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OB/GYN Chief Clinical Consultant's Corner

Volume 4, No. 9, September 2006

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

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

## FDA Approves OTC Access for Plan B for 18 and Older: A 'Catch-22' for AI/AN patients?

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

Carolyn Aoyama:

#### -USPSTF Best Practices - Cervical Cancer Screening {#uspstf-best-practices---cervical-cancer-screening .Style-Heading-4-+-Arial-14-pt-Underline}

#### -USPSTF Breast Cancer Screening Guidelines {#uspstf-breast-cancer-screening-guidelines .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Tips for Improving Access to Mammography {#tips-for-improving-access-to-mammography .Style-Heading-4-+-Arial-14-pt-Underline}

Burt Attico:

-Congenital Anomalies Linked to NSAID Use in First Trimester

Judy Thierry:

Influenza is coming: Are you ready?

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

##### Obstetrics page 7

-Cesarean delivery: Increased risks / costs plus poor postpartum
outcomes -- 4 articles

-S. aureus colonization in pregnant women is 17.1%, MRSA found in the
vaginal-rectal area

-Controlling pregnancy weight gain: adverse neonatal outcomes -- 2
articles

-Electronic fetal monitoring has no effect on perinatal morbidity or
mortality: A Review

-Two-stage protocol for placenta accreta: US first, and then MRI for
inconclusive US

and more.....

**Gynecology page 10**

-See and treat: HPV positive, HSIL cytology, and a high-grade impression
at 2^nd^ colposcopy

-Activity Restriction After Pelvic Floor Surgery?

-Urinary incontinence and age at the first and last delivery

-TVT is effective: Recurrent stress urinary incontinence and/or previous
prolapse surgery

-Diagnosis and Management of Endometriosis

and more.....

**Child Health page 11**

-Metformin Useful for Treating PCOS in Adolescents

-Should Pacifier Use in Infants Be Discouraged?

-Opportunities to prevent injury among children and adolescents: New
fact sheet

-Early-Onset and Late-Onset Neonatal Group B Streptococcal Disease

-Prolonged Bottle-feeding and Iron Deficiency Anemia

**Chronic Illness and Disease page 13**

-Varenicline was significantly more efficacious for smoking cessation

-Clinical Prediction Rule for Stratifying Patients with PE

-Predicting Four-Year Mortality Risk in Older Adults

-Criteria for Diabetes Testing in Asymptomatic Adults

-Light Therapy vs. Fluoxetine for Treatment of SAD

and more.....

#### Features: page 19 {#features-page-19 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician

-Acupressure vs. Physical Therapy for Low Back Pain

-Naltrexone and Counseling Reduce Alcohol Dependence

American College of Obstetricians and Gynecologists

-Human Papillomavirus Vaccination

-HPV Vaccine Shows Promise, at Least in Short Term

**Agency for Healthcare Research and Quality**

-Surgeons vary widely in their approaches to disclosing medical errors
to their patients

-Case management dramatically reduces care use for minority children on
Medicaid

-NICU babies are frequently at risk for misidentification

**Ask a Librarian**

Daily Health Policy News Summaries - New on Your Library Website

**Breastfeeding**

-Engorgement - It only feels like it is going to last forever

-Breastfeeding: Data and Statistics: Breastfeeding Practices --- Results
from 2005 Survey

**CCC Corner Digest**

#### August 2006 Highlights include: {#august-2006-highlights-include .Style-Heading-4-+-Arial-14-pt-Underline}

-Uterine rupture rate hasn't changed for 20 years -- Why have our
practices?

-New Women's Health Work Group Forming: Looking for interested
volunteers

-Update your standing post partum discharge orders: Tdap in pregnancy

-ACOG Releases HPV Vaccine Recommendations for Ob-Gyns

-Emergency Contraception: A Primer for Pediatric Providers

-Antidepressant Discontinuation Syndrome

-Norethindrone More Effective for Menses Suppression

-Induction of Labor for Vaginal Birth After Cesarean Delivery

-Early Milk Supply Issues

-Randomized trial: Screening for intimate partner violence in health
settings

-Is 75 Years an Appropriate Upper Age Limit for Mammography?

-Addressing Depression in Family Planning Services

-HIV/AIDS in Latin America and the Caribbean

-First trimester screening: How would you counsel this patient?

-VBAC: Pendulums and Ecstasy

-Native Alaskan and American Indian Nurses Scholarship Opportunity

-The indications for IUD use have vastly expanded

-Glyburide flows from fetus to mother by placental transport system

-September 1, 2006: Palliative Medicine\'s Role in the Continuity of
Care

-Condom Use and the Risk of Genital HPV Infection in Young Women

-Obese Girls: 3 x Risk for Early Death than Slim Counterparts

**Domestic Violence**

Randomized trial assesses screening for intimate partner violence in
health settings

**Elder Care News**

Where is the Indian Health System when it comes to providing palliative
/ end-of-life care?

**Family Planning**

Adolescent perception of sexual abstinence

**Featured Website**

The Indian Health MCH Frequently Asked Question (FAQ) site

**Frequently asked questions**

Are there any cultural barriers/among Native Americans to becoming cord
blood donors?

**Indian Child Health Notes**

**September 2006 -- Highlights**

-Thank you Captain Obvious - Meta analysis shows that drinking sugar
sweetened beverages is linked to obesity

-If you cant beat \'em sue \'em: The intersection of obesity and public
health law

-Pneumococcal vaccine has decreased the rates of otitis media and PE
tube placement in AI/AN children

-Cancer data for adolescent Native Americans

-Mystery person gives \$100,000 to the Committee on Native American
Child Health - Help us decide how to spend it

-Survey Monkey in this issue - let us know what you want

**Information Technology**

HIV Management System, v1.0 - National Release, BKM

International Health

-Health care and indigenous peoples: the other side of the planet

-Planes, trains, automobiles and asthma in China

#### MCH Alert

-Adolescents' Use of Contraception

-New website provides easy access to information on SIDS and infant
death

#### Medical Mystery Tour

#### First trimester screening: How would you counsel this patient? {#first-trimester-screening-how-would-you-counsel-this-patient .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

**Menopause Management**

-Clonidine and Gabapentin Effective for Hot Flashes

#### -Estrogen Alone Does Not Increase Breast Cancer Risk {#estrogen-alone-does-not-increase-breast-cancer-risk .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

-Postpartum Care: Still the neglected step child of perinatal services?

-Midwives applaud new false labor EMTALA regulations

**Navajo News**

Implanon- A single rod contraceptive implant...

**Nurses Corner**

#### Harm Resulting from Inappropriate Telephone Triage in Primary Care {#harm-resulting-from-inappropriate-telephone-triage-in-primary-care .Style-Heading-4-+-Arial-14-pt-Underline}

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

Trends in HIV-Related Risk Behaviors Among High School Student**s**

**Oklahoma Perspective**

The indications for IUD use have vastly expanded

Osteoporosis

Calcium during pregnancy: Higher maternal Vit. D / folate and newborn Wt
/ mineralization

Patient Education

Endometriosis: What You Should Know

Perinatology Picks

-How important is maternal intratpartum glucose to neonatal
hypoglycemia?

-Adverse outcomes with DM are 3-9 times worse vs normal and not improved
in 15 years

-17 hydroxyprogesterone caproate results in cost-savings in women with
prior PTD

-No difference in pregnancy loss: Chorionic villus sampling vs
amniocentesis, 1998 to 2003

-Vitamin Supplements Do Not Prevent Preeclampsia

Primary Care Discussion Forum

Palliative Medicine\'s Role in the Continuity of Care -- Ongoing

STD Corner

**Sexual Education / HIV Education and youth**

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

Weight Loss Should be the Primary Intervention for Risk of Diabetes

###### Save the Dates: Upcoming events of interest page 41

#### What's new on the ITU MCH web pages page 42

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

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

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

## FDA Approves OTC Access for Plan B for 18 and Older: A 'Catch-22' for AI/AN patients?

## Prescription Remains Required for Those 17 and Under

The U.S. Food and Drug Administration (FDA) announced approval of Plan
B, a contraceptive drug, as an over-the-counter (OTC) option for women
aged 18 and older. Plan B is often referred to as emergency
contraception or the \"morning after pill.\" It contains an ingredient
used in prescription birth control pills\--only in the case of Plan B,
each pill contains a higher dose and the product has a different dosing
regimen. Like other birth control pills, Plan B has been available to
all women as a prescription drug. When used as directed, Plan B
effectively and safely prevents pregnancy. Plan B will remain available
as a prescription-only product for women age 17 and under.

Duramed, a subsidiary of Barr Pharmaceuticals, will make Plan B
available with a rigorous labeling, packaging, education, distribution
and monitoring program. In the CARE (Convenient Access, Responsible
Education) program Duramed commits to:

> -Provide consumers and healthcare professionals with labeling and
> education about the appropriate use of prescription and OTC Plan B,
> including an informational toll-free number for questions about Plan
> B;

·  -Ensure that distribution of Plan B will only be through licensed
drug wholesalers, retail operations with pharmacy services, and clinics
with licensed healthcare practitioners, and not through convenience
stores or other retail outlets where it could be made available to
younger women without a prescription;

·    -Packaging designed to hold both OTC and prescription Plan B. Plan
B will be stocked by pharmacies behind the counter because it cannot be
dispensed without a prescription or proof of age; and

·     -Monitor the effectiveness of the age restriction and the safe
distribution of OTC Plan B to consumers 18 and above and prescription
Plan B to women under 18.

Today\'s action concludes an extensive process that included obtaining
expert advice from a joint meeting of two FDA advisory committees and
providing an opportunity for public comment on issues regarding the
scientific and policy questions associated with the application to
switch Plan B to OTC use. Duramed\'s application raised novel issues
regarding simultaneously marketing both prescription and
non-prescription Plan B for emergency contraception, but for different
populations, in a single package.

The agency remains committed to a careful and rigorous scientific
process for resolving novel issues in order to fulfill its
responsibility to protect the health of all Americans.

<http://www.fda.gov/cder/drug/infopage/planB/default.htm>

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

**Let's make sure that it is not a 'Catch-22' for AI/AN patients**

While this is long overdue good news for women over 18 yo, we need to be
sure it is not a 'Catch-22' for our AI/AN patients.

Why a 'Catch-22' ?

As drugs develops 'over the counter' status many Indian Health
pharmacies have been known to drop the drug from their formulary for
cost and space reasons. So if it had been a complete change to OTC
status, many of our more cash strapped patients would actually have less
access to Plan B as it may have been removed from the formulary and that
particular patient may not have had the funds to buy it OTC. Ironically,
the fact that a prescription is still required for this particular
product for women less than 18 yo will actually preserve Plan B's place
on your facility's formulary.

I would urge you to remind your P / T Committee of that requirement, so
that Plan B stays on formulary at your facility.

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

**Carolyn Aoyama, HQE**

#### USPSTF Best Practices - Cervical Cancer Screening {#uspstf-best-practices---cervical-cancer-screening-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/W/CanCerv.cfm#USPSTF**](http://www.ihs.gov/MedicalPrograms/MCH/W/CanCerv.cfm#USPSTF) {#httpwww.ihs.govmedicalprogramsmchwcancerv.cfmuspstf .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### USPSTF Breast Cancer Screening Guidelines {#uspstf-breast-cancer-screening-guidelines-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/W/documents/bestpractices-breastcancerscreening.doc**](http://www.ihs.gov/MedicalPrograms/MCH/W/documents/bestpractices-breastcancerscreening.doc) {#httpwww.ihs.govmedicalprogramsmchwdocumentsbestpractices-breastcancerscreening.doc .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Tips for Improving Access to Mammography {#tips-for-improving-access-to-mammography-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/W/documents/tipstoimprovingaccesstomammography.doc**](http://www.ihs.gov/MedicalPrograms/MCH/W/documents/tipstoimprovingaccesstomammography.doc) {#httpwww.ihs.govmedicalprogramsmchwdocumentstipstoimprovingaccesstomammography.doc .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Congenital Anomalies Linked to NSAID Use in First Trimester**

BACKGROUND: Many women take non-steroidal anti-inflammatory drugs
(NSAIDs) during pregnancy but the risks for the infant remain
controversial. We carried out a study to quantify the association
between those women prescribed NSAIDs in early pregnancy and congenital
anomalies.

CONCLUSIONS: Our study suggests that women prescribed NSAIDs during
early pregnancy may be at a greater risk of having children with
congenital anomalies, specifically cardiac septal defects

[Ofori
B](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Ofori+B"%5BAuthor%5D),
et al Risk of congenital anomalies in pregnant users of non-steroidal
anti-inflammatory drugs: a nested case-control study. [Birth Defects Res
B Dev Reprod
Toxicol.](javascript:AL_get(this, 'jour', 'Birth Defects Res B Dev Reprod Toxicol.');)
2006 Aug 23

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16929547>

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

**Influenza is coming: Are you ready?**

This CDC Chart shows the ACIP recommended groups for influenza vaccine
over the past forty years.  Estimated group size is in millions. Note
Pregnant women are sandwiched in the middle with roughly 4 million
births annually in the US.  There are about 42,000 AIAN births
annually.  Inactivated Influenza is recommended for pregnant women who
will be pregnant during the influenza season.  Vaccination can occur in
any trimester. 

![](media/image2.png){width="3.6979166666666665in"
height="2.7083333333333335in"} 

Guidelines for vaccinating pregnant women can be found at the following
link: <http://www.cdc.gov/nip/publications/preg_guide.htm#flu>   

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

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

**Cesarean delivery: Increased risk of postpartum maternal death versus
vaginal delivery**

RESULTS: After adjustment for potential confounders, the risk of
postpartum death was 3.6 times higher after cesarean than after vaginal
delivery (odds ratio 3.64 95% confidence interval 2.15--6.19). Both
prepartum and intrapartum cesarean delivery were associated with a
significantly increased risk. Cesarean delivery was associated with a
significantly increased risk of maternal death from complications of
anesthesia, puerperal infection, and venous thromboembolism. The risk of
death from postpartum hemorrhage did not differ significantly between
vaginal and cesarean deliveries.

CONCLUSION: Cesarean delivery is associated with an increased risk of
postpartum maternal death. Knowledge of the causes of death associated
with this excess risk informs contemporary discussion about cesarean
delivery on request and should inform preventive strategies.

[Deneux-Tharaux
C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Deneux-Tharaux+C"%5BAuthor%5D),
et al Postpartum Maternal Mortality and Cesarean Delivery. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Sep;108(3):541-548.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16946213&dopt=Abstract>

**Cesarean delivery in the first delivery is associated with increased
cumulative costs**

RESULTS: A total of 27,613 pregnancies satisfied inclusion and exclusion
criteria. When cumulative costs by type of labor at first delivery were
considered, induction of labor (\$7,220) was more costly than
spontaneous onset of labor (\$6,919, P=.006). The cumulative costs of
assisted vaginal delivery at first delivery (\$7,288) and cesarean
delivery in labor at first delivery (\$9,524) were similar in magnitude
and were higher than spontaneous vaginal delivery at first delivery
(P\<.001). Cesarean delivery in labor in the first delivery was the most
costly type of delivery (\$9,524), and the differences in cost increased
with increasing number of deliveries (P\<.05).

CONCLUSION: Cesarean delivery in labor in the first delivery is
associated with increased cumulative costs compared with other methods
of delivery, regardless of the number or type of subsequent deliveries.

[Allen
VM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Allen+VM"%5BAuthor%5D)
et al Cumulative economic implications of initial method of delivery.
[Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');)
2006 Sep;108(3):549-55.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16946214&dopt=Abstract>

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

[Deneux-Tharaux
C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Deneux-Tharaux+C"%5BAuthor%5D),
et al and [Allen
VM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Allen+VM"%5BAuthor%5D)
et al above have joined the expanding literature that has documented the
downside of the now nearly 30 percent cesarean delivery rate. Here are
three recent additions to that growing body of literature. In the
meantime, please continue to be an advocate for vaginal delivery in your
AI/AN patients when possible.

Here is an excerpt from a recent ACOG Press Release on this topic:

**Cesarean Delivery Associated with Increased Risk of Maternal Death
from Blood Clots, Infection, Anesthesia**

'...Many developed countries, including the US and France, have seen a
considerable rise in the number of cesareans performed each year (28%
and 20% in 2003, respectively). Women today may view cesarean delivery
as a relatively low-risk procedure and to request it for themselves,
even though it may not be medically necessary. Though rates of maternal
death in most developed countries are relatively low---US women have a 1
in 3,500 chance of pregnancy-related death---incidences of maternal
mortality have not significantly decreased in the last two decades.
These study results suggest that mode of delivery may be a modifiable
risk factor, and in some cases, choosing vaginal delivery over
non-medically indicated cesarean delivery could help lower maternal
mortality rates....."

<http://www.acog.org/from_home/publications/press_releases/nr08-31-06-2.cfm>

**Does Delivery Type Affect Postpartum Health?**

More than three fourths of first-time mothers in the United States who
are employed during pregnancy return to work within one year after
giving birth, many before the end of the traditional six-week postpartum
period. Little evidence exists about what factors influence physical and
mental well-being and symptoms during this period. McGovern and
colleagues studied how delivery type and breastfeeding status relate to
the health of working mothers five weeks after childbirth.

The authors conclude that women who delivered by cesarean section were
in significantly worse physical health five weeks after birth than women
who delivered vaginally. Although most women experienced some postpartum
symptoms at five weeks, breastfeeding mothers were more likely to have
symptoms. The authors suggest that these findings could help guide
physicians when counseling pregnant women about expectations for
physical recovery after childbirth and about postpartum symptoms

McGovern P, et al. Postpartum health of employed mothers 5 weeks after
childbirth. Ann Fam Med March/April 2006;4:159-67.

[American Family
Physician](http://ezproxyhhs.nihlibrary.nih.gov:2312/pqdweb?RQT=318&pmid=24034&TS=1157549446&clientId=53612&VType=PQD&VName=PQD&VInst=PROD). Kansas
City: [Aug 15,
2006](http://ezproxyhhs.nihlibrary.nih.gov:2312/pqdweb?RQT=572&VType=PQD&VName=PQD&VInst=PROD&pmid=24034&pcid=33246441&SrchMode=3&aid=1). Vol. 74, Iss. 4;  pg. 662

<http://www.aafp.org/online/en/home/publications/journals/afp.html>

Below is the report from last month's CCCC that showed repeat cesarean
deliveries also raise risk of maternal morbidity from Silver RM, et al.

**Repeat Cesarean Deliveries Raise Risk of Maternal Morbidity (from
August CCCC)**

As the number of repeat cesarean deliveries increases, so does the risk
of bowel injury, ICU admission, and other maternal complications,

CONCLUSION: Because serious maternal morbidity increases progressively
with increasing number of cesarean deliveries, the number of intended
pregnancies should be considered during counseling regarding elective
repeat cesarean operation versus a trial of labor and when debating the
merits of elective primary cesarean delivery. LEVEL OF EVIDENCE: II-2.

Silver RM, et al Maternal morbidity associated with multiple repeat
cesarean deliveries. Obstet Gynecol. 2006 Jun;107(6):1226-32.

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0806_HT.cfm#ob>

**S. aureus colonization in pregnant women is 17.1%, MRSA found in the
vaginal-rectal area**

CONCLUSION: The prevalence of S aureus colonization identified in GBS
screening cultures from pregnant women was substantial and associated
with GBS co-colonization. Although we do not advocate routine screening
of pregnant women for methicillin-sensitive S aureus and
methicillin-resistant S aureus colonization, we recommend continued
monitoring of both methicillin-sensitive S aureus and
methicillin-resistant S aureus infections in this population and their
infants. LEVEL OF EVIDENCE: II-3.

[Chen
KT](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Chen+KT"%5BAuthor%5D),
et al Prevalence of Methicillin-Sensitive and Methicillin-Resistant
Staphylococcus aureus in Pregnant Women. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Sep;108(3):482-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16946204&dopt=Abstract>

**Controlling pregnancy weight gain may reduce birth weight in
individual women with GDM**

RESULTS: Higher maternal weight gain was significantly associated with
increased birth weight within mothers, but not between different women

[Hutcheon
JA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Hutcheon+JA"%5BAuthor%5D),
Et al Is birth weight modified during pregnancy? Using sibling
differences to understand the impact of blood glucose, obesity, and
maternal weight gain in gestational diabetes. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Aug;195(2):488-94.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16626616>

**Wt. gain above IOM guidelines: adverse neonatal outcomes, but Wt. gain
below is not**

CONCLUSION: Gestational weight gain above guidelines was common and
associated with multiple adverse neonatal outcomes, whereas gestational
weight gain below guidelines was only associated with SGA status. Public
health efforts among similar populations should emphasize prevention of
excessive gestational weight gain.

[Stotland
NE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Stotland+NE"%5BAuthor%5D)
et al Gestational Weight Gain and Adverse Neonatal Outcome Among Term
Infants. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Sep;108(3):635-643.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16946225&dopt=Abstract>

**Electronic fetal monitoring has no effect on perinatal morbidity or
mortality: A Review**

METHODS OF STUDY SELECTION: This search strategy identified 1,628
articles, and 41 were selected for further review. Articles were
excluded for the following reasons: in case reports, letters,
commentaries, and review articles, intrapartum EFM was not quantified,
or specific perinatal neurologic morbidity was not measured. Three
observational studies and a 2001 meta-analysis of 13 randomized
controlled trials were selected for determination of the effect of
intrapartum EFM on perinatal brain injury.

CONCLUSION: Although intrapartum EFM abnormalities correlate with
umbilical cord base excess and its use is associated with decreased
neonatal seizures, it has no effect on perinatal mortality or pediatric
neurologic morbidity

[Graham
EM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Graham+EM"%5BAuthor%5D),
et al Intrapartum Electronic Fetal Heart Rate Monitoring and the
Prevention of Perinatal Brain Injury. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Sep;108(3):656-666

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16946228>

**Two-stage protocol for placenta accreta: US first, and then MRI for
inconclusive US**

RESULTS: Of the 453 women with placenta previa, previous cesarean
delivery and low-lying anterior placenta, or previous myomectomy, 39 had
placenta accreta confirmed by pathological examination. Ultrasonography
accurately predicted placenta accreta in 30 of 39 of women and correctly
ruled out placenta accreta in 398 of 414 without placenta accreta
(sensitivity 0.77, specificity 0.96). Forty-two women underwent MRI
evaluation because of findings suspicious or inconclusive of placenta
accreta by ultrasonography. Magnetic resonance imaging accurately
predicted placenta accreta in 23 of 26 cases with placenta accreta and
correctly ruled out placenta accreta in 14 of 14 (sensitivity 0.88,
specificity 1.0).

CONCLUSION: A two-stage protocol for evaluating women at high risk for
placenta accreta, which uses ultrasonography first, and then MRI for
cases with inconclusive ultrasound features, will optimize diagnostic
accuracy.

[Warshak
CR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Warshak+CR"%5BAuthor%5D),
et al Accuracy of ultrasonography and magnetic resonance imaging in the
diagnosis of placenta accreta. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Sep;108(3):573-81\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16946217&dopt=Abstract>

Early vs. Late Epidural Impact on Risk of Cesarean Delivery

Epidural analgesia is used as a pain management tool during labor.
Studies evaluating the impact of epidural analgesia on the risk of
cesarean delivery have had conflicting results. A recent review stated
that epidural analgesia does not increase the risk of cesarean delivery.
Another issue with epidural analgesia is when to initiate the treatment.
Initial studies have implied that there may be a heightened risk of
cesarean delivery if the epidural analgesia is initiated before 5 cm of
cervical dilatation. Other studies, however, have found no difference
between early initiation of epidural analgesia and late initiation. Ohel
and colleagues evaluated the effect of the timing of epidural analgesia
on the risk of cesarean delivery in nulliparous patients.

The authors concluded that earlier initiation of epidural analgesia
during active labor did not result in an increased risk of cesarean
delivery compared with late initiation. They add that early epidural
analgesia was associated with a shorter duration of labor and was
preferred by most of the women in the study.

Ohel G, et al. Early versus late initiation of epidural analgesia in
labor: does it increase the risk of cesarean section? A randomized
trial. Am J Obstet Gynecol March 2006;194:600-5.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16522386>

**Preventing Alcohol-exposed Pregnancies**

Fetal alcohol exposure affects approximately 1% to 3% of live births in
the United States. Family physicians are in a unique position to reduce
the incidence of alcohol-exposed pregnancy. Fetal alcohol exposure can
be minimized through 2 general approaches: reducing alcohol consumption
or increasing effective contraception among childbearing-aged women who
engage in \"at-risk\" drinking and encouraging pregnant women to abstain
from alcohol. Although no safe level of alcohol consumption during
pregnancy is established, women who binge drink are more likely to
deliver infants with physical and cognitive-developmental anomalies.
Screening tools, such as quantity/frequency questions, the TWEAK and the
T-ACE, developed specifically for prenatal care, are more useful with
women than the CAGE and Michigan Alcohol Screening Test (MAST).
Screening alone seems to reduce alcohol use among pregnant women. Brief
interventions, including education about alcohol\'s effects on the
developing fetus, are effective among women not responding to screening.
Unfortunately, many barriers exist to effective implementation of
alcohol-exposed pregnancy (AEP) prevention in the clinical setting.
Designing effective office base systems so the entire burden of
implementing AEP prevention activities does fall solely on the family
physician is critical.

[Mengel
MB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Mengel+MB"%5BAuthor%5D)
et al Preventing Alcohol-exposed Pregnancies. [J Am Board Fam
Med.](javascript:AL_get(this, 'jour', 'J Am Board Fam Med.');) 2006
September-October;19(5):494-505.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16951299&dopt=Abstract>

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

**See and treat: HPV positive, HSIL cytology, and a high-grade
impression at 2^nd^ colposcopy**

CONCLUSION: In the ALTS population, after the first colposcopic
diagnosis of \<CIN2, clear risk stratification for CIN3 outcomes was
obtained among women with a subsequent HPV-positive test. Because
absolute risk for histologic CIN3 outcomes was high for women with HPV
positive tests, HSIL cytology, and a high-grade impression at second
colposcopy, it is worth considering whether this combination of findings
might warrant immediate excisional therapy in some circumstances.

[Walker
JL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Walker+JL"%5BAuthor%5D),
et al Predicting absolute risk of CIN3 during post-colposcopic
follow-up: Results from the ASCUS-LSIL Triage Study (ALTS) [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Aug;195(2):341-8

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16890545>

**Activity Restriction After Pelvic Floor Surgery?**

After having pelvic floor surgery, most women are advised not to lift
more than 10 lb (4.5 kg) and to avoid exercise or heavy work. Weir and
colleagues found little evidence in the research literature that such
activity restrictions are associated with improved outcomes. They
conducted experiments to assess the intra-abdominal pressures associated
with lifting and other common activities in women differing in age, body
habitus, and grip strength.

The researchers conclude that many activities that commonly are
restricted following surgery have no greater effect on intra-abdominal
pressure than normal daily activities. They call for additional research
to clarify guidance given to patients after surgery.

Weir LF, et al. Postoperative activity restrictions. Any evidence?
Obstet Gynecol February 2006;107:305-9.
<http://www.aafp.org/afp/20060901/tips/20.html>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16449116>

**Urinary incontinence and age at the first and last delivery**

CONCLUSION: Being older than 25 years at the first delivery was
associated with incontinence. The effect attenuated with actual age.

[Rortveit
G](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Rortveit+G"%5BAuthor%5D),
[Hunskaar
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Hunskaar+S"%5BAuthor%5D).
 Urinary incontinence and age at the first and last delivery: the
Norwegian HUNT/EPINCONT study. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Aug;195(2):433-8

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16890552>

**TVT is effective: Recurrent stress urinary incontinence and/or
previous prolapse surgery**

RESULTS: The decrease in Impact Questionnaire (IIQ-7) and Urogenital
Distress Inventory (UDI-6) mean scores was statistically significant.
The Incontinence Impact Questionnaire (IIQ-7) and Urogenital Distress
Inventory (UDI-6) were used to measure the results of the TVT procedure
(preoperative at 2, 6, 12, 24, and 36 months postoperative). According
the recommendation of the International Continence Society, the question
\"Do you experience urinary leakage during physical activity, coughing
or sneezing?\" was selected from the UDI to assess stress urinary
incontinence.

[Schraffordt Koops
SE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Schraffordt+Koops+SE"%5BAuthor%5D),
et al The effectiveness of tension-free vaginal tape (TVT) and quality
of life measured in women with previous urogynecologic surgery: analysis
from The Netherlands TVT database. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Aug;195(2):439-44

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16635472>

**Diagnosis and Management of Endometriosis**

Signs and symptoms of endometriosis are nonspecific, and an acceptably
accurate noninvasive diagnostic test has yet to be reported. Serum
markers do not provide adequate diagnostic accuracy. The preferred
method for diagnosis of endometriosis is surgical visual inspection of
pelvic organs with histologic confirmation. Such diagnosis requires an
experienced surgeon because the varied appearance of the disease allows
less-obvious lesions to be overlooked. Empiric use of nonsteroidal
anti-inflammatory drugs or acetaminophen is a reasonable symptomatic
treatment, but the effectiveness of these agents has not been
well-studied. Oral contraceptive pills, medroxyprogesterone acetate, and
intrauterine levonorgestrel are relatively effective for pain relief.
Danazol and various gonadotropin-releasing hormone analogues also are
effective but may have significant side effects. There is limited
evidence that surgical ablation of endometriotic deposits may decrease
pain and increase fertility rates in women with endometriosis. Presacral
neurectomy is particularly beneficial in women with midline pelvic pain.
Hysterectomy and bilateral salpingo-oophorectomy definitively treat pain
from endometriosis at 10 years in 90 percent of patients.

[American Family
Physician](http://ezproxyhhs.nihlibrary.nih.gov:2312/pqdweb?RQT=318&pmid=24034&TS=1157548781&clientId=53612&VType=PQD&VName=PQD&VInst=PROD). Kansas
City: [Aug 15,
2006](http://ezproxyhhs.nihlibrary.nih.gov:2312/pqdweb?RQT=572&VType=PQD&VName=PQD&VInst=PROD&pmid=24034&pcid=33246441&SrchMode=3&aid=1). Vol. 74, Iss. 4;  pg. 594

<http://www.aafp.org/online/en/home/publications/journals/afp.html>

**Spinal manipulation not effective in treatment of primary and
secondary dysmenorrhoea**

MAIN RESULTS: Results from the four trials of high velocity, low
amplitude manipulation suggest that the technique was no more effective
than sham manipulation for the treatment of dysmenorrhoea, although it
was possibly more effective than no treatment.

AUTHORS\' CONCLUSIONS: Overall there is no evidence to suggest that
spinal manipulation is effective in the treatment of primary and
secondary dysmenorrhoea.

Proctor ML et al Spinal manipulation for primary and secondary
dysmenorrhoea.

[Cochrane Database Syst Rev.  2006;
3:CD002119](http://www.medscape.com/medline/publicationbrowser/123?pmid=16855988) (ISSN:
1469-493X)

<http://www.update-software.com/publications/cochrane/>

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

Metformin Useful for Treating PCOS in Adolescents

Polycystic ovary syndrome (PCOS) is a common hormonal disorder in women
that is characterized by excessive androgen and menstrual dysfunction.
Originally believed to be a cosmetic and fertility problem, PCOS can
increase risk of cardiovascular disease and diabetes mellitus. The cause
of PCOS is not fully understood, but insulin resistance and
hyperinsulinemia can increase androgen production in the ovaries and
adrenal glands. Studies have found that weight loss and the use of
insulin-sensitizing agents have improved clinical status and
hyperinsulinemia, and reduced excessive androgens in women with the
syndrome. However, these studies do not address PCOS in adolescents.
Bridger and colleagues evaluated insulin-sensitizer (metformin
\[Glucophage\]) use with healthy lifestyle counseling in adolescents
with the disorder.

The authors conclude that metformin lowers testosterone levels and
improves menstrual regularity in adolescent women with PCOS. They also
note an improvement in HDL cholesterol but none in other lipid
parameters. There is a trend toward improvement in insulin sensitivity
in the metformin group, but long-term follow-up studies need to be
performed to determine if it is significant.

Bridger T, et al. Randomized placebo-controlled trial of metformin for
adolescents with polycystic ovary syndrome. Arch Pediatr Adolesc Med
March 2006;160:241-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16520442>

Should Pacifier Use in Infants Be Discouraged?

Several studies have supported the speculation that pacifiers may
protect against sudden infant death syndrome (SIDS). Mitchell and
colleagues performed a literature review to determine the effects of
pacifier use in infants and whether it reduces the risk of SIDS.

Of eight studies (seven case-control and one prospective), all but one
found an association between routine pacifier use and reduced risk of
SIDS, a result that was significant when the results were pooled (odds
ratio \[OR\] = 0.83; 95% confidence interval \[CI\], 0.75 to 0.93).
Another series of case-control studies found reduced risk of SIDS
associated with pacifier use at last sleep (pooled OR = 0.48; 95% CI,
0.43 to 0.54). Overall, the risk of SIDS appears to be halved in
children using pacifiers compared with those not using pacifiers.

The authors propose several possible mechanisms for this association,
including airway protection, reduction of gastroesophageal reflux,
lighter sleep, and avoidance of the prone sleeping position. Pacifier
use may deter children from thumbsucking, but it could decrease
breastfeeding. An increased risk of otitis media and oral thrush also
has been found, although it is unclear if pacifier use is a cause or an
effect of these infections.

The authors conclude that there is evidence favoring pacifier use as a
means of preventing SIDS, but that it must be balanced against the
risks. Although the means for reduction is uncertain, pacifier use
should no longer be actively discouraged.

Mitchell EA, et al. Should pacifiers be recommended to prevent sudden
infant death syndrome? Pediatrics May 2006:117;1755-8.
<http://www.aafp.org/afp/20060901/tips/13.html>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16651334>

**Opportunities to prevent injury among children and adolescents: New
fact sheet**

Leading Causes of Injuries Among Children and Adolescents presents
statistics on common injury mechanisms among children and adolescents as
well as opportunities for prevention. The fact sheet, produced by the
Association of State and Territorial Health Officials, includes
information on motor vehicle injuries, child and adolescent violence,
suicide, recreational injuries, and child maltreatment.
[[http://www.astho.org/pubs/AdolescentfactsheetfinalAugust2006.pdf]{.underline}](http://www.astho.org/pubs/AdolescentfactsheetfinalAugust2006.pdf)

**Early-Onset and Late-Onset Neonatal Group B Streptococcal Disease**

In 2002 the Centers for Disease Control and Prevention (CDC), the
American College of Obstetricians and Gynecologists, and the American
Academy of Pediatrics recommended universal screening of pregnant women
at 35 to 37 weeks\' gestation for rectovaginal group B streptococcus
(GBS) colonization; intrapartum antimicrobial prophylaxis was
recommended for carriers. To assess the impact of this strategy, the CDC
analyzed data from 1996 to 2004 from the Active Bacterial Core
surveillance system.

The data represented approximately 337,000 live births in 1996 to
approximately 427,000 live births in 2004. GBS found in children between
zero and six days of age was defined as early onset, and disease found
in children between seven and 89 days of age was considered late onset.
The CDC found that the incidence of early-onset GBS infection in 2004
decreased 31 percent from 2000 and 2001, the period just before the
universal screening was implemented. The incidence of late-onset GBS
infection remained the same from 1996 to 2004.

Although the absolute difference between blacks and whites in the
incidence of early-onset infection declined 68 percent from 1993 (before
the prevention guidelines were released) to 2003, racial disparities
still exist. In 2004, the rates of late-onset GBS infection per 1,000
live births were 0.83 for blacks, 0.28 for whites, and 0.19 for infants
of other races. Similarly, the rates of early-onset disease per 1,000
births were 0.73 for blacks, 0.26 for whites, and 0.15 for other races.

In both early- and late-onset GBS infection, the fatality ratio was
highest for preterm infants (23 percent of infants with early-onset
infection and 9 percent of those with late-onset infection). Of term
infants, 4 percent with early-onset infections died, whereas no infants
with late-onset infection died. Continued examination is needed to
evaluate the effects of the 2002 guideline revision on early-onset
infections and to determine the long-term effects of intrapartum use of
antimicrobial agents on neonatal GBS infection.

Morbidity and Mortality Weekly Report December 2, 2005 /
54(47);1205-1208

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5447a2.htm>

**Prolonged Bottle-feeding and Iron Deficiency Anemia**

Iron deficiency anemia in young children can cause delayed mental and
psychomotor development and behavioral disturbances. These problems may
persist into adolescence and can result in impaired learning, decreased
school achievement, and lower mental and motor development test scores.
Iron deficiency without anemia is more common than iron deficiency with
anemia. In the general population, the prevalence of iron deficiency is
9 percent among children 12 to 30 months of age. The prevalence
increases substantially in urban areas and is highest among children in
lower socioeconomic groups.

One simple technique to reduce the risk of iron deficiency anemia is to
limit the amount of cow\'s milk children ingest. In a previous study, 8
percent of children between two and five years of age were still being
bottle-fed. The current recommendation for bottle-feeding is to
introduce a cup at six months of age and wean off the bottle by 15
months of age. Only one study examined the relationship between
prolonged bottle-feeding and iron deficiency. Brotanek and associates
studied the impact of prolonged bottle- feeding on the prevalence of
iron deficiency anemia in children.

The authors conclude that prolonged bottle-feeding increases the risk of
iron deficiency anemia in children. In addition, Mexican American
ethnicity is a significant risk factor. The authors add that screening
practices and nutritional counseling should be directed at these two
high-risk groups, and they encourage physicians and other health care
providers to educate parents about the importance of being weaned from
the bottle by 15 months of age.

Brotanek JM, et al. Iron deficiency, prolonged bottle-feeding, and
racial/ethnic disparities in young children. Arch Pediatr Adolesc Med
November 2005;159:1038-42.

[American Family
Physician](http://ezproxyhhs.nihlibrary.nih.gov:2312/pqdweb?RQT=318&pmid=24034&TS=1157553755&clientId=53612&VType=PQD&VName=PQD&VInst=PROD). Kansas
City: [Aug 15,
2006](http://ezproxyhhs.nihlibrary.nih.gov:2312/pqdweb?RQT=572&VType=PQD&VName=PQD&VInst=PROD&pmid=24034&pcid=33246441&SrchMode=3&aid=2). Vol. 74, Iss. 4;  pg. 661

<http://www.aafp.org/online/en/home/publications/journals/afp.html>

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

**Varenicline was significantly more efficacious for smoking cessation**

CONTEXT: The alpha4beta2 nicotinic acetylcholine receptors (nAChRs) are
linked to the reinforcing effects of nicotine and maintaining smoking
behavior. Varenicline, a novel alpha4beta2 nAChR partial agonist, may be
beneficial for smoking cessation.

CONCLUSION: Varenicline was significantly more efficacious than placebo
for smoking cessation at all time points and significantly more
efficacious than bupropion SR at the end of 12 weeks of drug treatment
and at 24 weeks.

[Gonzales
D](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Gonzales+D"%5BAuthor%5D)
et al Varenicline, an alpha4beta2 nicotinic acetylcholine receptor
partial agonist, vs sustained-release bupropion and placebo for smoking
cessation: a randomized controlled trial.
[JAMA.](javascript:AL_get(this, 'jour', 'JAMA.');) 2006 Jul
5;296(1):47-55.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16820546&dopt=Abstract>

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

**Varenicline for smoking cessation: Deterrent effect - definite
promise, but no panacea**

Varenicline has just been released to the public and may signify an
advance as it both decreases the desire for nicotine and provides a
deterrent effect.

First, by partially activating the
![](media/image3.png){width="8.333333333333333e-2in"
height="6.25e-2in"}4![](media/image4.png){width="7.152777777777777e-2in"
height="0.14652777777777778in"}2 nAChR, craving and withdrawal symptoms
may be mitigated following abrupt cessation or reduction of nicotine
consumption. Second, by occupying part of the receptors and blockading
nicotine binding, a partial agonist may also act as a partial antagonist
to reduce smoking satisfaction prior to quitting or following a slip or
relapse.

In the above issue of JAMA, Gonzales and colleagues, Jorenby and
colleagues, and Tonstad and colleagues report the results of 3
randomized trials on the efficacy of the nicotinic acetylcholine
receptor partial agonist varenicline for achieving smoking cessation.

The JAMA Editorial points out: "It is important for clinicians to
moderate some of the potential enthusiasm that is likely to occur as the
result of the publication of these trials, FDA approval of the drug, and
promotion by this manufacturer. On the one hand, these
studies[1](http://ezproxyhhs.nihlibrary.nih.gov:2537/cgi/content/full/296/1/94#REF-JED60039-1%23REF-JED60039-1)-[3](http://ezproxyhhs.nihlibrary.nih.gov:2537/cgi/content/full/296/1/94#REF-JED60039-3%23REF-JED60039-3)
demonstrate that varenicline is associated with higher smoking cessation
rates than placebo and may produce better cessation rates than
bupropion, a first-line--approved smoking cessation drug. Importantly,
varenicline represents a third class of drug with probably a different
mechanism of action than either nicotine replacement therapy or
bupropion. On the other hand, varenicline definitely is not a panacea
for smoking cessation. Many participants in these trials experienced
adverse events, stopped taking their study medication before they should
have, and discontinued participation in the studies. Importantly, the
majority of participants in these 3 studies did not quit smoking even
with varenicline."

Treatobacco.net is another resource for those working on the treatment
of tobacco dependence throughout the world. It presents authoritative
evidence-based information about the treatment of tobacco dependence,
under five headings:\
[Efficacy](http://www.treatobacco.net/efficacy/efficacy.cfm)\
[Safety](http://www.treatobacco.net/safety/safety.cfm)\
[Demographics and Health
Effects](http://www.treatobacco.net/demographics/demographics.cfm)\
[Health Economics](http://www.treatobacco.net/health/health.cfm)\
[Policy\
](http://www.treatobacco.net/policy/policy.cfm)<http://www.treatobacco.net/home/home.cfm>

[Klesges
RC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Klesges+RC"%5BAuthor%5D),
et al Varenicline for smoking cessation: definite promise, but no
panacea. [JAMA.](javascript:AL_get(this, 'jour', 'JAMA.');) 2006 Jul
5;296(1):94-5.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16820552&dopt=Abstract>

**Clinical Prediction Rule for Stratifying Patients with PE**

Aujesky and colleagues set out to develop a purely clinical prediction
rule for stratifying the risk of mortality or other adverse medical
outcomes in patients with PE with the intent that low-risk patients can
be treated in an outpatient setting.

The authors conclude that the use of a practical clinical risk
assessment tool that accurately classifies patients with PE from low
risk to high risk has the potential to decrease hospital stays and lower
patient care costs. The authors also state that this tool needs further
testing before it can be incorporated into practice.

Aujesky D, et al. Derivation and validation of a prognostic model for
pulmonary embolism. Am J Respir Crit Care Med October 15,
2005;172:1041-6.

[American Family
Physician](http://ezproxyhhs.nihlibrary.nih.gov:2312/pqdweb?RQT=318&pmid=24034&TS=1157548429&clientId=53612&VType=PQD&VName=PQD&VInst=PROD). Kansas
City: [Aug 15,
2006](http://ezproxyhhs.nihlibrary.nih.gov:2312/pqdweb?RQT=572&VType=PQD&VName=PQD&VInst=PROD&pmid=24034&pcid=33246441&SrchMode=3&aid=1). Vol. 74, Iss. 4;  pg. 658

<http://www.aafp.org/online/en/home/publications/journals/afp.html>

**Predicting Four-Year Mortality Risk in Older Adults**

**Clinical Question**

What is the four-year mortality risk for community-dwelling older
adults?

**Evidence Summary**

Survival prognoses for older adults may help patients and physicians
make decisions about screening, treatment, and advance directives.
Although a variety of prognostic tools have been developed, they have
had limitations. For example, these tools require laboratory tests; are
limited to recently hospitalized patients1 or patients with specific
diagnoses; only include functional status measures and do not address
comorbidities; or are largely limited to the presence or absence of
comorbidities.

A population-based study5 identified 19,710 community-dwelling persons
older than 50 years. Information was collected via telephone interviews
regarding comorbidities and functional status. During the four-year
follow-up, 2,433 (12 percent) of the participants died. A prognostic
index (Table 15) for predicting four-year mortality risk in
community-dwelling older adults was developed using data from 11,701 of
the study participants in eastern, western, and central regions of the
United States and was validated in 8,009 participants in the southern
region of the United States.5 The index performed as well in the
validation group as it did in the original group.5

The prognostic index is simple and quick to use and includes age,
comorbidities, and functional status. The study showed that those in the
lowest risk group had a four-year mortality risk of less than 4 percent,
whereas the highest risk group had a four-year mortality risk of 64
percent.5

**Applying the Evidence**

A 77-year-old woman asks whether she should continue to receive annual
mammograms. She has diabetes and chronic lung disease that somewhat
limit her activities. She has difficulty walking several blocks and
moving large objects such as the armchair in her living room. The
patient no longer smokes and has a body mass index (BMI) of 21 kg per
m2.

Answer: Using the prognostic index, you determine that the patient has a
risk score of 11 points: she receives four points for age, one for
diabetes, two for chronic lung disease, one for a low BMI, and three for
functional limitations. Therefore, you predict that the patient has a
four-year mortality risk of 42 percent. After you discuss the advantages
and disadvantages of continued screening with her, she decides not to
receive further mammograms. Instead, you and the patient discuss ways to
optimize treatment for her chronic lung disease and how she can get help
with home maintenance (e.g., cleaning, yard work) and with other
activities of daily living

[American Family
Physician](http://ezproxyhhs.nihlibrary.nih.gov:2312/pqdweb?RQT=318&pmid=24034&TS=1157552762&clientId=53612&VType=PQD&VName=PQD&VInst=PROD). Kansas
City: [Aug 15,
2006](http://ezproxyhhs.nihlibrary.nih.gov:2312/pqdweb?RQT=572&VType=PQD&VName=PQD&VInst=PROD&pmid=24034&pcid=33246441&SrchMode=3&aid=2). Vol. 74, Iss. 4;  pg. 633

<http://www.aafp.org/online/en/home/publications/journals/afp.html>

**Criteria for Diabetes Testing in Asymptomatic Adults**

Type 2 diabetes usually is not diagnosed until complications develop,
and approximately one third of all persons with diabetes may be
undiagnosed. Screening to detect prediabetes should be considered in
persons 45 years and older, particularly in persons with a body mass
index (BMI) of at least 25 kg per m2. Screening also should be
considered in persons who are younger than 45 years if they are
overweight and have an additional risk factor (Table 1). If test results
are normal, repeat testing should be performed at three-year intervals
in adults and at two-year intervals in children.

+-----------------------------------------------------------------------+
| TABLE 1                                                               |
|                                                                       |
| **Criteria for Diabetes Testing in Asymptomatic Adults**              |
+-----------------------------------------------------------------------+
| Testing should be considered in all persons 45 years and older,       |
| particularly in persons with a BMI of 25 kg per m^2^ or greater. If   |
| test results are normal, testing should be repeated at three-year     |
| intervals.                                                            |
|                                                                       |
| Testing should be considered in younger persons and performed more    |
| frequently in persons with a BMI of 25 kg per m^2^ or greater who     |
| have additional risk factors, such as those who:                      |
|                                                                       |
| Are habitually physically inactive                                    |
|                                                                       |
| Are members of a high-risk ethnic population (e.g., Hispanics,        |
| blacks, Native Americans, Asian Americans, Pacific islanders)         |
|                                                                       |
| Have a first-degree relative with diabetes                            |
|                                                                       |
| Have a high-density lipoprotein cholesterol level of less than 35 mg  |
| per dL (0.90 mmol per L) or a triglyceride level of more than 250 mg  |
| per dL (2.82 mmol per L)                                              |
|                                                                       |
| Have a history of vascular disease                                    |
|                                                                       |
| Have been diagnosed with gestational diabetes                         |
|                                                                       |
| Have delivered an infant weighing more than 9 lb (4.1 kg)             |
|                                                                       |
| Have hypertension (blood pressure of 140/90 mm Hg or greater)         |
|                                                                       |
| Had impaired glucose tolerance or impaired fasting glucose levels on  |
| previous testing                                                      |
|                                                                       |
| Have polycystic ovary syndrome                                        |
|                                                                       |
| Have other clinical considerations associated with insulin resistance |
| (e.g., acanthosis nigricans)                                          |
+-----------------------------------------------------------------------+
| *BMI = body mass index.*                                              |
|                                                                       |
| *Adapted with permission from American Diabetes Association.          |
| Standards of medical care in diabetes-2006. Diabetes Care             |
| 2006;29(suppl 1):S6.*                                                 |
+-----------------------------------------------------------------------+

The two-hour oral glucose tolerance test (OGTT) identifies persons with
impaired glucose tolerance levels, and thus, more persons who are at
increased risk for developing diabetes and cardiovascular disease.
Although the effectiveness of interventions for primary prevention of
type 2 diabetes has been proven in persons with impaired glucose
tolerance, data for persons with impaired fasting glucose levels (who do
not also have impaired glucose tolerance) are not available. The fasting
plasma glucose test is more convenient for patients, more reproducible,
less costly, and easier to administer than the two-hour OGTT; therefore,
the fasting plasma glucose test is recommended as the initial screening
test for nonpregnant adults.

Standards of Medical Care in Diabetes-2006 Diabetes Care 2006 29: S1-85

[**http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16373930**](http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16373930)

Light Therapy vs. Fluoxetine for Treatment of SAD

**Clinical Question:** Is light therapy an acceptable alternative to
antidepressants for patients with seasonal affective disorder (SAD)?

**Study Design:** Randomized controlled trial (double-blinded)

**Synopsis**: Light therapy and antidepressants are effective in the
treatment of SAD, but few studies have directly compared the two
treatments.

**Bottom Line:** Light therapy and fluoxetine are equally effective
treatment options for patients with SAD. Patient preference and an
individual assessment of risks and benefits should guide treatment
selection. (Level of Evidence: 1b)

Lam RW, et al. The CAN-SAD study: a randomized controlled trial of the
effectiveness of light therapy and fluoxetine in patients with winter
seasonal affective disorder. Am J Psychiatry May 2006;163:805-12.
<http://www.aafp.org/afp/20060901/tips/18.html>

[**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16648320**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16648320)

Cholinesterase Inhibitors for Alzheimer\'s Disease

[Clinical Scenario]{.underline}

A 72-year-old woman is brought into the office by her daughter, who
complains that her mother has become increasingly forgetful over the
past two years. On a Mini-Mental State Examination (MMSE) she scores 20
out of 30 points, and after an appropriate evaluation you diagnose
Alzheimer\'s disease. Her daughter asks if there are medicines that
could help.

[Clinical Question]{.underline}

Do cholinesterase inhibitors improve function in persons with mild,
moderate, or severe dementia caused by Alzheimer\'s disease, and is one
cholinesterase inhibitor better tolerated or more effective than the
others?

[Evidence-Based Answer]{.underline}

Cholinesterase inhibitors produce a small benefit on several cognitive
and noncognitive function scales. Although data for patients with severe
dementia are sparse, there is no evidence to suggest a difference in
effectiveness among patients with mild, moderate, or severe dementia.
Compared with placebo, adverse reactions are significantly more common
in treatment groups. Limited evidence suggests donepezil (Aricept) is
better tolerated than rivastigmine (Exelon). There is no consistent
evidence to suggest treatment reduces health care costs or prolongs time
until institutionalization.

Cochrane for Clinicians-Putting Evidence into Practice

[**http://www.aafp.org/afp/20060901/cochrane.html**](http://www.aafp.org/afp/20060901/cochrane.html)

Acute Low Back Pain Clinical Evidence Concise

What are the effects of oral drug treatments?

beneficial

**Nonsteroidal Anti-inflammatory Drugs.** One systematic review and one
subsequent randomized controlled trial (RCT) showed that nonsteroidal
anti-inflammatory drugs (NSAIDs) increased overall improvement after one
week compared with placebo. One systematic review and additional RCTs
showed no significant difference in pain relief among NSAIDs or between
NSAIDs and other drug treatments (i.e., paracetamol \[acetaminophen\],
opioids, muscle relaxants, NSAIDs plus muscle relaxants). One systematic
review provided insufficient evidence about the effects of NSAIDs
compared with nondrug treatments.

trade-off between benefits and harms

**Muscle Relaxants.** One systematic review showed that muscle relaxants
decreased pain and improved overall clinical assessment compared with
placebo, but the review showed no significant difference among different
muscle relaxants. The review showed that benzodiazepine and
nonbenzodiazepine muscle relaxants increased adverse effects
(particularly drowsiness, dizziness, and nausea) compared with placebo.

unknown effectiveness

**Analgesics (Paracetamol \[Acetaminophen\], Opioids).** We found no
placebo-controlled RCTs on the effects of analgesics. Three small RCTs
identified by a systematic review showed no significant difference in
symptoms or time off from work among an opioid analgesic, paracetamol
(acetaminophen), and an NSAID. Two small low-quality RCTs identified by
another systematic review provided limited evidence that paracetamol
(acetaminophen) and unspecified analgesics were less effective in
achieving pain relief than electroacupuncture and ultrasound treatment,
respectively.

What are the effects of local injections?

unknown effectiveness

**Epidural Steroid Injections.** One systematic review provided no RCTs
on the effects of epidural steroid injections in persons with acute low
back pain.

What are the effects of nondrug treatments?

beneficial

**Advice to Stay Active.** One systematic review and two subsequent RCTs
showed that advice to stay active reduced sick leave and chronic
disability compared with no advice or traditional medical treatment
(e.g., analgesics as required, advice to rest, \"let pain be your
guide\"). One systematic review showed that advice to stay active
reduced pain and improved functional outcomes after three to four weeks
and after 12 weeks compared with advice to rest in bed.

likely to be beneficial

**Multidisciplinary Treatment Programs (for Subacute Low Back Pain).**
One systematic review including persons with subacute low back pain
provided limited evidence that multidisciplinary treatment, including a
workplace visit, reduced sick leave compared with usual care.

**Spinal Manipulation (in the Short Term).** One systematic review and
one subsequent RCT showed that spinal manipulation slightly reduced pain
within six weeks compared with sham treatment, but they showed no
significant difference in functional outcomes. The review showed no
significant difference in pain or functional outcomes between spinal
manipulative therapy and primary care, physical therapy, exercises, or
back school.

unlikely to be beneficial

**Multidisciplinary Treatment Programs (for Acute Low Back Pain).** We
found no RCTs on the effects of multidisciplinary treatment programs in
persons with acute low back pain.

**Acupuncture.** One systematic review provided insufficient evidence on
the effects of acupuncture in persons with acute low back pain.

**Back Schools.** One systematic review provided insufficient evidence
on the effects of back schools in persons with acute low back pain.

**Behavior Therapy.** One RCT identified by a systematic review provided
limited evidence that cognitive behavior therapy reduced acute low back
pain and disability after nine to 12 months compared with traditional
care.

**Electromyographic Biofeedback.** We found no RCTs on the effects of
electromyographic biofeedback.

**Lumbar Supports.** We found no RCTs on the effects of lumbar supports.

**Massage.** One RCT identified by a systematic review provided
insufficient evidence on the effects of massage compared with spinal
manipulation or electrical stimulation.

**Temperature Treatments (Short Wave Diathermy, Ultrasonography,
Application of Ice or Heat).** Two systematic reviews identified no RCTs
on the effects of temperature treatments.

**Traction.** Three systematic reviews identified no RCTs on the effects
of traction in persons with acute low back pain.

**Transcutaneous Electrical Nerve Stimulation.** We found no RCTs on the
effects of transcutaneous electrical nerve stimulation.

likely to be ineffective or harmful

**Bed Rest.** One systematic review showed increased pain and poorer
functional outcomes after three to four weeks and after 12 weeks of
advice to rest in bed compared with advice to stay active. RCTs
identified by the review provided limited evidence that there is no
significant difference in outcomes between advice to rest in bed and
exercise or between three and seven days of bed rest. One of these RCTs
provided limited evidence that there is no significant difference in
pain among advice to rest in bed, exercise plus education, and no
advice; whereas another of these RCTs showed limited evidence that there
is no significant difference in improvement between bed rest and
manipulation, drug therapy, physiotherapy, back school, or placebo. One
systematic review showed that adverse effects of bed rest included joint
stiffness, muscle wasting, decreased bone mineral density, pressure
sores, and venous thromboembolism.

unknown effectiveness

**Back Exercises.** One systematic review evaluating acute low back pain
(less than six weeks in duration) showed no significant difference in
pain or function between exercise and no treatment or between exercise
and other conservative treatments. It provided limited evidence on
subacute low back pain (six to 12 weeks in duration) that a graded
activity exercise program may reduce time off from work associated with
subacute low back pain compared with usual care; otherwise, it provided
insufficient evidence on subacute low back pain.

Definition

Low back pain is pain, muscle tension, or stiffness localized below the
costal margin and above the inferior gluteal folds with or without leg
pain (sciatica),1 and is defined as acute when it persists for less than
12 weeks.2 Nonspecific low back pain is low back pain not attributed to
a recognizable pathology (e.g., infection, tumor, osteoporosis,
rheumatoid arthritis, fracture, inflammation).1 This chapter excludes
acute low back pain with symptoms or signs at presentation that suggest
a specific underlying condition. Persons with sciatica (lumbosacral
radicular syndrome) and herniated disks also are excluded. Unless
otherwise stated, persons included in this chapter have acute back pain.
Some RCTs included in this chapter further subdivided acute low back
pain of less than 12 weeks\' duration into acute (less than six weeks\'
duration) or subacute (six to 12 weeks\' duration).

Incidence

More than 70 percent of persons in developed countries will experience
low back pain at some time in their lives.3 Each year, 15 to 45 percent
of adults have low back pain, and one out of 20 (5 percent) present to a
health care professional with a new episode. Low back pain is most
common from 35 to 55 years of age.3 About 30 percent of European workers
reported that their occupation caused them to have low back pain.
Prevalence rates from different countries range from 13 to 44 percent.
About 70 percent of persons who take sick leave because of low back pain
return to work within one week, and 90 percent return within two months.
However, as the period of sick leave increases, the likelihood that the
person will return to work decreases. Less than one half of persons with
low back pain who have been off of work for six months will return to
work.3,4

Etiology

Symptoms, pathology, and radiologic appearances are poorly correlated.
Pain is nonspecific in about 85 percent of persons. About 4 percent of
patients presenting in primary care with low back pain have compression
fractures, and about 1 percent have a tumor.5 The prevalence of a
prolapsed intervertebral disk is about 1 to 3 percent.3 Ankylosing
spondylitis and spinal infections are less common.5 Risk factors for
back pain include heavy physical work; frequent bending, twisting, and
lifting; and prolonged static postures. Psychosocial risk factors
include anxiety, depression, and mental stress at work.3,6

Prognosis

Acute low back pain usually is self-limiting (90 percent of persons
recover within six weeks), although 2 to 7 percent develop chronic pain.
Acute low back pain has a high recurrence rate: 50 to 80 percent of
persons experience less severe recurrent symptoms within a year.7

A Publication of BMJ Publishing Group

Adapted with permission from Koes B, van Tulder M. Low back pain
(acute). Clin Evid 2006;15:416-8.

REFERENCES

1\. Van der Heijden GJ, Bouter LM, Terpstra-Lindeman E. De effectiviteit
van tractie bij lage rugklachten. De resultaten van een pilotstudy
\[Dutch\]. Ned T Fysiotherapie 1991;101:37-43.

2\. Bigos S, Bowyer O, Braen G, et al. Acute low back problems in
adults. Clinical Practice Guideline No. 14. AHCPR Publication No.
95-0642. Rockville, Md.: Agency for Health Care Policy and Research,
Public Health Service, U.S. Department of Health and Human Services,
December 1994.

3\. Andersson GB. The epidemiology of spinal disorders. In: Frymoyer JW,
ed. The Adult Spine: Principles and Practice. 2nd ed. New York, N.Y.:
Raven Press, 1997:93-141.

4\. Waddell G. The Back Pain Revolution. Edinburgh, U.K.: Churchill
Livingstone, 1998.

5\. Deyo RA, Rainville J, Kent DL. What can the history and physical
examination tell us about low back pain? JAMA 1992;268:760-5.

6\. Bongers PM, de Winter CR, Kompier MA, et al. Psychosocial factors at
work and musculoskeletal disease. Scand J Work Environ Health
1993;19:297-312.

7\. Frymoyer JW. Back pain and sciatica. N Engl J Med 1988;318:291-300.

<http://www.aafp.org/afp/20060901/bmj.html>

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

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

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

**Acupressure vs. Physical Therapy for Low Back Pain**

**Clinical Question:** Is acupressure more effective than physical
therapy for chronic low back pain?

**Study Design:** Randomized controlled trial (single-blinded)

**Synopsis:** The Taiwanese researchers conducting this study enrolled
129 patients who attended an orthopedic clinic for low back pain for at
least one month. Physical therapy could include pelvic manual traction,
spinal manipulation, thermotherapy, infrared light therapy, electrical
stimulation, or exercise therapy as directed by a physical therapist.
Acupressure is significantly more effective than standard physical
therapy modalities and exercise at decreasing disability scores and pain
in patients with chronic low back pain.

**Bottom Line:** Acupressure is significantly more effective than
standard physical therapy modalities and exercise at decreasing
disability scores and pain in patients with chronic low back pain.
(Level of Evidence: 1b)

Study Reference: Hsieh LL, et al. Treatment of low back pain by
acupressure and physical therapy: randomised controlled trial. BMJ March
25, 2006;332:696-700.

[American Family
Physician](http://ezproxyhhs.nihlibrary.nih.gov:2312/pqdweb?RQT=318&pmid=24034&TS=1157547765&clientId=53612&VType=PQD&VName=PQD&VInst=PROD). Kansas
City: [Aug 15,
2006](http://ezproxyhhs.nihlibrary.nih.gov:2312/pqdweb?RQT=572&VType=PQD&VName=PQD&VInst=PROD&pmid=24034&pcid=33246441&SrchMode=3&aid=1). Vol. 74, Iss. 4;  pg. 651

[**http://www.aafp.org/online/en/home/publications/journals/afp.html**](http://www.aafp.org/online/en/home/publications/journals/afp.html)

Naltrexone and Counseling Reduce Alcohol Dependence

**Clinical Question:** What interventions are most effective in the
treatment of alcohol dependence?

**Study Design:** Randomized controlled trial (double-blinded)

**Synopsis:** Behavioral interventions and at least two
medications-naltrexone (Revia) and acamprosate (Campral)-are effective
in the treatment of alcohol dependence. Whether combining
pharmacotherapy with behavior therapy will improve outcomes is unknown.
These investigators randomized (concealed allocation) 1,383 adults (428
women and 955 men; median age = 44 years) meeting *Diagnostic and
Statistical Manual of Mental Disorders, 4th ed.* criteria for alcohol
dependence to one of nine groups for 16 weeks of outpatient treatment.

**Bottom Line:** Naltrexone and subspecialist-delivered combined
behavioral intervention are equally effective in the short-term (16
weeks) treatment of alcohol dependence. This study found no evidence of
effectiveness for acamprosate alone or evidence of incremental
effectiveness for combinations of naltrexone, acamprosate, and combined
behavioral intervention. The beneficial effects of naltrexone and
combined behavioral intervention compared with the other interventions
were no longer significantly different after one year. Primary care
physicians wishing to help patients with alcohol dependence can expect
equal short-term success by prescribing naltrexone or referring for
subspecialty intervention. Effective treatments to improve long-term
outcomes are still needed. (Level of Evidence: 1b)

###### [**http://www.aafp.org/afp/20060901/tips/16.html**](http://www.aafp.org/afp/20060901/tips/16.html)

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

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

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

**Human Papillomavirus Vaccination**

ABSTRACT: The U.S. Food and Drug Administration recently approved a
quadrivalent human papillomavirus (HPV) vaccine for females aged 9--26
years. The American College of Obstetricians and Gynecologists
recommends the vaccination of females in this age group. The Advisory
Committee on Immunization Practices has recommended that the vaccination
routinely be given to girls when they are 11 or 12 years old. Although
obstetrician-- gynecologists are not likely to care for many girls in
this initial vaccination target group, they are critical to the
widespread use of the vaccine for females aged 13--26 years. The
quadrivalent HPV vaccine is most effective if given before any exposure
to HPV infection, but sexually active women can receive and benefit from
the vaccination. Vaccination with the quadrivalent HPV vaccine is not
recommended for pregnant women. It can be provided to women who are
breastfeeding. The need for booster vaccination after 5 years has not
been established. (see Harper et al below) Health care providers are
encouraged to discuss with their patients the benefits and limitations
of the quadrivalent HPV vaccine and the need for continued routine
cervical cytology screening.

Human papillomavirus vaccination. ACOG Committee Opinion No. 344.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2006;108:699--705.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16946235>

HPV Vaccine Shows Promise, at Least in Short Term

Initial studies of vaccines against HPV 16 and 18 indicate that 90
percent of infections can be prevented, but long-term immunogenicity is
required to prevent malignant change. Harper and colleagues studied
participants in a randomized controlled trial of HPV vaccines to
determine the long-term effectiveness and safety of these vaccines.

The authors conclude that the immunization provided effective protection
against HPV-16 and HPV-18 infections. The degree of protection exceeded
expectations and may be attributed to additional protection against
other oncogenic HPV types such as HPV-45 and HPV-31. The vaccine
protection appears to last for four to five years.

Harper DM, et al. Sustained efficacy up to 4.5 years of a bivalent L1
virus-like particle vaccine against human papillomavirus types 16 and
18: follow-up from a randomised control trial. Lancet April 15,
2006;367:1247-55.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16631880>

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

**Surgeons vary widely in their approaches to disclosing medical errors
to their patients**

<http://www.ahrq.gov/research/jul06/0706RA3.htm>

**Reductions in primary and preventive care use under Medicaid primary
care case management are more dramatic for minority children**

<http://www.ahrq.gov/research/jul06/0706RA23.htm>

**NICU babies are frequently at risk for misidentification**

<http://www.ahrq.gov/research/jul06/0706RA1.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}

**New on Your Library Website**

**Daily Health Policy News Summaries**

You might notice something different when you go to your HSR Library
website. Headlines now appear at the top of the Features Panel. Click on
the headline links and you will go to news summaries on the latest in
women's health policy, health policy in general, and HIV/AIDS news.
These summaries provide further links to the actual full-text articles
and papers on the subject.

These news summaries are called the Kaiser Daily Health Reports, and are
written and published by a for-profit organization, The Advisory Board
Company, for the Henry J. Kaiser Family Foundation. The Reports are free
and we have a trial subscription. Take a look and give some feedback on
rather this service is useful or not to you.

Filter Preferences in PubMed

When you conduct a literature search in PubMed, you can use LIMITS to
limit your subject search to humans, English language only, publication
years, age groups and other limits. After you enter GO, your retrieval
page will now show two default tabs above the results, "All" and
"Review". The "All" tab includes all citations found on the subject you
typed into the search box; the "Review" tab will show you only those
citations in the "All" group that are review articles.

What's new is this: Now you can group your search results further by
areas of interest using Filter Preferences. To get to the Filter
Preference page, click on the tiny hammer/wrench icon located next to
the "Review" tab. You will now be in My NCBI (formerly "My Cubby"),
where you will need to login using your user name and password. If you
haven't registered, you will need to create your user name and password.

On the Filter Preference page, you can click on Browse to further select
areas of interest. For example in the Properties Group under Clinical
Queries you may select "diagnosis" or "therapy" among many
possibilities. Another example in the Properties Group under the
category, Health Services Research Queries is "Outcomes Assessment."

Here's an example. Let's look for articles on vitamin D and diet using
the "Outcomes Assessment" filter. When you hit the Go, your search
retrieval will now show 3 tabs:

"All" tab; "Review" tab; and "Outcomes Assessment" tab.

Tip: If you want to see citations that fit two or more categories (e.g.,
aged and outcomes assessment), use LIMIT to select "aged" and then go on
to the FILTER PREFERENCE page and select the filter "Outcomes
Assessment." Using the LIMIT selection for "aged" will guarantee that
the citations in the "Outcomes Assessment" tab are only "aged." On the
other hand, if you were to select "aged" in the FILTER PREFERENCE page,
then you would see "aged" as a tab and all articles key-worded to "aged"
are in this group of search results. Under the "Outcomes Assessment" tab
will be "aged" and "not aged" in the citations.

Another Tip: Through the magic of cookies and central memory, your tab
selections will stay with you for your next search. You can always
delete a tab selection by checking on "My Selections."

If you need help using this feature or any of the electronic resources
available to you through the HSR Library, please email me at
<cooperd@mail.nih.gov>

##### 

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

**Engorgement - It only feels like it is going to last forever**

New mothers might forget the pain of childbirth, but they usually do not
forget the discomfort of engorgement. New moms describe engorgement as
"having rock hard, huge breasts," "being so full that the baby can't
latch," "having pain all over, even into the back," and generally a
frustrating and difficult problem.

If engorgement occurs, it will be 2-5 days after birth. As hormones
shift to support the new phase of lactation. colostrum transitions to
mature milk, and the milk supply increases. If the baby is not drawing
the milk off the breast every 2-3, the breasts can become congested. The
congestion usually lasts a long 24-48 hours. Some moms will experience a
low-grade fever (100 degrees).

Treatment for engorgement is:

-   Re-assurance that the engorgement/swelling/congestion will calm down
    in 24-48 hours.

-   Apply cold compresses to the breasts between feedings. Some moms
    report relief with applying cold, washed cabbage leaves to the
    breast, replacing them as they wilt. Research has not found clinical
    difference when cabbage is compared to other treatments such a cold
    packs. However, no harm has been found and cabbage may be more
    accessible to families.

-   Use gentle heat while nursing. Warm packs are soothing and allow
    more milk to be released.

-   If latching in not possible, hand express or use a pump to gently
    express enough milk for the areola to soften and the baby to latch.
    If a hospital grade pump is available, use it. Using a department
    store pump or vigorously hand pumping can damage the nipple,
    aggravating an already difficult situation.

-   Sometimes with the arrival of the mature milk, babies will change
    how they suck. This could be because the shape of the breast and/or
    nipple have changed -- but it can mean a dysfunctional latch, sore
    nipples, and an unhappy dyad. So ask the mom, watch and help her
    make the sure the latch is still okay.

-   Stress to the mom that breastfeeding or expressing milk about every
    2 hours for the next 24 hours will help. Assure the mom that it will
    get better.

-   Motrin/ibuprofen as an anti-inflammatory treatment helps also. It is
    generally considered safe to use with lactation.

Prevention will help. To keep engorgement from happening, encourage new
families to breastfeed 8-12 times in 24 hours -- that is about every 2-3
hours. Caution new families that letting the baby or mom sleep through
feedings in the first 2-5 days can have miserable results.

Once the new family is past the first 5 days, profound engorgement goes
away. The mom may notice that her breasts become softer as the weeks
progress. Sometimes moms will fear that their milk supply is dwindling.
It helps to assure the mom that her milk is still there, her body is
becoming accustomed to it being there.

[References:]{.underline}

Snowden HM et al. Treatment for breast engorgement during lactation.
Cochrane Database Syst Review, 2001; (2):CD000046.

Roberts KL. A comparison of chilled cabbage leaves and chilled gelpaks
in reducing breast engorgement. J Hum Lact. 1995 Mar; 11(1):17-20.

Alden KR. Newborn nutrition and feeding. In DL Lowdermilk et al., eds.,
Maternity Nursing, 5th ed., (1999). pp. 549--577. St. Louis: Mosby.

Neifert MR. Clinical aspects of lactation: Promoting breastfeeding
success. Clinics in Perinatology, (1999). 26(2): 281--306.

**Other**

**Breastfeeding: Data and Statistics: Breastfeeding Practices ---
Results from 2005 Survey**

Since January 2003, breastfeeding questions have been asked of all
National Immunization Survey (NIS) respondents to assess the
population's breastfeeding practices. As a result, the 2005 NIS results
not only provide overall population estimates for the initiation,
duration, and exclusivity of breastfeeding, but also provide
geographically-specific breastfeeding rates. In 2005, the breastfeeding
questions analyzed for this report were: "Was \[child's name\] ever
breastfed or fed breastmilk?"; "How long was \[child's name\] breastfed
or fed breastmilk?"; and "How old was \[child's name\] when \[he/she\]
was fed something other than breastmilk? This includes formula, juice,
solid foods, cow's milk, water, sugar water, anything else."

<http://www.cdc.gov/breastfeeding/data/NIS_data/data_2005.htm>

#### 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}

#### August 2006 Highlights include: {#august-2006-highlights-include-1 .Style-Heading-4-+-Arial-14-pt-Underline}

-Uterine rupture rate hasn't changed for 20 years -- Why have our
practices?

-New Women's Health Work Group Forming: Looking for interested
volunteers

-Update your standing post partum discharge orders: Tdap in pregnancy

-ACOG Releases HPV Vaccine Recommendations for Ob-Gyns

-Emergency Contraception: A Primer for Pediatric Providers

-Antidepressant Discontinuation Syndrome

-Norethindrone More Effective for Menses Suppression

-Induction of Labor for Vaginal Birth After Cesarean Delivery

-Early Milk Supply Issues

-Randomized trial: Screening for intimate partner violence in health
settings

-Is 75 Years an Appropriate Upper Age Limit for Mammography?

-Addressing Depression in Family Planning Services

-HIV/AIDS in Latin America and the Caribbean

-First trimester screening: How would you counsel this patient?

-VBAC: Pendulums and Ecstasy

-Native Alaskan and American Indian Nurses Scholarship Opportunity

-The indications for IUD use have vastly expanded

-Glyburide flows from fetus to mother by placental transport system

-September 1, 2006: Palliative Medicine\'s Role in the Continuity of
Care

-Condom Use and the Risk of Genital HPV Infection in Young Women

-Obese Girls: 3 x Risk for Early Death than Slim Counterparts

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/06AugOL.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/06AugOL.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocuments06augol.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-5 .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-6 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Randomized trial assesses screening for intimate partner violence in
health settings**

The findings from this study examining 3 approaches to IPV \[intimate
partner violence\] screening in health care settings suggest that the
face-to-face approach is the least preferred by women, irrespective of
instrument.

The authors found that

\* Twelve-month prevalence of IPV ranged from 4.1% to 17.7%, depending
on screening method, instrument, and health care setting.

\* Prevalence was significantly lower on the written WAST than on the
PVS.

\* Lower levels of missing data occurred for the WAST vs. the PVS and
for the written method vs. the face-to-face and computer-based methods
combined.

\* On all three evaluation indicators (easy, preferred, private), women
chose computerized and written methods over face-to-face questioning.

\* The positive predictive value of the WAST was minimally higher than
that of the PVS, and the negative predictive values were almost the
same, leading to very similar accuracies.

Prevalence, missing data, and preference are all important
considerations for both clinical and research efforts in IPV screening.

MacMillan HL, Wathen CN, Jamieson E, et al. 2006. Approaches to
screening for intimate partner violence in health care settings: A
randomized trial. The Journal of the American Medical Association
296(5):530-536
[[http://jama.ama-assn.org/cgi/content/abstract/296/5/530?etoc]{.underline}](http://jama.ama-assn.org/cgi/content/abstract/296/5/530?etoc)

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

**Where is the Indian Health System when it comes to providing
palliative / end-of-life care?**

We need your help. We are trying to get a handle on where we are in the
Indian Health System (IHS, Tribal, and Urban programs) when it comes to
providing palliative and end-of-life care.

We have designed a brief (5 minutes) survey to get the perspective of
physicians, nurses, pharmacists, and administrators working in the
health system, tasked with providing the care.

This survey is being sent out through various list serves. If you have
already completed the survey, we apologize for the duplication;
disregard this message.

Please feel free to share the link with others. We hope to reach as many
facilities as possible and recognize that there may be different
perspectives in a single facility.

The survey is available by cutting and pasting this URL into your
browser:

[http://www.surveymonkey.com/s.asp?u=231271843431](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.surveymonkey.com/s.asp?u=231271843431) 

The Survey will be open through Friday, October 13.

If you have questions, feel free to call me at 413-584-0790 or
615-417-4915.

Thank you!

Bruce Finke

<bruce.finke@ihs.gov>

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

**Adolescent perception of sexual abstinence**

Findings of confusion around the definition of sexual abstinence
underscore the need for a clear operational definition of abstinence in
research and programs. Sexual abstinence is an important component of
adolescent sexually transmitted infection and pregnancy prevention.
Despite high levels of public investment in \"abstinence only\"
interventions, research is needed to more clearly define sexual
abstinence, as well as the factors that influence adolescent
decision-making around abstinence.

The authors found that

\* Participants knew that abstinence had something to do with sex, but
many were unsure of its exact meaning. However, although the term
\"abstinence\" was misunderstood, the concept of choosing not to have
sex was clear and relevant.

\* Participants viewed abstinence as a natural stage of development:

people are abstinent for some time during their lives and then
transition to sexual activity when they feel \"ready.\" According to
participants, readiness was influenced by individual characteristics;
relationship characteristics; and a balance of health, family, and
social risks and benefits.

\* Participants considered the transition from abstinence to sexual
activity as an irreversible, life-changing decision.

\* Age and sexual experience influenced how participants determined
readiness for sexual activity.

Adolescents are likely to be best served by placing abstinence back
within the framework of broader sexuality education. This would provide
adolescents with the information and decision-making skills to evaluate
relationships, develop communication within relationships, and
accurately assess their own level of readiness.

#### **Ott MA, Pfeiffer EJ, Fortenberry D. 2006. Perceptions of sexual abstinence among high-risk early and middle adolescents. Journal of Adolescent Health 39(2):192-197. Abstract available at <http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16857530>** {#ott-ma-pfeiffer-ej-fortenberry-d.-2006.-perceptions-of-sexual-abstinence-among-high-risk-early-and-middle-adolescents.-journal-of-adolescent-health-392192-197.-abstract-available-at-httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids16857530 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**The Indian Health MCH Frequently Asked Question (FAQ) site**

This site offers over 425 answers to common questions about the care of
women and children in the unique settings found in Indian Country.
Answers include both a quick answer and then significant background and
multiple resources and links.

The site is maintained frequently (see section below) with 11 new FAQs
this month and numerous existing FAQs being updated. There are 15
answers to questions on bilateral tubal ligation alone.

Go here to explore the frequently asked question page

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

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

**Q. Are there any cultural barriers/among Native Americans to becoming
cord blood donors?**

A. Yes, there are issues of the cost for long term cord blood storage,
as well as cultural issues. Below are five resources about various
aspects of cord blood and tissue donation. The MCH web page also has a
Frequently Asked Question with a sample cord blood donation disclaimer
and many other resources.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CordStem4206.doc>

1.) Why should minorities be concerned about organ donation?

Some diseases of the kidney, heart, lung, pancreas, and liver are found
more frequently in racial and ethnic minority populations than in the
general population. For example, African Americans, Asian and Pacific
Islanders, and Hispanics are three times more likely to suffer from
end-stage renal disease than Caucasians. Native Americans are four times
more likely than Caucasians to suffer from diabetes. Some of these
diseases are best treated through transplantation; others can only be
treated through transplantation.

Successful transplantation often is enhanced by the matching of organs
between members of the same ethnic and racial group. For example, any
patient is less likely to reject a kidney if it is donated by an
individual who is genetically similar. Generally, people are genetically
more similar to people of their own ethnicity or race than to people of
other races. Therefore, a shortage of organs donated by minorities can
contribute to death and longer waiting periods for transplants for
minorities. <http://www.unos.org/qa.asp>

2.) Q: Why is there a need for women from all racial and ethnic groups
to donate their baby\'s cord blood?

## A: Because the tissue traits that are used to match a cord blood unit with a patient are inherited, a patient\'s most likely match will be cord blood donated by someone of the same heritage. American Indian and Alaska Native, Asian, Black and African American, Hispanic and Latino, Native Hawaiian and Other Pacific Islander, and multiple-race patients face a greater challenge in finding a match than White patients. 

NMDP cord blood banks are working in local communities to increase the
racial and ethnic diversity of NMDP cord blood listings. From 2001 to
2003, the likelihood of finding a matched cord blood unit has grown at
least twofold for patients from all racial and ethnic groups. Still,
some patients are unable to find a match because of the rarity of their
tissue traits. Some tissue traits are more likely to be found among
people of a particular racial or ethnic heritage. That is why a pressing
need remains for more cord blood donations from American Indian and
Alaska Native, Asian, Black and African American, Hispanic and Latino,
Native Hawaiian and Other Pacific Islander, and multiple-race donors.
<http://www.marrow.org/DONOR/cord_blood_faqs.html#minority>

National Marrow Donor Program
<http://www.marrow.org/DONOR/cord_blood_faqs.html>

3.) Native Village: Youth and Education News: Umbilical Cord Blood
Donation

Cryobanks International is a facility accepting umbilical cord blood
donations throughout the United States. Umbilical cord blood is rich in
stem cells used in place of bone marrow for transplants.  Cryobanks is
now working with Dave Jackson, a Native American Advocate and high-risk
OB physician, to sponsor an umbilical cord blood donation program. 
Umbilical Cord Blood Donation is a painless, non-invasive process that
utilizes cord blood that would otherwise be discarded as medical waste. 
Currently, Native Americans in life and death searches have little
chance to find a stem cell match. Donations are accepted from anywhere
in the Continental United States.

There is no charge to donate, but be sure to ask about storage charges.
[[ipressler@cryo-intl.com]{.underline}](mailto:ipressler@cryo-intl.com)

Native Village: Youth and Education News December 10, 2003 Issue 124,
Volume 3

[http://www.nativevillage.org/Archives/2003/Dec%2010%20NEWS/Native%20Village%20News%20,%20Dec%2010%202003%20I%20124%20V3.htm](http://www.nativevillage.org/Archives/2003/Dec 10 NEWS/Native Village News , Dec 10 2003 I 124 V3.htm)

Learn more about Cryobanks: <http://www.cryo-intl.com/>

4.) Sacred symbolic value associated with the placenta, umbilical cord,
and umbilical cord blood

Excerpt:

Yet, in many indigenous cultures, including Native American, the
placenta, umbilical cord, and umbilical cord blood have sacred symbolic
value associated \...

Abstract:. Religious discussion of human organs and tissues has
concentrated largely on donation for therapeutic purposes. The retrieval
and use of human tissue samples in diagnostic, research, and education
contexts have, by contrast, received very little direct theological
attention. Initially undertaken at the behest of the National Bioethics
Advisory Commission, this essay seeks to explore the theological and
religious questions embedded in nontherapeutic use of human tissue. It
finds that the \"donation paradigm\" typically invoked in religious
discourse to justify uses of the body for therapeutic reasons is
inadequate in the context of nontherapeutic research, while the
\"resource paradigm\" implicit in scientific discourse presumes a
reductionist account of the body that runs contrary to important
religious values about embodiment. The essay proposes a \"contribution
paradigm\" that provides a religious perspective within which research
on human tissue can be both justified and limited.
<http://muse.jhu.edu/>

Campbell, Courtney S. 1956- \"Religion and the Body in Medical
Research\"\
Kennedy Institute of Ethics Journal - Volume 8, Number 3, September
1998, pp. 275-305\
The Johns Hopkins University Press

<http://muse.jhu.edu/cgi-bin/access.cgi?uri=/journals/kennedy_institute_of_ethics_journal/v008/8.3campbell.html>

5.) Ethical bases for the draft Indian Health Service\'s (IHS)
Guidelines about the collection and use of research specimens

"34. People in some Tribes have traditional beliefs that the placenta,
umbilical cord, and umbilical cord blood are sacred and must be handled
in a special manner. IHS hospitals give such tissues back to the patient
or family upon request. "

This paper presents the ethical bases for the DRAFT Indian Health
Service\'s (IHS) Guidelines about the collection and use of research
specimens (Appendix A). The Guidelines were designed to be a working
document for American Indian and Alaska Native (AI/AN)(3) Tribal
communities and people; its ethical rationale was not discussed. The
Guidelines are relevant to most U.S. people, researchers, and policy
makers; if researchers and ethicists are to them as relevant, however,
that ethical rationale must be clarified and convincing...

For the proper perspective please view the entire paper at link below.

<http://scholar.google.com/scholar?hl=en&lr=&q=cache:lN-Ni_NcrDoJ:www.unm.edu/~hsethics/pubfreeman.htm+The+role+of+Community+in+research+with+stored+tissue+samples>

This was published in Weir R (ed.). Stored tissue samples: Ethical,
legal, and public policy implications. U. Iowa Press; Iowa City, IA.
1998: 267-301. This file is the pre-edited next-to-final version. For
the final, printed, version, please see the book.

This paper does not necessarily represent the views of the Indian Health
Service

Frequently Asked Question: MCH website

**Q. Is cord blood stem cell storage a viable option in Indian
Country?**

A. Cord blood stem cell storage can offer patients both advantages and
disadvantages.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CordStem4206.doc>

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

**September 2006 -- Highlights**

-Thank you Captain Obvious - Meta analysis shows that drinking sugar
sweetened beverages is linked to obesity

-If you cant beat\'em sue\'em: The intersection of obesity and public
health law

-Pneumococcal vaccine has decreased the rates of otitis media and PE
tube placement in AI/AN children

-Cancer data for adolescent Native Americans

-Mystery person gives \$100,000 to the Committee on Native American
Child Health - Help us decide how to spend it

-Survey Monkey in this issue - let us know what you want

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/IHSchildnotesSept06.doc>

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

**HIV Management System, v1.0 - National Release, BKM**

The HIV Management System software will be a component of the IHS
Resource and Patient Management System (RPMS) that provides case
management functions. Case management provides a mechanism for
healthcare providers to be informed about and to follow up on clinical
interventions and information on single or multiple disease states and
conditions. These applications can assist healthcare providers to
identify high-risk patients, proactively track care reminders and the
health status of individuals or populations, provide appropriate care by
embedding evidence-based guidelines, and report outcomes. Appropriate
case management improves the delivery of care, as well as outcomes. In
addition, there are documented fiscal benefits when appropriate case
management is introduced into the health care business process model.

HIV is a key tool for accomplishing the IHS goal to improve compliance
with clinical practice guidelines for five chronic diseases that are
significant to the American Indian/Alaska Native (AI/AN) population:
diabetes, HIV/AIDS, asthma, obesity, and cardiovascular disease. It
provides the capability to establish and maintain a patient register for
managing the health care of any select groupings of HIV/AIDS and/or At
Risk patients defined by a facility's providers. It also provides the
ability to collect data not currently available within RPMS that is
specific to the health care and management of HIV/AIDS patient and
provide relevant reminders and alerts to providers. Finally, HMS
provides the capability to analyze and report patient data for
individuals and populations.

This application is similar to existing case management modules in RPMS,
such as Diabetes Management. However, due to the highly sensitive nature
of healthcare information regarding HIV and related illnesses, HMS has
additional functionality to protect the security of that information.

The new release of this software is available on the IHS Web site:
<http://www.ihs.gov/Cio/RPMS/index.cfm?module=home&option=software>

or ITSC system, cmbsyb, in the /usr/spool/uucppublic/DIST/2006cert
directory

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

**Health care and indigenous peoples: the other side of the planet**

New Zealand's indigenous minority people, the Maori, have substantially
worse health indicators than the majority population, mostly descendants
of British colonizers or later migrants. The authors of this article
questioned whether part of the problem might be a lesser quality of
hospital care for Maori patients. (New Zealand's health system is
publicly funded; hospital care is both free of charge and reasonably
evenly geographically distributed; 90% of the population lives within an
hour's drive of a hospital).

A team of research assistants reviewed records of nearly 6000 admissions
randomly selected from a stratified sample of six tertiary care
hospitals, four secondary hospitals with 300 beds or more, and four
secondary hospitals with less than 300 beds. Outpatient, psychiatric,
and rehabilitation admissions were excluded. They identified adverse
events (any unintended injury resulting in disability that could be
considered at least in part iatrogenic) and used multiple logistic
regression to assess the likelihood of an adverse event against gender,
socioeconomic status, indigeneity status, and age. Age-adjusted rates of
preventable adverse events were found to be significantly higher for
Maori patients, especially for those who were over 45 or hospitalized
for a musculoskeletal or digestive problem. (Interestingly, Maori
patients had a significantly *lower* risk of adverse outcomes related to
surgery or obstetrical admissions, data the authors present in tables
but do not discuss.) Socioeconomic status did not affect adverse events.

Though the authors concluded that a higher likelihood of suboptimal care
might contribute to the poor health indicators of New Zealand's Maori
population, their study raises more questions than it answers. The
utility of chart audits for assessing quality of care has been
questioned, for instance; as the authors acknowledge, preventable
adverse events are only one small measure of overall health system
access and process issues that may be important in indigenous health.
Nonetheless, the study is an interesting contribution to a surprisingly
small body of research on health systems issues for indigenous people.

Davis P. et [al]{.underline}. Quality of hospital care for Maori
patients in New Zealand: retrospective cross-sectional assessment. The
Lancet 367:1920-5, June 10, 2006

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16765761>

**Planes, trains, automobiles and asthma in China**

Rising childhood asthma rates are not just a first-world problem. In the
Lancet, Jonathan Watts reports on recent findings that asthma rates have
increased sharply in China. Authors in the *China Journal of Pediatrics*
note that the prevalence of asthma in children rose by 64% between 1990
and 2000, with double the rates in urbanized areas. Asthma rates seemed
to correlate well with growth in urban economies: areas with lagging
growth -- like Xining in Qinghai or Lhasa in Tibet -- had much reduced
rates of asthma, while the most rapidly developing cities show asthma
rates in children approaching 5%. (US national rates in the same year
were about 8%.) Figures for adults are poor, but doctors guess the rates
to be about half what they are for children. In a country with
notoriously poor air quality, and one where respiratory ailments are the
lead cause of mortality, these changes are a matter of concern in the
medical community and beyond. Other factors cannot be ignored: smoking
rates are very high in China, and second-hand smoke is a well-accepted
trigger for asthma; in addition, Chinese doctors cited research on a
link between asthma and the pollen of the Artemisia species planted to
combat desertification. However, the Chinese doctors Watts interviewed
believed that air pollution was the major culprit, noting that hospital
admissions and clinic visits rise sharply on days with poor air quality.
Though industrial pollution is part of the problem, most observers
believe that automobile exhaust in particular is to blame -- motorized
vehicle use in China has exploded in recent years, and emissions
standards are weak.

There may be a silver lining to the smoggy cloud, some Chinese doctors
pointed out. Rapid economic development brings poor air quality, but it
also means that for the first time many of their patients can afford
Western-made inhalers.

Watts J. Doctors blame air pollution for China's asthma increases. The
Lancet 368:719-20, August 26, 2006

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16938905>

Editorial Note:

You can access both of these article at [www.thelancet.com]{.underline}
(requires free registration)

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

**Adolescents' Use of Contraception**

Trends and Recent Estimates: Contraceptive Use Among U.S. Teens focuses
on trends and characteristics of contraceptive use among adolescents in
the United States, including contraceptive use at first sex and most
recent sex, as well as specific method used. The research brief,
published by Child Trends, presents an analysis of recently released
nationally representative data from a survey of never-married
adolescents ages 15-19. Patterns of adolescent contraceptive use are
examined by gender, race and ethnicity, and age. A summary and a
discussion of policy implications are also included.

[http://www.childtrends.org/Files/ContraceptivesRB.pdf]{.underline}

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

**New website provides easy access to information on SIDS and infant
death**

The National SIDS/Infant Death Resource Center has launched a new
feature on its Web site, providing access to electronic versions of
print publications (fact sheets, brochures, booklets, and posters) and
information on materials in other formats (CDs, DVDs, and videotapes).

#### The information was collected from national, state, and local SIDS/infant death programs, as well as from perinatal, stillbirth, maternal and child health, and bereavement organizations. [[http://www.sidscenter.org/Topics.aspx?heading=TopicsA-Z]{.underline}](http://www.sidscenter.org/Topics.aspx?heading=TopicsA-Z) {#the-information-was-collected-from-national-state-and-local-sidsinfant-death-programs-as-well-as-from-perinatal-stillbirth-maternal-and-child-health-and-bereavement-organizations.-httpwww.sidscenter.orgtopics.aspxheadingtopicsa-z .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### First trimester screening: How would you counsel this patient? {#first-trimester-screening-how-would-you-counsel-this-patient-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Let's review last week's case.... {#lets-review-last-weeks-case. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Ms. L. is a 40 y/o G1P0 at 9 weeks gestation (by a 6 week ultrasound) and is aware of her age-related risks for fetal aneuploidy. She inquires about the possibility of early screening.  Which ONE of the statements below is the most accurate way to counsel her: {#ms.-l.-is-a-40-yo-g1p0-at-9-weeks-gestation-by-a-6-week-ultrasound-and-is-aware-of-her-age-related-risks-for-fetal-aneuploidy.-she-inquires-about-the-possibility-of-early-screening.-which-one-of-the-statements-below-is-the-most-accurate-way-to-counsel-her .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### A. Ultrasonic measurement of fetal nuchal translucency combined with biochemical tests between  {#a.-ultrasonic-measurement-of-fetal-nuchal-translucency-combined-with-biochemical-tests-between .Style-Heading-4-+-Arial-14-pt-Underline}

####  11 and 13 weeks may detect close to 90% of chromosomally abnormal fetuses {#and-13-weeks-may-detect-close-to-90-of-chromosomally-abnormal-fetuses .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### B. Early trimester screening has a better detection rate, but a higher false positive rate, than  {#b.-early-trimester-screening-has-a-better-detection-rate-but-a-higher-false-positive-rate-than .Style-Heading-4-+-Arial-14-pt-Underline}

####  Mid-trimester screening {#mid-trimester-screening .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### C. Women who have first trimester screening that is negative will not need further testing {#c.-women-who-have-first-trimester-screening-that-is-negative-will-not-need-further-testing .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### Ultrasonographic measurement of the fetal nuchal translucency combined with biochemical tests between 11 and 13 weeks may detect close to 90% of chromosomally abnormal fetuses Ms L. is likewise 40 years old and has the same age-related risks as Ms Walks Alone. First trimester screening between 11 and 13 weeks may be an option for her if you are able to refer her to a site where she can have nuchal translucency (NT) performed by a certified sonographer, and have free beta HCG and PAPP-A determinations done. Studies to date demonstrate that such testing will have an 85-89 % detection rate for fetal aneuploidy, if the NT is reliably measured. These detection rates and false positive rates are comparable, or better, than a second trimester strategy utilizing the \'quad screen\' and high resolution ultrasound, and much better than \'triple testing\'. Remember that second trimester screening for neural tube defects is still necessary since that issue will not be addressed by this testing. The important logistic issue is whether you have the resources available to provide accurate testing and appropriate follow up. If so, and if the patient requests it, this is certainly an appropriate strategy for this patient. {#ultrasonographic-measurement-of-the-fetal-nuchal-translucency-combined-with-biochemical-tests-between-11-and-13-weeks-may-detect-close-to-90-of-chromosomally-abnormal-fetuses-ms-l.-is-likewise-40-years-old-and-has-the-same-age-related-risks-as-ms-walks-alone.-first-trimester-screening-between-11-and-13-weeks-may-be-an-option-for-her-if-you-are-able-to-refer-her-to-a-site-where-she-can-have-nuchal-translucency-nt-performed-by-a-certified-sonographer-and-have-free-beta-hcg-and-papp-a-determinations-done.-studies-to-date-demonstrate-that-such-testing-will-have-an-85-89-detection-rate-for-fetal-aneuploidy-if-the-nt-is-reliably-measured.-these-detection-rates-and-false-positive-rates-are-comparable-or-better-than-a-second-trimester-strategy-utilizing-the-quad-screen-and-high-resolution-ultrasound-and-much-better-than-triple-testing.-remember-that-second-trimester-screening-for-neural-tube-defects-is-still-necessary-since-that-issue-will-not-be-addressed-by-this-testing.-the-important-logistic-issue-is-whether-you-have-the-resources-available-to-provide-accurate-testing-and-appropriate-follow-up.-if-so-and-if-the-patient-requests-it-this-is-certainly-an-appropriate-strategy-for-this-patient. .Style-Heading-4-+-Arial-14-pt-Underline}

**References**

-Nadel et al. NEJM 1990;323:557-61.

-Nadel et al. Obstet Gynecol 1997; 89:660-5.

-Lennon et al. Obstet Gynecol 1999; 94:562-6.

-Johnson et al. Ultrasound Obstet Gynecol 1997; 9:14-6.

-Nicolaides et al. Lancet 1986; 2:72-4.

-Palomaki et al. Obstet Gynecol 1988; 71:906-9.

#### [MFM Editorial comment:]{.underline}

**Do We Need to do MSAFP Testing after First Trimester Down Syndrome
Screening?**

A recent Fetal Medicine Foundation newsletter (Vol.2, Issue 3, July
2006)\* discussed this topic and reached some interesting conclusions
that may be pertinent to our practices. The current standard of care in
the United States has been in place since the early 1980's, and is to
offer maternal serum alpha fetoprotein (MSAFP) testing to all pregnant
women in order to screen for fetal open neural tube defects (ONTD),
including anencephaly and meningomyelocele. Other important
abnormalities suggested by an elevated MSAFP are the abdominal wall
defects, including gastroschisis and omphalocele. Most MSAFP
determinations are done between 15 and 20 weeks gestation, and are now
part of either the "triple" or "quad" screens, which are also done to
screen for fetal Down syndrome (DS). Unfortunately, MSAFP has less than
optimal sensitivity and specificity for ONTD, with a detection rate of
about 80% (MSAFP \>2.5 MoM) at a fixed false positive rate of 5%.

Second trimester ultrasound on the other hand has sensitivity and
specificity for ONTD that are \>95%. The diagnosis of anencephaly is
usually immediate. The diagnosis of spinal defects is also excellent. In
addition to vertebral column defects, the cranial findings of an
abnormal cerebellum, the "banana" sign (Chiari type II malformation),
and the resultant cranial deformity of the "lemon" sign, have been well
described for several decades. Fetal abdominal wall defects are usually
also easily diagnosed with ultrasound. The more rare fetal problems,
such as the genitourinary abnormalities, bowel obstruction, and
teratomas, which are also associated with elevated MSAFP, are also
usually apparent on ultrasound.

If your patient has chosen first trimester "combined" screening for Down
syndrome (measurement of the fetal nuchal translucency (NT) and
determinations of pregnancy associated plasma protein A \[PAPP-A\] and
free beta HCG between 11 and 13 weeks), does she also need to undergo
MSAFP screening in the second trimester? Does she need a second
trimester anatomic survey to look for the abnormalities detailed above?
Ultrasound at 11-13 weeks should easily be able to diagnose anencephaly,
as well as abdominal wall defects. At the present time however, there
are no studies that have looked at the accuracy of screening for spinal
defects at this gestational age.

In our system in Alaska, those women who have had negative first
trimester screening for fetal DS receive a second trimester sonographic
anatomic survey, and are thus screened for ONTD with the modality with
the best detection rate. If a woman has had a negative first trimester
screen, we have elected not to do "integrated" DS screening with a quad
screen in the second trimester, and thus we do not get an MSAFP. Women
who present after 13 weeks can elect multiple marker screening, with
MSAFP, and may also require second trimester ultrasound as indicated.
However, this scheme may not be most cost-effective in your setting,
especially if "level II" ultrasound services are not readily available.
Likewise, remember that ACOG guidelines continue to recommend MSAFP
screening for women who have had first trimester screening, despite the
above evidence. As this is a continuously evolving field, remember to
"stay tuned for further details...."

By George Gilson, MFM, ANMC

**Reference:**

1\. Malone FD, D\'Alton ME. First-trimester sonographic screening for
Down syndrome. Obstet

Gynecol 2003; 102:1066-79.

2\. Malone FD, et al (FASTER Study). First-trimester or second-trimester
screening, or both, for

Down syndrome. NEJM 2005; 353:2001-11.

3\. Wald NJ, Rodeck C, et al. First and second trimester antenatal
screening for Down syndrome

(SURUSS Study). J Med Screen 2003; 10:56-104.

4\. Wapner R, et al. (BUN Study). First-trimester screening for
trisomies 21 and 18. NEJM 2003;

349:1405-13.

5\. Reddy UM, Mennuti MT (NICHD Workshop). Incorporating first-trimester
Down syndrome

studies into prenatal screening. OG 2006; 107:167-73.

6\. Berkowitz RL, Cuckle HS, Wapner R, D\'Alton ME. Aneuploidy
screening: What test should I

use? OG 2006; 107:715-8.

7\. Chervenak FA, McCullough LB. Implementation of first-trimester risk
assessment for trisomy

21: Ethical considerations. Am J Obstet Gynecol 2005; 192: 1777-81.

8\. Odibo AO, et al. A cost-effectiveness analysis of prenatal screening
strategies for Down

syndrome. OG 2005; 106:562-8.

9\. ACOG. First-trimester screening for fetal aneuploidy. ACOG Committee
Opinion No.296,

ACOG July 2004.  

\* Fetal Medicine Foundation newsletter (Vol.2, Issue 3, July 2006

[[http://fetalmedicine.com/usa/pdf/Newsletter%20volume%202%20number%203.pdf]{.underline}](http://fetalmedicine.com/usa/pdf/Newsletter volume 2 number 3.pdf)

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

#### For more background on this and other Prenatal genetic screening questions, please go to this free CME module which is also just a great resource {#for-more-background-on-this-and-other-prenatal-genetic-screening-questions-please-go-to-this-free-cme-module-which-is-also-just-a-great-resource .Style-Heading-4-+-Arial-14-pt-Underline}

#### Prenatal genetic screening: Serum and ultrasound {#prenatal-genetic-screening-serum-and-ultrasound .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/TM01.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/TM01.cfm) {#httpwww.ihs.govmedicalprogramsmchmtm01.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-15 .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**

Clonidine and Gabapentin Effective for Hot Flashes

**Study Question:** Which nonhormonal therapies are effective in the
management of menopausal hot flashes?

**Study Design:** Meta-analysis (randomized controlled trials)

**Synopsis:** Recent concerns about the adverse effects of hormonal
therapy have increased interest in alternative treatments of menopausal
hot flashes.

**Bottom Line:** Evidence supports the nonhormonal treatment of
menopausal hot flashes with paroxetine, clonidine, gabapentin, and soy
isoflavone extract. The overall effect size of all nonhormonal
treatments is less than that of estrogen. Treatment should be
individualized according to symptom severity and risk profiles. (Level
of Evidence: 1a-)

Nelson HD, et al. Nonhormonal therapies for menopausal hot flashes:
systematic review and meta-analysis. JAMA May 3, 2006;295:2057-71.

#### [**http://www.aafp.org/afp/20060901/tips/21.html**](http://www.aafp.org/afp/20060901/tips/21.html) {#httpwww.aafp.orgafp20060901tips21.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Estrogen Alone Does Not Increase Breast Cancer Risk {#estrogen-alone-does-not-increase-breast-cancer-risk-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Clinical Question:** Does unopposed estrogen therapy in postmenopausal
women with hysterectomy increase the risk of breast cancer?

**Study Design:** Randomized controlled trial (double-blinded)

**Synopsis:** Hormone therapy with estrogen and progesterone increases
the risk of invasive breast cancer. The risk in postmenopausal women
with hysterectomy who have been treated with estrogen alone is
uncertain. As part of the Women\'s Health Initiative, investigators
randomized (concealed allocation assignment) 10,739 postmenopausal
women, 50 to 79 years of age, who had undergone hysterectomy. The women
received 0.625 mg per day of conjugated equine estrogen or placebo.
Persons assessing outcomes remained blinded to treatment group
assignment. Follow-up occurred for nearly 95 percent of the participants
for a mean of 7.1 years.

Using intention-to-treat analysis, investigators observed nonsignificant
reductions in invasive breast cancer and total breast cancer in women
receiving conjugated equine estrogen. Significantly more women in this
group had questionably abnormal mammography results (36.2 versus 28.1
percent in the placebo group over seven years), requiring further
short-term evaluation.

**Bottom Line:** Estrogen therapy alone does not increase the risk of
breast cancer in postmenopausal women who have had a hysterectomy. Women
receiving estrogen are more likely to require further testing because of
questionably abnormal mammography results, which could lead to
heightened anxiety and a reduced quality of life. The decision to use
estrogen in postmenopausal women after hysterectomy should be
individualized based on overall potential risks and benefits. Women most
likely to benefit from estrogen therapy include those with disabling hot
flashes and an increased risk of osteoporotic fractures. Treatment
should be limited, whenever possible, to within the first five years
after menopause.

(Level of Evidence: 1b)

Stefanick ML, et al., for the WHI Investigators. Effects of conjugated
equine estrogens on breast cancer and mammography screening in
postmenopausal women with hysterectomy. JAMA April 12, 2006;295:1647-57.

#### [American Family Physician](http://ezproxyhhs.nihlibrary.nih.gov:2312/pqdweb?RQT=318&pmid=24034&TS=1157550562&clientId=53612&VType=PQD&VName=PQD&VInst=PROD). Kansas City: [Aug 15, 2006](http://ezproxyhhs.nihlibrary.nih.gov:2312/pqdweb?RQT=572&VType=PQD&VName=PQD&VInst=PROD&pmid=24034&pcid=33246441&SrchMode=3&aid=2). Vol. 74, Iss. 4;  pg. 651,  {#american-family-physician.-kansas-city-aug-15-2006.-vol.-74-iss.-4-pg.-651 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/online/en/home/publications/journals/afp.html**](http://www.aafp.org/online/en/home/publications/journals/afp.html) {#httpwww.aafp.orgonlineenhomepublicationsjournalsafp.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Postpartum Care: Still the neglected step child of perinatal
services?**

Noelle Borders, CNM, a recent UNM graduate did a meta-analysis of the
literature on postpartum health, experience, and care. What she found
overall was a dearth of good studies especially in this country, but in
those available, mainly from the UK, Australia, New Zealand, and
Scandinavia, she did find intriguing information about women's
experience of postpartum.

The vast majority (87-94%) of postpartum women report at least one
health problem in the immediate (birth to 3 months) postpartum period.
These include: backache, urinary stress incontinence, fecal
incontinence, urinary frequency, depression and anxiety, hemorrhoids,
extreme tiredness, frequent headaches, migraines, perineal pain,
constipation, increased sweating, acne, hand numbness or tingling,
dizziness, hot flashes, dyspareunia, decreased libido, and breast
discomforts (lactating or not!).

Many of these problems slowly resolve with time, but some worsen and new
ones become identified. One fascinating trend is that perineal pain is
reported at 25-30% at 0-3 months, 11% at 3-6 months and 21% at greater
than 6 months. Two small studies tried to assess functional status at 6
weeks (when we conventionally call the postpartum over and done
with??!!) and found that none of the mothers had resumed full functional
status per self reports. Another very important finding was that "women
experience an array of symptoms, the majority of which they may never
report to health care providers." Borders then looks at the effect of
delivery method on postpartum health. The literature shows that women
with a cesarean or assisted vaginal birth fare significantly worse than
women who had a spontaneous vaginal birth. For example, women with an
assisted vaginal birth had more perineal pain, constipation,
hemorrhoids, break down of stitches, sexual problems, and fecal
incontinence, although the last was not associated with vacuum assists.

After cesarean section women had more bodily pain, backaches, and
greatly increased risk of readmission for problems such as hemorrhage,
uterine infection, wound complications, cardiopulmonary and
thromboembolic conditions, pelvic injury, genitourinary problems, etc.
The much-touted-of-late protective effects of cesarean birth on urinary
and fecal incontinence were not borne out. Fecal incontinence was less
after cesarean births but did happen and the urinary incontinence
protection was only in the immediate postpartum, was negated entirely if
it was c-section number three or more and, actually, women who had
cesareans were more likely to report other urinary problems by 6 months
postpartum. Interestingly headaches and tiredness were not related to
mode of delivery and, contrary to common beliefs, neither was
depression. However, maternal satisfaction, fulfillment and
distress/sense of feeling cheated were related to delivery mode.
Spontaneous vaginal birth gave women the highest sense of fulfillment
and satisfaction and the lowest levels of distress or sense of being
cheated, while assisted vaginal births and c-sections were the exact
opposite and these findings persisted after six months. From the
literature, Borders makes it clear that the gold standard for optimal
postpartum health is a spontaneous vaginal birth.

Borders next tackles research and care---both are greatly lacking,
especially in the United States. She calls for more research quoting the
results of a study using focus groups where participants voluntarily
asked "What is normal postpartum recovery?" and no one knew the answer.
She also very nicely points out that just doing research is not
enough---the information then needs to be shared with women so they
better know what to expect postpartum and to clinicians so they can
provide better care.

As for care, she points out how abysmal the US standard of one visit at
6 weeks really is. She reports an amazing standard in England of 6-7
home visits by a midwife in the first 2 weeks, other visits as needed,
and a check up at 6 to 8 weeks. Other models include: the WHO's
recommendation of visits at times of greatest need, i.e., 6 hours, 6
days, 6 weeks and 6 months; a study looked at customizing care to each
woman's response on a symptoms checklist and found lower rates of
depression and higher satisfaction with care; but another study found no
difference with simply adding a 1-week visit to the 6-week visit model.
Borders calls for all of us "to improve postpartum care by experimenting
with flexible ways of meeting women's needs after the birth of a baby"
and reminds us of the tremendously far reaching effects this improvement
in postpartum care can have.

**[Editorial Comment: Lisa Allee, CNM]{.underline}**

When I was in midwifery school more than 10 years ago the poor state of
postpartum care in this country was decried and we were encouraged to do
better! I read this article and realized not much has changed in the
ensuing years. I felt a bit personally reassured that I had for a time
fulfilled our postpartum professor's dream when I had my own homebirth
practice and I was able to provide home visits at 24 hours and 3-5 days
and office visits at 2 and 6 weeks and frequently stayed in touch with
women beyond that. The reality for us in IHS is drastically different,
but I have reason for hope! Here at Chinle we have started offering 2
week postpartum visits and the response has been encouraging. Another
big source of encouragement is Centering Pregnancy, which is sweeping
through IHS. Many non-IHS Centering sites have found that women and
families want to continue the groups past birth and so postpartum visits
have been added and Centering Parenting (for the whole first year) has
been born! As we embrace Centering in IHS let's be sure to remember the
neglected step child and include postpartum care! If you are not doing
Centering and for the women not electing to do Centering, we also need
to heed Borders call for innovative, flexible change in how we do
postpartum care and support---home visits, phone calls, support
group\--dream big!

Borders, N, After the Afterbirth: A Critical Review of Postpartum Health
Relative to Method of Delivery Journal of Midwifery & Women's Health Vol
51 No 4 July/August 2006

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16814217>

**Other**

**Midwives applaud new false labor EMTALA regulations**

Silver Spring, MD - The American College of Nurse-Midwives (ACNM), the
nation\'s oldest women\'s health organization, commends the Centers for
Medicare and Medicaid Services (CMS) for changes it makes today, to
regulations governing the Emergency Medical Treatment and Labor Act
(EMTALA), that highlight the important role of certified nurse-midwives
(CNM) and certified midwives (CM), and helps to improve hospital
efficiency with respect to discharging women who are not yet in labor. \
\
Today, the CMS published its final rule (link below) addressing changes
to the hospital inpatient payment rates for fiscal year 2007.  As part
of this final rule, it also addresses the definition of \'labor\' within
the regulations that govern the EMTALA.  The final rule changes existing
regulations to revise the definition of \'labor\' in §489.24(b) to state
that:\
\
\"a woman experiencing contractions is in true labor unless a physician,
certified nurse-midwife, or other qualified medical person acting within
his or her scope of practice as defined in hospital medical staff bylaws
and State law, certifies that, after a reasonable time of observation,
the woman is in false labor.\"\
\
The current regulation requires a physician to certify when a woman is
in false labor.  While not specifically named in the new regulation, CMs
would also be covered by this new definition in that it identifies that
other qualified personnel acting within their scope of practice may
certify when a woman is in false labor.\
\
CMS states in the rule that the effect of this change would be to have a
single, uniform policy on the personnel who are authorized to make a
determination as to whether an individual has an emergency medical
condition. The final rule takes effect October 1, 2006.\
\
\"This change demonstrates that the bureaucratic process can work,\"
stated Katherine Camacho Carr, CNM, PhD, president of the ACNM.  \"ACNM
has been working with an EMTALA Technical Advisory Group and CMS
officials for more than a year and a half to get this regulation
modified.  ACNM appreciates the thoughtful work CMS and the EMTALA TAG
put into making this modification that will benefit the women CNMs and
CMs serve.\" 

ACNM also wishes to express its appreciation to the American College of
Obstetricians and Gynecologists for its support during the process.
August 18, 2006

<http://a257.g.akamaitech.net/7/257/2422/01jan20061800/edocket.access.gpo.gov/2006/pdf/06-6692.pdf>

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

The changes above represent a major shift in the regulation on how false
labor can be triaged.

Kudos to ACNM and ACOG for their hard work on this. Each facility should
re-evaluate their triage policies and procedures based on the new
regulations.

**Navajo News Jean Howe, Chinle**

**Implanon- A single rod contraceptive implant...**

On July 17, 2006 the FDA approved a new single rod contraceptive implant
for use in the United States. Implanon consists of a 40 x 2.0 mm (about
the size of a matchstick) rod of ethylene vinyl acetate (EVA) and
etonogestrel (ENG). The total dose of 68mg of ENG is initially released
at a rate of 60 micrograms per day, gradually declining to 30 micrograms
per day over 3 years of use. Implanon has been sold in over 30 countries
worldwide and has been used by more than 2.5 million women since 1998.
This is the first contraceptive implant to be marketed in the U.S. since
Norplant, a six-rod system, was withdrawn from the market in 2000.
Because it is a single rod system, insertion and removal are simplified;
one study (Zheng) comparing Implanon and Norplant demonstrated insertion
times of 0.61 minutes vs. 3.90 minutes and removal times of 2.18 minutes
vs. 11.25 minutes respectively.

Contraceptive efficacy is achieved primarily by suppression of ovulation
by the effect of etonogestrel on the hypothalamic-pituitary-ovarian
axis. A secondary effect is thickening of the cervical mucus, making it
less penetrable to sperm. Additionally, the endometrial lining is
rendered less favorable for implantation. Overall efficacy is cited as
\>99%, with most failures in study populations occurring at the time of
insertion or removal. The U.S. study populations did not include women
over 130% of their ideal weight; it is unclear if efficacy is reduced in
obese women.

As with most hormonal contraception, changes in bleeding patterns are
likely and are the most frequent reason for patient dissatisfaction and
for requests for early removal. There is no single bleeding pattern to
be anticipated and some women experience amenorrhea while others have
more frequent bleeding. One U.S. study (Funk, et al.) followed 330 women
using Implanon for 474 women-years of exposure. Amenorrhea rates from
month 4 onwards ranged from 14 to 20%. Of women enrolled in the study
population, withdrawal was attributed to the following side effects:
bleeding pattern changes (13%), emotional lability (6.1%), weight
increase (3.3%), depression (2.4%), and acne (1.5%). To improve patient
tolerance, extensive counseling prior to selection of this method will
be essential.

Organon, the manufacturer of Implanon, is sponsoring trainings for
clinicians on insertion and removal techniques. Implanon will not be
dispensed to providers who have not completed the training. Training
sessions can be arranged by calling 1-877-IMPLANON and are expected to
start this fall. Organon states that Implanon will be available in the
fourth quarter of this year; no pricing has been established yet but an
Organon representative states that the price will be "no more than the
cost of a 3 year supply of combined oral contraceptive pills".
Similarly, information on federal pricing has not yet been released.

Implanon is likely to be a useful addition to the contraceptive options
available in the United States. Women selecting this method must be
carefully counseled about bleeding irregularities to improve tolerance.
Addition to the formulary at Indian Health Service facilities is likely
to be influenced by cost; availability of federal pricing will be
important in making this method widely available throughout IHS.

The manufacturer's website:

[http://www.IMPLANON-USA.com/](http://www.implanon-usa.com/)

The patient information:

<http://www.implanon-usa.com/authfiles/images/543_174732.pdf>

The prescribing information:

<http://www.implanon-usa.com/authfiles/images/543_174733.pdf>

Funk S, et al. Safety and efficacy of Implanon, a single-rod implantable
contraceptive containing etonogestrel. Contraception. 2005. 71;319-326.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15854630>

Zheng SR, et al. A randomized multicenter study comparing the efficacy
and bleeding pattern of a single-rod (Implanon) and a six-capsule
(Norplant) hormonal contraceptive implant. Contraception. 1999. 60;1-8.

[www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=10549446](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=10549446)

**Nurses Corner, Sandra Haldane, HQE**

#### Harm Resulting from Inappropriate Telephone Triage in Primary Care {#harm-resulting-from-inappropriate-telephone-triage-in-primary-care-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### RESULTS: When patient calls were not forwarded, 51% had an appointment, 4% an Emergency Department visit, and 2% were admitted to the hospital within 2 weeks. Analysis revealed that 3% suffered harm, and 26% experienced discomfort due to the delay. Although 66% required no intervention, 1% required emergency transport and 4% a medication change. CONCLUSIONS: Harm may occur when patients\' calls are not forwarded to the on-call physician. Although the level of harm is generally temporary and minimal, the potential exists for serious harm to occur. Physicians need to re-evaluate the way they handle after-hours calls. {#results-when-patient-calls-were-not-forwarded-51-had-an-appointment-4-an-emergency-department-visit-and-2-were-admitted-to-the-hospital-within-2-weeks.-analysis-revealed-that-3-suffered-harm-and-26-experienced-discomfort-due-to-the-delay.-although-66-required-no-intervention-1-required-emergency-transport-and-4-a-medication-change.-conclusions-harm-may-occur-when-patients-calls-are-not-forwarded-to-the-on-call-physician.-although-the-level-of-harm-is-generally-temporary-and-minimal-the-potential-exists-for-serious-harm-to-occur.-physicians-need-to-re-evaluate-the-way-they-handle-after-hours-calls. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Hildebrandt DE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Hildebrandt+DE"%5BAuthor%5D), et al Harm Resulting from Inappropriate Telephone Triage in Primary Care. [J Am Board Fam Med.](javascript:AL_get(this, 'jour', 'J Am Board Fam Med.');) 2006 September-October;19(5):437-442. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16951292&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16951292&dopt=Abstract) {#hildebrandt-de-et-al-harm-resulting-from-inappropriate-telephone-triage-in-primary-care.-j-am-board-fam-med.-2006-september-october195437-442.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids16951292doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-19 .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}

**Trends in HIV-Related Risk Behaviors Among High School Students**

CDC analyzed data from eight national Youth Risk Behavior Surveys and
this report summarizes the results of that analysis, which indicated
that, during 1991-2005, the percentage of U.S. high school students
engaging in HIV-related sexual risk behaviors decreased. However, many
students still engage in HIV-related risk behaviors. During 1991-2005,
the prevalence of sexual experience decreased 13% from 54.1% to 46.8%
among high school students. Logistic regression analyses indicated a
significant linear decrease overall and among female, male, 9th-grade,
10th-grade, 11th-grade, 12th-grade, black, and white students. The
overall decrease in HIV-related sexual risk behaviors among high school
students discussed in this report corresponds to a simultaneous decrease
in gonorrhea, pregnancy, and birth rates among adolescents.

Trends in HIV-Related Risk Behaviors Among High School Students \-\--
United States, 1991---2005 MMWR August 11, 2006 / 55(31);851-854

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5531a4.htm?s_cid=mm5531a4_e>

####  {#section-20 .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}

**The indications for IUD use have vastly expanded**

Intrauterine devices are the most common reversible method of
contraception worldwide. However, here in the US, less than 1% of
contraceptive users use an IUD. Due to the Dalkon Shield controversy,
many different forms of IUDs were removed from the market. Today, there
are only two IUDs on the market here in the US, the copper T380A
(Paraguard) and the Levonorgesterel intrauterine system (Mirena).
Today's IUDs have corrected a design flaw that was unique to the Dalkon
Shield and recent research has shown that they are safe and very
effective, with pregnancy rates approaching that of tubal sterilization.
The Levonorgesterel intrauterine system offers the non-contraceptive
benefit of reducing menstrual flow and can be used for idiopathic
menorrhagia. Recent evidence suggests that IUDs can be used in the
Adolescent population and that 75% of adolescents that had IUDs placed
were very happy with their contraceptive choice at 1 year. IUD use in
the properly selected adolescent could be a useful weapon in the
prevention of teenage pregnancy. One of the largest concerns with IUD
use is the increased risk of pelvic infections which appears to be
greatest at the time of insertion but returns to the background rate 1
month after insertion. Candidates for IUDs include:

Multiparous and nulliparous women at low risk for STDs

Women who desire long-term reversible contraception

Women with the following medical conditions:

Diabetes, Thromboembolism, Menorrhagia / dysmenorrhea, breastfeeding,

breast cancer, and liver disease

When your next patient is searching for a contraceptive option, and
isn't absolutely certain she does not want to have more children, an IUD
is an excellent option.

**Resources:**

ACOG practice bulletin. Number 59, January 2005. Intrauterine device.
Obstet Gynecol. 2005 Jan;105(1):223-32

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15625179>

ACOG committee opinion. No. 337: Noncontraceptive uses of the
levonorgestrel intrauterine system. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Jun;107(6):1479-82.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16738186>

Revisiting the intrauterine contraceptive device in adolescents. J
Pediatr Adolesc Gynecol. 2006 Aug;19(4):291-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16873034>

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

**Calcium during pregnancy: Higher maternal Vit. D / folate and newborn
Wt / mineralization**

RESULTS: All mothers were similar in weight, height, and BP. Mothers in
the orange juice plus calcium and dairy groups had higher intakes of Ca
(1,472 mg and 1,771 mg) than controls (862 mg). One half of the mothers
in the orange juice plus calcium group required Ca tablets. Mothers in
the dairy group had higher intakes of P, D, and Mg, higher serum folate
and D, and higher cord D levels. Mothers in the orange juice plus
calcium group had higher serum P but lower serum folate and D. Infants
(3,517±273 g) in the dairy group were heavier than infants in the
control (3,277±177 g) and orange juice plus calcium (3,292±165 g)
groups. Infants in the dairy group had higher total body calcium than
control infants.

CONCLUSION: Calcium diet supplemented with dairy products during
adolescent pregnancy resulted in higher maternal vitamin D and folate
serum levels and higher newborn weight and bone mineralization compared
with controls.

[Chan
GM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Chan+GM"%5BAuthor%5D),
et al Effects of dietary calcium intervention on adolescent mothers and
newborns: a randomized controlled trial. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Sep;108(3):565-71.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16946216&dopt=Abstract>

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

**Endometriosis: What You Should Know**

[American Family
Physician](http://ezproxyhhs.nihlibrary.nih.gov:2312/pqdweb?RQT=318&pmid=24034&TS=1157550777&clientId=53612&VType=PQD&VName=PQD&VInst=PROD). Kansas
City: [Aug 15,
2006](http://ezproxyhhs.nihlibrary.nih.gov:2312/pqdweb?RQT=572&VType=PQD&VName=PQD&VInst=PROD&pmid=24034&pcid=33246441&SrchMode=3&aid=2). Vol. 74, Iss. 4;  pg. 601

#### [**http://www.aafp.org/online/en/home/publications/journals/afp.html**](http://www.aafp.org/online/en/home/publications/journals/afp.html) {#httpwww.aafp.orgonlineenhomepublicationsjournalsafp.html-1 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-21 .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}

**How important is maternal intratpartum glucose to neonatal
hypoglycemia?**

Review of the Literature and Summary of the Evidence

1\. Anderson O, et al. Influence of maternal plasma glucose
concentration at delivery on the risk of hypoglycaemia in infants of
insulin-dependent diabetic mothers. Acta Paediatr Scand 1985; 74:268-73.

N=53 infants of diabetic mothers. 20.8% incidence of neonatal
hypoglycemia. None of the IDMs became hypoglycemic if the maternal
glucose at delivery was \<7.1 mmol/L (128 mg/dL). Infants with
hypoglycemia had elevated cord blood insulin levels.

[Conclusion:]{.underline} A major factor in neonatal hypoglycemia in IDM
is the maternal plasma glucose concentration at the time of delivery.

2\. Lean ME et al. Insulin management during labour and delivery in
mothers with diabetes. Diab Med 1990; 7: 162-4.

N=25 insulin dependent diabetic women. Blood glucose attempted to be
maintained at \<6.0 mmol/L (113 mg/dL) for 24 h prior to delivery.
Neonatal hypoglycemia (\<2.0 mmol/L \[\<36 mg/dL\] occurred in 1 infant
(4%).

[Conclusion:]{.underline} Neonatal blood sugar correlated with maternal
blood glucose at delivery.

3\. Njenga E et al. Five year audit of peripartum blood glucose control
in type 1 diabetic patients. Diab Med 1992; 9:567-70.

N=37 type 1 diabetic women. Glucose-insulin drip was instituted the
morning labor was induced; target glucose of 3-6 mmol/L (54-108 mg/dL).
There was a 19% incidence of neonatal hypoglycemia (\<2.2 mmol/L \[\<40
mg/dL\]), but 4 of these infants' mothers had been given dextrose
boluses for maternal hypoglycemia.

[Conclusion:]{.underline} Less stringent intra-partum blood glucose
control may be appropriate.

4\. Curet LB et al. Effect of antepartum and intrapartum maternal blood
glucose levels on incidence of neonatal hypoglycemia. J Perinatol 1997;
17: 113-5.

\*(this is the UNM study, of which I am a co-author, and which has the
largest "n"...)

N=233 pregnant insulin-requiring diabetic women. Intra-partum glucose
and insulin drips were begun at the time of induction of labor to try to
maintain plasma glucose \<100 mg/dL. The incidence of neonatal
hypoglycemia was 10% in women who achieved this goal (mean IP glucose 84
mg/dL), and 43% in those women who didn't (mean IP glucose 107 mg/dL,
p\<.05), even if antepartum control had been suboptimal.

[Conclusion:]{.underline} Even in the presence of poor antepartum
diabetic control, tight regulation of the intrapartum plasma glucose
levels will significantly reduce the incidence of neonatal hypoglycemia.

5\. Carron-Brown S, et al. Effect of management policy upon 120 type 1
diabetic pregnancies: Policy decisions in practice. Diab Med 1999;
16:573-8.

N=80 type 1 pregnant diabetic women in period 1 (tight control) compared
to 40 women in period 2 (less stringent control). In the "less
stringent" study period, there was a 47% incidence of neonatal
hypoglycemia. However, if the maternal blood glucose was maintained
between 4-7 mmol/L (72-126 mg/dL) during labor, there was only 1 infant
who had hypoglycemia.

[Conclusion:]{.underline} Control of hyperglycemia during labor results
in reduced newborn hypoglycemia.

6\. Balsells M, et al. Gestational diabetes mellitus: Metabolic control
during labor. Diab Nutr Metab 2000; 13:257-62.

N=85 women with GDM, 54 on insulin, who received intra-partum glucose
and insulin infusions. Target capillary blood glucose (CBG) of 2.8-6.9
mmol/L (50-124 mg/dL) was obtained in 83%. In several logistic
regression models, CBG during labor was predictive of neonatal
hypoglycemia.

[Conclusion:]{.underline} Insulin requirements during labor are
unrelated to therapy during pregnancy, and high CBG during labor
increases the risk of neonatal hypoglycemia.

7\. Taylor R, et al. Clinical outcomes of pregnancy in women with type 1
diabetes. Obstet Gynecol 2002; 99:537-41.

N=107 type 1 diabetic women who received glucose and insulin infusions
during induction of labor. Mean maternal blood glucose in labor was 6.3
mmol/L (113 mg/dL, range 72-153 mg/dL). Neonatal hypoglycemia (\<2.5
mmol/L \[\<45 mg/dL\]) occurred in 17% of infants, all of whose mothers
had a mean glucose \>144 mg/dL. There was no correlation between
neonatal blood glucose and maternal glycemic control during pregnancy as
assessed by HbA1C.

U Neonatal hypoglycemia correlates with maternal hyperglycemia in labor.

(There is no Cochrane review of this topic.)

[Summary:]{.underline} 6 of the 7 studies of maternal intra-partum
glycemic control (total N=660) demonstrate a lower incidence of neonatal
hypoglycemia in women who were euglycemic during labor. Surprisingly,
neonatal hypoglycemia was not necessarily correlated with maternal
antepartum glycemic control.

**Other**

**Adverse outcomes with DM are 3-9 times worse vs normal and not
improved in 15 years**

CONCLUSION: Rates of adverse neonatal outcomes are 3--9 times greater in
infants of diabetic mothers compared with those of nondiabetic mothers.
There were no significant improvements in rates of perinatal mortality,
congenital anomaly, or LGA birth in infants of diabetic mothers in
1996--2002 compared with 1988--95.

Fetal and neonatal outcomes of diabetic pregnancies. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Sep;108(3):644-50.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16946226&dopt=Abstract>

**17 hydroxyprogesterone caproate results in cost-savings in women with
prior PTD**

RESULTS: The use of
17![](media/image3.png){width="8.333333333333333e-2in"
height="6.25e-2in"}-hydroxyprogesterone caproate for the prevention of
preterm deliveries result in cost-savings in women with prior preterm
deliveries less than 32 weeks and 32--37 weeks. The sensitivity analyses
revealed the model to be robust over a wide range of values for
evaluated variables.

CONCLUSION: Within our baseline assumptions,
17![](media/image3.png){width="8.333333333333333e-2in"
height="6.25e-2in"}-hydroxyprogesterone caproate was associated with
cost-savings when used for the prevention of preterm deliveries in women
with prior preterm deliveries.

[Odibo
AO](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Odibo+AO"%5BAuthor%5D),
et al 17{alpha}-hydroxyprogesterone Caproate for the Prevention of
Preterm Delivery: A Cost-effectiveness Analysis. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Sep;108(3):492-499.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16946206&dopt=Abstract>

**No difference in pregnancy loss: Chorionic villus sampling vs
amniocentesis, 1998 to 2003**

RESULTS: There were 9,886 CVS and 30,893 amniocentesis procedures
performed during the study period that resulted in a normal karyotype.
The overall loss rates were 3.12% for CVS and 0.83% for amniocentesis (P
\< .001). When examined by 5-year intervals, there was a statistically
significant decrease in the CVS loss rate (P \< .001) and a
nonsignificant lesser decrease in the loss rate for amniocentesis over
time. Although the pregnancy loss rate from CVS over the entire study
period was higher than from amniocentesis (adjusted odds ratio 4.23, 95%
confidence interval 2.29--7.81), in the most recent time period, 1998 to
2003, there was no difference between the two procedures (adjusted odds
ratio 1.03, 95% confidence interval 0.23--4.52).

CONCLUSION: The loss rates for both amniocentesis and CVS at our
institution have decreased over time. Because the decrease in loss rate
for CVS has been greater, there is no longer a statistically significant
difference between the two. These results are informative in both
patient counseling and establishing widespread prenatal diagnostic and
screening programs.

[Caughey
AB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Caughey+AB"%5BAuthor%5D),
et al Chorionic Villus Sampling Compared With Amniocentesis and the
Difference in the Rate of Pregnancy Loss. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Sep;108(3):612-616

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

Vitamin Supplements Do Not Prevent Preeclampsia

Preeclampsia is a major cause of maternal death and complicates 2 to 3
percent of pregnancies. Although speculative, preeclampsia likely
involves a maternal inflammatory response that originates in the
placenta. Because patients with preeclampsia have maternal and placental
circulations with high levels of oxidative stress, antioxidants have
been suggested as preventive therapy. Poston and colleagues conducted a
randomized controlled trial of vitamins C and E in pregnant women who
were at risk of preeclampsia.

The authors conclude that vitamin supplements during the second
trimester are not associated with any change in the development of
preeclampsia in women with risk factors. The poor outcomes in the
intervention group, particularly low birth weight and small size for
gestational age, raise concerns that vitamins C and E supplementation
could potentially be harmful. The researchers also stress that the
effects of vitamin supplements in pregnancy most likely depend on the
normal intake of the mothers. Studies in developing countries could show
benefit; however, based on the outcomes of this study, vitamin C and E
supplements are only recommended for vitamin-deficient mothers.

Poston L, et al. Vitamin C and vitamin E in pregnant women at risk for
pre-eclampsia (VIP trial): randomised placebo-controlled trial. Lancet
April 8, 2006;367:1145-54, and Lindheimer MD, Sibai BM. Antioxidant
supplementation in pre-eclampsia \[Editorial\]. Lancet April 8,
2006;367:1119-20.

<http://www.aafp.org/afp/20060901/tips/22.html> or

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16616557>

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

#### September 1, 2006: Palliative Medicine\'s Role in the Continuity of Care Moderator: Tim Domer, M.D.

-   Management of acute vs chronic pain

-   Quality of Life in chronic illness

-   The meaning of \"Code Status\"

-   Preparing for a \"Good Death\"

-   End-of-Life Care as part of Continuity of Care and Prevention

[http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm#](http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm#disc)

### 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**

**Sexual Education / HIV Education and youth**

Here are three reports form a recent WHO series on Sexual Education /
HIV Education and youth in the developing world. I think much of it is
relevant for reservation communities. All three reports (and more) can
be downloaded from the full WHO report at this site below.\*

# Effectiveness of sex education and HIV education interventions in schools 

CONCLUSIONS: A large majority of school-based sex education and HIV
education interventions reduced reported risky sexual behaviours in
developing countries. The curriculum-based interventions having the
characteristics of effective interventions in the developed and
developing world should be implemented more widely. All types of
school-based interventions need additional rigorous evaluation, and more
rigorous evaluations of peer-led and non-curriculum-based interventions
are necessary before they can be widely recommended.

Kirby D, Obasi A, Laris BA. The effectiveness of sex education and HIV
education interventions in schools in developing countries. World Health
Organ Tech Rep Ser. 2006;938:103-50; discussion 317-41

# Effectiveness of community interventions targeting HIV and AIDS prevention at youth

CONCLUSIONS: Considerable creativity, ingenuity and commitment is
demonstrated in designing and delivering HIV interventions but there is
a paucity of adequate evidence of their effectiveness. This precludes
identification of the types of interventions that actually produce the
targeted changes. It is essential that governments and donor agencies
invest in high quality process and outcome evaluations and cost-benefit
analyses so that effective interventions can be identified and promoted.

Maticka-Tyndale E, Brouillard-Coylea C.  The effectiveness of community
interventions targeting HIV and AIDS prevention at young people in
developing countries. World Health Organ Tech Rep Ser. 2006;938:243-85;
discussion 317-41

# Effectiveness of mass media in changing HIV/AIDS-related behaviour among youth

CONCLUSIONS: We found that mass media programmes can influence
HIV-related outcomes among young people, although not on every variable
or in every campaign. Campaigns that include television require the
highest threshold of evidence, yet they also yield the strongest
evidence of effects. This suggests that comprehensive mass media
programmes are valuable.

Bertrand JT, Anhang R. The effectiveness of mass media in changing
HIV/AIDS-related behaviour among young people in developing countries.
 World Health Organ Tech Rep Ser. 2006;938:205-41; discussion 317-41

\*Full WHO report

<http://www.who.int/child-adolescent-health/New_Publications/ADH/TRS/ISBN_92_4_120938_0.pdf>

**Other**

**Sexually Transmitted Diseases Treatment Guidelines, 2006**

These guidelines for the treatment of patients who have STDs were
developed by CDC after consultation with a group of professionals
knowledgeable in the field of STDs. Physicians and other health-care
providers play a critical role in preventing and treating STDs, and
these guidelines are intended to assist with that effort.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm>

**Older Women\'s Attitudes, Behavior, and Communication about Sex and
HIV**

Objectives: To examine the effects of race and marriage on the sexual
attitudes, behavior, and patient-physician communication about sexuality
and HIV/AIDS among older women. Methods: This was a cross-sectional
survey of 55 community-residing women aged 58-93. Results: 57% of
respondents had engaged in sexual activity since the 60th birthday.
Nearly 60% of single women who had been sexually active in the previous
10 years reported that they had not used a condom; 21% of women with a
current sexual partner agreed that condom use is not necessary \"if you
can no longer get pregnant.\" African American women were significantly
more likely to report making changes in their sexual behavior due to HIV
(53% vs. 19% white, p = 0.02). Married and African American women were
more likely to discuss sex with a physician (80% vs. 47%; p = 0.03 and
75% vs. 46%, p = 0.05, respectively). African Americans were more likely
to have had a physician initiate such a discussion (69% vs. 38%, p =
0.04). Conclusions: Older women in this sample were sexually active,
engaged in potentially risky sexual behavior, and believed that
physicians should address issues of sexuality. Older African American
women were significantly more likely than white women to report HIV
related changes in their behavior and to discuss sex with a physician.
This community-based study corroborates clinical research and suggests
both a gap and a disparity in older women\'s dialogue with physicians.
It also indicates the need for more broadly generalizable data on issues
pertinent to older women\'s sexual health.

[Lindau
ST](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Lindau+ST"%5BAuthor%5D),
et al Older Women\'s Attitudes, Behavior, and Communication about Sex
and HIV: A Community-Based Study. [J Womens Health
(Larchmt).](javascript:AL_get(this, 'jour', 'J Womens Health (Larchmt).');)
2006 Jul-Aug;15(6):747-53.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16910906>

# Condom Use with \"Casual\" and \"Main\" Partners: What\'s in a Name?

RESULTS: Participants were divided into two groups: the 65% who reported
main partners only (MP group) and the 35% who had at least one casual
partner (CP group). Adolescents in the MP group were more likely to be
female, whereas males were significantly more likely to report casual
partners. Race/ethnicity, age, education level, household income, and
sexually transmitted infection (STI) history were unrelated to group
status (i.e., sexual partner type). Greater substance use and riskier
attitudes were reported by teens in the CP group. The number of
unprotected sex acts in the past 90 days was substantial and equivalent
between the main and casual partner groups (19.2 vs. 21.5,
respectively). Regression analyses revealed that perceptions of main
partner attitudes toward condom use and condom use expectations were
significantly related to condom use with MPs, but that attitudes were
not related to condom use with CPs. CONCLUSIONS: Adolescents with either
casual or main partners may be at continued risk for contracting human
immunodeficiency virus (HIV) and STIs, given high rates of unprotected
sex. Interventions that do not target attitudes and practices related to
casual partners as compared with main partners may miss an opportunity
to change risk behaviors. This study demonstrates the importance of
understanding an adolescent\'s perception of partner types in order to
design effective interventions.

# Lescano CM, et al Condom Use with \"Casual\" and \"Main\" Partners: What\'s in a Name? J Adolesc Health. 2006 Sep;39(3):443.e1-443.e7.

<http://www.jahonline.org/article/PIIS1054139X06000176/abstract>

####  {#section-22 .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}

**Weight Loss Should be the Primary Intervention for Risk of Diabetes**\
In a randomized trial with 1079 participants, for over 3 years it was
found that for every 2 pounds of weight loss there was a 16% reduction
in risk.

With the increasing prevalence of overweight and adoption of a Western
lifestyle, many populations are at risk of developing diabetes and may
be reasonable candidates for a prevention intervention like that of the
DPP. Weight loss, largely determined by changes in diet and exercise, is
the primary factor resulting in reduced diabetes incidence among those
in the ILS group. An increase in physical activity helps sustain weight
loss and independently reduces diabetes risk among those who do not lose
weight. Interventions to reduce the incidence of diabetes should aim at
weight loss as the primary determinant of success.

[Hamman
RF](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Hamman+RF"%5BAuthor%5D),
et al Effect of weight loss with lifestyle intervention on risk of
diabetes. Diabetes Care 29: 2102-2107.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16936160>

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

**Best Practices** **and GPRA Tracking**

-   Nov 1-2, 2006

-   Sacramento CA

-   California IHS Area Office, Contact <Elaine.brinn@ihs.gov>

-   <http://www.ihs.gov/MedicalPrograms/MCH/F/documents/BestPracticesFlyer1.pdf>

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

-   For providers caring for Native women and children

-   January 26-26, 2007

-   Telluride, CO

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

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

-   April 20-22, 2007

-   Montreal, Quebec, Canada

-   Solutions, not Problems

-   Joint meeting of IHS, AAP-CONACH, First Nations and several other
    stakeholders

-   <http://www.aap.org/nach/2InternationalMeeting.htm>

**2007 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

-   11 months away and counting

-   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-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5%)}

#### USPSTF Best Practices - Cervical Cancer Screening {#uspstf-best-practices---cervical-cancer-screening-2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/W/CanCerv.cfm#USPSTF**](http://www.ihs.gov/MedicalPrograms/MCH/W/CanCerv.cfm#USPSTF) {#httpwww.ihs.govmedicalprogramsmchwcancerv.cfmuspstf-1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### USPSTF Breast Cancer Screening Guidelines {#uspstf-breast-cancer-screening-guidelines-2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/W/documents/bestpractices-breastcancerscreening.doc**](http://www.ihs.gov/MedicalPrograms/MCH/W/documents/bestpractices-breastcancerscreening.doc) {#httpwww.ihs.govmedicalprogramsmchwdocumentsbestpractices-breastcancerscreening.doc-1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Tips for Improving Access to Mammography {#tips-for-improving-access-to-mammography-2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/W/documents/tipstoimprovingaccesstomammography.doc**](http://www.ihs.gov/MedicalPrograms/MCH/W/documents/tipstoimprovingaccesstomammography.doc) {#httpwww.ihs.govmedicalprogramsmchwdocumentstipstoimprovingaccesstomammography.doc-1 .Style-Heading-4-+-Arial-14-pt-Underline}

There are several upcoming **Conferences**

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

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

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

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

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

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

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

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

#### The August 2006 OB/GYN CCC Corner is available at: {#the-august-2006-obgyn-ccc-corner-is-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0806.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0806.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn0806.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

####  Abstract of the Month page 4 {#abstract-of-the-month-page-4-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Rate of uterine rupture hasn't changed for 20 years -- Why have our
practices changed?

#### From your colleagues page 8 {#from-your-colleagues-page-8 .Style-Heading-4-+-Arial-14-pt-Underline}

Carolyn Aoyama

-New Women's Health Work Group Forming: Looking for interested
volunteers

-AHRQ's  "Women's Health 2006: Translating Research into Practice"  

Jean Howe

# Adults with Self-Assessed Symptoms of Serious Psychological Distress, by Sex and Race 

Judy Thierry:

Providers should conduct psychosocial screening of all women in
pregnancy

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

##### Obstetrics page 10

-Update your standing post partum discharge orders: Tdap in pregnancy /
postpartum

-Repeat Cesarean Deliveries Raise Risk of Maternal Morbidity

-Membrane Sweeping at 41 Weeks Helps Prevent Post-Term Pregnancy

-Most Stillbirths Worldwide Are Preventable

-Sudden infant death syndrome and complications in other pregnancies

**Gynecology page 11**

-ACOG Releases HPV Vaccine Recommendations for Ob-Gyns

-Sensitivity of colposcopy in ASCUS / LGSIL improves with more than two
biopsies

-HPV-Based Triage May Result in Excess Colposcopies in Young Women

-Urodynamics-based detrusor overactivity diagnoses may be insufficiently
reliable

-Pessaries Helpful in Pelvic Organ Prolapse Patients

And more.....

**Child Health page 14**

-Emergency Contraception: A Primer for Pediatric Providers

-Role of subthreshold symptoms on major depressive disorder in
adolescents

**Chronic Illness and Disease page 15**

-Antidepressant Discontinuation Syndrome

-Are laxatives effective for the treatment of symptomatic hemorrhoids in
adults?

-Interventions to Facilitate Smoking Cessation

-Exercise and Older Patients: Prescribing Guidelines

#### Features page 16 {#features-page-16 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician

-Norethindrone More Effective for Menses Suppression

-Fecal Occult Blood Testing in Healthy Patients Does Not Reduce
Mortality

-Mammography Results in Overdiagnosis of Breast Cancers

-Omega-3 Fats Do Not Affect Mortality Rates

-Screening for Iron Deficiency Anemia for Children and Pregnant Women

American College of Obstetricians and Gynecologists

-Induction of Labor for Vaginal Birth After Cesarean Delivery

-Management of alloimmunization during pregnancy. ACOG Practice Bulletin

-Psychosocial Risk Factors: Perinatal Screening and Intervention

**Agency for Healthcare Research and Quality**

-More data are needed to better identify health care disparities among
AI/AN

-Increasing cervical cancer screening intervals is cost-effective for
women with three consecutive normal Pap smears

-ACE inhibitors during the first trimester of pregnancy: Increased risk
of birth defects

**Ask a Librarian**

New on Your Library Website - Daily Health Policy News Summaries

**Breastfeeding**

-Early Milk Supply Issues

-Breastfeeding Basics: Generalist to Generalist

**CCC Corner Digest**

\-[Refusals by pharmacists to dispense emergency
contraception](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_AOM.cfm)

\-[How to address health disparities? One story of
success](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Coll.cfm)\
-[Pendulum swing:  Vaginal breech delivery approved within
guidelines](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_HT.cfm#ob)

\-[CDC's Advisory Committee Recommends Human Papillomavirus Virus
Vaccination](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_HT.cfm#gyn)

\-[New Guidelines for Pediatric and Neonatal Emergency Cardiovascular
Care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_HT.cfm#child)

\-[Driving, Other Erratic Behaviors Reported After Taking Zolpidem
(Ambien)](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_HT.cfm#chrIll)

\-[Planned Early Birth vs. Expectant Management for
PROM](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#afp)

\-[William H. J. Haffner American Indian / Alaska Native Women's Health
Award](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#acog)

\-[Pain is one the reasons that moms quit breastfeeding in the first 2
weeks](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#breast)

\-[Injectable Contraception and Skeletal
Health](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#fp)

\-[Hospital Computer Keyboards Should Be Disinfected
Daily](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#it)

\-[Where There is No Doctor & A Book for
Midwives](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#ih)

\-[Copious post operative mucous secretions: The rest of the
story](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#mmtour)

\-[Nuchal cords, somersaults, and the value of a pulsing cord: Nuchal
Cord
Management](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#MidWives)

\-[Methamphetamine abuse among women on Navajo: Part IV - The "Drop- in"
gravida](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#navajo)

\-[The Association of Nurses in Aids
Care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#nurseCorner)

\-[IHS Division of Epidemiology and Disease Prevention Launches New
Website](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#okie)

\-[Osteoporosis Guidelines Updated: North American Menopause
Society](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#oste)

\-[Only 29% of ACOG recommendations are level A: Good and consistent
scientific
evidence](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#periPicks)

\-[September 1, 2006: Palliative Medicine\'s Role in the Continuity of
Care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#pcf)

\-[Focus on adolescent sexual behavior this
month](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#std)

\-[Diabetes Is The Clinical Equivalent of Aging 15
Years](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#stillW)

**Domestic Violence**

-Randomized trial assesses screening for intimate partner violence in
health settings

-Physical Dating Violence Common Among Teens, Linked to Risky Behaviors

-After the Crisis - Resource Papers and Issue Briefs

-Primary care assessment of intimate partner violence and may prevent
its recurrence

**Elder Care News**

-Is 75 Years an Appropriate Upper Age Limit for Mammography?

-Performance by Elderly on 400-Meter Walk Predicts Disability and Death

-Second Annual American Indian and Alaska Native Long Term Care
Conference

**Family Planning**

Addressing Depression in Family Planning Services

**Featured Website**

Try Michigan's Health Department website. It's super!

**Frequently asked questions**

The Indian Health MCH Frequently Asked Question (FAQ) site

**Indian Child Health Notes**

\- High levels of bilirubin in newborns - more good than bad news

\- The elevated risk of jaundice in AI/AN infants

\- A round up of new vaccines for 2006 by Ros Singleton

\- Mental Health disorders in parents of AI/AN adolescents

**Information Technology**

Hospital Computer Keyboards Should Be Disinfected Daily

International Health

-HIV/AIDS in Latin America and the Caribbean

-The next influenza pandemic: what public health measures might help?

#### MCH Alert

AAP encourages implementation of new shopping cart standards to prevent
child injury

#### Medical Mystery Tour

#### First trimester screening: How would you counsel this patient? {#first-trimester-screening-how-would-you-counsel-this-patient-2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

**Menopause Management**

-Gabapentin is an effective alternative to estrogen for the treatment of
hot flushes

-AHRQ: Menopausal hormone therapy declined after published WHI trial
results

**Midwives Corner**

VBAC: Pendulums and Ecstasy

**Navajo News**

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

**Nurses Corner**

Native Alaskan and American Indian Nurses Scholarship Opportunity

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

Final Births for 2004

**Oklahoma Perspective**

The indications for IUD use have vastly expanded

Osteoporosis

Soy Isoflavones Protect Postmenopausal Women From Bone Loss 

Patient Education

#### -Antidepressant Discontinuation Syndrome: What You Should Know {#antidepressant-discontinuation-syndrome-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Tips to Help You Quit Smoking {#tips-to-help-you-quit-smoking .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Health Care for Lesbians and Bisexual Women {#health-care-for-lesbians-and-bisexual-women .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Glyburide flows from fetus to mother by placental transport system

-Inappropriate Discontinuation of Asthma Medication Common in Early
Pregnancy

Primary Care Discussion Forum

September 1, 2006: Palliative Medicine\'s Role in the Continuity of Care

STD Corner

# -Condom Use and the Risk of Genital Human Papillomavirus Infection in Young Women

#### -Latest CDC STD Treatment Guidelines Just Released {#latest-cdc-std-treatment-guidelines-just-released .Style-Heading-4-+-Arial-14-pt-Underline}

-Rapid HIV Test Distribution Picks up Thousands of Infections in US

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

-Obese Girls: Threefold Risk for Early Death than Slim Counterparts\
-New Recommendations Regarding Exercise and Type 2 Diabetes Issued 

-Just how effective are diabetes management programs**?**

###### Save the Dates: Upcoming events of interest page 35

#### What's new on the ITU MCH web pages page 36

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/M/MCHdiscuss.asp>

9/21/06