005.
Of that total, 35,000 women were officers, and 168,000 were enlisted.

(Source: Statistical Abstract of the United States: 2007, Table 500.)

15%

Proportion of members of the armed forces who were women, as of Sept.
30, 2005. In 1950, women comprised less than 2 percent.

(Source: Statistical Abstract of the United States: 2007, Table 500.)

1.7 million

The number of military veterans who are women.

(Source: Statistical Abstract of the United States: 2007, Table 508.)

Marriage

63 million

Number of married women (including those who are separated or have an
absent spouse) in 2005. There are 55 million unmarried (widowed,
divorced or never married) women. (Source: 2005 American Community
Survey via American FactFinder)

17%

Percentage of married couples in which the wife earns at least \$5,000
more than the husband in 2005. Among 22 percent of married couples, the
wife has more education than the
husband.<http://www.census.gov/PressRelease/www/releases/archives/families_households/006840.html>

5.6 million

Number of stay-at-home mothers nationwide in 2005, up from 4.4 million a
decade earlier.
[[http://www.census.gov/population/socdemo/hh-fam/shp1.pdf]{.underline}](http://www.census.gov/population/socdemo/hh-fam/shp1.pdf)

Computers

84%

Proportion of women who used a computer at home in 2003, 2 percentage
points higher than the corresponding proportion for men. This reverses
the computer use "gender gap" exhibited during the 1980s and
1990s.<http://www.census.gov/PressRelease/www/releases/archives/miscellaneous/005863.html>

Sports and Recreation

2.9 million

Number of girls who participated in high school athletic programs in the

2004-05 school year. In the 1973-74 school year, only 1.3 million girls
were members of a high school athletic team. (Source: Statistical
Abstract of the United States: 2007, Table 1232.)

166,728

Number of women who participated in an NCAA sport in 2004-05.

(Source: Statistical Abstract of the United States: 2007, Table 1234.)

85%

Among those who purchased aerobic shoes in 2004, the proportion who were
women. Women also comprised a majority (64 percent) of those who bought
walking shoes.

(Source: Statistical Abstract of the United States: 2007, Table 1237.)

57%

Percentage of women who participated in gardening at least once in the
past

12 months, compared with 37 percent of men. Women were also much more
likely than men to have done charity work (32 percent versus 26
percent), attended arts and crafts fairs (39 percent versus 27 percent)
and read literature (55 percent versus 38 percent).

(Source: Statistical Abstract of the United States: 2007, Tables 1221,
1222 and 1223.)

**Hormone replacement therapy and survival after colorectal cancer
diagnosis**

CONCLUSION: Current postmenopausal estrogen use before diagnosis of
colorectal cancer was associated with improved colorectal
cancer-specific and overall mortality. This benefit was principally
limited to women who initiated estrogens within 5 years of diagnosis.
Additional efforts to understand mechanisms through which estrogens
influence colorectal carcinogenesis and cancer progression seem
warranted.

[Chan
JA](http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Chan+JA"%5BAuthor%5D),
et al Hormone replacement therapy and survival after colorectal cancer
diagnosis. [J Clin
Oncol.](javascript:AL_get(this, 'jour', 'J Clin Oncol.');) 2006 Dec
20;24(36):5680-6.\
<http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17179103&dopt=Abstract>

**New Report on the Detection and Treatment of Ovarian Cancer**

According to a new evidence report supported by a partnership of the
Agency for Healthcare Research and Quality (AHRQ), the Centers for
Disease Control and Prevention\'s (CDC) Division of Cancer Prevention
and Control, and CDC\'s National Office of Public Health Genomics, many
genomic tests currently used to diagnose and guide treatment of ovarian
cancer have not been shown to decrease the number of women who die from
the disease or improve their quality of life.

About the CDC/AHRQ partnership that produced the new report, Janet
Collins, Ph.D., Director of CDC\'s National Center for Chronic Disease
Prevention and Health Promotion, says, \"This first-ever collaboration
of the CDC\'s cancer and genomics programs with AHRQ provides important
evidence-based guidance to inform both public health and medical
practitioners about the appropriate use of genetic testing in cancer
prevention and control.\"

The report indicates that physical exams, ultrasounds, and other routine
screening efforts have been unsuccessful in reducing the numbers of
women affected by and who die from ovarian cancer, compared with similar
efforts aimed at other causes of cancer deaths in women. Because current
strategies have not proven to be effective, there is tremendous interest
in identifying the disease in its earliest stages by looking at genes,
gene expression levels, proteins, and tumor markers. These tests focus
on (1) detecting a gene-based tumor marker, such as CA-125; or (2)
identifying genetic mutations such as BRCA1 and BRCA2 that indicate
increased risk for developing cancer; or (3) identifying genetic changes
that predict response to therapy in women with ovarian cancer.

Researchers performed a comprehensive review of the literature and found
few studies evaluated genetic tests other than CA-125 or BRCA1 and BRCA2
to diagnose ovarian cancer or identify women at risk. Among the tests
evaluated in the report, the researchers found no studies showing that
changing treatment based on test results reduced deaths or improved
quality of life in women who were diagnosed with ovarian cancer.

The team stated that research aimed at improving treatment options and
the discovery of treatment, lifestyle, or dietary choices that could
prevent ovarian cancer would likely offer greater promise for major
reductions in deaths from the disease.
[[http://www.ahrq.gov/clinic/tp/genovctp.htm]{.underline}](http://www.ahrq.gov/clinic/tp/genovctp.htm)

**ACOG Releases Revised Recommendations for Women\'s Health Screenings
and Care**

Washington, DC \-- Recent recommendations for HIV screening, human
papillomavirus (HPV) vaccination, and preconception care are among those
highlighted in the revised primary and preventive care periodic
assessments recommended for women by The American College of
Obstetricians and Gynecologists (ACOG). The updated recommendations,
published in the December issue of Obstetrics & Gynecology, provide
ob-GYNs with a comprehensive schedule of age-appropriate screening
exams, laboratory tests, immunizations, and counseling for non-pregnant
adolescents and adult women.

The document incorporates recent guidance from individual ACOG
committees on specific issues in women\'s health.

[HIV Testing]{.underline}\
Routine HIV testing should be offered to women ages 19 to 64 regardless
of personal risk factors, following the new Centers for Disease Control
and Prevention (CDC) guidelines. Ob-GYNs should be aware of and follow
their states\' HIV testing requirements. In addition, ACOG recommends
HIV testing for adolescents who are or ever have been sexually active.
ACOG previously recommended HIV testing only for women considered high
risk or for those in areas with high HIV prevalence.

[Preconception Care]{.underline}\
Ob-GYNs should encourage women of childbearing age to develop a
reproductive health plan to help conscientiously assess the desire for a
child or children or desire not to have children. The plan also should
address the optimal number, timing, and spacing of children; determine
the steps needed to prevent or plan for and optimize a pregnancy; and
evaluate current health status and other issues relevant to the health
of a pregnancy.

[Colorectal Cancer Screening]{.underline}\
Women age 50 and older should be screened for colorectal cancer using
one of five recommended screening strategies. If fecal occult blood
testing (FOBT) is used, patients should collect two or three samples at
home and return them for laboratory analysis. Single samples obtained by
digital rectal examination in the ob-gyn\'s office are not adequate for
colorectal cancer screening.

[HPV Vaccine]{.underline}\
An HPV vaccine was made available for the first time in 2006. ACOG
recommends that HPV vaccination be offered to all girls and women 9 to
26 who have not previously been vaccinated. The vaccine protects against
four HPV strains that cause most cervical cancers and genital warts and
is most effective when administered before the onset of sexual activity.

[Tdap Vaccine]{.underline}\
Pertussis has been added to the tetanus and diphtheria booster
recommendation in accordance with CDC recommendations. Adolescents
should receive the Tetanus, Diptheria, Pertussis (Tdap) booster once
between ages 11 and 16, then every 10 years thereafter up to age 64.

[Meningococcal Vaccine]{.underline}\
ACOG now recommends that adolescents not previously immunized receive
meningococcal conjugate vaccination before entry into high school. Older
women at high risk also should receive the vaccine.

Committee Opinion #357, \"Primary and Preventive Care: Periodic
Assessments,\" is published in the December 2006 issue of Obstetrics &
Gynecology.

<http://www.acog.org/from_home/publications/press_releases/nr12-01-06-2.cfm>

# Save the dates {#save-the-dates .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

**22nd Annual Midwinter Indian Health OB/PEDS Conference**

-   For providers caring for Native women and children

-   January 26-28, 2007

-   Telluride, CO

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

**TeenScreen Conference: Second Annual**

-   March 14 and 15, 2007

-   Washington D.C.

-   Contact <TSConference@childpsych.columbia.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 Indian Health MCH and Women's Health National Conference**

-   August 15 -17, 2007

-   Albuquerque, NM

-   THE place to be for anyone involved in care of AI/AN women, children

-   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}

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

<http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-neph.asp>

**Diabetes: Understandings About the Causes of Type 2 - Old / New**

<http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#diabetes>

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 Chief Clinical Consultant Corner? {#did-you-miss-something-in-the-last-chief-clinical-consultant-corner .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

#### The December 2006 / January 2007 CCC Corner is available at: {#the-december-2006-january-2007-ccc-corner-is-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1206.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1206.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn1206.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}

Organizational silence threatens patient safety

#### From your colleagues page 6 {#from-your-colleagues-page-6 .Style-Heading-4-+-Arial-14-pt-Underline}

Carolyn Aoyama

Diabetes on the rise in young Native Americans

Burt Attico

Reducing Cardiovascular Risk: Science, Treatment, and Culture

Steve Holve

The 2nd International Meeting on Indigenous Child Health

Judy Thierry

-Menstruation in girls and adolescents: using the menstrual cycle as a
vital sign

-ACOG Releases Revised Recommendations for Women\'s Health Screenings
and Care

-Smoking During Pregnancy May Influence Children\'s Smoking: 14 yr
cohort study

-Should a 1 year old be exposed to TV?

-US map with state health facts links on the following topics: 

and more....

#### Hot Topics {#hot-topics-2 .Style-Heading-4-+-Arial-14-pt-Underline}

##### Obstetrics page 12

-Emergency Simulation Practice: It's a Win x3

-Short course of hydrocortisone: Effective for intractable hyperemesis

-Majority of women with GDM not tested for glucose intolerance after
delivery

-Fetal Oximetry Plus Electronic Fetal Monitoring Does Not Reduce
Cesarean Delivery

-Leaner Women at Reduced Risk of Cesarean Delivery

and more....

**Gynecology page 15**

-HPV vaccine is effective: Why do we not provide it to most AI/AN?

-LEEP in adolescents, overly aggressive: High incidence of F/U abnormal
cytology

-Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic
endometriosis

-Overactive Bladder: the Importance of New Guidance 

-Preventing Eating Disorders in College-Age Women

and more....

**Child Health page 18**

-Why do disparities in infant mortality continue to persist between AIAN
and white infants?

-US Adults Prefer Comprehensive Teaching of Sex Education in Public
Schools

-Supersize This: Large entree portions may constitute an \"obesigenic\"
influence

-Perspectives on Confidential Care for Adolescent Girls

-61% of SIDS cases among smokers were attributable to maternal smoking

and more....

**Chronic Illness and Disease page 21**

-Firearm Safety in Homes with Adolescents

-Breast Cancers Within 1 Year of a Normal Screening Mammogram: How Are
They Found?

-Diabetic complications in 40 or older with undiagnosed DM is similar to
diagnosed DM

-Statins Should Be a Part of Preventive Management in Stroke Patients 

-Herniated Disk Improves With Either Surgical or Nonsurgical Treatment 

#### Features page 22 {#features-page-22 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-Treatment With Selective Serotonin Reuptake Inhibitors During Pregnancy

-Routine Cancer Screening

-Primary and Preventive Care: Periodic Assessments

-Innovative Practice: Ethical Guidelines

-Vaginal Agenesis: Diagnosis, Management, and Routine Care

##### American Family Physician

-Levothyroxine Reduces Preterm Birth in Euthyroid Women

-Opioids for Management of Breakthrough Pain in Cancer Patients

**Agency for Healthcare Research and Quality**

-Maternal psychological distress / use of seat belts: Children\'s low
use of vehicle restraints

-Less than half of parents infected with HIV tell their children about
the diagnosis

**Ask a Librarian**

Want to keep up with evidence-based medicine?

**Breastfeeding**

-Flu season and Breastfeeding

#### -Breast-Feeding Offers Resilience Against Psychosocial Stress in Children {#breast-feeding-offers-resilience-against-psychosocial-stress-in-children .Style-Heading-4-+-Arial-14-pt-Underline}

-More Evidence Showing Breastfeeding Protects Against Type 2 Diabetes

**CCC Corner Digest**

-Regular Cola Intake Reduces Bone Mineral Density in Women

-Perinatal depression evidence based care

-Magnesium sulfate tocolysis: time to quit

-'No touch' hysteroscopy much better tolerated

-Hot water bottles do work: Active Warming Cuts Pelvic Pain in
Pre-hospital Setting

-Early adolescents worry more as they age. . . .

-Health Behaviors among American Indian/Alaska Native Women, 1998--2000
BRFSS

-Please Get Umbilical Cord Blood Gas and Acid-Base Analysis When
Possible

-No Stirrups Preferred for Pelvic Examinations

-Want to keep up with evidence-based medicine?

-It is official, breastfeeding counts

-EC: Did not affect incidence of either pregnancy or STIs

-Telehealth Opportunity: Do you need nutrition services at your site?

-Anthropology in the clinic: the problem of cultural competency and how
to fix it

-The rest of the story RE: 'bizarre' and 'atypia' in the same
sentence...hmmm....

-What Women Want

-Prevalence of diabetes: Diagnosed Diabetes Among AI/AN Aged \<35 Years

-Preoperative Evaluation

-Assessment of Adult Health Literacy

-Be Prepared: The Boy Scout motto...er...the Maternity Care Provider
motto, too

-Causes of Type 2 Diabetes: Old and New Understandings

-IHS Consent Form 509 for an HIV Antibody Test is Hereby Cancelled

-Gestational Diabetes Linked to High Prevalence of Periodontal Disease

**Domestic Violence**

Improving the Health Care Response to Domestic Violence in AI/AN
Communities

**Elder Care News**

Moderate Alcohol Consumption May Be Beneficial to Older Women

**Family Planning**

-Bone Loss With Use of Depot Medroxyprogesterone Acetate Slows After 2
Years

#### -Few young pregnant women know about safety and effectiveness of intrauterine devices {#few-young-pregnant-women-know-about-safety-and-effectiveness-of-intrauterine-devices .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Pregnancy Rates Unchanged by Easy Access to Emergency Contraception {#pregnancy-rates-unchanged-by-easy-access-to-emergency-contraception .Style-Heading-4-+-Arial-14-pt-Underline}

-Scientific accuracy of materials for abstinence-until-marriage
education program

#### -Oral Contraceptive Use: Small Increased Risk for Premenopausal Breast Cancer {#oral-contraceptive-use-small-increased-risk-for-premenopausal-breast-cancer .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

The IHS Breastfeeding Home Page is live!

**Frequently asked questions**

-Is an informed consent necessary for all x-rays in pregnant women?

-Are there any Cochrane Reviews about problems with Ortho Evra or Nuva
Ring?

**Indian Child Health Notes**

-Diagnosis and management of bronchiolitis.

-Lower respiratory tract infections among American Indian and Alaska
Native children and the general population of U.S. Children

-Does in-home water service reduce the risk of infectious disease?

-Home-visiting intervention to improve child care among American Indian
adolescent mothers: a randomized trial

-Forty years in partnership: the American Academy of Pediatrics and the
Indian Health Service

**Information Technology**

-Exam Code and Health Factor Manual

-Self-study Course in Epidemiology Now Available Through CDC Web Site

-Patent Wellness Handout

International Health

A nurse, a doctor, and an epidemiologist were standing by the
river......

#### 

#### MCH Alert

-2007 Folic Acid Campaign Materials Released

-Three new programs proven to improve behavioral and mental health in
youth

-2006 Edition of Women's Health Data Book Released

#### Medical Mystery Tour

A boy has been born in Chile with a fetus in his stomach

#### Medscape

######### -Female Genital Cutting: Female Empowerment as a Means of Cultural Change

-Recurrent Pregnancy Loss

-Evaluation and Treatment of Overactive Bladder

**Menopause Management**

#### Estradiol less than 5 yrs, estriol, or vaginal estrogens not associated with breast cancer {#estradiol-less-than-5-yrs-estriol-or-vaginal-estrogens-not-associated-with-breast-cancer .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

Start 'Em Young for Future Success and Maybe No One Will Be Left Behind

**Navajo News**

GYN Spotlight: Endometrial ablation

**Nurses Corner**

-Nurses less satisfied than physicians or nurse managers: Perceptions of
teamwork on L/D

-Nurses play on important role in its detection and can reduce
depressive symptoms

-For Neonatal Nurses- Primer on Antenatal Testing: 2 Parts: Tests of
Fetal Well-Being / PTL

-6th Annual SUMMER INSTITUTE ON EVIDENCE-BASED PRACTICE '07

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

HPV Information for Clinicians

**Oklahoma Perspective**

Reduction in Teen Pregnancies

Osteoporosis

-Significant bone loss: Both low molecular weight heparin and
unfractionated heparin

-Updated Position Statement for Calcium Intake in Postmenopausal Women

-Teriparatide is less cost-effective than alendronate for severe
osteoporosis

Patient Education

#### -Preventing Injuries in School-age Children and Teenagers {#preventing-injuries-in-school-age-children-and-teenagers .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Lactose Intolerance: What You Should Know {#lactose-intolerance-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Myths and Facts About Food Allergies {#myths-and-facts-about-food-allergies .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Amniocentesis procedure-related loss risk of approximately 1 in 1600,
not prior 1 in 200

-Second twins: 97 cesarean deliveries (NNT) prevent a single serious
morbidity or mortality

-Iron / folate supplementation: Not replaced by a multiple-micronutrient
supplement

-Treatment of periodontitis does not alter PTB, low birth weight, or
fetal growth restriction

-Preterm babies have an increased risk of asthma compared with term
babies

Primary Care Discussion Forum

Causes of Type 2 Diabetes: Old and New Understandings

#### Ongoing Discussion - You still can join in

STD Corner

Less than half of parents infected with HIV tell their children about
the diagnosis

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

-Three Years Later, Participants in the Diabetes Prevention Study Still
Benefiting

-Stopping the Clock on Diabetes in Women: Strategies for Prevention and
Treatment

-Multiparity Increase Risk for Type 2 Diabetes

-New Study Weighs Benefits of Exercise, Diets

-Low-Carb Diets Reduce Coronary Disease Risk in Women

###### Save the Dates: Upcoming events of interest page 45

#### What's new on the ITU MCH web pages page 45

Diabetes: Understandings About the Causes of Type 2 - Old / New

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

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>

1/12/07