# ![](media/image1.jpeg){width="6.000694444444444in" height="1.1125in"} {#section .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

 

Chief Clinical Consultant's Corner

Volume 6, No. 5, May 2008

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

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

**How to increase usage of the HPV vaccine? Let's ask our patients and
their family**

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

Ben Garnett

Antimicrobial prophylaxis for surgery

Scott Giberson

Upcoming CDC Rapid HIV Testing Training through SAMHSA and IHS

Educate State Officials and Policy Makers about Prevention of STDs and
AIDS**\
**

**Amy Groom**

2008 IHS Immunization Awards

**Favian Kennedy**

From Collective Consciousness to Written Policy

**Elaine Locke**

ACOG / IHS Denver Course Now in Salt Lake City, Utah

**Cathy Stueckemann**

Community Health Representative National Educational Meeting

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

##### Obstetrics page 12

-Pregnant Women Who are Obese Linked with Greater Health Care Services
Use

-New Evidence Report on Management and Postpartum Follow-Up of
Gestational Diabetes

-High caffeine consumption during pregnancy may increase the risk of
miscarriage

-Grief subsequent to an early miscarriage

#### -Stillbirth: Good differential Dx plus an uncommon presentation of a common disease {#stillbirth-good-differential-dx-plus-an-uncommon-presentation-of-a-common-disease .Style-Heading-4-+-Arial-14-pt-Underline}

**Gynecology page 14**

-Non-surgical treatment of incontinence and prevention of urinary and
fecal incontinence

-Ultrasonography differentiated between benign and malignant: Improved
outcomes

-Saffron effective in the treatment of premenstrual syndrome: a
double-blind, RCT

-Biofeedback Reduces Psychological Burden in Older Women With Urge UI

**Child Health page 15**

-Preemies Face Risks As They Grow Up

-Cognitive and Neuromotor Impairments Seen at 5 Years in Children Born
Preterm 

-Is Short-term Therapy Effective for Treating Latent TB in Children?

**Chronic Illness and Disease page 16**

-FDA Approves Alternative Dosing Schedule for Combined Hepatitis Vaccine

-Lower targets for blood pressure and LDL cholesterol on atherosclerosis
in diabetes: RCT

-All drugs containing PHENYLPROPANOLAMINE are being recalled

#### Features page 17 {#features-page-17 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-Use of Psychiatric Medications During Pregnancy and Lactation

-End-of-Life Decision Making

-Late-Preterm Infants

##### American Family Physician

-Abstinence- Plus Programs for Prevention of HIV

-Evaluation of Acute Abdominal Pain in Adults

-Expanded Newborn Screening: Information and Resources

-Subclinical Hypothyroidism

-Colonoscopy Surveillance After Polypectomy and Colorectal Cancer
Resection

**Agency for Healthcare Research and Quality**

-Adolescents are willing to have chlamydial screening by pediatricians
during urgent care visits

-Antidepressants during pregnancy increases preterm birth and serious
infant problems

-Maternal asthma is associated with lower birth weight

-Noncancerous pelvic problems linked to poor quality of life and sexual
functioning

-Studies examine pediatricians\' and parents\' attitudes toward
childhood obesity

**Ask a Librarian**

Women\'s Health Resources

**Behavioral Health Insights**

School Refusal

**Breastfeeding**

What Do High Performance Cars and Near Term Neonates Have In Common?

**CCC Corner Digest**

April Headlines

\-[High prevalence of multiple HPV subtypes in AI women of the Northern
Plains](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08aom)

\-[Afghanistan Update: You can make a huge
difference](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08col)

\-[Cesarean delivery during nursing change of shift: Increased
complications](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ht#ob)

\-[The Evolution of Midurethral
Slings ](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ht#gyn)

\-[Maternal grandmothers' alcohol use linked to FAS in the Northern
Plains](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ht#child)

\-[Low-dose aspirin: Lower risk for all-cause mortality, especially
older
women](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ht#chrIll)

\-[Treatment of Urinary Infections in Nonpregnant
Women](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#acog)

\-[Care quality is not necessarily better with electronic health
records](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#ahrq)

\-[School
Refusal](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#bhi)

\-[What makes a good idea
work?](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#bhi)

\-[Teen dating violence: 3
articles](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#dv)

\-[Training in Palliative and End of Life Care, April 22-24, 2008,
Flagstaff ,
AZ](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#ecn)

\-[How to Increase contraceptive use and adherence in
adolescents](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#fp)

\-[Meeting notes now online: 2007 Native Women's Health and MCH
Conference](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#fws)

\-[Does anyone have an Indian Health EHR template for obstetrical
patients?](../Does%20anyone%20have%20an%20EHR%20template%20that%20is%20IHS%20approved%20for%20obstetrical%20patients%3F)

\-[Seeking input from the field - Clinician's Information
Management](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#it)

\-[Routes to TB treatment in rural
Nepal](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#ih)

\-[New Bullying-Prevention Toolkit
Released](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#alert)

\-[Maternal, Infant and Child Health Capacity Needs
Assessment](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#mchh)

\-[You know how to treat yeast infections,
right?](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#mmt)

\-[What Happened to Women in WHI study 3 years after stopping
HRT?](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#meno)

\-[Midwives Keep Birth Normal, and Midwife-Provided Acupuncture Helps
With
PROM](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#midw)

\-[Sexual Assault Nurse Examiner (SANE) Training Course, June 9 -- 13,
2008](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#navajo)

\-[Call for nominations of nurses working in Indian health: Deadlines
looming](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#nCrnr)

\-[Prenatal Care in
Oklahoma](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#okp)

\-[Look at all the drugs that affect bone
metabolism](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#ost)

\-[Treating Depression: What You Should
Know](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#pi)

\-[What is this all about the 'minor markers' for Down
Syndrome?](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#peri)

\-[USPSTF Recommendations for STI
Screening](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#std)

\-[Link between type 2 DM in adults: Diabetes in pregnancy or type 1 DM
in their
mothers](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#still)

\-[Have the Disparities Between AI/ANs and Caucasians
Narrowed?](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#whh)

**Domestic Violence**

-IPV and Sexual Violence Victimization Assessment Instruments in
Healthcare Settings

-Male Partner Violence Hurts Women\'s Health Worldwide

-IHS-ACF DV Project: dental and reconstructive surgery for DV survivors

**Elder Care News**

-Landmark Study on Treatment of Hypertension in the Very Old

-2008 IHS Long-Term Care Grants Program Is Now Open For Applications

**Family Planning**

**Contraceptive agents when initiating breastfeeding**

**Featured Website**

#### Meeting notes now online: [2007 Native Women's Health and MCH Conference](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Intro Slide and Eval Sli14.ppt)

**Frequently asked questions**

First Trimester Down Syndrome Testing

**Indian Child Health Notes**

-Autism Spectrum Disorders -- Guidelines for Identification and
Diagnosis

-Vaccines and Autism -- The Courts weigh in -- wrongly

-Child Safety Seats for AI/AN children -- how can we get children in
safety seats -- and more

importantly how can we keep them in them

**Information Technology**

-RPMS Immunization Package

-AI health advocates can learn to develop multimedia health projects for
rural communities

-Release of BGP Clinical Reporting System, Version 8.0

International Health

Is health a human right?

#### MCH Alert

Adverse Drug Events in Pediatrics

#### MCH Headlines

-CDC Releases Study on Abuse & Neglect of Infants

-Unique status of vaccines as disease prevention "tools"

-CDC funding 4.4 million to 15 awards oral health HPDP

#### Medical Mystery Tour

You know how to treat yeast infections, right? The right answers

#### Medscape

#### -Expanded HIV Testing in Primary Care: Implementing the CDC Recommendations {#expanded-hiv-testing-in-primary-care-implementing-the-cdc-recommendations .Style-Heading-4-+-Arial-14-pt-Underline}

#### -HIV Opt-out Testing and Primary Care Practice {#hiv-opt-out-testing-and-primary-care-practice .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Menopause Management**

#### -Estrogen therapy doubles rate of benign breast lumps {#estrogen-therapy-doubles-rate-of-benign-breast-lumps .Style-Heading-4-+-Arial-14-pt-Underline}

-Postmenopausal Systemic Hormone Therapy: Putting Risks Into Perspective

**Midwives Corner**

-Midwives Excel at Keeping Birth Normal, and Midwife-Provided
Acupuncture Helps With PROM

-Women given sterile water injection experience less labor pain compared
to acupuncture

-Irrespective of treatment, pelvic girdle pain regresses in majority by
12 weeks after delivery

-Cervical Cancer Screening Practices of Certified Nurse-Midwives in the
United States

**Navajo News**

Sexual Assault Nurse Examiner (SANE) Training Course, June 9 -- 13, 2008

**Nurses Corner**

#### Staff education and performance feedback  {#staff-education-and-performance-feedback .Style-Heading-4-+-Arial-14-pt-Underline}

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

Factors Associated with Elevated Risk of Postneonatal Mortality Among
Alaska Natives

**Oklahoma Perspective**

Prenatal Care in Oklahoma

Osteoporosis

#### Choosing a Drug for Women With Osteoporosis\--An Evidence-Based Clinical Perspective  {#choosing-a-drug-for-women-with-osteoporosis--an-evidence-based-clinical-perspective .Style-Heading-4-+-Arial-14-pt-Underline}

Patient Education

#### Colon Cancer Screening: What You Should Know {#colon-cancer-screening-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Clarification for 'What is this all about the 'minor markers' for Down
Syndrome?'

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

#### -Physiologic evidence to support levels of anomie and hostility with risk of PTD {#physiologic-evidence-to-support-levels-of-anomie-and-hostility-with-risk-of-ptd .Style-Heading-4-+-Arial-14-pt-Underline}

-Higher risk of offspring schizophrenia: Maternal exposure to severe
adverse life events

Primary Care Discussion Forum

Conclusion of the adolescent behavioral health on-line discussion

STD Corner

-HIV Screening in Dental Clinics?

#### -Racial Disparities Persist Across All Reportable STDs

-USPSTF Recommendations for STI Screening

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

-Take the stairs and live longer

-Possible Way to Detect Gestational Diabetes

#### -Periodontal pathogens and gestational diabetes mellitus {#periodontal-pathogens-and-gestational-diabetes-mellitus .Style-Heading-4-+-Arial-14-pt-Underline}

**Women's Health Headlines**

-Surgeon General\'s Conference on Women and Mental Health

\-[After School Programs Can Increase Physical Activity of Adolescent
Girls](http://public.nhlbi.nih.gov/newsroom/home/GetPressRelease.aspx?id=2558)

-Obesity: Pinn Point on Women's Health

-Chronic Pelvic Pain

###### Save the Dates: Upcoming events of interest page 53

#### What's new on the ITU MCH web pages page 54

[Breastfeeding: US Breastfeeding Committee Strategic
Plan](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm)

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

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

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

**How to increase usage of the HPV vaccine? Let's ask our patients and
their family**

**Alaska Native parental attitudes on cervical cancer, HPV, and the HPV
vaccine**

Melissa Toffolon-Weiss, PhD, MPH; Kyla Hagan, MPH; Jessica Leston, MPH;

Lynn Peterson, MPH; Ellen Provost, DO, MPH; Tom Hennessy, MD, MPH.

In June 2006, the U.S. Food and Drug Administration's Advisory Panel
approved Merck's HPV vaccine (GARDASIL ®) against the four strains of
HPV that are responsible for 70 percent of cervical cancer cases and 90%
of genital warts. The Advisory Commission on Immunization Practices
voted to recommend that the HPV vaccine be given routinely to girls aged
11-12 years old. In an effort to roll out the new vaccine in Alaska, the
CDC Arctic Investigations Unit and the Alaska Native Tribal Health
Consortium designed and implemented a qualitative study to assess Alaska
Native parents' knowledge and attitudes on cervical cancer, HPV, and the
new HPV vaccine. Findings from this study were used to design a tailored
educational campaign focused on promoting the HPV vaccine.

We recruited a convenience sample of Alaska Native parents from three
different size communities in Alaska (one urban area, two rural towns,
and a remote village). All participants were Alaska Native/American
Indian, English speaking, and had a 9-18 year old daughter/ward. The
focus groups, each lasting approximately 60 minutes, were carried out
between January through March, 2007. At this time the Merck educational
campaign was underway in Alaska, however, the vaccine was not widely
available in the Alaska Native Tribal Health System. Participants
received a \$25 incentive payment for their participation.

Prior to each focus group, each parent filled out a quantitative survey
that collected demographic information and asked knowledge questions.
During the focus groups, a moderator used a guide that consisted of
twelve open-ended questions inquiring about parents' perceptions of
cervical cancer, HPV, vaccines in general, and the new HPV vaccine. All
of the participants were Alaska Native parents or guardians of girls
between the ages of 9-18 yrs. Eighty percent of those involved in the
focus groups were mothers. Approximately 30% of parents were between the
ages of 31-40 years and 38% were 41-50 years old. Thirty-five percent of
participants had worked in or had a relative who worked in a medical
setting.

**Quantitative Survey Findings - Knowledge about Cervical Cancer,
Vaccines, HPV, and the HPV Vaccine**

The majority of parents (70%) knew that the Pap test is used to screen
for cervical cancer. Parents were asked what came to mind when they
heard the word "vaccine." Common themes that emerged in all focus groups
were a shot, prevention, protection, and a requirement for school. The
majority of participants (65%) knew that a vaccine prevents disease and
can stop the spread of a disease. Overall, only 56% of parents knew that
there was a vaccine for HPV and far less (20%) associated the vaccine
with the prevention of cervical cancer. Although many of the parents had
heard about HPV before, many were unaware that there was a link between
HPV and cervical cancer. Those who had heard about it said they had seen
a commercial or heard a news report, learned about it from working in a
medical setting, or from a visit to a clinic. Few village-based parents
knew how HPV is transmitted (36%) as compared to those from the urban
area (63%) and the rural towns (74%). In both the urban and rural
communities, a similar percentage of parents (38%) knew there was an
association between HPV and genital warts and only 6% of village-based
parents were aware of this association.

**Qualitative Focus Group Findings -- Attitudes and Perceptions about
Cervical Cancer, Vaccines, HPV, and the HPV Vaccine**

When asked what came to mind when they heard the words "cervical cancer"
the comments from participants centered around the following themes:
death; personal experiences with cancer; fear; pap smears; hysterectomy;
ability to reproduce; and older women. The majority of mothers said that
they alone make the decision to vaccinate their child against a disease.
Some said that they make the decision in conjunction with their spouse
and a few said that they involve their daughter and spouse in the
decision-making. Many of those who said that they involve their
daughters had older teenage daughters. For example, one mother stated
"My daughter is 17, and she's the one who went out, did her research on
the shot, and she's been patiently waiting for it." The majority of the
fathers said that the decision is a joint decision between them and
their spouse.

The majority of participants want to vaccinate their daughter due to:
health and safety concerns; a positive belief that vaccines work;
personal experience with the cancer/HPV; or a belief that their daughter
is susceptible to HPV. One mother described it this way, "I see it as
just part of being a mom and wanting to protect your child against
cancer." Another parent stated "For me, having a strong history of all
kinds of cancers in my family, one less cancer - the vaccine could
protect my daughter from at least that." Another theme that was
mentioned by at least one parent in each community is that often a
sexual exposure is not under the control of the young woman, as in the
case of rape, and this vaccine would offer the young woman protection
from HPV. Reasons that participating parents would refuse vaccination
include general concerns about vaccines, need for more information, fear
of side effects, wanting more research studies, wanting to wait to see
if problems develop, and fear of being in an experimental trial. A
typical comment about the newness of the vaccine came from a mother who
stated, "I don't like to be the first to use a new vaccine. That makes
me uncomfortable that it hasn't been used by a lot of people yet. Some
side effects may turn up that they don't know about until they vaccinate
a whole bunch of kids."

In all the communities, when parents were asked what information should
be included in an educational campaign on the new vaccine, parents
stressed a focus on prevention, the importance of describing HPV,
cervical cancer, and the vaccine and letting people know that the
vaccine is safe. Parents said to keep it simple, to talk about side
effects, the shot schedule, the need for continued Pap smears, and how
HPV is transmitted. When asked "Who should deliver the message about the
vaccine?" the same answers came up in all regions: providers (nurses,
doctors, health aides, children services workers, tribal health workers)
and teachers. The parents specified that the faces they want to see on
posters should be Alaska Native and some suggested having a girl in the
target age for the vaccine, a family oriented picture, an elder, or a
multi-generational picture with a grandmother, mother, and daughter.

This study has several limitations. The sample was small and selected in
a non-random manner. Thus, the results, including the survey data,
should not be generalized to the whole Alaska Native population. Rather,
the results should be interpreted as an array of possible findings that
are present among some Alaska Native parents.

The findings of this study have been used to design a poster and flyer
on the new vaccine oriented towards Alaska Native parents. The pictures
on these materials show an Alaska Native teenage girl, her mother, and
grandmother and the text stresses the safety of the vaccine and the
testing that has occurred. The theme of "protection" is present in the
headline that reads, "Love her, protect her.....with a vaccine against
cervical cancer." This research is unique in that it was undertaken
prior to widespread vaccine introduction and was used to guide
educational material development. This approach should be considered for
other vaccines or for other populations where vaccine introduction may
be controversial or require special attention to cultural or religious
sensitivities. Copies of the brochure and poster can be requested by
emailing Tania Smallenberg, Immunization Nurse Specialist, ANTHC, at
<tlsmallenberg@anmc.org>.

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

**How to institutionalize a 'well adolescent' visit that previously did
not exist**

Melissa Toffolon-Weiss and her colleagues offer a very helpful paradigm
on how to query our patients and their families to explore possible
barriers to instituting what could be a life saving vaccine
intervention. Each facility should consider similar projects for HPV
vaccine implementation or other health strategies.

In the meantime we all have been struggling on how to encourage our
young women to actually get this vaccine, largely because there is not a
common 'well adolescent' visit. Many of these young women get their
first HPV vaccine injection at a volleyball physical or similar visit.
It is an even greater struggle to make sure our adolescents get the
subsequent next two injections to complete the 3 dose series.

We may not be able to lift a direct cookie cutter approach from the
successful the infant oriented vaccine strategies, but we need to learn
from that approach. Call back lists, tickler files, or just apply your
best public health experience to whatever works.

Please let me know if you develop a particularly successful approach to
start and complete the HPV vaccine series at your facility.
<nmurphy@scf.cc>

**Acknowledgements:** We would like to acknowledge the extensive
assistance we received from the following individuals who helped in the
design and implementation of the study: Rosalyn Singleton, CDC AIP;
Debbie Hurlburt, CDC AIP; Gina Carpenter, Bristol Bay Area Health
Corporation (BBAHC); Helen Gregorio, BBAHC Corporation; Tish Luckhurst,
BBAHC; Ryan Mclane, State of Alaska Public Health Nursing; Emily Hughes,
Norton Sound Health Corporation.

**Funding:** Primary funding for this project was provided by the
Centers for Disease Control and Prevention Arctic Investigations Unit.
Secondary funding was provided by the Alaska Native Tribal Health
Consortium

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

#### Ben Garnett, ANMC {#ben-garnett-anmc .Style-Heading-4-+-Arial-14-pt-Underline}

**Antimicrobial prophylaxis for surgery**

**An Advisory Statement from the National Surgical Infection Prevention
Project: Antimicrobial Prophylaxis for Surgery**

Vaginal or abdominal hysterectomy

-Cefazolin

-Cefotetan

-Cefoxitin

-Cefuroxime

-Ampicillin sulbactam

[Other]{.underline}

If Beta lactam allergy, metronidazole monotherapy is recommended in the
ACOG Practice Bulletin as an alternative to cephalosporin prophylaxis
for patients undergoing hysterectomy. Trovafloxacin, although still
available in the United States, is recommended only for serious
infections.

 

Synthetic pubovaginal sling

-Cefazolin

-Cefotetan

-Cefoxitin

-Cefuroxime

[Other]{.underline}

If Beta lactam allergy, aminoglycoside, clindamycin, or metronidazole

**Resources**

[Bratzler
DW](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Bratzler DW"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Antimicrobial prophylaxis for surgery: an advisory statement from
the National Surgical Infection Prevention Project. Clin Infect Dis.
2004 Jun 15;38(12):1706-15.
<http://www.ncbi.nlm.nih.gov/pubmed/15227616>

Antimicrobial prophylaxis 2007

<http://www.premierinc.com/quality-safety/toolsservices/safety/topics/guidelines/downloads/anbx-cid-scip-04.pdf>

Surgical Care Improvement Project (SCIP)

<http://www.premierinc.com/safety/topics/scip/index.jsp>

or

<http://www.premierinc.com/quality-safety/tools-services/safety/topics/guidelines/other.jsp#antimicro-pro>

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

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

**Upcoming CDC Rapid HIV Testing Training through SAMHSA and IHS**

SAMHSA and IHS work together on multiple initiatives. One of which is
rapid testing training. With some of SAMHSA\'s Minority AIDS Initiative
dollars, we have been able to coordinate HIV rapid testing training (and
one training of trainers session) for I/T/U personnel from the CDC.
Below is the announcement.

If you work for a Tribal or Urban facility and are interested, please
contact Deepa or Ivy <dchhatwal@iqsolutions.com> and
<ivedamuthu@iqsolutions.com>. Part of this initiative will also involve
IHS staff. The IHS HIV Program has secured a small amount of funding for
a cadre of IHS providers to become CDC certified in rapid testing and
/or become a Trainer. (In order to participate in the \"training of
trainers session\" you will need to have already be certified in CDC
Rapid Testing).

 

If you are an IHS employee and provider of HIV services and are
interested in ANY of the trainings below or know someone on your staff
that should attend, please contact me as soon as possible and we will
discuss this in detail. This IHS/SAMHSA collaboration will thus provide
training for all three personnel, I/T/U, tribal and urban sites,

The trainings participant capacity is 24 participants.  Registration
will be on a first come first served basis.  The trainings will be
provided at no cost and logistical support will be provided to
participants.

 

The other trainings dates and locations are listed below and you can
sign-up for those now as well.

 

CDC Rapid HIV Testing Training - July 22-24 in Denver, CO5-7
Albuquerque, NM

CDC Rapid HIV Testing Train the Trainer -- August 5-7 in Albuquerque, NM

 

These trainings are designed to increase the capacity of HIV screening
in Native communities by certified and train providers.

**Educate State Officials and Policy Makers about Prevention of STDs and
AIDS\
**The following funding information has been recently added to the CDC
National Prevention Information Network\'s (NPIN) Funding Database
(http://www.cdcnpin.org/scripts/locates/LocateFund.asp). For more
information about HIV, Hepatitis, STD, and TB funding opportunities,
please contact the CDC NPIN at 1-800-458-5231.

**[Fund Number:
3546](https://webmail.hhs.gov/exchange/Scott.Giberson/Drafts/FW: %5BCDC News%5D HIV_x005F_xF8FF_Hepatitis_x005F_xF8FF_STD_x005F_xF8FF_TB Funding Information 04_x005F_xF8FF_07_x005F_xF8FF_2008-2.EML?Cmd=forward&Create=0#3546) -
Fund Title**: Initiatives to Educate State Officials and Policy Makers
about Priority Public Health Issues Related to the Prevention and
Control of Sexually Transmitted Diseases (STDs) and Human
Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome
(AIDS)

**Fund Number:** 3546\
\
**Fund Title:** Initiatives to Educate State Officials and Policy Makers
about Priority Public Health Issues Related to the Prevention and
Control of Sexually Transmitted Diseases (STDs) and Human
Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome
(AIDS)\
\
**Fund Category:**\
HIV/AIDS\
\
**Description:**\
Approximate Current Fiscal Year Funding: \$140,000. Approximate Total
Project Period Funding: \$415,000 (This amount is an estimate, and is
subject to availability of funds, and includes both direct and indirect
costs.)\
\
The purpose of the program is to fund national organizations to provide
education on accurate, comprehensive, and timely public health
information for state Governors, legislatures, policy makers, and those
involved in state efforts to protect the public health. This program can
be accomplished through targeted meetings, workshops, conferences,
educational materials, and other communication channels, with a focus on
educating these sectors about public health policy matters. The proposed
program will address the current and emerging STD and HIV/AIDS
prevention, and potentially viral hepatitis and tuberculosis prevention,
concerns of states including barriers to effective public health. The
proposed program may also be expanded to include adolescent and school
health and reproductive health issues of concern to states including
barriers to effective public health. This program addresses Healthy
People 2010 focus area 25 - Sexually Transmitted Diseases (STD) and
focus area 13 - HIV. It also supports the overarching goals of Healthy
People 2010: (1) to increase years and quality of healthy life, and (2)
eliminate disparities among subgroups of the population.\
\
**Sponsor(s):**\
US Department of Health and Human Services\
Public Health Service\
Centers for Disease Control and Prevention\
\
**Funder\'s Fund ID:** CDC-RFA-PS08-813\
\
**Web Page:**
[www.cdc.gov/od/pgo/funding/PS08-813.htm](http://www.cdc.gov/od/pgo/funding/PS08-813.htm)\
\
**Application Due Date:** 05/12/2008\
\
**Award Date:** 07/01/2008\
\
**Application Process:**\
To apply for this funding opportunity use the application forms package
posted in Grants.gov.\
\
HHS/CDC strongly encourages applicants to submit applications
electronically at www.Grants.gov. The application package can be
downloaded from www.Grants.gov. Applicants are able to complete it
off-line, and then upload and submit the application via the Grants.gov
Web site. E-mail submissions will not be accepted. If the applicant has
technical difficulties in Grants.gov, customer service can be reached by
E-mail at support@grants.gov or by phone at 1-800-518-4726
(1-800-518-GRANTS). The Customer Support Center is open from 7:00a.m. to
9:00p.m. Eastern Time, Monday through Friday.\
\
**Number of Awards:** 1 award\
\
**Maximum Award:** \$250,000.00\
\
**Average Award:** \$140,000.00\
\
**Award Notes:**\
Approximate Current Fiscal Year Funding: \$140,000. Approximate Total
Project Period Funding: \$415,000 (This amount is an estimate, and is
subject to availability of funds, and includes both direct and indirect
costs.)\
Approximate Average Award: \$ 140,000 (This amount is for the first
12-month budget period, and includes both direct and indirect costs.)\
Ceiling of Individual Award Range: \$250,000 (This ceiling is for the
first 12-month budget period, and includes both direct and indirect
costs.)\
\
**Eligible Locations:**\
- National\
\
**Application Contact Name:**\
Cheryl A Pressley\
**Title:** Grants Management Specialist\
**Application Contact Address:**\
DHHS\
CDC Procurement & Grants Office\
2920 Brandywine Rd, MS E-15\
Atlanta, GA 30341\
United States\
**Email:** <cam6@cdc.gov>\
**Phone:** 404-639-8164

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

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

**2008 IHS Immunization Awards**

Please join me in congratulating the following IHS Areas, who received
awards at CDC's 2008 National Immunization Conference from Dr. Anne
Schuchat, Director of the CDC's National Center for Immunization and
Respiratory Diseases:

The Centers for Disease Control and Prevention held their 42nd National
Immunization Conference this March. This event brings together a wide
variety of local, state, federal, and private-sector immunization
partners to explore science, policy, education, and planning issues
related to immunization in general, and vaccine-preventable disease. The
intention is to provide information that will help participants provide
comprehensive immunization coverage for all age groups and explore
innovative strategies for developing programs, policy, and research to
promote immunization coverage for all age groups.

**Phoenix Area  - Highest Immunization Coverage**

Achieved 90% coverage with the 43133 vaccine series for 2 year old
children

**Oklahoma Area -  Most Improved Coverage**

Improved coverage for 2 year olds with the 43133 series from 64% in 2006
to 83% in 2007.

**Navajo Area -- Most Complete Reporting**

Captured over 95% of  the User Population in the 2 year old immunization
reports.

In addition, the Indian Health Service received the Service Excellence
Award from the American Immunization Registry Association (AIRA) for its
work in promoting data exchange between the RPMS system and state
immunization information systems (IIS), and for the "Working Together on
Data Exchange: A Guide to IHS and IIS Interfaces" document developed by
Cecile Town in conjunction with Scott Hamstra (Sells) and John Parker
(Chinle).

Find information about the *RPMS Immunization Module* online at:

[http://www.ihs.gov/CIO/ca/ca-immunization-module.asp]{.underline}

Extensive information/resources for Immunization are available online
at:

[http://www.ihs.gov/medicalprograms/epi/index.cfm?module=health_issues&option=immunizations&cat=sub_4]{.underline}

#### [**Amy.Groom@ihs.gov**](mailto:Amy.Groom@ihs.gov) {#amy.groomihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

**Favian Kennedy, Aberdeen Area Tribal Tobacco Prevention Project**

**From Collective Consciousness to Written Policy**

Colleagues,

We work hard to keep you up-to-date on the latest health promotion/
disease prevention issues. Let our newsletters be your literature
review. The latest issue of Tobacco Prevention Project News Issue 8,
Winter 2008 available at
<http://www.aatchb.org/nptpp/Resources/publications.html>

Don't forget to visit us on the web
[www.aatchb.org/nptpp](http://www.aatchb.org/nptpp)

Favian Kennedy

NPTPP Program Director

Aberdeen Area Tribal Chairmen's Health Board

605-721-1922 x112

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

#### Elaine Locke, ACOG {#elaine-locke-acog .Style-Heading-4-+-Arial-14-pt-Underline}

**ACOG / IHS Denver Course Now in Salt Lake City, Utah**

Obstetric, Neonatal and Gynecologic Care

September 14-18, 2008

Salt Lake City, Utah

This annual women's health update for Nurses, Advanced Practice
Clinicians, and physicians provides a four-day schedule of lectures,
workshops, hands-on sessions, and team building. The large
interdisciplinary faculty collaborates to teach clinical and practical
topics as they apply in Indian health settings. Many faculty members are
your colleagues in IHS and Tribal facilities; private sector faculty
also bring a wide range of experience providing Indian health care.

Learn the latest evidence-based approaches to maternal and child health
services, and share problems and solutions with your colleagues from
across Indian country. The course can also serve as a good foundation
for professionals who are new to women's health care or new to the
Indian health system.

In addition to the basic course, you may sign up for the Neonatal
Resuscitation Program, and come away with your certificate from this
convenient pre-course program. The opportunity to fulfill continuing
education requirements in a concentrated format is significant: With the
optional NRP, we can document your participation in seven half-days of
education.

Sign up early! You'll have first chance for support from your facility
and coverage for your time in Salt Lake City. Getting these benefits
lined up takes time, so don't delay and miss out! In addition, early
registration holds your place, and puts you in line for possible
availability of scholarship funds.

Watch your mail for the course brochure and registration form, or
download it from here

<http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm?module=08&option=9#top>

Contact Yvonne Malloy <ymalloy@acog.org> for additional information.

**Cathy Stueckemann** **Community Health Representative Program**

**Community Health Representative National Educational Meeting**

-   July 29-31 2008

-   Las Vegas, Nevada

-   40th anniversary of the CHR Program. 

<http://www.nachr.net/conferences/2008/>

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

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

**Pregnant Women Who are Obese Linked with Greater Health Care Services
Use**

Obesity during pregnancy is associated with greater use of health care
services and longer hospital stays. The primary reasons for the
increased utilization of these services were increases in Caesarean
section and obesity-related high risk conditions. Caesarean delivery
rates were 45.2 percent for extremely obese women, compared to 21.3
percent for normal weight women.

Given the health and economic costs, the importance of preventing
obesity in women of child-bearing age in order to enhance health during
pregnancy and throughout the course of life still remains a vital public
health concern.

CONCLUSIONS: Obesity during pregnancy is associated with increased use
of health care services

[Chu
SY](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Chu SY"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Association between obesity during pregnancy and increased use of
health care. N Engl J Med. 2008 Apr 3;358(14):1444-53.
<http://www.ncbi.nlm.nih.gov/pubmed/18385496>

**New Evidence Report on Management and Postpartum Follow-Up of
Gestational Diabetes Mellitus**

A new AHRQ evidence report finds there are no substantial differences in
maternal or neonatal outcomes associated with the use of glyburide or
insulin analogues, as opposed to the use of insulin in women with
gestational diabetes.  The report also finds that further studies are
needed to inform the development of evidence-based guidelines for
elective induction or cesarean delivery in women with diabetes.  Select
to review an abstract of the report. A print copy is available by
sending an e-mail to <ahrqpubs@ahrq.hhs.gov>.  

Therapeutic Management, Delivery, and Postpartum Risk Assessment and
Screening in Gestational Diabetes
<http://www.ahrq.gov/clinic/tp/gestdiabtp.htm>

**High caffeine consumption during pregnancy may increase the risk of
miscarriage**

The results from our prospective cohort study supported previous
findings that high caffeine consumption during pregnancy may increase
the risk of miscarriage. Caffeine is among the most frequently ingested
pharmacologically active substances in the world. Caffeine can readily
cross the placental barrier to the fetus and has been reported to
increase the risk of miscarriage. However, the effect of caffeine on the
risk of miscarriage remains controversial because of methodological
limitations in past studies. The objective of the present
population-based prospective study was to examine the effect of maternal
caffeine intake during pregnancy on the risk of miscarriage, taking into
account a number of potential confounders, especially the impact of
nausea and vomiting during pregnancy.

The authors found that

\* Overall, 172 women (16.18%) miscarried.

\* Whereas 264 women (25%) reported no caffeine consumption during
pregnancy, 635 women (60%) reported 0-200 mg of caffeine consumption per
day, and 164 women (15%) reported 200 mg or more of caffeine consumption
per day.

\* Compared with non-users, women who consumed 0-200 mg of caffeine per
day had an increased risk of miscarriage (15% vs. 12%), and the
corresponding risk was much greater (25%) among women who consumed 200
mg or more per day.

\* After adjusting for potential confounders, including maternal age,
race, education, household income, marital status, previous miscarriage,
smoking, alcohol consumption, Jacuzzi use, MF exposure, and nausea and
vomiting, the hazard ratio of miscarriage was 1.42 and 2.23 for daily
caffeine consumption of 0-200 mg and 200 mg or more, respectively.

\* Caffeine\'s affect on the risk of miscarriage remained strong among
women without a history of miscarriage, whereas the association no
longer existed among women with such a history.

The authors conclude that \"it may be prudent to stop or reduce caffeine
intake during pregnancy.\"

Weng X, Odouli R, Li D. 2008. Maternal caffeine consumption during
pregnancy and the risk of miscarriage: a prospective cohort study.
American Journal of Obstetrics and Gynecology 198(3):279.e1-278.e8
<http://www.ncbi.nlm.nih.gov/pubmed/18221932>

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

**Grief subsequent to an early miscarriage**

The paucity of clear information as to the incidence, characteristics,
and duration of grief following miscarriage suggests that practitioners
can offer only suggestive guidelines as to what constitutes an adaptive
or typical reaction to miscarriage.

The author found that

\* The affective and behavioral reactions that typically occur following
miscarriage seem similar to the affective and behavioral reactions that
typically occur following other types of significant loss. At the same
time, grief following miscarriage seems somewhat distinct from grief
that typically occurs following other losses in the preponderant
emphasis on times ahead rather than on remembered times.

\* With regard to the percentage of individuals who experience a grief
reaction following miscarriage, no clear guidelines can be formulated.

The available literature does suggest that grief reactions are common
and that the grief is similar in intensity to grief following other
types of losses. In addition, like grief following other types of
losses, grief after miscarriage seems to abate in intensity by about 6
months following the miscarriage.

\* Gender differences in relation to grief following miscarriage are
evident, with men seeming to experience less intense and enduring grief
than women.

\* Although many variables have been studied to determine their role as
moderators of the intensity and duration of grief following miscarriage,
few clear conclusions can be drawn.

The authors conclude that \"the similarity in the results of studies
examining the duration and intensity of grief following miscarriage and
the duration and intensity of grief following other types of losses
supports using the general literature on grief to help guide patient
expectations.\"

#### Brier N. 2008. Grief following miscarriage: A comprehensive review of the literature. Journal of Women\'s Health ahead of print. [[http://www.liebertonline.com/doi/abs/10.1089/jwh.2007.0505]{.underline}](http://www.liebertonline.com/doi/abs/10.1089/jwh.2007.0505) or [**http://www.ncbi.nlm.nih.gov/pubmed/18345996**](http://www.ncbi.nlm.nih.gov/pubmed/18345996) {#brier-n.-2008.-grief-following-miscarriage-a-comprehensive-review-of-the-literature.-journal-of-womens-health-ahead-of-print.-httpwww.liebertonline.comdoiabs10.1089jwh.2007.0505-or-httpwww.ncbi.nlm.nih.govpubmed18345996 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Stillbirth: Good differential Dx plus an uncommon presentation of a common disease {#stillbirth-good-differential-dx-plus-an-uncommon-presentation-of-a-common-disease-1 .Style-Heading-4-+-Arial-14-pt-Underline}

[Gibbs
RS](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Gibbs RS"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Roberts
DJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Roberts DJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
Case records of the Massachusetts General Hospital. Case 27-2007. A
30-year-old pregnant woman with intrauterine fetal death. N Engl J Med.
2007 Aug 30;357(9):918-25

#### [**http://www.ncbi.nlm.nih.gov/pubmed/17761596**](http://www.ncbi.nlm.nih.gov/pubmed/17761596) {#httpwww.ncbi.nlm.nih.govpubmed17761596 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Non-surgical treatment of urinary incontinence and prevention of
urinary and fecal incontinence**

A recent AHRQ sponsored review of published evidence on the non-surgical
treatment of urinary incontinence in women included the following
estimates of efficacy, based on a review of the available randomized
controlled trials:

Background: Urinary incontinence in women is a common problem that
adversely affects quality of life.

Conclusions: Moderate levels of evidence suggest that pelvic floor
muscle training and bladder training resolved urinary incontinence in
women. Anticholinergic drugs resolved urinary incontinence, with similar
effects from oxybutynin or tolterodine. Duloxetine improved but did not
resolve urinary incontinence. The effects of electrostimulation, medical
devices, injectable bulking agents, and local estrogen therapy were
inconsistent.

Specific estimates of efficacy from available randomized controlled
trials included that pelvic floor muscle training would resolve 490
cases of stress incontinence per 1000 cases treated.

This article was accompanied by an NIH "state of the science" statement
addressing prevention of urinary and fecal incontinence. Conclusions
included that "routine episiotomy is the most easily preventable risk
factor for fecal incontinence" and that pelvic floor muscle training may
prevent or reduce incontinence in older women and lifestyle changes,
such as weight loss and exercise, may prevent both urinary and fecal
incontinence.

[Shamliyan
TA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Shamliyan TA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
[Kane
RL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Kane RL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
[Wyman
J](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Wyman J"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
[Wilt
TJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Wilt TJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract).Systematic
review: randomized, controlled trials of nonsurgical treatments for
urinary incontinence in women. [Ann Intern
Med.](javascript:AL_get(this, 'jour', 'Ann Intern Med.');) 2008 Mar
18;148(6):459-73.

<http://www.ncbi.nlm.nih.gov/pubmed/18268288> or
<http://www.annals.org/cgi/content/full/0000605-200803180-00211v1>

[Landefeld
CS](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Landefeld CS"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
[Bowers
BJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Bowers BJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
[Feld
AD](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Feld AD"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
[Hartmann
KE](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Hartmann KE"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
[Hoffman
E](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Hoffman E"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
[Ingber
MJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Ingber MJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
[King JT
Jr](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="King JT Jr"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
[McDougal
WS](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="McDougal WS"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
[Nelson
H](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Nelson H"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
[Orav
EJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Orav EJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
[Pignone
M](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Pignone M"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
[Richardson
LH](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Richardson LH"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
[Rohrbaugh
RM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Rohrbaugh RM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
[Siebens
HC](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Siebens HC"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
[Trock
BJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Trock BJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract).
National Institutes of Health state-of-the-science conference statement:
prevention of fecal and urinary incontinence in adults. [Ann Intern
Med.](javascript:AL_get(this, 'jour', 'Ann Intern Med.');) 2008 Mar
18;148(6):449-58.

<http://www.ncbi.nlm.nih.gov/pubmed/18268289> or
<http://www.annals.org/cgi/content/full/0000605-200803180-00210v1>

**Ultrasonography differentiated between benign and malignant: Improved
outcomes**

BACKGROUND: The diagnostic accuracy of ultrasonography for
differentiating between benign and malignant adnexal masses is
proportional to the expertise of the operator. However, we do not know
whether improved diagnostic accuracy will affect the management of these
tumours. We assessed the effect of the quality of gynaecological
ultrasonography on the management of patients with suspected ovarian
cancer in a randomised controlled trial.

INTERPRETATION: Improved quality of ultrasonography has a measurable
effect on the management of patients with suspected ovarian cancer in a
tertiary gynaecology cancer centre, and results in a significant
decrease in the number of major staging procedures and a shorter
inpatient hospital stay.

[Yazbek
J](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Yazbek J"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Effect of quality of gynaecological ultrasonography on management
of patients with suspected ovarian cancer: a randomised controlled
trial. Lancet Oncol. 2008 Feb;9(2):124-31.
<http://www.ncbi.nlm.nih.gov/pubmed/18207461>

**Saffron effective in the treatment of premenstrual syndrome: a
double-blind, RCT**

CONCLUSION: The results of this study indicate the efficacy of C.
sativus L. in the treatment of PMS. However, a tolerable adverse effects
profile of saffron may well confirm the application of saffron as an
alternative treatment for PMS. These results deserved further
investigations.

[Agha-Hosseini
M](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Agha-Hosseini M"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
et al Crocus sativus L. (saffron) in the treatment of premenstrual
syndrome: a double-blind, randomised and placebo-controlled trial.

BJOG. 2008 Mar;115(4):515-9.
<http://www.ncbi.nlm.nih.gov/pubmed/18271889>

**Biofeedback Reduces Psychological Burden in Older Women With Urge UI**

In older women with urge urinary incontinence (UI), biofeedback (BFB)
therapy significantly improved psychological burden, especially in those
with a history of depression.

CONCLUSION: In older women with urge UI, BFB significantly improves
psychological burden, especially in those with a history of depression,
in whom psychological burden is linked to change in perception of
control. Psychological factors are relevant outcome measures for UI, and
these data suggest that focusing on UI frequency alone may have
underestimated BFB\'s efficacy and additional therapeutic benefits.

[Tadic
SD](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Tadic SD"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Effect of biofeedback on psychological burden and symptoms in
older women with urge urinary incontinence. J Am Geriatr Soc. 2007
Dec;55(12):2010-5. Epub 2007 Nov 20.

<http://www.ncbi.nlm.nih.gov/pubmed/18028340>

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

**Preemies Face Risks As They Grow Up**

CONTEXT: Preterm birth is a major cause of infant morbidity and
mortality. Less is known about long-term health among persons born
preterm. OBJECTIVE: To determine the long-term effects of preterm birth
on survival, reproduction, and next-generation preterm birth.

CONCLUSION: In persons born in Norway in 1967-1988, preterm birth was
associated with diminished long-term survival and reproduction.

[Swamy
GK](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Swamy GK"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Association of preterm birth with long-term survival,
reproduction, and next-generation preterm birth. JAMA. 2008 Mar
26;299(12):1429-36.

<http://www.ncbi.nlm.nih.gov/pubmed/18364485>

**Cognitive and Neuromotor Impairments Seen at 5 Years in Children Born
Preterm **

Follow-up of a large cohort of children born before 33 weeks\' gestation
shows that, despite improvements in treatment and survival, many of
these children have cognitive and neuromotor impairment and require
specialized care by 5 years of age

INTERPRETATION: In children who are born very preterm, cognitive and
neuromotor impairments at 5 years of age increase with decreasing
gestational age. Many of these children need a high level of specialised
care. Prevention of the learning disabilities associated with cognitive
deficiencies in this group is an important goal for modern perinatal
care for children who are born very preterm and for their families.

[Larroque
B](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Larroque B"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Neurodevelopmental disabilities and special care of 5-year-old
children born before 33 weeks of gestation (the EPIPAGE study): a
longitudinal cohort study. Lancet. 2008 Mar 8;371(9615):813-20.
<http://www.ncbi.nlm.nih.gov/pubmed/18328928>

Is Short-term Therapy Effective for Treating Latent TB in Children?

**Results:** Final analysis included 926 patients with a mean age of 8.7
years. Overall, 850 participants (91.8 percent) had excellent or
moderate compliance rates, although significantly lower compliance rates
occurred in patients receiving the nine-month isoniazid regimen compared
with the other groups. No patient in any group progressed to active TB
during the study or follow-up period, and no serious drug-related
adverse events were reported. Six percent of patients receiving the
long-term regimen had transient liver enzyme elevations compared with
1.2 percent in the short-term treatment groups, and 6.5 percent of
patients receiving the long-term regimen developed nausea and epigastric
pain compared with 0.7 percent in the short-term treatment groups. In
addition, 2 percent of patients in the short-term treatment groups
developed photosensitivity reactions or transient maculopapular rashes.
Treatment discontinuation was not required in any patient.

**Conclusion:** The authors conclude that a three- to four-month course
of isoniazid/rifampin combination therapy is well tolerated in children
and is as effective as the traditional nine-month course of isoniazid
monotherapy. In addition, the shorter treatment courses are associated
with higher compliance rates.

Spyridis NP, et al. The effectiveness of a 9-month regimen of isoniazid
alone versus 3- and 4-month regimens of isoniazid plus rifampin for
treatment of latent tuberculosis infection in children: results of an
11-year randomized study. *Clin Infect Dis.* 2007;45:715-722.

<http://www.ncbi.nlm.nih.gov/pubmed/17712755>

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

**FDA Approves Alternative Dosing Schedule for Combined Hepatitis
Vaccine**

In April 2007, the U.S. Food and Drug Administration (FDA) approved an
alternative schedule for the combined hepatitis A and hepatitis B
vaccine Twinrix (GlaxoSmithKline). The vaccine was first licensed in
2001 for vaccination of persons 18 years and older with a schedule of
three doses administered at zero, one, and six months. An alternative
four-dose schedule can now be used, with doses administered at zero,
seven, and 21 to 30 days, and at 12 months.

Studies showed that the first three doses of the four-dose schedule
provide equivalent protection to the first two doses in the three-dose
series, as well as to a single dose of monovalent hepatitis A vaccine
and to two doses of monovalent hepatitis B vaccine. The FDA suggests
that the four-dose schedule may be useful if vaccination with the
combination vaccine has been initiated but potential exposure (e.g.,
through travel) is expected before the second dose is due, according to
the standard three-dose schedule. Additional information is available
from the manufacturer\'s package insert and GlaxoSmithKline Vaccines
(telephone, 800-366-8900).

Morbidity and Mortality Weekly Report, October 12, 2007

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5640a5.htm>

**Effect of lower targets for blood pressure and LDL cholesterol on
atherosclerosis in diabetes: The SANDS randomized trial**

CONCLUSIONS: Reducing LDL-C and SBP to lower targets resulted in
regression of carotid IMT and greater decrease in left ventricular mass
in individuals with type 2 diabetes. Clinical events were lower than
expected and did not differ significantly between groups. Further
follow-up is needed to determine whether these improvements will result
in lower long-term CVD event rates and costs and favorable risk-benefit
outcomes

[Howard
BV](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Howard BV"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Effect of lower targets for blood pressure and LDL cholesterol on
atherosclerosis in diabetes: the SANDS randomized trial.

JAMA. 2008 Apr 9;299(14):1678-89.
<http://www.ncbi.nlm.nih.gov/pubmed/18398080>

**All drugs containing PHENYLPROPANOLAMINE are being recalled**

The Food and Drug Administration (FDA) is taking steps to remove
phenylpropanolamine (PPA) from all drug products and has requested that
all drug companies discontinue marketing products containing PPA. In
addition, FDA has issued a [public health
advisory](http://www.fda.gov/cder/drug/infopage/ppa/advisory.htm)
concerning phenylpropanolamine. This drug is an ingredient that was used
in many over-the-counter (OTC) and prescription cough and cold
medications as a decongestant and in OTC weight loss products.

All drugs containing PHENYLPROPANOLAMINE are being recalled. STOP TAKING
anything containing this ingredient. It has been linked to increased
hemorrhagic stroke (bleeding in brain )\
among women ages 18-49 in the three days after starting use of
medication. Problems were not found in men, but the FDA recommended that
everyone ( \</ SPAN\>even children ) seek alternative medicine.
<http://www.fda.gov/cder/drug/infopage/ppa/>

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

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

**ACOG Practice Bulletin: Use of Psychiatric Medications During
Pregnancy and Lactation**

Summary of Recommendations and Conclusions:

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

-   Lithium exposure in pregnancy may be associated with a small
    increase in congenital cardiac malformations, with a risk ratio of
    1.2--7.7.

-   Valproate exposure in pregnancy is associated with an increased risk
    of fetal anomalies, including neural tube defects, fetal valproate
    syndrome, and longterm adverse neurocognitive effects. It should be
    avoided in pregnancy, if possible, especially during the first
    trimester.

-   Carbamazepine exposure in pregnancy is associated with fetal
    carbamazepine syndrome. It should be avoided in pregnancy, if
    possible, especially during the first trimester.

-   Maternal benzodiazepine use shortly before delivery is associated
    with floppy infant syndrome.

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

-   Paroxetine use in pregnant women and women planning pregnancy should
    be avoided, if possible. Fetal echocardiography should be considered
    for women who are exposed to paroxetine in early pregnancy.

-   Prenatal benzodiazepine exposure increased the risk of oral cleft,
    although the absolute risk increased by 0.01%.

-   Lamotrigine is a potential maintenance therapy option for pregnant
    women with bipolar disorder because of its protective effects
    against bipolar depression, general tolerability, and a growing
    reproductive safety profile relative to alternative mood
    stabilizers.

-   Maternal psychiatric illness, if inadequately treated or untreated,
    may result in poor compliance with prenatal care, inadequate
    nutrition, exposure to additional medication or herbal remedies,
    increased alcohol and tobacco use, deficits in mother--infant
    bonding, and disruptions within the family environment.

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

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

-   Whenever possible, multidisciplinary management involving the
    patient's obstetrician, mental health clinician, primary health care
    provider, and pediatrician is recommended to facilitate care.

-   Use of a single medication at a higher dose is favored over the use
    of multiple medications for the treatment of psychiatric illness
    during pregnancy.

-   The physiologic alterations of pregnancy may affect the absorption,
    distribution, metabolism, and elimination of lithium, and close
    monitoring of lithium levels during pregnancy and postpartum is
    recommended.

-   For women who breastfeed, measuring serum levels in the neonate is
    not recommended.

-   Treatment with all SSRIs or selective norepinephrine reuptake
    inhibitors or both during pregnancy should be individualized.

-   Fetal assessment with fetal echocardiogram should be considered in
    pregnant women exposed to lithium in the first trimester.

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

#### ACOG Practice Bulletin No. 92: Use of Psychiatric Medications During Pregnancy and Lactation. [**Obstet Gynecol.**](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2008 Apr;111(4):1001-20. [**http://www.ncbi.nlm.nih.gov/pubmed/18378767**](http://www.ncbi.nlm.nih.gov/pubmed/18378767) {#acog-practice-bulletin-no.-92-use-of-psychiatric-medications-during-pregnancy-and-lactation.-obstet-gynecol.-2008-apr11141001-20.-httpwww.ncbi.nlm.nih.govpubmed18378767 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**ACOG Committee Opinion: End-of-Life Decision Making**

ABSTRACT: The purpose of this Committee Opinion is to discuss issues
related to end-of-life care, including terms and definitions, ethical
principles, legal constructs, physician--patient communication, and
educational opportunities pertinent for specialists in obstetrics and
gynecology. Assumptions about the objectives of care---which may be
understood differently by the patient and her caregivers---inevitably
shape perceptions about appropriate treatment. Because unarticulated
commitments to certain goals may lead to misunderstanding and conflict,
the goals of care should be identified through shared communication and
decision making and should be reexamined periodically. A good
opportunity to initiate the discussion of caregiving goals, including
end-of-life care, is during well-patient care. Physicians must be
careful not to impose their own conception of benefit or burden on a
patient. End-of-life care is particularly challenging for pregnant
women, whose autonomy is limited in many states. Many apparent conflicts
will be averted by recognizing the shared interests of the woman and her
fetus. When interests diverge, however, pregnant women's autonomous
decisions should be respected.

#### ACOG Committee Opinion No. 403: End-of-Life Decision Making. [**Obstet Gynecol.**](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2008 Apr;111(4):1021-7. [**http://www.ncbi.nlm.nih.gov/pubmed/18378768**](http://www.ncbi.nlm.nih.gov/pubmed/18378768) {#acog-committee-opinion-no.-403-end-of-life-decision-making.-obstet-gynecol.-2008-apr11141021-7.-httpwww.ncbi.nlm.nih.govpubmed18378768 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**ACOG Committee Opinion: Late-Preterm Infants**

ABSTRACT: Late-preterm infants (defined as infants born between 34 0⁄7
weeks and 36 6⁄7 weeks of gestation) often are mistakenly believed to be
as physiologically and metabolically mature as term infants. However,
compared with term infants, late-preterm infants are at higher risk than
term infants of developing medical complications, resulting in higher
rates of infant mortality, higher rates of morbidity before initial
hospital discharge, and higher rates of hospital readmission in the
first months of life. Preterm delivery should occur only when an
accepted maternal or fetal indication for delivery exists. Collaborative
counseling by both obstetric and neonatal clinicians about the outcomes
of late-preterm births is warranted unless precluded by emergent
conditions.

ACOG Committee Opinion No. 404: Late-Preterm Infants. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2008
Apr;111(4):1029-32. <http://www.ncbi.nlm.nih.gov/pubmed/18378769>

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

#### AFP American Family Physician {#afp-american-family-physician .Style-Heading-4-+-Arial-14-pt-Underline}

Abstinence- Plus Programs for Prevention of HIV - Cochrane Briefs

[Clinical Question]{.underline}

Do abstinence-plus programs prevent human immunodeficiency virus (HIV)
infection?

[Evidence-Based Answer]{.underline}

Abstinence-plus is sex education that includes information on
abstinence, condom use, and contraception. Compared with a variety of
controls-including usual care, no intervention, or other programs-there
is no evidence of increased rates of pregnancy or sexually transmitted
infection (STI). Based on limited data, abstinence-plus programs
increase knowledge, reduce pregnancy rates, and decrease incidence of
unprotected sex and frequency of sex.

[Practice Pointers]{.underline}

Abstinence-plus interventions are designed to prevent, stop, or decrease
sexual activity while promoting safer sex practices for persons who
choose to engage in sex. In contrast, abstinence-only interventions
promote abstinence as the only way to prevent HIV infection.

In this Cochrane review of randomized and quasi-randomized controlled
trials of abstinence-plus interventions, the authors identified 39
studies with a total of 37,724 participants. All studies were conducted
on adolescents or young adults in North America, and 37 studies were
conducted in the United States. Most of the studies took place in urban
schools or community centers, and the participants were primarily of
ethnic minorities. Active parental consent was required by 28 of the
studies. Interventions varied considerably, but they all promoted
abstinence as the best choice and condom or contraception use for those
who have sex. Control interventions also varied considerably. All
interventions included information on HIV, STI prevention, sexual risks,
and strategies for HIV prevention. Interventions ranged from a single
session to programs that were three years in duration. Results were
self-reported.

Because of methodologic differences, meta-analysis was not possible.
There was no evidence that abstinence-plus programs increased the risk
of HIV infection, and there were no adverse effects reported.
Abstinence-plus education improved participants\' knowledge of HIV
across trials. Only two studies (with 1,700 participants, total)
included STI screening as an outcome. No statistical differences were
found among interventions. Limited evidence suggests that
abstinence-plus programs reduce the incidence of pregnancy. Limited data
also demonstrate a reduction in the incidence of unprotected intercourse
and a reduced frequency of vaginal and anal sex.

In a previous review, the authors evaluated 13 trials of abstinence-only
programs with a total of 15,940 U.S. adolescent participants.1 Compared
with various controls, the abstinence-only programs did not reduce
self-reported biologic (e.g., STIs) or behavioral (e.g., unprotected
vaginal sex) outcomes in participants. One study in the review found
increases in short- and long-term incidences of STIs, an increased rate
of pregnancy, and an increased frequency of vaginal sex (4,652
participants).1 However, these findings of harm were limited to that one
study.

Underhill K, Montgomery P, Operario D. Abstinence-plus programs for HIV
infection prevention in high-income countries. *Cochrane Database Syst
Rev.* 2008;(1):CD007006.

<http://www.ncbi.nlm.nih.gov/pubmed/18254124>

**Evaluation of Acute Abdominal Pain in Adults**

Acute abdominal pain can represent a spectrum of conditions from benign
and self-limited disease to surgical emergencies. Evaluating abdominal
pain requires an approach that relies on the likelihood of disease,
patient history, physical examination, laboratory tests, and imaging
studies. The location of pain is a useful starting point and will guide
further evaluation. For example, right lower quadrant pain strongly
suggests appendicitis. Certain elements of the history and physical
examination are helpful (e.g., constipation and abdominal distension
strongly suggest bowel obstruction), whereas others are of little value
(e.g., anorexia has little predictive value for appendicitis). The
American College of Radiology has recommended different imaging studies
for assessing abdominal pain based on pain location. Ultrasonography is
recommended to assess right upper quadrant pain, and computed tomography
is recommended for right and left lower quadrant pain. It is also
important to consider special populations such as women, who are at risk
of genitourinary disease, which may cause abdominal pain; and the
elderly, who may present with atypical symptoms of a disease. Am Fam
Physician. 2008;77(7):971-978

<http://www.aafp.org/afp/20080401/971.html>

**Expanded Newborn Screening: Information and Resources**

Family physicians treat an increasing number of children with metabolic
disorders identified through newborn screening, and they are often the
first line of defense in responding to an abnormal screening result. How
the family physician chooses to interpret information from the screening
and what he or she chooses to tell the family affects the parent-child
relationship, as well as the infant\'s medical and developmental
outcomes. Family physicians must, therefore, be familiar with the
current state of expanded newborn screening to effectively communicate
results and formulate interventions. They also must recognize signs of
metabolic disorders that may not be detected by newborn screening or
that may not be a part of newborn screening in their state. For every
infant identified with a metabolic disorder, 12 to 60 additional infants
will receive a false-positive screening result. One recommendation for
communicating results to parents is to explain what the initial and
follow-up findings mean, even if the diagnosis is not confirmed. For
infants with true-positive results, long-term follow-up involves regular
medical examinations, communication with a metabolic treatment center,
and developmental and neuropsychological testing to detect possible
associated disorders in time for early intervention. This article
provides a description of metabolic disorders included in expanded
newborn screening programs; a list of disorders screened for in each
state; and resources for obtaining ACTion sheets (guidelines for
responding to newborn screening results), fact sheets, and emergency and
acute illness protocols. Am Fam Physician. 2008;77(7):987-994.

<http://www.aafp.org/afp/20080401/987.html>

**Subclinical Hypothyroidism**

[Clinical Scenario]{.underline}

A 65-year-old woman with a history of poorly controlled hypertension and
mild, untreated depression presents with an elevated thyroid-stimulating
hormone (TSH) level and normal free thyroxine (T4) and free
triiodothyronine (T3) levels. She denies any symptoms related to
hypothyroidism, but is wondering if she should start thyroid replacement
therapy.

[Clinical Question]{.underline}

Should physicians recommend thyroid hormone therapy for any nonpregnant
patient with [subclinical hypothyroidism?]{.underline}

[Evidence-Based Answer]{.underline}

Although there is evidence that thyroid hormone therapy in patients with
subclinical hypothyroidism may improve lipid profiles, cognitive
function, and echographic left ventricular function, there is no
evidence that this will decrease morbidity or mortality.

Cochrane for Clinicians, Putting Evidence into Practice

<http://www.cochrane.org/reviews/en/ab003419.html>

**Colonoscopy Surveillance After Polypectomy and Colorectal Cancer
Resection**

This article describes a joint update of guidelines by the American
Cancer Society and the U.S. Multi-Society Task Force on Colorectal
Cancer delineating evidence-based surveillance recommendations for
patients after polypectomy and colorectal cancer resection. Although
there are some qualifying conditions, the following general guidelines
apply: after colonoscopic polypectomy, patients with hyperplastic polyps
should be considered to have normal colonoscopies, and subsequent
colonoscopy is recommended at 10 years. Patients with one or two small
(less than 1 cm) tubular adenomas, including those with only low-grade
dysplasia, should have their next colonoscopy in five to 10 years.
Patients with three to 10 adenomas, any adenoma 1 cm or larger, or any
adenoma with villous features or high-grade dysplasia should have their
next colonoscopy in three years. Following curative resection of
colorectal cancer, patients should undergo a colonoscopy at one year,
with subsequent follow-up intervals determined by the results of this
examination. Adoption of these guidelines will have a dramatic impact on
the quality of care provided to patients after a colorectal cancer
diagnosis, will assist in shifting available resources from intensive
surveillance to screening, and will ultimately decrease suffering and
death related to colorectal cancer. Am Fam Physician.
2008;77(7):995-1002, 1003-1004
<http://www.aafp.org/afp/20080401/995.html>

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

**Adolescents are willing to have chlamydial screening by pediatricians
during urgent care visits**
<http://www.ahrq.gov/research/apr08/0408RA5.htm>

**Antidepressant use during pregnancy is linked to increases in preterm
birth and potentially serious infant perinatal problems**

<http://www.ahrq.gov/research/may08/0508RA8.htm>

**Maternal asthma is associated with lower birth weight**

<http://www.ahrq.gov/research/apr08/0408RA7.htm>

**Noncancerous pelvic problems are linked to poor quality of life and
sexual functioning for premenopausal women**

<http://www.ahrq.gov/research/may08/0508RA9.htm>

**Studies examine pediatricians\' and parents\' attitudes toward
childhood obesity**

<http://www.ahrq.gov/research/may08/0508RA10.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}

**Women\'s Health Resources**

A new Web resource providing scientists and consumers with the latest
information on significant topics in women\'s health research from
scientific journals and other peer-reviewed sources is now available
through the National Library of Medicine (NLM). The NLM Division of
Specialized Information Services, Office of Outreach and Special
Populations has partnered with the NIH Office of Research on Women\'s
Health (ORWH) to create this one-stop resource.\
\
The 2008 National Institutes of Health (NIH) Research Priorities for
Women\'s Health were used to identify overarching themes, specific
health topics, and research initiatives in women\'s health. Within each
section of the Web site are topics with links to relevant and
authoritative resources and research initiatives for women\'s health.\
\
Women\'s Health Resources from the NLM Web site can be found at:

<http://sis.nlm.nih.gov/outreach/womenshealthoverview.html>

##### 

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

**School Refusal**

By Elise Fatimi, MD\*

It is estimated that up to 4% of children refuse school because of
anxiety. Ten- to 14-year-olds are especially prone to school refusal.
These children may go on to be less likely to ever marry or have
children, and are at increased risk for future anxiety disorders and
depression. Because anxiety is strongly hereditary, a parent may be too
fearful to set firm limits in the face of their child's panic. With each
day's unexcused absence it grows harder to reestablish regular school
attendance.

Sometimes the goal of returning to full attendance is abandoned, and a
child may be home-schooled, or provided home-based instruction by the
school. This may maintain academic achievement, but social confidence
and age-appropriate friendships often suffer. It takes a strong
commitment of time and social networking for a parent to engage with
other home-schooling families. For working parents, or those with
anxiety problems of their own, this is a tall order.

A child who refuses school may have a real illness or a good reason to
worry (e.g. a depressed parent, a bully in the playground). But when
these have been ruled out with reasonable confidence, explore for
anxiety symptoms. Have other separations been difficult? Is the child a
'worrier'? Have there been past attempts at school refusal after holiday
breaks or illnesses? Is there a family history of anxiety?

There are many "flavors" of anxiety. Children who refuse school may have
Separation Anxiety Disorder. A child may also have Generalized Anxiety
Disorder, with worries about illness, worst-case scenarios, or far-off
events, and physical symptoms such as headaches and stomachaches. In
Social Anxiety Disorder, children are fearful of embarrassment,
scrutiny, or interacting with unfamiliar people.

I consider school refusal to be a genuine psychiatric emergency, much
like heavy bleeding. A child's confidence in his ability to "make it"
is, in a sense, hemorrhaging. Time is of the essence. Here are some
elements of an effective treatment plan:

1.  ***Educate the whole family***. Explain clearly that the goal is a
    return to full attendance, but that you will work hard to make this
    tolerable. Avoid bargaining ("let's wait until after Spring break,
    it's only another week") or granting of retroactive medical excuses.
    Get permission to contact school staff. Refer for therapy as needed
    to develop and follow a plan for reintroduction to school- children
    with more severe problems may start with a class period and increase
    steadily to a full day.

2.  ***Work with school staff***. Most principals will allow a child to
    use a 'time-out' in the nurse's office is he/she is too upset to
    stay in class. Ask the nurse not to send the child home before the
    agreed time unless there is objective evidence of illness. Devise a
    specific strategy for morning drop off at school. Parents should
    keep goodbyes brief. Avoid parent-child phone contact during the
    school day, as it tends to exacerbate anxiety.

> 3\. ***Medication may be indicated*** when a child is severely
> anxious. Short-term use of benzodiazepines (e.g. clonazepam at bedtime
> before a school day) can help with anticipatory anxiety and insomnia.
> If the child is sleepy in the morning, reassure parents and teachers
> that "asleep at school is better than awake at home" at the start of
> treatment. Ongoing treatment of anxiety disorders is best achieved
> with SSRI medications (e.g. fluoxetine, sertraline). Self-injurious or
> aggressive behavior may (rarely) require inpatient management.

Most children can resume full school attendance within days to weeks,
and many seem to forget the episode in a little while. In overcoming
this challenge, the whole family will build confidence and skills for
the future.

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

Here's a link to the American Academy of Child and Adolescent Psychiatry
that has information on this topic as well as a large range of other
psychosocial/mental health related ones:

<http://www.aacap.org/cs/root/facts_for_families/children_who_wont_go_to_school_separation_anxiety>

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

\*This month's column is provided by Elise Fatimi, MD, a child and
adolescent psychiatrist with long experience in IHS in the Southwest.
She currently presides over the Greater Phoenix Chapter of the Academy
of Child and Adolescent Psychiatry. She mixes clinical acumen and
patient advocacy exceedingly well.

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

#### Breastfeeding Kendra Carter, Northern Navajo Medical Center {#breastfeeding-kendra-carter-northern-navajo-medical-center .Style-Heading-4-+-Arial-14-pt-Underline}

**What Do High Performance Cars and Near Term Neonates Have In Common?**

Infants like high performance cars, require consistent care and unique
fuel. Many people understand the car scenario when educated on the
characteristics of near-term infants who by definition are of a
gestational age between 34-37 weeks. These late premature infants are at
higher risk for the following:

-hypothermia due to less body fat and low weight (may actually weigh
1-1.5 pounds less than full term infants.)

-hypoglycemia and even dehydration can occur if infants miss feedings.

-infection related to an immature immune system

-hyperbilirubinemia related to immature liver

-uncoordinated ability to feed due to suck, swallow, breathe pattern
when breastfeeding adding to fatigue.

-become easily over stimulated, resulting in an unorganized state
compounding feeding difficulty.

It is vital that the nursing plan reflect understanding of the above
risks and sometimes subtle signs, especially if the infant rooms-in and
is breastfeeding.

-Feed baby every three hours and be aware that these infants can rapidly
move from a hyper-alert to a deep sleep state and may require waking up
techniques to feed.

-Limit total feeding time to thirty minutes to allow infant to rest-

-Allow the mother time to pump afterward as baby sleeps on her lap.

-Teach mothers and family members to look for signs of an effective
latch and feeding of the infants. Families can help, awaken infant,
change infant's diapers, and provide mothers with a snacks, water and
uninterrupted time for breastfeeding.

-Vigorous, rhythmic sucking burst with brief pauses between sucking
bursts is a sign of effective suck. No dimpling in baby's cheeks should
be seen during sucking. Audible swallows and listen for soft "k" sound

-Supplement five to ten ml of pumped breast milk using a special nurser
or syringe feeding techniques.

-Mother is relaxed and comfortable. Like the car scenario, the pit crew
is a mom's lifeline. She may need to be reminded to take care of herself
and accept help.

[-Moms]{.underline} need to **drink to thirst**- keep healthy drinks,
water, and natural juice, watch out for caffeinated drinks. Drink to
thirst- keep healthy drinks, water, and natural juice, watch out for
caffeinated drinks. **Eat to hunger**- keep healthy snacks of veggies
and protein snacks. This is not the time to diet to lose weight. Let
some else take care of the **household** chores for the first day or two
at home. **Nap** when baby nap, do not forget sleep is important to you
as well.

-Lactation consultants brought in early can anticipate discharge
instructions and home follow-ups.

-Use of infant feeding records can reassure and be used for emphasis.

-Baby is having adequate numbers of wet and soiled diapers

-Baby regains birth weight between days ten and fourteen of life.

**Resources:**

The AWHONN Late Preterm Infant Initiative, launched in 2005, a
multi-year endeavor, addresses the special needs of infants born between
34 and 36 completed weeks of gestation.
[www.awhonn.org](http://www.awhonn.org/).

Meek, Joan, Tippins, Sherill. American Academy of Pediatrics, New
Mother's Guide to Breastfeeding. Bantam Books. 2002.

Shannon, Teresa, O'Donnell, Mary Jane, Skinner, Kristen. Breastfeeding
in the 21st Century, Overcoming Barriers to Help Women and Infants.
Nursing for Women's Health. AWHONN 11: 6, pp570-575. 2008

Submitted by LTJG Kendra A. Carter RN BSN USPHS

Northern Navajo Medical Center, Dzilth Outpatient Nursing

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

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

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

#### April 2008 highlights include: {#april-2008-highlights-include .Style-Heading-4-+-Arial-14-pt-Underline}

\-[High prevalence of multiple HPV subtypes in AI women of the Northern
Plains](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08aom)

\-[Afghanistan Update: You can make a huge
difference](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08col)

\-[Cesarean delivery during nursing change of shift: Increased
complications](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ht#ob)

\-[The Evolution of Midurethral
Slings ](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ht#gyn)

\-[Maternal grandmothers' alcohol use linked to FAS in the Northern
Plains](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ht#child)

\-[Low-dose aspirin: Lower risk for all-cause mortality, especially
older
women](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ht#chrIll)

\-[Treatment of Urinary Infections in Nonpregnant
Women](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#acog)

\-[Care quality is not necessarily better with electronic health
records](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#ahrq)

\-[School
Refusal](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#bhi)

\-[What makes a good idea
work?](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#bhi)

\-[Teen dating violence: 3
articles](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#dv)

\-[Training in Palliative and End of Life Care, April 22-24, 2008,
Flagstaff ,
AZ](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#ecn)

\-[How to Increase contraceptive use and adherence in
adolescents](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#fp)

\-[Meeting notes now online: 2007 Native Women's Health and MCH
Conference](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#fws)

\-[Does anyone have an Indian Health EHR template for obstetrical
patients?](../Does%20anyone%20have%20an%20EHR%20template%20that%20is%20IHS%20approved%20for%20obstetrical%20patients%3F)

\-[Seeking input from the field - Clinician's Information
Management](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#it)

\-[Routes to TB treatment in rural
Nepal](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#ih)

\-[New Bullying-Prevention Toolkit
Released](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#alert)

\-[Maternal, Infant and Child Health Capacity Needs
Assessment](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#mchh)

\-[You know how to treat yeast infections,
right?](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#mmt)

\-[What Happened to Women in WHI study 3 years after stopping
HRT?](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#meno)

\-[Midwives Keep Birth Normal, and Midwife-Provided Acupuncture Helps
With
PROM](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#midw)

\-[Sexual Assault Nurse Examiner (SANE) Training Course, June 9 -- 13,
2008](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#navajo)

\-[Call for nominations of nurses working in Indian health: Deadlines
looming](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#nCrnr)

\-[Prenatal Care in
Oklahoma](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#okp)

\-[Look at all the drugs that affect bone
metabolism](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#ost)

\-[Treating Depression: What You Should
Know](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#pi)

\-[What is this all about the 'minor markers' for Down
Syndrome?](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#peri)

\-[USPSTF Recommendations for STI
Screening](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#std)

\-[Link between type 2 DM in adults: Diabetes in pregnancy or type 1 DM
in their
mothers](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#still)

\-[Have the Disparities Between AI/ANs and Caucasians
Narrowed?](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#whh)

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm#apr08**](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm#apr08) {#httpwww.ihs.govmedicalprogramsmchmob.cfmapr08 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-18 .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-19 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Intimate Partner Violence and Sexual Violence Victimization Assessment
Instruments for Use in Healthcare Settings**

[Intimate Partner Violence and Sexual Violence Victimization Assessment
Instruments for Use in Healthcare
Settings](http://www.cdc.gov/NCIPC/pub-res/images/IPVandSVscreening.pdf)
is a compilation of existing tools for assessing intimate partner
violence (IPV) and sexual violence (SV) victimization in
clinical/healthcare settings. The purpose of this compilation is to
provide practitioners and clinicians with the most current inventory of
assessment tools for determining IPV and/or SV victimization and to
inform decisions about which instruments are most appropriate for use
with a given population.

This document will aid in the selection of assessment instruments to
identify victims requiring additional services. This can help
practitioners make appropriate referrals for both victims and
perpetrators.
[www.cdc.gov/ncipc/dvp/IPV/IPVandSV-Screening.pdf](http://www.cdc.gov/ncipc/dvp/IPV/IPVandSV-Screening.pdf)

**Other resources**

Below is the link to CDC's Injury publications that also has some useful
resources.

<http://www.cdc.gov/ncipc/pub-res/pubs.htm>

This is a successful CDC resource called "Choose Respect" which also
provides useful information.
<http://www.chooserespect.org/scripts/index.asp>

**Male Partner Violence Hurts Women\'s Health Worldwide**

Women who are victims of male partner violence suffer a wide range of
physical and mental health problems, says a World Health Organization
study that included 25,000 women in 11 countries. INTERPRETATION: In
addition to being a breach of human rights, intimate partner violence is
associated with serious public-health consequences that should be
addressed in national and global health policies and programmes.

[Ellsberg
M](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Ellsberg M"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Intimate partner violence and women\'s physical and mental health
in the WHO multi-country study on women\'s health and domestic violence:
an observational study. Lancet. 2008 Apr 5;371(9619):1165-72.
<http://www.ncbi.nlm.nih.gov/pubmed/18395577>

**IHS-ACF DV Project: dental and reconstructive surgery for DV
survivors**

Give Back a Smile:

This program was developed to address a need in the communities of the
members of the AACD. Volunteer members of the AACD agree to restore the
broken and damaged teeth of survivors of domestic violence. Survivors
know that bruises and scars will fade but broken and missing teeth will
not. Our generous dentists erase that memory by restoring the smiles at
no cost to the survivor thereby restoring their lives.

 

FACE TO FACE is a program that was started in 1994 by the Educational
and Research Foundation for the American Academy of Facial Plastic and
Reconstructive Surgery (AAFPRS). The FACE TO FACE Program offers facial
plastic and reconstructive surgery to domestic violence survivors to
repair injuries on the face, head and neck caused by an intimate partner
or spouse. The toll-free number for the FACE TO FACE Program
is 1-800-842-4546.\
\
The American Society for Dermatologic Surgery (ASDS) was formally known
as the Skin Care Outreach Empowers Survivors or S.C.O.R.E.S. Program and
was started in 1999. This program is no longer recognized by ASDS as of
2004 although they still provide volunteers from their membership that
offer dermatologic surgery to domestic violence survivors to repair skin
injuries (scars, burns, tattoos) on the body caused by an intimate
partner or spouse. The toll-free number for the program formally known
as S.C.O.R.E.S. is 1-888-892-6702.

 

<http://www.aacd.com/foundation/> (800) 773-4227

To learn more, visit:
<http://www.ncadv.org/programs/CosmeticandReconstructiveSupport_118.html>**  **

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

**Landmark Study on Treatment of Hypertension in the Very Old**

This international randomized controlled trial addresses the important
unanswered question of the value of treatment for hypertension in men
and women aged 80 and older. Although treatment of elevated systolic and
diastolic blood pressure has clearly been shown to benefit younger
elders, prior to this study the data in the older elderly has been
inconclusive.

Nearly 4000 elders aged 80 and older with systolic blood pressures of
160mm Hg or higher were randomized to receive either placebo or a
diuretic similar to HCTZ. An ACE-I was added to the diuretic as needed
to reach the target blood pressure of 150/80.

Over a 2 year study period active treatment was associated with a 30%
reduction of stroke (fatal and nonfatal), a 39% reduction in death from
stroke, a 21% reduction in death from any causes, a 23% reduction in
death from cardiovascular causes, and a 64% reduction in heart failure.
There were fewer serious adverse events in the active treatment group
than in the placebo group.

**Elder Care Initiative Editorial comment:**

This is a landmark study that makes clear the benefit of treatment of
hypertension, diastolic and systolic, in the very old. I was especially
interested in the marked reduction in stroke and heart failure, two
conditions with huge implications for the function and quality of life
of older people. Treatment of high blood pressure is not just about
preventing death, but also about preserving quality of life.

[Beckett
NS](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Beckett NS"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Peters
R](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Peters R"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Fletcher
AE](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Fletcher AE"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Staessen
JA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Staessen JA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Liu
L](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Liu L"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Dumitrascu
D](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Dumitrascu D"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Stoyanovsky
V](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Stoyanovsky V"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Antikainen
RL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Antikainen RL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Nikitin
Y](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Nikitin Y"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Anderson
C](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Anderson C"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Belhani
A](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Belhani A"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Forette
F](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Forette F"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Rajkumar
C](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Rajkumar C"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Thijs
L](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Thijs L"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Banya
W](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Banya W"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Bulpitt
CJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Bulpitt CJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus);
[the HYVET Study
Group](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="the HYVET Study Group"%5BCorporate Author%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus).
Treatment of Hypertension in Patients 80 Years of Age or Older.

[N Engl J Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2008
Mar 31 <http://www.ncbi.nlm.nih.gov/pubmed/18378519>

**2008 IHS Long-Term Care Grants Program Is Now Open For Applications**

The IHS Long Term Care Grants program is intended to support Tribes,
Tribal organizations, and Urban Indian Health programs to plan and
implement long-term care services. This program will award 8 -- 10
grants for the purpose of Assessment and Planning (up to \$50,000 per
year for 2 years) or Implementation (up to \$75,000 per year for 2
years) of long-term care services.

[Key dates]{.underline}:

**May 2** is the deadline for the **mandatory Letter of Intent** to
Apply (LOI).

**June 20** is the closing date for the RFA

The Federal Register Announcement can be found at
<http://edocket.access.gpo.gov/2008/pdf/E8-6409.pdf>

Look for the Grant Announcement at
[www.grants.gov](http://www.grants.gov/). You will find it listed under
the Funding Announcement Number: HHS-2008-IHS-EHC-0001.

Please spread the word about this funding opportunity

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

**Contraceptive agents when initiating breastfeeding**

Nonhormonal methods of contraception (barrier contraception, copper
intrauterine device) are preferred in nursing mothers because hormonal
contraception may interfere with lactation and transfer of hormones into
milk poses a theoretical risk to the infant.

Progestin only --- If hormonal methods are to be used, progestin-only
contraceptives are the preferred method for breastfeeding women,
although timing of initiation of therapy is somewhat controversial.
Because falling progesterone levels trigger lactogenesis, early
initiation of progestin-containing contraceptives theoretically could
interfere with this process, particularly if injection contraception is
given in the first 72 hours after delivery. The immature metabolism of
neonates theoretically could lead to accumulation of progesterone and
its metabolites in the infant.

Due to these concerns, manufacturers\' package inserts recommend
starting progesterone-containing oral contraceptives six weeks
postpartum if the mother is exclusively breastfeeding, and three weeks
postpartum if she is supplementing with formula. However, there are no
data on the impact of earlier initiation of progestin-only
contraception. The American College of Obstetricians and Gynecologists
(ACOG) recommends that breastfeeding women initiate progestin-only oral
contraceptives at two to three weeks postpartum, and depot
medroxyprogesterone acetate at six weeks postpartum. In certain clinical
situations, such as concern about patient follow-up, ACOG states that it
may be appropriate to start progesterone-containing contraception
earlier.

The levonorgestrel releasing intrauterine device is recommended for
insertion six weeks postpartum in breastfeeding women.

Combined estrogen-progestin --- Combined estrogen-progestin
contraceptives are known to

suppress milk production in the early post-partum period, and have even
been used to treat

engorgement. Clinical trials examining the effect of combined oral
contraceptives on milk

supply and infant growth have reported mixed results. A large review of
the literature concluded

that the data were of such poor quality that no evidence-based
recommendation could be made

regarding use of combined contraceptives in lactating women.

Expert recommendations vary:

      - ACOG recommends delaying the initiation of combined
estrogen-progestin contraceptives until at least six weeks postpartum,
and then only if lactation is well-established and the infant\'s
nutritional status can be closely monitored.

      - The World Health Organization (WHO) recommends delaying the
initiation of combined contraceptives until six months postpartum.
Between six weeks and six months, WHO states that the theoretical or
proven risks usually outweigh the advantages.

**Helpful resources**

Combined hormonal versus nonhormonal versus progestin-only contraception
in lactation: Cochrane Review

<http://www.cochrane.org/reviews/en/ab003988.html>

National Guidelines Clearinghouse

<http://www.guidelines.gov/summary/summary.aspx?ss=15&doc_id=7098&nbr=004270&string=contraceptive+AND+choices+AND+breastfeeding+AND+women>

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

#### [Faculty of Family Planning & Reproductive Health Care](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Faculty of Family Planning %26 Reproductive Health Care"%5BCorporate Author%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract). Contraceptive choices for breastfeeding women. J Fam Plann Reprod Health Care 2004 Jul;30(3):181-9 {#faculty-of-family-planning-reproductive-health-care.-contraceptive-choices-for-breastfeeding-women.-j-fam-plann-reprod-health-care-2004-jul303181-9 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/pubmed/15222930?dopt=Abstract**](http://www.ncbi.nlm.nih.gov/pubmed/15222930?dopt=Abstract) {#httpwww.ncbi.nlm.nih.govpubmed15222930doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### Meeting notes now online: [2007 Native Women's Health and MCH Conference](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Intro Slide and Eval Sli14.ppt)\*

#### -More lecture notes added daily

-Lectures listed in alphabetical order by author

**Kelly Acton, M.D.**

-   [Diabetes in American Indian & Alaska Native
    Women](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/2007 OB GYN conf DM & women.ppt)

**Gail Bolan MD**

-   [Current Issues in STD Management: Implications for Improving
    Women's Reproductive Health
    Outcomes](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/IHS womens STD update 8.16.07.ppt)

**Karen Carey CNM MS**

-   [Obstetric
    Drills](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/McBride - OB Emergency Drills.ppt)

**Peter Cherouny, MD**

-   [Idealized Design of Perinatal Care:
    Plenary](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/9-15 am - Cherouny - New Mexico 0815.ppt)

-   [Quality Care in Obstetrics-Clinical Bundles:
    Workshop](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 1 AND 20 - New Mexico 0815 breakout.ppt)

**Donald Coustan, M.D.**

-   [GESTATIONAL
    DIABETES](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/9-00am Coustan -- NewMex17.ppt)

-   [Gestational
    Diabetes](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/9-00am Coustan -- NewMexicoGDM2007.ppt)

-   [Use of Oral Antidiabetic Agents in Obstetrics:
    Workshop](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/Ws 42 - Coustan -- Albuquerque Workshop 2007 oral_1.ppt)

**Scott Deasy, M.D.**

-   [Navajo Nation Breast & Cervical Cancer Prevention
    Program](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8.16.07 Presentation.ppt)

**Willeen Druley, RN, MS, BC, FNP**

-   [Mobile Women's Health
    Unit](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Mobile Unit-presentation updated 8-7-07.ppt)

**Denise Findlay, RN BSN**

-   [Using the Feeding & Teaching Scales to Plan Effective
    Interventions](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 7 - Findlay - Albuquerque PCI.ppt)

-   [Promoting Maternal Mental Health During
    Pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 10 - Findlay -- Albuquerque PMMH.ppt)

**Terry Friend, CNM**

-   [SCHOOL-BASED HEALTH (BY
    ACCIDENT)](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/SCHOOL PRESENTATION 2.ppt)

**Cindy Gebremariam, RN**

-   [iCare: A population management
    tool](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/iCare presentation Nashville Best Practices Conference 2007_.ppt)
    )

**Scott Giberson, Ph.C, PharmD, MPH**

-   [IHS HIV Program: Risk and
    Response](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Women's Health HIV Program Final Aug 14.ppt)

**George Gilson, M.D.**

-   [HIV Infection in Pregnancy: 2007
    Update](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/HIV-2007.ppt)

-   [Prenatal Testing Update
    2007](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/prenataltesting2007.ppt)

-   [THE OB-PEDS INTERFACE:"GOT
    ISSUES?"](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Gilson - OB-Peds talk.ppt)

**Amy Groom, MPH**

-   [HPV Vaccine
    Implementation](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Groom HPV Vaccine.ppt)

**Kathleen Harner, M.D.**

-   [Balancing Motherhood: Helping Moms Stay Drug
    Free](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Balancing Motherhood power point%5B1%5D.ppt)

**Howard Hays, M.D.**

-   [Women's Health Software Application V
    3.0](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/WHPresNAWConference FINAL 2007_08.ppt)

**Mary Henrikson MN, RNC**

-   [Us versus Them and Being in the
    Middle](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-17Fri/8-00 am --Henrickson -- Us Versus Them.ppt)

**Stephen W. Heath, MD, MPH**

-   [Risk Management in Maternal Child
    Health](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/MCH Talk.ppt)

**Lynn Hoefer, DV Advocate**

-   [Ketchikan Indian Clinic Domestic Violence Project: Take Home
    Tips](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Native Women's Health and MCH Conference 081507.ppt)

-   [Take Home Tips from Alaska IPV/DV Screening Project: Linking
    Culture and Community to
    Action](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Take Home Tips DV 8-14-07.ppt)

**Diane Jeanotte RN**

-   [Billings Area SIDS / Infant Mortality
    Reduction](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Jeanotte - August PresentationNO.ppt)

**Wanda K. Jones, Dr.P.H.**

-   [Optimizing Women's Health in the United States:
    Deaths](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/Jones Handout -- OWHhandhout-deaths.doc)

-   [Optimizing Women's Health in the United States:
    URLs](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/Jones Handout -- OWHhandout-URLs.doc)

**Favian Kennedy, MSW**

-   [Northern Plains Smoke-Free Homes
    Campaign](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/SFH for IHS.pdf)

**Nancy Knapp MPH & Brenda Isaacs**

-   [Integrating Brief Motivation Enhancing Interventions into the
    Primary Care
    Setting](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 21 0 Knapp - WISEWOMAN IHS womens health conf Aug 2007-ha.ppt)

-   [Integrating Brief Motivation Enhancing Interventions into the
    Primary Care Setting:
    Handout](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 21 0 Knapp -Hand Out ONLY.ppt)

**Michele R. Lauria, MD, MS**

-   [Optimizing Care Through Simulations and Structured Communication:
    Plenary](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/10-15am - Lauria - New Mexico 2007.ppt)

-   [Vaginal Birth after Cesarean: Still a Viable Option?
    Workshop](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 8 - Lauria Indian Health servcie to use.ppt)

-   **Rachel Locker, M.D.**

-   [Domestic Violence: Screening and
    Documentation](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/MCH DV locker clark.ppt)

**Tami McBride, CNM, MS, RNC**

-   [Obstetric Emergency
    Drills](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/OBEmergDrills.ppt)

-   [Obstetric Drill De-Brief
    Form](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/OBDrillDebriefForm.doc)

**Richard McClain, MD**

-   [MONARC vs. Paravaginal wall Repair: A system and surgeon
    perspective](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/WS 30 - McClain -- Stress Urinary Incontinence Pres.ppt)

**Paul Melinkovich, M.D.**

-   [Denver School-Based Health
    Centers](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/IHS MCH 8 07.ppt)

**Connie Monahan, MPH**

-   [Challenges of SANE in the Clinical Setting
    (Plenary)](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Nat Am & MCH 07 - genera12.ppt)

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-   [Making SANE Work: Operational Details
    (Workshop)](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Nat Am & MCH 07 - breakout.ppt)

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```
-   [Challenges of SANE in the Clinical
    Setting](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/10-15 am - Monahan - Nat Am & MCH 07 - general session.ppt)

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```
-   [Challenges of SANE in the Clinical Setting:
    Handout](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/10-15 am - Monahan - HANDOUT ONLY.ppt)

```{=html}
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```
-   [Making SANE Work: Operational
    Details](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/WS 40 - Slides - Monahan - Nat Am & MCH 07 - breakout.ppt)

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```
-   [Appendices: Making SANE
    work](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/WS 40 - HANDOUT - Monahan - Nat Am & MCH 07 - APPENDICES for.doc)

**Neil Murphy MD**

-   [2007 Data
    Tally](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/HandoutsPres/Dr Muphys 2 -- DataTally81107.doc)

-   [2007 Birth Statistics by
    Facility](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/HandoutsPres/Murphy - Packet BirthStats7904.xls)

-   [2007 Narrative
    Tally](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/HandoutsPres/Dr Murphys 3 -- NarrativeTally81107.doc)

-   [Human Papilloma Virus Vaccine
    2007](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/ABQHPV81607.ppt)

-   [Save the
    World](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/SaveTheWorld81407.ppt)

-   [How to keep
    current](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/HowtokeepcurrentABQ81607.ppt)

**Sue Murphy, RD, MPH, CDE, CLE**

-   [Breastfeeding
    Update](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Murphy - MCH OB-GYN conf 8-15-07.ppt)

**Tony Ogburn MD**

-   [Contraception for teens: What's
    new?](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Ogburn - Contraception-adolescents IHS 8-07.ppt)

**Sharon Phelan MD**

-   [Obesity: A weighty
    problem](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Phelan - OBESITY IHS August 2007.ppt)

**Marilyn Pierce Bulger**

-   [Community Approaches to Reducing Infant Mortality: Nutaqsiivik
    Program](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Community Approaches To Reducing IM Nutaq.ppt)

-   [Approaches To Reducing Infant Mortality- Nutaqsiivik
    Program](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Pierce-Bulger - Community Approaches To Reducing IM Nutaq.ppt)

**Usha Ranji, M.S.**

-   [Health Coverage and Access to Care: Key Issues for Native
    Women](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/Ranji IHS Conference August 2007.ppt)

**Brigg Reilley**

-   [Prenatal HIV Screening:
    Workshop](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 4 - Reilley - native women conference.ppt)

-   **Sharon Schindler Rising, MSN, CNM**

-   [Essential Elements of the Centering
    Model](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/HandoutsPres/Suzan Murphy HO - Model overview-4 page-8-07.doc)

**Greg Shorr, M.D.**

-   [PCC+ Obstetric Care
    Module](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/ShorrMCH_aug_07.ppt)

**Melanie Taylor MD, MPH**

-   [Chlamydia Among AI/AN Adolescents: The Stop Chlamydia
    Project](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Taylor - NewMexPresentation Aug1407.ppt)

**Judy Thierry, DO MPH**

-   [Improve the System, Improve the
    Outcome](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/8-00am -Welcome -- slides - thierry.ppt)

-   [PCC+ Obstetric Care
    Module](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/MCH_aug_07.ppt)

**Shelley Thorkelson , CNM MSN CDE**

-   [Case Tracking Strategies Using RPMS , CMS, DMS and Hard
    Copy](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/DM and Preg Program Over12.ppt)

-   [Diabetes in Pregnancy: Case Tracking
    Strategies](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/Ws 42 - Handout 2 Thorkelson SJT GDM Flowsheet.doc)

-   [DM & Pregnancy Program
    Flowsheet](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/WS 42 - Slides - Thorkelson DM and Preg Program Overview2006.ppt)

**Sheila Warren, MPH, RN, CPHQ**

-   [Patient Safety in Maternal Child
    Health](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/MCH conference 8 2007 sheila.ppt)

**Judy Whitecrane MSN, CNM**

-   [What We Did About Prenatal Substance
    Abuse](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 9 - Whitecrane - Special Care Clinic Services-2007.ppt)

**Nancy Whitney, MS, LMHC**

-   [Intervention as Prevention: Working Effectively with Mothers Who
    Abuse Alcohol and Drugs During
    Pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 16 - Slides (Print 3 slides per pg) Nancy Whitney HANDOUT.ppt)

-   [Parent-Child Assistance Program
    (PCAP)](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 16 - HANDOUT 2 Nancy Whitney HANDOUT 2.doc)

    [**2007 Native Women's Health and MCH
    Conference**](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Intro Slide and Eval Sli14.ppt)

[Conference
Brochure](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NWHMCH51507.pdf)

<http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NWHMCH51507.pdf>

\*Web link
<http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm#wHealthConf>

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

**First Trimester Down Syndrome Testing**

1.  **Q.** **Who should be offered first trimester Down syndrome (DS)
    screening?**

    A.  Women presenting for prenatal care at less than 14 weeks
        gestation.

2.  **Q. Should only high-risk women (over 35 y/o) be offered 1^st^
    trimester DS screening?**

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A.  **No**, all women who desire the testing are candidates.

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3.  **Q. At what gestational age should first trimester DS screening be
    scheduled?**

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A.  Between 11 weeks 0 days and 13 weeks 6 days (by ultrasound).

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4.  **Q. What are the components of the 1^st^ trimester DS screen?**

    A.  Ultrasound measurement of the nuchal translucency (NT) + blood
        for PAPP-A (pregnancy-associated plasma protein-A) and free beta
        HCG.

> (Most ultrasound exams at ANMC will also include the fetal heart rate,
> nasal bone, and ductus venosus or tricuspid waveform, if able to be
> obtained, which increase the sensitivity and reduce the false
> positives.)

5.  **Q. I'm pretty good at office ultrasound. Can I do my own NT
    measurements?**

    A.  Without certification, unfortunately no. Accurate NT
        measurements are difficult to obtain without special training. A
        lot is riding on the results. NT measurement requires a
        certificate of competency which can be obtained by attending a
        one-day didactic course, taking a written examination, and
        submitting 10 ultrasound images for critique and/or acceptance.
        Following certification, annual certification of competency
        needs to be accomplished by submitting more images. If
        interested, the certification process can be initiated at this
        website: [www.ntqr.org](http://www.ntqr.org/).

6.  **Q. I'm happy with our usual 2^nd^ trimester screening. What's the
    advantage to offering first trimester DS screening?**

    A.  The advantages are earlier diagnosis, increased sensitivity
        (91%), and fewer false positives (4%).

> (This is compared to 2^nd^ trimester screening that has a 78%
> sensitivity and a 5% FPR for screening in younger women (\<35 y/o),
> and an 85% sensitivity but an 11% FPR in women \>35 y/o. Many women
> will present too late for 1^st^ trimester screening, so 2^nd^
> trimester screening will continue to be an appropriate option.)

7.  **Q. What is "integrated screening"?**

    A.  Integrated screening is a screening strategy which relies on the
        results of both the 1^st^ and 2^nd^ trimester testing to give a
        final risk assessment.

> (The ANMC contract with our reference lab, NTD Laboratories, is
> currently not set up to do integrated screening. Also, we felt that
> most women would want to have the results of an abnormal 1^st^
> trimester screen divulged to them right away, and not wait for another
> several weeks.)

8.  **Q. What is "sequential contingent screening"?**

    A.  Sequential contingent screening is the strategy that we are
        currently using at ANMC. If women have an abnormal 1^st^
        trimester result, they are informed, and offered the option of
        immediate invasive testing, or subsequent 2^nd^ trimester
        testing. If they have a normal result, their DS screening is
        considered to have been completed.

9.  **Q. What are the cut-off values used for 1^st^ trimester
    screening?**

    A.  A 1^st^ trimester cut-off of 1:50 or higher is used to counsel
        about immediate invasive testing, if the woman so desires.

> -A 1^st^ trimester cut-off of 1:300 or higher is used to recommend a
> detailed 2^nd^ trimester anatomic ultrasound, and/or possible
> amniocentesis.
>
> -According to our current ANMC protocol, women with a screening result
> of less than 1:300 have completed DS screening.
>
> (If the pregnancy is 13 weeks or less, ANMC patients may be referred
> to Seattle for chorionic villus sampling \[CVS\], if they so desire.
> If a woman is beyond 13 weeks, or does not wish CVS, or would prefer
> amniocentesis, she will need to wait 2 weeks and be referred for amnio
> after 15 weeks. "Early amnio", between 12-15 weeks, has a high
> \[2.6%\] pregnancy loss rate, and is not recommended.)

10. **Q. If my client's 1^st^ trimester DS screen is negative, is any
    further testing necessary?**

    A.  If the woman's 1^st^ trimester DS screen is less than 1:300, our
        strategy of contingent sequential screening does not require any
        further testing for fetal aneuploidy. However, testing for fetal
        open neural tube defects (ONTD) still needs to be carried out.

> (In the current ANMC system, it is unfortunately currently not
> possible to order a maternal serum alpha fetoprotein (MSAFP) for ONTD
> screening alone, apart from a quad screen. Following negative 1^st^
> trimester screening, 2^nd^ trimester serum screening, if not
> "integrated", has an unacceptably high false positive rate (17%) for
> fetal Down syndrome, and is not recommended.
>
> However, we are fortunate to be able to order routine fetal anatomic
> surveys at 16-20 weeks, which have a high sensitivity (96%) for fetal
> ONTD and fetal abdominal wall defects. MSAFP screening only has an 80%
> sensitivity for ONTD in ultrasound-dated pregnancies (only 65% in
> LMP-dated pregnancies), so ultrasound is superior in this regard. In
> order to follow ACOG guidelines, some sort of ONTD screening needs to
> be done.)

11. **Q. At 12 weeks 2 days, a woman undergoes 1^st^ trimester screening
    and has a nuchal translucency (NT) of 2.9 mm, which is \>95^th^
    percentile for this crown rump length. How should she be
    counseled?**

    A.  The NT alone does not determine the screening result. It needs
        to be combined with the PAPP-A and free beta HCG for a final
        risk assessment. The NT alone only has a sensitivity for fetal
        DS of 72%, with a (high) false positive rate of 19%. The NT
        combined with the biochemistries has a sensitivity of 91% and a
        FPR of 4%. The full screen result requires both, and it is not
        prudent to act on the NT measurement alone.

(**Important exception:** If the NT measurement is over 3.5 mm (+3 SD),
it is considered a cystic hygroma, and the woman may be counseled about
having invasive testing right away, if she so desires. A cystic hygroma
raises the risk of aneuploidy to as high as 1:2.)

12. **Q. I've heard that an enlarged NT can also signal fetal heart
    defects. How large does the NT have to be to be considered a marker
    for potential heart defects?**

    A.  About 1% of patients have an NT[\>]{.underline}3.5 mm (\>99^th^
        percentile), which is used as the cutoff for making a referral
        for fetal echocardiography after 20 weeks. Even if the fetus is
        found to have a normal karyotype, it should still be screened
        for cardiac defects. (The sensitivity of a NT \>3.5 mm for
        congenital heart disease is about 40%, but the positive
        predictive value is only about 4%.)

13. **Q. What about multiple gestations? Can they undergo 1^st^
    trimester screening?**

    A.  Twins can be screened for fetal aneuploidy in the 1^st^
        trimester since nomograms are available to calculate their
        overall risk. Higher order multiples however are not able to be
        accurately screened at present, although an NT \>3.5 mm should
        always raise suspicion.

14. **Q. Does 1^st^ trimester screening only screen for fetal Down
    syndrome, or can other fetal trisomies also be detected?**

A. First trimester combined screening tests screen for trisomy 21 (Down
syndrome) and trisomy 18. Trisomy 13 and sex chromosome aneuploidies
(Turner syndrome, XO, and Klinefelter syndrome, XXY, etc.) are not
efficiently screened with this test. (However, remember, over 50% of
fetuses with Turner syndrome will have a cystic hygroma, i.e., NT\>3.5
mm.)

15. **Q. My client has a negative 1^st^ trimester DS screening result,
    and a normal 2^nd^ trimester ultrasound, but she still desires
    amniocentesis. Is that indicated?**

    A.  Both 1^st^ and 2^nd^ trimester screening is just that,
        screening, not diagnostic. Screening is able to lower risks, but
        only an invasive diagnostic test can definitively diagnose fetal
        aneuploidy. If a woman still wishes invasive testing and
        understands the risks of pregnancy loss following testing (which
        are quoted in the literature as ranging from 1:200 to 1:1600),
        that is her choice. (It would have been more cost-effective if
        she had decided that earlier and been referred before having any
        screening!)

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

**First trimester screening is a reality**

Though first trimester screening a reality, please note that these
comments are from George Gilson, MFM, at the Alaska Native Medical
Center so are based on the resources available in tertiary care center.
You may wish to do something different in your service unit, but it is
helpful to be aware which direction your clinical care will be heading
when the resources are available.

**REFERENCES**

1.  Malone FD, D'Alton ME. First trimester sonographic screening for
    Down syndrome. Obstet Gynecol 2003; 102:1066-79.

2.  Malone FD, et al. First trimester or second trimester screening, or
    both, for Down syndrome (FASTER Study). N Eng J Med 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. First trimester screening for trisomies 21 and 18.
    NEJM 2003; 349:1405-13.

5.  Reddy UM, Mennuti MT. Incorporating first trimester Down syndrome
    studies into prenatal screening (NICHD Workshop). OG 2006;
    107:167-73.

6.  Berkowitz RL, et al. 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 for fetal aneuploidy. ACOG Committee Opinion
    No.296. ACOG July 2004.

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

**May 2008 --**

-Autism Spectrum Disorders -- Guidelines for Identification and
Diagnosis

-Vaccines and Autism -- The Courts weigh in -- wrongly

-Child Safety Seats for AI/AN children -- how can we get children in
safety seats -- and more

importantly how can we keep them in them

<http://www.ihs.gov/MedicalPrograms/MCH/M/ChPedNotes.cfm#may08>

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

**RPMS Immunization Package**

**Patch Release Announcement**

The Indian Health Service Office of Information Technology and the
Immunization Program announce the following application patch release:

-   Patch 1 of Immunization Package v8.2 (RPMS namespace: BI)

A patch release notice from the IHS Office of Information Technology
have been sent to all RPMS site managers. Site managers are advised to
notify users once the patch has been installed. Complete details of the
modifications included in these patches are included in the official
patch release notices.  The beta sites for this patch were:

-   Alaska Native Medical Center

-   Chinle Service Unit

-   Sells Service Unit

The patch is available for download at
<http://www.ihs.gov/Cio/RPMS/index.cfm?module=home&option=software>. 
When the patch is loaded, the version number for the Immunization
Package should change to 8.2\*1.

The following changes are included in Patch 1: 

1.  The Vaccine Table has been updated and all Vaccine Group, Related
    Contraindications, and other default fields are included in the
    update. 

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```
1.  The Menactra forecasting option was updated to forecast for 11 -- 18
    year olds.

2.  The Adolescent report now excludes immunizations given after the
    Quarter Ending Date.

3.  Lot Number validity is now checked before a visit is filed.

4.  PNE, VAR, and HEPA are no longer included in the Minimum Needs when
    the Quarterly Report is queued.

5.  A Facility field filter on the Imm Lot file was created to help
    limit inappropriate lot choices.

6.  Restricted DEFAULT Lot Numbers will no longer appear to users logged
    onto other facilities.

7.  State immunization data with longer Other Locations field lengths
    can now be imported.

8.  Additional code was added to support IHS sites running 64-bit
    environments.

9.  A new error trap was added and the error code table was updated.

10. Pre-installation routine was updated to preserve local templates.

11. New public entry point was added for EHR compatibility.

12. New code was added to allow imported data strings larger than 32K.

13. Updated access to ICD and CPT codes to comply with Code Set
    Versioning requirement.

For user support please contact the RPMS help desk at
[[RPMSHelp@ihs.gov]{.underline}](mailto:RPMSHelp@ihs.gov) or call (888)
830-7280.

**American Indian health advocates can learn to develop multimedia
health projects for rural communities**

The development and dissemination of culturally relevant health care
information has traditionally taken a \"top-down\" approach.
Governmental funding agencies and research institutions have too often
dictated the importance and focus of health-related research and
information dissemination. In addition, the digital divide has affected
rural communities in such a way that their members often do not possess
the knowledge or experience necessary to use technological resources.
And, even when they do, their skills may be limited, adequate only for
implementing applications and programs designed by others who live and
work outside of these communities. This need became the driving force in
the creation of the Native Telehealth Outreach and Technical Assistance
Program. The goal of the program is to equip Native community members,
at both the lay and professional levels, with the means to use
technology to address tribal health care needs. The transfer of relevant
technical knowledge and skills enables participants to develop projects
which enhance the community-wide dissemination of health care
information. Nine community health advocates and professionals
participated in the initial cohort. Eight of the participants
successfully developed multimedia-based projects including Web sites,
interactive CD-ROMs, and video focusing on a variety of health concerns.
At the conclusion of the 18-month program period, projects were
disseminated throughout rural communities. The NTOTAP staff continues to
evaluate the use of these projects and their benefits within the rural
communities.

[Dick
RW](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Dick RW"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al The Native Telehealth Outreach and Technical Assistance Program: a
community-based approach to the development of multimedia-focused health
care information. Am Indian Alsk Native Ment Health Res.
2007;14(2):49-66. <http://www.ncbi.nlm.nih.gov/pubmed/17874365>

**Release of BGP Clinical Reporting System, Version 8.0**

We are pleased to announce the release of BGP Clinical Reporting System,
Version 8.0 on April 1, 2008.

The BGP Clinical Reporting System v8.0 package was tested at: Rapid City
Service Unit, Red Lake Hospital, Cherokee Indian Hospital, Fort Defiance
Indian Hospital, Choctaw Nation Health Services, Hastings Indian Medical
Center, Pawnee Service Unit, Portland Area Office and Warm Springs
Health and Wellness Center.

The key changes that are included in this version are listed below. For
a full list of changes, please refer to the CRS 2008 v.8.0 User Manual.

\- Split the National GPRA Report and all related reports and patient
lists into separate reports: National GPRA Report and a new Other
National Measures (ONM) Report. NOTE: The Breastfeeding Rates topic is
now included in the ONM Report. There is also a new Other National
Measures Report Patient List that provides the user with lists of
patients either meeting or not meeting an ONM Report measure(s).

\- New GPRA Measure Forecast Patient List: Created to allow users to run
a GPRA-measure forecast for individual patients, a clinic or facility\'s
scheduled patients, or for any patient regardless of appointment status.

This list uses modified National GPRA logic and indicates the GPRA
measures will be due for during the GPRA year. It also includes
information for the provider on how the measure can be met. This is
included on the National GPRA Reports menu as option FOR. There is also
an accompanying denominator definitions page (menu option FORD from
National GPRA Reports menu) users can run to see how the denominators
are defined for the Forecast list.

\- 4 new non-GPRA performance topics:

\- Alcohol Screening and Brief Intervention (ASBI) in the ER

\- Heart Failure and Evaluation of LVS Function

\- Sexually Transmitted Infection (STI) Screening

\- Palliative Care

\- Updated CRS GUI: Includes updated functionality to match all
functionality available in the CRS roll-and-scroll version.

\- CMS Report: Complete redesign of the report and new choices for
running lists of patients for each of the 4 topics of AMI, Heart
Failure, Pneumonia, and Surgical Infection Prevention (SIP). Also added

4 new measures (2-Pneumonia, 2-SIP).

-   Logic Changes to both GPRA and Non-GPRA Measures: See CRS 2008 v.8.0
    User Manual, section 1.1 for detailed list of logic changes.

<Theresa.Cullen@ihs.gov>

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

**Is health a human right?**

In the arena of international development and health, the use of
human-rights language to advocate for the health of the poor is
increasingly popular. This language raises many serious questions, yet
it also historically and morally powerful. The two articles referenced
at the end of this column give those who are interested a place to start
with this rights-and-ethics discussion.

What can a "right to health" possibly mean? If we interpret the phrase
as "a right to be healthy," it's a difficult proposition to swallow.
Everyone dies, and nearly everyone contracts a serious disease at some
point in life: in that light, a right to be healthy seems positively
nonsensical. In practice, though, the phrase "right to health" usually
serves as a shorthand for a right to the conditions necessary to produce
the best attainable standard of health -- conditions including basic
education and access to information, adequate health care, food
security, a safe environment, protection from severe poverty, decent
sanitation and clean water. Public health research has consistently
shown these factors to be strong social determinants of health; many
have been enshrined in the Millenium Development Goals as keys to world
human development.

In fact, the right to the conditions necessary for health has been part
of the Universal Declaration of Human Rights (to which the US is one of
many signatories) since 1948. An expanded version became international
law in the 1970s. Though a US ambassador to the United Nations derided
this law as a "letter to Santa Claus" the decade after that, soon a
terrible epidemic was to draw the world's attention to the conjunction
of health and human rights. In the 1990s, the devastating spread of
HIV/AIDS exposed to the view of wealthy countries the links between
inequality and disease, marginalization and disease, poverty and
disease, lack of adequate health care and disease. In this context, the
work of Jonathan Mann called for human rights to be the foundation of
public health ethics, an idea that has spread widely in the new
millennium.

This framework is not without problems. First, it does not address the
issue of competing priorities. Why is health a priority over all other
communal values, or is it? What happens in situations of extreme
scarcity? What about when one country's priorities (for national
security, for instance, or for intellectual property rights) cause
damaged health in other countries? Second, it carries an ambiguity
between judicial and moral claims. Rights in the legal sense are things
a person may reasonably expect to have satisfied by the force of the
law. Is a decent standard of living really this kind of right? Is access
to health care? If so, how much health care? (Those in the Indian Health
Service, where treaty rights really did establish legal claims to health
care and education, will recognize some of these debates.) Even if the
"right to health" is not thought of as a legal right, but a moral one,
whose responsibility is it? Finally, what about transnational or
supra-national institutions? Mechanisms of international accountability
remain fairly thin. If the World Bank's policies, or Chevron's, or
Pfizer's, hurt the health of the Third-World poor, who holds them
accountable and how?

Despite these serious concerns, thinking about health as a human right
does have an impact in the international health arena. I see it as
having two major functions. It creates a right to assistance -- and *a
duty to intervene* -- in the name of health. This right and duty have
been established for decades in humanitarian conflicts (though they are
not completely without controversy); what's new here is their use in the
setting of severe disease. Again, the HIV/AIDS epidemic, especially in
Africa, was paramount in shifting this discussion. More broadly, health
as a human right rhetorically establishes a framework of ethics, a
language of moral urgency that does not depend on religious creed and
therefore opens the way to international consensus on public health
issues. In this sense, it is an important counter-discourse to the
dominant argument of neo-liberal economics: that the invisible hand of
the market, working through economic growth, is alone enough to improve
human well being. In this realm human rights as a framework for public
health ethics meets social justice movements. The powerful language of
rights moves the disciplines of medicine and public health away from
narrow disease-specific intervention programs, away from a preoccupation
with individual genetics and behavioral choices and into the realm of
social determinants of health.

Here's how I see Jonathan Mann's project, Paul Farmer's project, the
project of those who work within this model: they are calling us to a
passion for social justice. They are getting public health up beside
them on the soapbox in defense of a set of values embedded in human
rights talk. Their language has echoes of Mandela and Gandhi, Jefferson
and Lincoln, Tiananmen Square, Birmingham and Martin Luther King. They
marshal deep history and moral force to move us forward -- with genuine
partnerships and a shared vision of the future -- into a struggle for
the human commonwealth.

Sounds good, doesn't it?

Buchanan, DR. Autonomy, paternalism, and justice: ethical priorities in
public health. American

Journal of Public Health 98(1):15-21, 2008.
<http://www.ncbi.nlm.nih.gov/pubmed/18048780>

Mann, JM. Medicine and public health, ethics and human rights. Hastings
Center Report 27(3):6-

13, 1997. <http://www.ncbi.nlm.nih.gov/pubmed/9219018>

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

**Adverse Drug Events in Pediatrics**

This study is the first to develop and evaluate a trigger tool to detect
ADEs \[adverse drug events\] in an inpatient pediatric population.

The authors found that

\* A total of 960 randomly selected charts reflecting a total of 6,806
patient days were evaluated. A total of 2,388 triggers were detected
(mean rate of 2.49 triggers per patient) and a total of 107 ADEs were
identified (mean rates of 11.1 ADEs per 1,000 patients, 15.7 ADEs per
1,000 patient days, and 1.23 ADEs per 1,000 medication doses).

\* Of the 107 ADEs identified in the study, 104 (97.2%) contributed to
or resulted in temporary harm to the patient and required intervention;
22% percent were preventable, 17.8% could have been identified earlier,
16.8% could have been mitigated more effectively, and only 3.7% had a
voluntary hospital occurrence report associated with the event.

\* The medication-management stage during which a medication error was
most likely to occur (resulting in a preventable ADE) was the monitoring
phase (62.5%; defined as failure to review a prescribed regimen for
appropriateness and detection of problems or failure to use appropriate
clinical or laboratory data for adequate assessment of patient response
to prescribed therapy).

\* The medication class most frequently associated with an ADE was
analgesics or opioids.

\* The most frequent type of ADE was pruritis (severe itching).

These data should provide the groundwork for aggressive, evidence-based
prevention strategies to decrease the substantial risk for
medication-related harm to our pediatric inpatient population.

Takata GS, Mason W, Taketomo C, et al. 2008. Development, testing, and
findings of a pediatric-focused trigger tool to identify
medication-related harm in US children\'s hospitals. Pediatrics
121(4):e927-e935. Abstract available at
[[http://pediatrics.aappublications.org/cgi/content/abstract/121/4/e927]{.underline}](http://pediatrics.aappublications.org/cgi/content/abstract/121/4/e927)

**MCH Headlines Judy Thierry HQE**

**CDC Releases Study on Abuse & Neglect of Infants**

CDC released a study today entitled \"Nonfatal Maltreatment of Infants
\-- United States, October 2005--September 2006.\" The study, published
in CDC's Morbidity and Mortality Weekly Report, found that in the year
studied, there were 91,278 babies less than 1 year old who were
documented victims of child abuse or neglect. Of those, 29,881 were
victims of abuse or neglect before they were 1 week old.

Almost 70% of babies less than 1 week old were reported for neglect and
13.2% were reported for physical abuse. The study also found that
medical professionals, such as doctors, nurses, and other hospital staff
were most likely to report child abuse and neglect of babies. The study
was authored by researchers from CDC's National Center for Injury
Prevention & Control and the Administration for Children & Families
(ACF).

The study is available at <http://www.cdc.gov/mmwr>.

Child maltreatment is a huge problem throughout the United States, and
it disproportionately affects the youngest members of our society. The
few cases of abuse or neglect we see in the news are only a small part
of the problem. Many cases are not reported to police or social
services. What we do know is that approximately 1,530 children died in
the United States in 2006 from abuse and neglect. In addition, the legal
and health care costs for child maltreatment exceed \$24 billion each
year.

April was National Child Abuse Prevention Month, an observance intended
to increase awareness of child maltreatment and encourage individuals
and communities to support children and families. CDC defines child
maltreatment as any act or series of acts of commission or omission by a
parent or other caregiver that results in harm, potential for harm, or
threat of harm to a child. During April, CDC and ACF will highlight a
range of child maltreatment prevention measures at the national, state,
and local levels, including promotion of safe, stable, and nurturing
relationships (SSNR) between children and caregivers.

More information on child maltreatment and the SSNR framework can be
found in the following publications, available online:

-   [The Effects of Childhood Stress on Health Across the
    Lifespan](http://www.cdc.gov/ncipc/pub-res/pdf/Childhood_Stress.pdf)

-   [Preventing Child Sexual Abuse within Youth Serving Organizations:
    Getting Started on Policies and
    Procedures](http://www.cdc.gov/ncipc/dvp/PreventingChildSexualAbuse.pdf)

-   [Child Maltreatment Surveillance, Uniform Definitions for Public
    Health and Recommended Data
    Elements](http://www.cdc.gov/ncipc/dvp/CMP/CMP-Surveillance.htm)

The MMWR article is available at:
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5713a2.htm>

Additional CDC information on child maltreatment can be found at
<http://www.cdc.gov/ncipc/dvp/CMP/default.htm>.

Additional information from ACF is available at
[http://www.acf.hhs.gov](http://www.acf.hhs.gov/), and from the Child
Welfare Information Gateway at
[http://www.childwelfare.gov](http://www.childwelfare.gov/).

**Unique status of vaccines as disease prevention "tools"**

There are several distinctions that I have selected below from the 10
page -- article. 

The online article is well written if you do not want to hop through my
bulleted excerpts.

·If thresholds fall below certain levels (90 -- 95%) the protective herd
immunity is lost. 

(A simplistic animation on herd immunity from the WHO can be found at:
<http://www.immunisation.nhs.uk/About_Immunisation/Science/Herd_immunity_-_animation> )

·"Natural infection may provide life long immunity but with risk of
complications of pneumonia, brain damage, and birth defects.  These
consequences including death are unlikely with immunizations."

·"Research shows that infants are fully capable of responding safely and
effectively to multiple vaccines" -- Antigenic load

·"...5200 families have filed autism injury claims with the federal
government, a collective action known as the Omnibus Autism
Proceeding..." [Vaccine Program/Office of Special
Masters](http://www.uscfc.uscourts.gov/OSM/OSMAutism.htm)  The
combination theory, the basis of 3 of the collective actions attempts to
link the vaccine with the mercury containing preservative.

·"Adverse Reaction (AR) classified into 3 groups:

1\. Vaccine-induced (eg, pain at the injection site, allergic
reactions);

2\. Programmatic error (eg, administering an intramuscular vaccine by
the subcutaneous route); or

3\. Coincidental (having a temporal association with the vaccine but
would have occurred even in the absence of vaccination)."

·"The nation\'s voluntary reporting system for adverse events following
vaccine administration confirms that vaccine side effects are
surprisingly uncommon. Vaccine Adverse Event Reporting System (VAERS)
data reveal that 11.4 adverse events occur per 100,000 vaccine doses
distributed. Adverse events often depend upon the nature of the vaccine
itself. The events and the frequency of events are similar to those that
occur with placebo injections in controlled trials and include pain,
swelling, and redness at the injection site."

·"The National Childhood Vaccine Injury Act of 1986 established the
Vaccine Injury Compensation Program (VICP). The VICP went into effect on
October 1, 1988 and is a federal \"no-fault\" system designed to
compensate individuals or families of individuals who have been injured
by covered vaccines, whether administered in the private or public
sector. Since its inception, the VICP has helped stabilize the US
vaccine market by providing liability protection to vaccine
manufacturers and providers, encouraged research and development of new
and safer vaccines, and provided a more streamlined and less adversarial
way to resolve vaccine injury claims."

·Custodian/parent education includes receiving a Vaccine Information
Statement (VIS) on the vaccines being administered.  Us of the VIS is
required by law. " The VIS lists both the risks and benefits of the
vaccine. On page 2 of every VIS, the potential serious injuries that can
occur with the vaccine are described, and the telephone number and Web
site of the VICP are provided." 

·Underreporting of AR's in general and for post-immunization events is
well known.  Physicians and nurse need training in reporting any kind of
significant event and anyone can report to VAERS by calling
1-800-822-7967 or directly on the [VAERS Web
site](http://www.vaers.hhs.gov/).

·"VAERS is not a vaccine injury compensation program. That is an
entirely separate process; it is important to realize that submitting a
report to VAERS does not initiate the process to compensate an
individual or family for a potential vaccine injury."

·"The DTaP vaccine is an example that \"lets the numbers do the
talking.\" If a child gets diphtheria, the risk of death is 1 in 20; for
tetanus, it is 1 in 5. Pertussis leads to pneumonia in 1 of 8
individuals, to encephalitis in 1 of 20, and death in 1 of 1500. These
figures must be contrasted to the risks of adverse outcomes of the DTaP
vaccine. Only 1 in 14,000 may experience seizures or shock with full
recovery, perhaps 10 in 1,000,000 suffer acute encephalopathy, and none
have been known to die as a result of the DTaP vaccine. Clearly,
children are far more likely to be injured as a result of contracting
one of these diseases than from the vaccine given to protect them.

**Summary:**

 "Vaccines remain the most powerful tools we have for disease prevention
today. However, their benefits can only be realized when the necessary
high coverage levels are achieved. The development of new, safer, and
more effective vaccines, as well as novel ways to administer these
vaccines, is one of the most important public health missions of the new
millennium."

<http://www.medscape.com/viewarticle/568534_2>  

**CDC funding 4.4 million to 15 awards oral health HPDP due May 27**

CDC -\"State-Based Oral Disease Prevention Program\"

-   \$4,400,000 in FY 2008 to fund up to

-   15 awards to states and/or territories.

-   assist state or territorial health departments to establish,
    strengthen, and enhance the infrastructure and capacity of
    states/territories to plan, implement, and evaluate population-based
    oral disease prevention and promotion programs, prioritizing
    populations based on oral disease burden. 

-   application due date is May 27, 2008. 

-   Anticipated award date is July 31, 2008.

\*Technical assistance and other information pertinent to this
FOA/cooperative agreement application, including reference information,
reporting requirements, future funding information, and guidelines, will
be provided on the Web-based CDC Sitescape.  To become a user, please
send an e-mail requesting Sitescape link information to Bridgette Smith
at bsn0@cdc.gov. 

\*CDC is planning two telephone conference calls to provide additional
technical assistance related to this FOA.  These calls will be scheduled
during April.  Information for accessing the conference calls will be
sent as soon as it is available.

\*Instructions for locating this announcement on
[www.grants.gov](../../../../../../../../%5C%5Cwww.grants.gov) are as
follows:

Select apply for grants

Select step 1: download grant application

Insert the Funding Opportunity Number:  CDC-RFA-DP08-802

Select Download Package

Again, select the download link on the bottom right

Pull up the Synopsis, Full Announcement, and electronic application
(under, \"How to Apply\") by selecting the buttons across the top of the
page.

CDC-RFA-DPO8-802 <http://www.cdc.gov/od/pgo/funding/FOAs.htm>

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

**You know how to treat yeast infections, right? Which of these are true
about vulvar pruritus ? The answers**

**Here are the answers to last month's questions**

1.) It is important to ask patients presenting with vulvar pruritus if
symptoms vary with their cycles

**True**

Discussion:

When did the symptoms start in relation to menses? Candida
vulvovaginitis often occurs in the premenstrual period, while
trichomoniasis often occurs during or immediately after the menstrual
period.

2.) *Candida glabrata* tends to respond to intravaginal boric acid
therapy

**True**

Discussion:

C. glabrata has low vaginal virulence and rarely causes symptoms, even
when identified by culture. Every effort should be made to exclude other
co-existent causes of symptoms and only then treat for yeast vaginitis.
Treatment failure with azoles is not uncommon (around 50 percent) in
patients with C. glabrata vaginitis. Moderate success (65 to 70 percent)
in women infected with this organism can be achieved with intravaginal
boric acid (600 mg capsule once daily at night for two weeks). Better
results (\>90 percent cure) have been achieved with intravaginal
flucytosine cream (5 g nightly for two weeks); however, flucytosine
cream is not readily available and must be made by a compounding
pharmacy. There are no good data regarding use of oral voriconazole for
C. glabrata vaginitis. Anecdotal reports suggest poor response and rare
if any success, and the potential for toxicity.

Sobel JD; Chaim W Treatment of Torulopsis glabrata vaginitis:
retrospective review of boric acid therapy. Clin Infect Dis 1997
Apr;24(4):649-52. <http://www.ncbi.nlm.nih.gov/pubmed/9145739>

3.) Nystatin successfully treats the majority of patients with tinea
cruris.

**False**

Discussion:

Tinea cruris (jock itch) is a special form of tinea corporis involving
the crural fold. It is a specific fungal infection, but it's a
dermatophyte infection, unlike Candida, which is a yeast form. In North
America the most common cause is T rubrum. A few cases are caused by E
floccosum and occasionally T mentagrophytes.

Tinea cruris is far more common in men than women. The disease often
begins after physical activity that results in copious sweating, and the
source of the infecting fungus is usually the patient\'s own tinea
pedis. Obesity predisposes to tinea cruris.

Topical antifungal treatment will suffice for the ordinary case. Failure
to treat concomitant tinea pedis usually results in prompt recurrence.
Lesions resistant to topical medications can be treated with
griseofulvin by mouth, 250 mg three times daily for 14 days, or any of
the other systemic agents.

Daily application of talcum or other desiccant powders to keep the area
dry will help prevent recurrences. Itching can be alleviated by over the
counter preparations such as Sarna or Prax, although these can be
irritating if applied to inflamed or excoriated skin. Patients should
also be advised to avoid hot baths and tight-fitting clothing, and to
wear boxer shorts rather than briefs.

4.) Topical steroid ointments at the correct treatment for lichen
sclerosus

**True**

Discussion:

The treatment with the best evidence of efficacy from randomized trials
is superpotent topical corticosteroid ointment. Approximately 95 percent
of women will achieve complete or partial relief of symptoms. No
specific superpotent steroid or regimen has been shown to be superior to
another. We use clobetasol or halobetasol propionate 0.05 percent
ointment daily at night for 6 to 12 weeks and then one to three times
per week for maintenance. The ointment is applied sparingly in a thin
film over the affected area. A 15 g tube of ointment should be
prescribed.

Diakomanolis ES et al Vulvar lichen sclerosus in postmenopausal women: a
comparative study for treating advanced disease with clobetasol
propionate 0.05%. Eur J Gynaecol Oncol. 2002;23(6):519-22.
<http://www.ncbi.nlm.nih.gov/pubmed/12556095>

5.) Classic psoriasis occurs often on the vulva

**False**

Discussion:

Classic psoriasis rarely presents primarily on the vulva. If it does
present on the vulva, it is usually in patients with psoriasis primarily
present in the classic psoriasis positions elsewhere on the body.

Patients with plaque type psoriasis usually present as young adults with
symmetrically distributed plaques involving the scalp, extensor elbows,
knees, and back. The plaques are erythematous with sharply defined
margins that are raised above the surrounding normal skin. A thick
silvery scale is usually present, although recent bathing may remove the
scale. The lesions can range from less than 1 to more than 10 cm in
diameter. The plaques typically are asymptomatic, although some patients
complain of pruritus. Close inspection may reveal pitting of the nail
plates and involvement of intertriginous areas such as the umbilicus and
intergluteal cleft.

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

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

#### Expanded HIV Testing in Primary Care: Implementing the CDC Recommendations {#expanded-hiv-testing-in-primary-care-implementing-the-cdc-recommendations-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/572204**](http://www.medscape.com/viewarticle/572204) {#httpwww.medscape.comviewarticle572204 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### HIV Opt-out Testing and Primary Care Practice {#hiv-opt-out-testing-and-primary-care-practice-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/572205**](http://www.medscape.com/viewarticle/572205) {#httpwww.medscape.comviewarticle572205 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### New Guidelines for Management of Urinary Tract Infection in Nonpregnant Women {#new-guidelines-for-management-of-urinary-tract-infection-in-nonpregnant-women .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://cme.medscape.com/viewarticle/571545?src=mp&uac=77433SY**](http://cme.medscape.com/viewarticle/571545?src=mp&uac=77433SY) {#httpcme.medscape.comviewarticle571545srcmpuac77433sy .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Hirsutism, CME/CE  {#hirsutism-cmece .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/9101**](http://www.medscape.com/viewprogram/9101) {#httpwww.medscape.comviewprogram9101 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-27 .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)

#########  {#section-28}

######### 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**

#### Estrogen therapy doubles rate of benign breast lumps {#estrogen-therapy-doubles-rate-of-benign-breast-lumps-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The concern not only because of the extra biopsies and worry those lumps cause, but benign proliferative breast disease may be associated with cancer development in approximately 10 years. {#the-concern-not-only-because-of-the-extra-biopsies-and-worry-those-lumps-cause-but-benign-proliferative-breast-disease-may-be-associated-with-cancer-development-in-approximately-10-years. .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Use of 0.625 mg/d of CEE was associated with a statistically significant increased risk of benign proliferative breast disease {#conclusion-use-of-0.625-mgd-of-cee-was-associated-with-a-statistically-significant-increased-risk-of-benign-proliferative-breast-disease .Style-Heading-4-+-Arial-14-pt-Underline}

[Rohan
TE](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Rohan TE"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Conjugated equine estrogen and risk of benign proliferative breast
disease: a randomized controlled trial. J Natl Cancer Inst. 2008 Apr
16;100(8):563-71

#### [**http://www.ncbi.nlm.nih.gov/pubmed/18398105**](http://www.ncbi.nlm.nih.gov/pubmed/18398105) {#httpwww.ncbi.nlm.nih.govpubmed18398105 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Postmenopausal Systemic Hormone Therapy: Putting Risks Into Perspective CME/CE [**http://www.medscape.com/viewarticle/569399**](http://www.medscape.com/viewarticle/569399) {#postmenopausal-systemic-hormone-therapy-putting-risks-into-perspective-cmece-httpwww.medscape.comviewarticle569399 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Midwives Excel at Keeping Birth Normal, and Midwife-Provided
Acupuncture Helps With PROM**

Amy Romano, CNM with the Lamaze Institute for Normal Birth presents four
fabulous studies in a review of research that further support the
extensive benefits of normal birth.

The first study convincingly shows that midwifery care is more effective
in keeping birth normal and, thus, women healthier. The study focused on
care for women at moderate obstetrical risk. This prospective cohort
study made use of an intriguing new tool called the "Optimality
Index-US" which assesses care processes as well as outcomes giving
better information than just mortality and morbidity. The study found
provider type to be predictive of optimality with midwifery care having
higher scores. For example: "The cesarean-section rate was 13% among
women in the midwife group versus 34% in the physician group, a
difference that also was not explained by health status alone. (The
rates were 5.6% and 15.6%, respectively, after excluding women with
preexisting chronic medical conditions.) In various statistical
analyses, only type of provider accurately predicted cesarean rates in
the two groups." As to why this may have been true some of the processes
of care looked at included: "Compared to women in the physician group,
women in the midwife group were more likely to drink or eat (95% vs.
80%); maintain mobility in labor (68% vs. 28%); and use nonpharmacologic
methods of pain relief (88% vs. 51%). Epidural use was lower in the
midwife group than in the physician group (31% vs. 51%), as was use of
any pharmacologic pain-relief methods (64% vs. 82%)." Romano concludes
her review with the following: "In this and other studies, midwifery
care has been associated with high optimality, demonstrating appropriate
use of interventions and good outcomes given the individual women\'s
clinical situations. Midwives are often assumed to care for only
low-risk women, but many midwives also care for women at moderate or
high risk. This study finds that midwifery may be optimal for a
moderate-risk population by promoting good outcomes with less reliance
on technological and surgical intervention and greater attention to the
care practices that support normal birth." This certainly rings very
true for midwifery in the Indian Health Service---we care for women of
all risk levels and have impressive outcomes and I would bet
"optimality" scores as well. Anyone ready to do the research with this
new tool?

The second study looked at third and forth degree perineal tears and
again found the less interventionist path to be the preferred route.
They looked at six modifiable factors\-- forceps, vacuum, episiotomy,
prolonged second-stage labor, fetal occiput posterior position during
crowning, and epidural---and found that avoiding these individually and
definitely in combination helped prevent third and forth degree tears.
In her assessment of this study in regards to normal birth Romano says:
"Third- and fourth-degree anal tears are highly associated with pain and
incontinence in the postpartum period and contribute to long-term pelvic
floor dysfunction. Unfortunately, this argument has fueled the debate
about the rights of women to choose medically unnecessary cesarean
surgeries rather than prompting examination of the obstetric management
practices that contribute to excess risk of anal sphincter damage in
vaginal births. This study provides evidence of a strong link between
modifiable obstetric practices such as episiotomy, epidural use, and
instrumental vaginal birth and anal sphincter tears. This study also
reinforces that, when instrumental vaginal birth becomes necessary,
episiotomy should be avoided and vacuum extraction is less likely to
injure the anal sphincter than forceps birth. Although some instances
will always occur when these interventions are necessary for fetal or
maternal well-being, their overuse contributes to excess maternal
morbidity with long-term consequences. Care practices such as avoiding
routine interventions, promoting comfort in labor through mobility and
nonpharmacologic techniques, and encouraging physiologic, spontaneous
pushing in nonsupine positions (none of which were assessed in this
study) minimize the risk of severe lacerations both directly in the case
of spontaneous nonsupine pushing and indirectly, by reducing the need
for epidural, promoting optimal positioning of the fetus, and reducing
forceps and vacuum use." Again these are all aspects of the midwifery
model of care.

The third study looked at midwives providing a 20-minute acupuncture
treatment to women with PROM. The women in the treatment group had
significantly shorter active labor---4.4 hours vs. 6.1 hours---and the
relationship was even stronger when they controlled for parity, epidural
use, and infant birth weight. For women who were induced the active
phase in the control group was *twice* as long as in the acupuncture
group and acupuncture was associated with less augmentation of labor as
well. This study was small but the results are impressive. Romano makes
some very meaningful conclusions as to the relevance of this to the
promotion of normal birth: "Although the majority of women will go into
labor on their own after membranes rupture at term, many providers
encourage pharmacologic induction out of concern about infection.
Minimal evidence suggests that a policy of routine induction for PROM
prevents infection, and several studies report an increase in cesarean
rates with induction for PROM versus expectant management. Furthermore,
pharmacologic induction always requires other interventions such as
intravenous lines, electronic fetal monitoring, and restrictions on
mobility in labor, transforming a normal birth into a medicalized one
and introducing potentially unnecessary risks. Low-risk techniques to
encourage labor to start may be beneficial in preventing complications
of both prolonged membrane rupture\` and aggressive induction protocols.
This small but well-designed study suggests that acupuncture treatment
influences labor initiation and progress in women with PROM. A larger
trial may be able to confirm an effect on mode of birth, rates of
induction, and likelihood of infection. However, in the meantime, the
fact that acupuncture has not been shown to be harmful to birthing women
or their newborns suggests that it is an optimal first-line approach
when the option of encouraging labor to start is desirable." Some IHS
sites are providing acupuncture services (finally!) for patients. I
think it behooves midwives to work with acupuncture providers in IHS
and/or outside IHS to get trained in this technique of promoting labor.

The forth study was published in the ACNM journal and looked at the
experience of women in early labor. The study's results and Romano's
comments are very encouraging for all of us to examine how we prepare
and care for women in early labor. Romano says: "For women who choose
hospital birth, mounting evidence suggests that their likelihood of
achieving vaginal birth is strongly influenced by how long they stay
home. However, simply advising women to stay home until active labor is
well established may contribute to anxiety and confusion if they are not
equipped with appropriate information, support, and anticipatory
guidance. This small study suggests that women spend energy and time in
early labor sorting out their expectations, devising new plans, managing
mixed emotions, and second-guessing decisions. Providing women with
strategies to anticipate and deal with gaps between expectations and
experiences may help them adapt better to early labor and have
confidence in their management strategies. Reassessing how childbirth
educators teach women to self-diagnose labor---or introducing models
that include home visitation or outpatient early-labor assessment and
support, as proposed by the study authors---may help women who choose
hospital birth to optimize the timing of hospitalization to achieve
normal births." I highly recommend that each midwifery service in IHS
read this study, examine how early labor is talked about with patients
in classes, groups, or clinic, and how early labor triaging and care is
provided for in the labor and birthing areas.

Romano, A., Research Summaries for Normal Birth, J Perinat Educ. 2007
Spring; 16(2): 47--50.

<http://www.ncbi.nlm.nih.gov/pubmed/18311339>

**Women given sterile water injection experience less labor pain
compared to acupuncture**

RESULTS: The main results of this study were that sterile water
injections yielded greater pain relief (p\<0.001) during childbirth
compared to acupuncture. The secondary outcome showed that women in the
sterile water group had a higher degree of relaxation (p\<0.001)
compared to the acupuncture group. The women\'s own assessment of the
effects also favoured sterile water injections (p\<0.001). There were no
significant differences regarding requirements for additional pain
relief after treatment between the 2 groups. CONCLUSIONS: Women given
sterile water injection experience less labour pain compared to women
given acupuncture.

[Mårtensson
L](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Mårtensson L"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Acupuncture versus subcutaneous injections of sterile water as
treatment for labour pain. Acta Obstet Gynecol Scand. 2008;87(2):171-7.
<http://www.ncbi.nlm.nih.gov/pubmed/18231884>

**Irrespective of treatment, pelvic girdle pain regresses in majority by
12 weeks after delivery**

RESULTS: Approximately three-quarters of all the women were free of pain
3 weeks after delivery. There were no differences in recovery between
the 3 treatment groups. According to the detailed physical examination,
pelvic girdle pain had resolved in 99% of the women 12 weeks after
delivery. CONCLUSIONS: This study shows that irrespective of treatment
modality, regression of pelvic girdle pain occurs in the great majority
of women within 12 weeks after delivery.

[Elden
H](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Elden H"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Regression of pelvic girdle pain after delivery: follow-up of a
randomised single blind controlled trial with different treatment
modalities. Acta Obstet Gynecol Scand. 2008;87(2):201-8.

<http://www.ncbi.nlm.nih.gov/pubmed/18231889>

**Cervical Cancer Screening Practices of Certified Nurse-Midwives in the
United States**

Many nurse-midwives initiate cervical cancer screening earlier than
guidelines recommend; 72% would initiate screening in an 18-year-old
within 1 month of coitarche, while 36% would begin screening virginal
girls at age 18, and many continue cervical cancer screening after
guidelines recommend cessation. More than 60% of the respondents would
continue screening a woman who had undergone total hysterectomy for
symptomatic fibroids who had no history of dysplasia, and half would
continue to screen a 70-year-old woman with a 30-year history of
previous normal Pap tests. In addition, despite guidelines which
recommend less frequent screening, more than one-quarter (28%) would
continue annual screening in a 35-year-old woman with three or more
normal tests. Certified nurse-midwives are performing cervical cancer
screening more frequently than current guidelines recommend. Comparisons
to the practice of other providers are offered. Education to limit
unnecessary testing is needed.

[Murphy
PA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Murphy PA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Cervical cancer screening practices of certified nurse-midwives in
the United States. J Midwifery Womens Health. 2008 Jan-Feb;53(1):11-8.
<http://www.ncbi.nlm.nih.gov/pubmed/18164429>

**Navajo News Jean Howe, Chinle**

**Sexual Assault Nurse Examiner (SANE) Training Course, June 9 -- 13,
2008**

Navajo Nation Museum, Window Rock, Arizona.

 

This 5-day intensive training course will focus on the basic forensic
medical examination techniques and issues in providing care for adult
and adolescent victims of sexual assault. It will provide nurses and
other licensed healthcare professionals with the didactic training
necessary for certification as a Sexual Assault Nurse Examiner (SANE) or
a Sexual Assault Forensic Examiner (SAFE) and discuss next steps after
training. Strategies for developing a multi-disciplinary Sexual Assault
Response Team (SART) will also be reviewed.

 

This course provides the classroom curriculum portion of SANE/SAFE
training. For nurses or other healthcare professionals who do not
routinely perform pelvic examinations, practical experience to acquire
pelvic examination skills should be arranged outside of this course. It
would be beneficial to begin this process prior to attending the course
if possible. After completion of the course, proctoring is also strongly
recommended for the initial forensic examinations performed.

 

This course is open to Indian Health Service healthcare professionals,
including nurses, advanced practice nurses, PAs, and physicians. A
brochure and registration forms will be available soon, as well as
information on lodging. There is no fee to attend the course.
Transportation, lodging, and per diem are the responsibility of the home
health system or individual.

 

This course is being co-sponsored by Carolyn Aoyama, Senior Consultant
for Women's Health and Advanced Practice Nursing Program at IHS
Headquarters and by the Chinle Family Violence Prevention Task Force and
the Navajo-Hopi-Zuni SANE/SART Work Group. For questions about content,
please contact Sharon Jackson (<Sharon.jackson@ihs.gov>) or Sandra Dodge
(<Sandra.dodge@ihs.gov>). For questions about registration or logistics,
please contact Alberta Gorman (<Alberta.gorman@ihs.gov>).

IHS and Tribal sites throughout the Four Corners area are working with
the Northern Arizona Center Against Sexual Assault to formulate an
integrated approach to sexual assault. This training is a part of that
effort. The goal is to have SANE and SART services available throughout
the Four Corners area. 

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

**Nurses Corner Sandra Haldane, HQE**

#### Staff education and performance feedback only slightly improve fracture prevention among nursing home residents {#staff-education-and-performance-feedback-only-slightly-improve-fracture-prevention-among-nursing-home-residents .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ahrq.gov/research/may08/0508RA12.htm**](http://www.ahrq.gov/research/may08/0508RA12.htm) {#httpwww.ahrq.govresearchmay080508ra12.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Factors Associated with Elevated Risk of Postneonatal Mortality Among
Alaska Native**

[Objective]{.underline} Compared to non-Natives in Alaska, the Alaska
Native population has a postneonatal mortality rate 2.3 times higher
(95% CI 1.9, 2.7). The objective of the study was to identify variables
that account for this elevated risk.

[Methods]{.underline} The dataset used included birth and death
certificate records for all Alaska-resident live births and infant
deaths occurring during 1992-2004. Race was defined as Alaska Native or
non-Native. The association between race and postneonatal mortality was
examined using univariate, stratified and regression analyses. Variables
were considered confounding if they resulted in a change of at least 10%
in the odds ratio between race and postneonatal mortality when added to
a bivariate model, or when removed from a multivariate model.

[Results]{.underline} In stratified analysis, race remained associated
with postneonatal mortality within most categories of marital status,
maternal education, maternal age, prenatal tobacco or alcohol use,
prenatal care utilization, parity and residence. The odds ratio between
race and postneonatal mortality was reduced to 1.3 (95% CI 1.0, 1.6) by
controlling for education, a composite variable of marital status and
the presence of father\'s name on the birth certificate, and prenatal
tobacco or alcohol use.

[Conclusions]{.underline} A small number of potentially modifiable
factors explain most of the postneonatal mortality disparity between
Alaska Natives and non-Natives, leaving a relatively small increase in
risk. These findings suggest that by targeting Alaska Native women who
display these characteristics, the postneonatal mortality gap may be
reduced.

[Blabey
MH](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Blabey MH"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Gessner
BD](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Gessner BD"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus).Three
Maternal Risk Factors Associated with Elevated Risk of Postneonatal
Mortality Among Alaska Native Population. Matern Child Health J. 2008
Apr 4

#### [**http://www.ncbi.nlm.nih.gov/pubmed/18389352**](http://www.ncbi.nlm.nih.gov/pubmed/18389352) {#httpwww.ncbi.nlm.nih.govpubmed18389352 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-33 .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}

**Prenatal Care in Oklahoma**

A study released last fall compared the state of Oklahoma statistics of
Native American women receiving prenatal care versus White women. The
study showed a significant increase in the numbers of Native American
women receiving prenatal care since the previous study was done in 1994.
Today 76.7% of Native American women receive prenatal care in the first
trimester, not significantly different from White women (78.8%). This
improvement is greatly attributed to the significant improvement in
access to care through construction of new and expansion of existing
Indian Health Service, Tribal and Urban Health facilities. Barriers to
care included in decreasing order: Lack of pregnancy recognition
(51.8%), inability to get an earlier appointment (21.2%) and no Medicaid
card (16.7%).

Other Statistics

Native American women were more likely to have their first baby before
18 (24.5% versus 14.3%)

Number one barrier to obtaining prenatal care as early as desired for
Native American mothers was "I didn't know I was pregnant".

[http://www.ok.gov/health/documents/PRAMS_Native%20Am_2007.pdf](http://www.ok.gov/health/documents/PRAMS_Native Am_2007.pdf)

or

<http://www.tulsaworld.com/news/article.aspx?articleID=071213_1_A24_hAnew76523>

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

#### Drug Insight: Choosing a Drug Treatment Strategy for Women With Osteoporosis\--An Evidence-Based Clinical Perspective  {#drug-insight-choosing-a-drug-treatment-strategy-for-women-with-osteoporosis--an-evidence-based-clinical-perspective .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/572416**](http://www.medscape.com/viewarticle/572416) {#httpwww.medscape.comviewarticle572416 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### Colon Cancer Screening: What You Should Know {#colon-cancer-screening-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20080401/1003ph.html**](http://www.aafp.org/afp/20080401/1003ph.html) {#httpwww.aafp.orgafp200804011003ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-35 .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}

**Maternal Fetal Medicine Editorial Comment:**

**Clarification for 'What is this all about the 'minor markers' for Down
Syndrome?'**

We would like to clarify a few points from the April Perinatology Picks
story entitled: **What is this all about the 'minor markers' for Down
Syndrome?**

 

If women undergo first trimester Down syndrome (DS), and the results
are negative (risk \<1:300), the system set up at ANMC, \"contingent
sequential screening\", considers them as not requiring further second
trimester screening for DS. This is because second trimester quadruple
marker screening will increase the number of false positive results if
first trimester results are not taken into account. Other screening
systems, such as \"integrated screening\" do use both first and second
results do compute a final risk estimate, but this is not the strategy
we have chosen to use at ANMC. Despite negative first trimester DS
screening, women still need to be screened for open neural tube defects
(NTD). We accomplish this at ANMC by having all women undergo a
comprehensive fetal anatomic survey at 16-20 weeks. Ultrasound has a 96%
sensitivity for NTD, whereas quad screening with maternal alpha
fetoprotein (AFP) only has an 80% sensitivity (only 65% in pregnancies
not ultrasound dated!). If your service unit is unable to do routine
second trimester ultrasounds however, you still must offer women NTD
screening with AFP testing, even if they have had negative first
trimester DS screening results. 

 

If you have further questions, please contact George Gilson at
<gjgilson@anmc.org>

 

**What is this all about the 'minor markers' for Down Syndrome?** April
2008 CCC Corner

[http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#peri](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft%23peri)

 

**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...."

References

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

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

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

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

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

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

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

#### Physiologic evidence to support levels of anomie\* and hostility with risk of PTD {#physiologic-evidence-to-support-levels-of-anomie-and-hostility-with-risk-of-ptd-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Underlying maternal vascular disease has been implicated as one of several pathways contributing to preterm delivery (PTD) and psychosocial factors such as hostility, anomie, effortful coping, and mastery may be associated with PTD by affecting maternal vascular health. Using data from the Pregnancy Outcomes and Community Health (POUCH) study, we included 2018 non-Hispanic White and 743 African American women from 52 clinics in five Michigan, USA communities. Women were interviewed at 15-27 weeks\' gestation and followed to delivery. In a subset of 395 women monitored for blood pressure, anomie scores were positively associated with systolic blood pressure and heart rate and hostility scores were positively associated with systolic and diastolic blood pressure, heart rate and mean arterial pressure in models that included time, awake/asleep, race/ethnicity, and age as covariates. Further adjustment for body mass index and smoking attenuated the anomie-vascular relations but had little effect on the hostility-vascular relations. Overall this study of pregnant women provides some physiologic evidence to support findings linking levels of anomie and hostility with risk of PTD. {#underlying-maternal-vascular-disease-has-been-implicated-as-one-of-several-pathways-contributing-to-preterm-delivery-ptd-and-psychosocial-factors-such-as-hostility-anomie-effortful-coping-and-mastery-may-be-associated-with-ptd-by-affecting-maternal-vascular-health.-using-data-from-the-pregnancy-outcomes-and-community-health-pouch-study-we-included-2018-non-hispanic-white-and-743-african-american-women-from-52-clinics-in-five-michigan-usa-communities.-women-were-interviewed-at-15-27-weeks-gestation-and-followed-to-delivery.-in-a-subset-of-395-women-monitored-for-blood-pressure-anomie-scores-were-positively-associated-with-systolic-blood-pressure-and-heart-rate-and-hostility-scores-were-positively-associated-with-systolic-and-diastolic-blood-pressure-heart-rate-and-mean-arterial-pressure-in-models-that-included-time-awakeasleep-raceethnicity-and-age-as-covariates.-further-adjustment-for-body-mass-index-and-smoking-attenuated-the-anomie-vascular-relations-but-had-little-effect-on-the-hostility-vascular-relations.-overall-this-study-of-pregnant-women-provides-some-physiologic-evidence-to-support-findings-linking-levels-of-anomie-and-hostility-with-risk-of-ptd. .Style-Heading-4-+-Arial-14-pt-Underline}

[Tiedje
L](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Tiedje L"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Hostility and anomie: links to preterm delivery subtypes and
ambulatory blood pressure at mid-pregnancy. Soc Sci Med. 2008
Mar;66(6):1310-21.

#### [**http://www.ncbi.nlm.nih.gov/pubmed/18179853**](http://www.ncbi.nlm.nih.gov/pubmed/18179853) {#httpwww.ncbi.nlm.nih.govpubmed18179853 .Style-Heading-4-+-Arial-14-pt-Underline}

\*[Dictionary:](http://www.answers.com/library/Dictionary-cid-3254)
Anomie (ăn\'ə-mē)

1.  Social instability caused by erosion of standards and values.

2.  Alienation and purposelessness experienced by a person or a class as
    a result of a lack of standards, values, or ideals: "We must now
    brace ourselves for disquisitions on peer pressure, adolescent
    anomie and rage" (Charles Krauthammer).

\[French, from Greek anomiā, lawlessness, from anomos, lawless : a-,
without; + nomos, law.\]

**Higher risk of offspring schizophrenia following antenatal maternal
exposure to severe adverse life events**

CONCLUSIONS: Our population-based study suggests that severe stress to a
mother during the first trimester may alter the risk of schizophrenia in
offspring. This finding is consistent with ecological evidence from
whole populations exposed to severe stressors and suggests that
environment may influence neurodevelopment at the
feto-placental-maternal interface.

[Khashan
AS](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Khashan AS"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Higher risk of offspring schizophrenia following antenatal
maternal exposure to severe adverse life events. Arch Gen Psychiatry.
2008 Feb;65(2):146-52.

<http://www.ncbi.nlm.nih.gov/pubmed/18250252>

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

**The conclusion of the adolescent behavioral health on-line
discussion:**

This month's discussion on adolescent behavioral health will be
terminated prematurely due to the non-negotiable demands of Spring Break
-- certainly an imperative that all self-respecting adolescents would
endorse enthusiastically.

I hope that the case discussed shed at least some light on issues
bearing on the diagnosis and management of behavioral health disorders
in adolescents. Precision in psychiatric diagnosis of children and teens
is problematic to say the least. A major proportion of drug
prescriptions in this population are off-label, which is perhaps
appropriate, as I am not sure we have an exact label for many struggling
kids. Many DSM diagnoses are derived from adult criteria, and often fail
to encompass the nuances of child and adolescent disorders.  No better
example exists than the diagnosis of PTSD, which works pretty well when
applied to an adult after a discrete trauma, but doesn't capture the
wide spectrum of behavioral and emotional responses we see in children
exposed to early life stress, whether chronic or acute. Adult derived
criteria for bipolar disorder, major depression, and even substance
abuse all leave room for "diagnostic orphans", and conversely, can
stretch-to-fit some youth who may not meet the classic definition, but
need help nevertheless.

As many of you know, the diagnosis of bipolar disorder in youth has
increased dramatically in recent years -- actually by 40-fold, according
to the Archives of General Psychiatry.^(1)^  This seems a bit excessive.
I think we now have more kids in this country who are bipolar than
bilingual, which is a sad indictment of both our educational system and
our behavioral health care non-system. If you look at these pediatric
bipolar cases, they are overwhelmingly boys, overwhelmingly young
(median age in one study, 12.8), and overwhelmingly co-diagnosed with
some classic non-zebra-like animals, such as ADHD, Oppositional Defiant
Disorder, and Substance Use Disorders. Bipolar disorder is no longer a
discrete diagnosis; it's a right of passage for troubled youth. However
much this trend may corrupt diagnostic purity while enhancing the ROI
for pharmaceutical companies, I think it may be even more problematic in
Indian Country.  There is a fair amount of evidence from the research
that Western/Caucasian-derived classification schemes for behavioral
health don't "fit" well at all with Native American conceptualizations
of mental and emotional dysfunction. Add this factor to the difficulties
with DSM criteria for youth in general, and throw in the reality that in
psychiatry one would be hard pressed to declare one symptom, sign, or
lab or imaging test as pathognomonic for *any* condition -- well, it is
easy to see how difficult it can be to acheive diagnostic clarity with
Native American adolescents amidst such chaos.  

We always need to remember that we in IHS are dealing with a population
that has been subjected to massive amounts of psychosocial deprivation.
It is well demonstrated that kids who grow up in such circumstances are
far more likely to exhibit signs and symptoms of emotional
dysregulation, disruptive behavior disorders, ADHD, substance use
disorders, and the whole gamut of psychiatric disorders -- whatever the
formal diagnosis may entail. Given the complexities and controversies in
medication management for these youth, the primary care provider needs
to develop a feel for when and how to refer teens and their families to
specialty care. And although child and adolescent psychiatrists are in
extremely short supply in IHS, thankfully we have a few, and have
attracted more in recent years. Most adult psychiatrists -- particularly
if they've been in IHS for a while -- do the best we can, and inevitably
acquire a lot of experience with youth. The American Academy of Child
and Adolescent Psychiatry has published guidelines for referral
(excerpted, with a link below):

**Specific Criteria for Referrals (AACAP)**\
The referring practitioner should consider the following criteria when
considering the decision to refer.

1.  When a child or adolescent demonstrates an emotional or behavioral
    problem that constitutes a threat to the safety of the
    child/adolescent or the safety of those around him/her. (e.g.
    suicidal behavior, severe aggressive behavioral, an eating disorder
    that is out of control, other self-destructive behavior),

```{=html}
<!-- -->
```
1.  When a child or adolescent demonstrates a significant change in
    his/her emotional or behavioral functioning for which there is no
    obvious or recognized precipitant. (e.g. the sudden onset of school
    avoidance, a suicide attempt or gesture in a previously well
    functioning individual),

2.  When a child or adolescent demonstrates emotional or behavioral
    problems (regardless of severity), and the primary caretaker has
    serious emotional impairment or substance abuse problem. (e.g. a
    child with emotional withdrawal, whose parent is significantly
    depressed, a child with behavioral difficulties whose parents are
    going through a "hostile" divorce),

3.  When a child or adolescent demonstrates an emotional or behavioral
    problem in which there is evidence of significant disruption in
    day-to-day functioning or reality contact. (e.g. a child/adolescent
    who has repeated severe tantrums with no apparent reason, a child
    reports hallucinatory experiences without an identifiable physical
    cause),

4.  When a child or adolescent is hospitalized for the treatment of a
    psychiatric illness,

5.  When a child or adolescent with behavioral or emotional problems has
    had a course of treatment intervention for six to eight weeks
    without meaningful improvement,

6.  When child or adolescent presents with complex diagnostic issues
    involving cognitive, psychological, and emotional components that
    may be related to an organic etiology or complex mental health/legal
    issues,

7.  When a child or adolescent has a history of abuse, neglect and/or
    removal from home, with current significant symptoms as a result of
    these actions,

8.  When a child or adolescent whose symptom picture and family
    psychiatric history suggests that treatment with psychotropic
    medication may result in an adverse response. (e.g. the prescription
    of stimulants for a hyperactive child with a family history of
    bipolar disorder or schizophrenia),

9.  When a child or adolescent has had only a partial response to a
    course of psychotropic medication or when any child is being treated
    with more than two psychotropic medications,

10. When a child under the age of five experiences emotional or
    behavioral disturbances that are sufficiently severe or prolonged as
    to merit a recommendation for the ongoing use of a psychotropic
    medication, or

11. When a child or adolescent with a chronic medical condition
    demonstrates behavior that seriously interferes with the treatment
    of that condition.

<http://www.aacap.org/cs/root/physicians_and_allied_professionals/when_to_seek_referral_or_consultation_with_a_child_and_adolescent_psychiatrist> 

At any rate, primary care providers do have a major therapeutic role to
play beyond referral. As was discussed earlier this month, attachment
deficits are central to traumatized youth. Building on family and other
interpersonal relationships is key, and encouraging participation in
community activities (Boys and Girls Clubs, Big Brothers, Big Sisters,
athletic activities), or organizing, mentoring or participating
ourselves in these programs helps rectify attachment deficits.
Participation in school and community activities also helps youth attain
a sense of mastery, and building competence and self-efficacy for kids
is invaluable. Often, teens will respond dramatically if given an
opportunity to be of service to others in need. And sometimes, it is
just a matter of helping a teen realize a strength or special talent
that might have gone unrecognized. It all sounds simplistic, but it is
often surprising how little effective guidance kids get from families in
a perpetual state of crisis. And the problems often go unrecognized at
school, where teens can either blend in with the crowd or act out enough
so that staff give up on them.

These therapeutic interventions depend on the fact that teens' brains
are the ultimate in plasticity -- always developing in response to
environmental demands and influences. This is not just a vague concept,
but based on research that demonstrates changes in synapses and even
gene expression for neurotrophic growth factors in response to
psychosocial and pharmacological interventions.

Adolescents and their families can and do respond to our efforts,
although of course, not uniformly. But much of the success is built on
the foundation of our primary care providers who take the time, even
when there is no time, to try and bring order out of chaos.     

^1^ Moreno C et al. Natural trends in the outpatient diagnosis and
treatment of bipolar discorder in youth. Archive General Psychiatry.
2007; 64:1032-1039.  

<http://www.ncbi.nlm.nih.gov/pubmed/17768268>

**Interested in joining future discussions?**

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

Subscribe to the Primary Care listserv

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directly

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

**HIV Screening in Dental Clinics?**

The 2006 Centers for Disease Control recommendations for routine HIV
screening in all health care settings could include dental clinics an
important testing venue. However, little is known about patients\'
attitudes regarding the routine use of rapid oral HIV screening at an
urban free dental clinic. This pilot study seeks to evaluate the patient
perspective on rapid HIV screening in this setting. In June 2007,
patients at a free dental clinic in Kansas City, Missouri, were provided
an attitude assessment survey prior to their dental visit. This dental
clinic serves a diverse patient population consisting of approximately
37% white, 47% black, 6% Hispanic, 4% Asian, and 1% Native American
uninsured patients. Results were analyzed for acceptance of testing and
potential barriers. Of the 150 respondents, 73% reported they would be
willing to take a free rapid HIV screening test during their dental
visit. Overall, 91% of Hispanics, 79% of Caucasians, and 73% of African
American patients reported they would be willing to be screened.
Patients with a history of multiple prior screening tests for HIV     
were more likely to agree to oral rapid HIV screening in the dental
clinic. The majority (62%) reported that it did not matter who provided
them with the screening result, although some (37%) preferred their
dentist above any other provider. Low self-perception of risk (37%) and
having already received screening elsewhere (24%) were the main reasons
for not accepting a free, rapid HIV screening. Overall, dental clinic
patients widely accepted the offer of rapid oral HIV screening. Rapid
HIV screening in the dental clinic setting is a viable option to
increase the number of individuals who know their HIV status.

Dietz CA, Ablah E, Reznik D, Robbins DK Patients\' attitudes about rapid
oral HIV screening in an urban, free dental clinic. AIDS Patient Care &
STDs. 22(3):205-12, 2008 Mar.

<http://www.liebertonline.com/doi/pdfplus/10.1089/apc.2007.0235>

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

#### Racial Disparities Persist Across All Reportable STDs

Racial and ethnic minorities continue to be disproportionately affected
by sexually transmitted diseases in the United States; data in CDC's
2006 STD Surveillance Report show higher rates of all STDs among
minority racial and ethnic populations when compared to whites, with the
exception of Asians/Pacific Islanders. These disparities may be, in
part, because racial and ethnic minorities are more likely to seek care
in public health clinics that report STDs more completely than private
providers. However, this reporting bias does not fully explain these
differences. Other contributing factors include limited access to
quality health care, poverty, and higher prevalence of disease in these
populations.

**Chlamydia**

In 2006, the rate of chlamydia among African Americans was more than
eight times higher than the rate among whites (1275.0 vs. 153.1 per
100,000 population), with approximately 46 percent of all chlamydia
cases reported among African Americans. Additionally, the rates among
American Indians/Alaska Natives (797.3 per 100,000) and Hispanics (477.0
per 100,000), were five times and three times higher than whites,
respectively. In 2006, chlamydia rates increased for all racial/ethnic
groups, except for Asians/Pacific Islanders.

**Gonorrhea**

Racial disparities in gonorrhea rates are even greater and racial gaps
in diagnosis of gonorrhea are more pronounced than any other disease.
The gonorrhea rate among African Americans was 18 times greater than
that for whites in 2006 (658.4 per 100,000 vs. 36.5 per 100,000). From
2005 to 2006, the gonorrhea rate among African Americans increased by
6.3 percent---the first increase since 1998. In 2006, African Americans
accounted for 69 percent of reported cases of gonorrhea.

In that same year, American Indians/Alaska Natives had the
second-highest gonorrhea rate (138.3 per 100,000), followed by Hispanics
(77.4), whites (36.5), and Asians/Pacific Islanders (21.1). In 2006,
there were increases in gonorrhea rates among all racial and ethnic
groups, except Asians/Pacific Islanders.

**Syphilis**

Although racial gaps in syphilis rates are narrowing, disparities
remain, with rates in 2006 approximately six times higher among blacks
than among whites. This represents a substantial decline from 1999, when
the rate among blacks was 29 times greater than among whites. It is
important to note that this narrowing reflects both declining disease
rates among African Americans as well as significant increases among
white males in recent years.

Despite some progress, African Americans continue to remain
disproportionately affected by syphilis with a rate of 11.3 cases per
100,000 population in 2006. This is more than three times the rate for
Hispanics, who have the second highest rate (3.6 cases per 100,000) as
well as American Indians/Alaska Natives (3.3 cases per 100,000).

In 2006, the P&S syphilis rate among blacks increased for the third
consecutive year, following more than a decade of declines. Between 2005
and 2006, the rate among blacks increased 16.5 percent (from 9.7 to
11.3), with the largest increase among black males (15.5 to 18.3, an
increase of 18.1 percent).

In 2006, the rate of P&S syphilis in black females was 16 times higher
than in white females. In that same year, 43.2 percent of all reported
P&S syphilis cases occurred among African Americans, while whites
accounted for 38.4 percent. Syphilis rates increased for all races and
ethnicities in 2006. <http://www.cdc.gov/std/stats/default.htm>

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

**USPSTF Recommendations for STI Screening**

Since 2000, the U.S. Preventive Services Task Force (USPSTF) has issued
eight clinical recommendation statements on screening for sexually
transmitted infections. This article, written on behalf of the USPSTF,
is an overview of these recommendations. The USPSTF recommends that
women at increased risk of infection be screened for chlamydia,
gonorrhea, human immunodeficiency virus, and syphilis. Men at increased
risk should be screened for human immunodeficiency virus and syphilis.
All pregnant women should be screened for hepatitis B, human
immunodeficiency virus, and syphilis; pregnant women at increased risk
also should be screened for chlamydia and gonorrhea. Nonpregnant women
and men not at increased risk do not require routine screening for
sexually transmitted infections. Engaging in high-risk sexual behavior
places persons at increased risk of sexually transmitted infections. The
USPSTF recommends that all sexually active women younger than 25 years
be considered at increased risk of chlamydia and gonorrhea. Because not
all communities present equal risk of sexually transmitted infections,
the USPSTF encourages physicians to consider expanding or limiting the
routine sexually transmitted infection screening they provide based on
the community and populations they serve.

Am Fam Physician. 2008;77(6):819-824.
<http://www.aafp.org/afp/20080315/819.html>

####  {#section-39 .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}

**Take the stairs and live longer**

Researchers at the University of Missouri in Columbia, Mo., and the
University of Copenhagen in Denmark, asked study participants to reduce
the amount of steps they take to just 1,400 per day. Instead of walking
or taking the stairs, they were instructed to use elevators, escalators
and cars whenever possible. Many doctors recommend taking 10,000 steps a
day for a healthy lifestyle, but the average American takes only 7,473
steps each day and inactive Americans \-- just 2,100.

After two weeks, participants\' glucose and fat levels increased greatly
and their bodies took much longer than before to clear the substances
from their blood streams. \"When extra fats and sugars (glucose) don\'t
clear the bloodstream, they go where we don\'t want them and cause
problems for our bodies\' typical metabolic functions,\" Frank Booth,
Ph.D., a professor of biomedical sciences at the University of
Missouri\'s College of Veterinary Medicine, was quoted as saying.

Researchers say study participants experienced accumulation of dangerous
abdominal fat, elevated blood-lipids \-- a sign of pre-diabetes \-- and
their total skeletal and muscle mass decreased.

"Previously, we thought that not exercising just wasn\'t healthy, but we
didn\'t think that a lack of activity could cause disease. That
assumption was wrong," Booth said.

[Olsen
RH](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Olsen RH"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Metabolic responses to reduced daily steps in healthy
non-exercising men.

JAMA. 2008 Mar 19;299(11):1261-3.
<http://www.ncbi.nlm.nih.gov/pubmed/18349087>

**Possible Way to Detect Gestational Diabetes**

This study showed that 7% of women diagnosed with gestational diabetes
were already diabetic at the time of first visit and were misdiagnosed
with gestational diabetes, when they had diabetes. They also found that,
a HBA1C level at the first visit of less than 5.3 would not develop
gestational diabetes during the entire course of pregnancy.

[Balaji
V](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Balaji V"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al A1C in gestational diabetes mellitus in Asian Indian women.
Diabetes Care. 2007 Jul;30(7):1865-7
<http://www.ncbi.nlm.nih.gov/pubmed/17416790>

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

**HgbA1C not ready for prime time to diagnose gestational diabetes**

We have all struggled with what to call those pts diagnosed in the first
trimester for just the reasons outlined by Balaji et al. The article is
of interest, but doing a HgbA1C on all pregnant women is probably not
ready for prime time of clinical diagnosis.

We have settled on the simple designation of First Trimester GDM because
it could represent pregestational DM, but using that term
(pregestational DM) can be confusing because many will have a normal
OGTT after they deliver. This concept has been discussed in the CCC
Corner.

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0607_AOM.cfm>

or here in pdf

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_06.pdf>

In the trenches the clinical differences during the pregnancy are
minimal as far as management goes....we still need to follow their
fingersticks and then add hypoglycemics if diet and exercise aren't
enough

####  {#section-40 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Periodontal pathogens and gestational diabetes mellitus {#periodontal-pathogens-and-gestational-diabetes-mellitus-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Study has found evidence that pregnant women with periodontal (gum)
disease have an increased risk of developing gestational diabetes than
pregnant women with healthy gums.

####  {#section-41 .Style-Heading-4-+-Arial-14-pt-Underline}

#### In previous cross-sectional or case-control studies, clinical periodontal disease has been associated with gestational diabetes mellitus. To test the hypothesis that, in comparison with women who do not develop gestational diabetes mellitus, those who do develop it will have had a greater exposure to clinical and other periodontal parameters, we measured clinical, bacteriological (in plaque and cervico-vaginal samples), immunological, and inflammatory mediator parameters 7 weeks before the diagnosis of gestational diabetes mellitus in 265 predominantly Hispanic (83%) women in New York. Twenty-two cases of gestational diabetes mellitus emerged from the cohort (8.3%). When the cases were compared with healthy control individuals, higher pre-pregnancy body mass index (p=0.004), vaginal levels of Tannerella forsythia (p=0.01), serum C-reactive protein (p=0.01), and prior gestational diabetes mellitus (p=0.006) emerged as risk factors, even though the clinical periodontal disease failed to reach statistical significance (50% in those with gestational diabetes mellitus vs. 37.3% in the healthy group; p=0.38). {#in-previous-cross-sectional-or-case-control-studies-clinical-periodontal-disease-has-been-associated-with-gestational-diabetes-mellitus.-to-test-the-hypothesis-that-in-comparison-with-women-who-do-not-develop-gestational-diabetes-mellitus-those-who-do-develop-it-will-have-had-a-greater-exposure-to-clinical-and-other-periodontal-parameters-we-measured-clinical-bacteriological-in-plaque-and-cervico-vaginal-samples-immunological-and-inflammatory-mediator-parameters-7-weeks-before-the-diagnosis-of-gestational-diabetes-mellitus-in-265-predominantly-hispanic-83-women-in-new-york.-twenty-two-cases-of-gestational-diabetes-mellitus-emerged-from-the-cohort-8.3.-when-the-cases-were-compared-with-healthy-control-individuals-higher-pre-pregnancy-body-mass-index-p0.004-vaginal-levels-of-tannerella-forsythia-p0.01-serum-c-reactive-protein-p0.01-and-prior-gestational-diabetes-mellitus-p0.006-emerged-as-risk-factors-even-though-the-clinical-periodontal-disease-failed-to-reach-statistical-significance-50-in-those-with-gestational-diabetes-mellitus-vs.-37.3-in-the-healthy-group-p0.38. .Style-Heading-4-+-Arial-14-pt-Underline}

[Dasanayake
AP](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Dasanayake AP"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Periodontal pathogens and gestational diabetes mellitus. J Dent
Res. 2008 Apr;87(4):328-33.
<http://www.ncbi.nlm.nih.gov/pubmed/18362313>

####  {#section-42 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Surgeon General\'s Conference on Women and Mental Health**

A summary of this 2005 conference is now available. You will find in the
report an entire section on trauma, violence, and abuse. Although the
workshop was in December of 2005, the lessons in it are still relevant.
[[http://www.surgeongeneral.gov/topics/womensmentalhealth/]{.underline}](http://www.surgeongeneral.gov/topics/womensmentalhealth/)

[**After School Programs Can Increase Physical Activity of Adolescent
Girls**](http://public.nhlbi.nih.gov/newsroom/home/GetPressRelease.aspx?id=2558)

After school programs can modestly increase the amount of physical
activity among girls in middle school, according to new results from the
Trial of Activity for Adolescent Girls, a multiple site, community-based
study supported by the National Heart, Lung, and Blood Institute of the
National Institutes of Health. \[National Institutes of Health\]

<http://public.nhlbi.nih.gov/newsroom/home/GetPressRelease.aspx?id=2558>

Obesity: Pinn Point on Women's Health

The Office of Research on Women's Health (ORWH) is broadcasting the
tenth in a series of podcasts, "Pinn Point on Women's Health," hosted by
Dr. Vivian W. Pinn, Associate Director for Research on Women's Health
and the Director of the Office of Research on Women's Health. The
monthly podcast discusses the latest news in women's health research and
includes conversations with guests on a variety of subjects.

In her latest podcast, Dr. Pinn discusses obesity with Dr. Susan
Yanovski, Co-Director, Office of Obesity Research, National Institute of
Diabetes and Digestive and Kidney Diseases, National Institutes of
Health.  Dr. Yanovski discusses the high rates of obesity among
Americans, and women, especially women of color. She also addresses
recent research linking obesity and gestational diabetes in pregnant
women to obesity and diabetes in children, and offers tips to women on
how to manage weight and nutrition issues for themselves and their
families in their already busy daily lives. 

 "Podcasting" is a relatively new method of distributing audio and video
information via the Internet to iPods and other portable media players
on demand, so that it can be listened to at the user's convenience. The
main benefit of podcasting is that listeners can sync content to their
media player and take it with them to listen to whenever they want.
Because podcasts are typically saved in MP3 format, they can also be
listened to on nearly any computer.

To listen to Dr. Pinn's podcast, visit the ORWH homepage at
<http://orwh.od.nih.gov/> and click on the Obesity podcast. If you need
further assistance on how to use podcasts, go to
<http://videocast.nih.gov/faq/podcast/default.asp>.

For questions, contact Marsha Love at the Office of Research on Women's
Health by calling (301) 496-9472 or e-mailing <lovem@od.nih.gov>.

**Chronic Pelvic Pain**

I wanted to share this article, \"Frequency and Distribution of Multiple
Diagnoses In Chronic Pelvic Pain Related to Previous Abuse Or
Drug-Seeking Behavior\", on chronic pelvic pain with you.

[[http://www.medicalnewstoday.com/articles/100761.php]{.underline}](http://www.medicalnewstoday.com/articles/100761.php)

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

**Sexual Assault Nurse Examiner (SANE) Training Course**

-   June 9 -- 13, 2008

-   Navajo Nation Museum, Window Rock, Arizona

-   

-   

-   

-   40 hour didactic portion of SANE/SAFE training

-   

-   

-   

-   Contacts for information: Sharon Jackson <Sharon.jackson@ihs.gov>,
    Sandra Dodge <Sandra.dodge@ihs.gov>, or Alberta Gorman
    (<Alberta.gorman@ihs.gov>).

**Community Health Representative National Educational Meeting**

-   July 29-31 2008

-   Las Vegas, Nevada

-   40th anniversary of the CHR Program. 

<http://www.nachr.net/conferences/2008/>

**Postgraduate Course on Obstetric, Neonatal and Gynecologic Care**

-   September 14-18, 2008

-   Salt Lake City, Utah

-   Comprehensive Women's Health Update for Nurses, Advanced Practice
    Nurses, and Physicians

-   NRP offered as pre-conference session

-   Contact Yvonne Malloy, <ymalloy@acog.org>, for more information

-   Download brochure here:

<http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm?module=08&option=9#top>

>  

# What's new on the ITU MCH web pages? {#whats-new-on-the-itu-mch-web-pages .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

[**Breastfeeding: US Breastfeeding Committee Strategic
Plan**](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm)

[http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm)

There are several upcoming **Conferences**

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

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

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

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

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

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

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

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

The **April 2008 CCC Corner** is available at:\
<http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08>

#### Abstract of the Month page 5 {#abstract-of-the-month-page-5-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**High prevalence of HPV infection in American Indian women of the
Northern Plains**

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

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

#### Current management of gestational diabetes mellitus {#current-management-of-gestational-diabetes-mellitus .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-43 .Style-Heading-4-+-Arial-14-pt-Underline}

#### David Gahn {#david-gahn .Style-Heading-4-+-Arial-14-pt-Underline}

Afghanistan Update

####  {#section-44 .Style-Heading-4-+-Arial-14-pt-Underline}

Scott Giberson

Women and HIV

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

##### Obstetrics page 8

-Cesarean delivery during nursing change of shift is associated with
increased complications

-No benefit in treating women with average-risk pregnancies for
asymptomatic bacterial vaginosis

-Further risks highlighted for obese pregnant women

-Early maternal feeding following CD is associated with higher maternal
satisfaction

-Physical abuse during pregnancy present a large increase in the risk of
preterm delivery

**Gynecology page 9**

-Co-Occurrence of Pelvic Floor Disorders May Be High in Women 

-The Evolution of Midurethral Slings 

-Acupuncture in dysmenorrhea associated with improved quality of life
plus cost-effective

-Uterine Artery Embolization a Good Alternative to Hysterectomy for
Fibroids 

-Overactive Bladder: Diagnosis and Treatment in Primary Care

**Child Health page 10**

-Maternal grandmothers' alcohol use linked to FAS in the Northern Plains

-Pediatricians often do not pursue answers to questions that arise
during medical visits

**Chronic Illness and Disease page 11**

-Low-dose aspirin is linked to lower risk for all-cause mortality in
women, especially older women

#### -How is Your Sleep: A Neglected Topic for Health Care Screening {#how-is-your-sleep-a-neglected-topic-for-health-care-screening .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Pedometer-Based Walking Programs Helpful for Overweight, Sedentary Adults {#pedometer-based-walking-programs-helpful-for-overweight-sedentary-adults .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Blood Pressure May Predict Incident Type 2 Diabetes in Healthy Women {#blood-pressure-may-predict-incident-type-2-diabetes-in-healthy-women .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Discussing reconstruction options prior to surgery influences breast cancer treatment choices  {#discussing-reconstruction-options-prior-to-surgery-influences-breast-cancer-treatment-choices .Style-Heading-4-+-Arial-14-pt-Underline}

#### Features page 12 {#features-page-12 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-Treatment of Urinary Infections in Nonpregnant Women

-Technologic Advances to Reduce Medication-Related Errors

-Relationships With Industry

-Antenatal Corticosteroid Therapy for Fetal Maturation

-ACOG Supports Effort to Encourage Electronic Prescribing

##### American Family Physician

-Pharmacologic Management of Adult Depression

-Diagnosis and Treatment of Female Sexual Dysfunction

**Agency for Healthcare Research and Quality**

-Care quality is not necessarily better with electronic health records

-Patients with DM and depression skip self-care behaviors that would
help keep their DM in check

-Rural emergency departments have high rate of medication errors with
potential to harm children

**Ask a Librarian**

Women\'s Health Resources

**Behavioral Health Insights**

School Refusal By Elise Fatimi, MD

**Breastfeeding**

What makes a good idea work?

**CCC Corner Digest**

March 2008 Highlights

\-[Minorities underrepresented in umbilical cord blood
banking](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08aom)

\-[HPV brochure for AI/AN: available for broad
dissemination](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08col)

\-[Evidence Favors Late Cord Clamping in
Infants](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ht#ob)

\-[Biofeedback Reduces Psychological Burden in Older Women With Urge
Incontinence](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ht#gyn)

\-[Sex education: Providers need to fill gaps in adolescent
knowledge](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ht#child)

\-[Diuretics most effective blood pressure medicine for people with
metabolic
syndrome](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ht#chrIll)

\-[Fatigue and Patient
Safety](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#acog)

\-[Treating Eating Disorders in
Primary](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#afp)

\-[PTSD: A technique that works for
me](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#bhi)

\-[Report cites high rate of violence against Native
women](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#dv)

\-[Exciting opportunity to develop new resources in
geriatrics](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#ecn)

\-[Ringing Endorsement: Women Prefer Contraceptive Ring Over
Patch](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#fp)

\-[Meeting notes now online: 2007 Native Women's Health and MCH
Conference](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#fws)

\-[How can we actually reduce infant mortality in
AI/AN?](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#faq)

\-[Good intentions and unintended
consequences](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#ih)

\-[Maternal depression as a risk factor affecting child readiness and
school
readiness](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#alert)

\-[Findings from the National Survey of Children\'s Health includes
Native
Americans](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#mchh)

\-[St. John\'s wort for depression in a young woman: The
Answers](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#mmt)

\-[Perineal warm packs reduce 3rd and 4th degree lacerations, pain,
urinary
incontinence](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#midw)

\-[Adnexal Masses during
Pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#navajo)

\-[Integrating Nursing and Behavioral
Health](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#nCrnr)

\-[SSRI Use and Bone Loss in Older
Women](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#ost)

\-[Assuring Quality Care for People With Limited Health
Literacy](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#pi)

\-[Usefulness of middle cerebral artery Doppler of the fetus at risk for
anemia](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#peri)

\-[Mental health issues in children and adolescents --Starts March
3rd](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#pcf)

\-[Diabetes A Stronger Risk Factor For Death In Women than In
Men](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#still)

\-[Women and
HIV/AIDS](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#whh)

**Domestic Violence**

-Teens, dating violence, and media use

-Linking dating violence, peer violence, and suicidal behaviors among
high-risk youth

-Non-condom use among young adolescent male perpetrators of dating
violence

-Domestic Violence Resources

-American Psychological Association's Violence Summit

**Elder Care News**

Training in Palliative and End of Life Care

**Family Planning**

#### Increasing contraceptive use and adherence in adolescents

**Featured Website**

#### Meeting notes now online: [2007 Native Women's Health and MCH Conference](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Intro Slide and Eval Sli14.ppt)

**Frequently asked questions**

-Does anyone have an EHR template that is IHS approved for obstetrical
patients?

\-[How to Strengthen Your Pelvic Floor
Muscles?](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/W/MatPT.cfm%23pelvic)

**Indian Child Health Notes**

April 2008 -- Highlights

-Estimating the effectiveness of screening for scoliosis

-Recent news highlights from the world of vaccines

-Invasive Pneumococcal Disease in Children 5 Years After Conjugate
Vaccine Introduction

**Information Technology**

-Seeking input from the field - Clinician's Information Management
Technology Advisory Council

-HIMSS Davies is proud to announce a new recognition opportunity

-iCare Training

International Health

-Routes to TB treatment in rural Nepal

-Unite For Sight Volunteer Abroad Opportunities

#### MCH Alert

-New Bullying-Prevention Toolkit Released

-Chartbook Reports Findings From National Survey of Children with
Special Health Care Needs

-Breastfeeding Improves Prevalence of Metabolic Syndrome Among Women in
Midlife

#### MCH Headlines

-Maternal, Infant and Child Health Capacity Needs Assessment

-GHSA and State Farm Partner to Keep \'Tweens and Teens Safe age 8 to 18

#### Medical Mystery Tour

You know how to treat yeast infections? Which of these are true about
vulvar pruritus ?

#### Medscape

Overactive Bladder: Diagnosis and Treatment in Primary Care, CME/CE

**Menopause Management**

#### -What Happened to Women in WHI study 3 years after stopping HRT?  {#what-happened-to-women-in-whi-study-3-years-after-stopping-hrt .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Associations between subjective night sweats and sleep study findings  {#associations-between-subjective-night-sweats-and-sleep-study-findings .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Beneficial Effect of HT on Mortality and Coronary Heart Disease in Younger Women {#beneficial-effect-of-ht-on-mortality-and-coronary-heart-disease-in-younger-women .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Black Cohosh and Menopausal Symptoms: [Cases in CAM](http://www.medscape.com/px/viewindex/more?Bucket=columns&SectionId=3089) {#black-cohosh-and-menopausal-symptoms-cases-in-cam .Style-Heading-4-+-Arial-14-pt-Underline}

-FDA Goes After \'Natural\' HRT Claims

**Midwives Corner**

-Midwives Excel at Keeping Birth Normal, and Midwife-Provided
Acupuncture Helps With PROM

-Women given sterile water injection experience less labor pain compared
to acupuncture

-Irrespective of treatment, pelvic girdle pain regresses in majority by
12 weeks after delivery

-Cervical Cancer Screening Practices of Certified Nurse-Midwives in the
United States

**Navajo News**

Sexual Assault Nurse Examiner (SANE) Training Course, June 9 -- 13, 2008

**Nurses Corner**

#### -Call for nominations of nurses working in Indian health: Deadlines looming {#call-for-nominations-of-nurses-working-in-indian-health-deadlines-looming .Style-Heading-4-+-Arial-14-pt-Underline}

-Consider nominating our incredible IHS (CO, CS, Tribal) nurses for the
following awards too

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

#### April 7 -- 13^th^ is National Public Health Week {#april-7-13th-is-national-public-health-week .Style-Heading-4-+-Arial-14-pt-Underline}

**Oklahoma Perspective**

Prenatal Care in Oklahoma

Osteoporosis

#### Drugs that affect bone metabolism {#drugs-that-affect-bone-metabolism .Style-Heading-4-+-Arial-14-pt-Underline}

Patient Education

-Treating Depression: What You Should Know

# -Self-management: Taking Charge of Your Health

Perinatology Picks

-What is this all about the 'minor markers' for Down Syndrome?

-Tobacco use increases the risk of a SGA infant at term across maternal
strata

Primary Care Discussion Forum

Mental health issues in children and adolescents

STD Corner

-USPSTF Recommendations for STI Screening

-ACS Releases Guidelines for HPV Vaccination

#### -Management of HIV Infection in Special Populations {#management-of-hiv-infection-in-special-populations .Style-Heading-4-+-Arial-14-pt-Underline}

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

-Link between type 2 DM in adults and type 1 DM or pregnancy-related
diabetes in their mothers

#### -Joslin Study Finds Restricting Insulin Doses Increases Mortality Risk {#joslin-study-finds-restricting-insulin-doses-increases-mortality-risk .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Low vitamin B12 in the first trimester and high folate in the second predispose insulin resistance {#low-vitamin-b12-in-the-first-trimester-and-high-folate-in-the-second-predispose-insulin-resistance .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Replacing sugar in diet sodas with reduced calorie sweeteners may make weight control harder {#replacing-sugar-in-diet-sodas-with-reduced-calorie-sweeteners-may-make-weight-control-harder .Style-Heading-4-+-Arial-14-pt-Underline}

**Women's Health Headlines**

-Have the Disparities Between AI/ANs and Caucasians Narrowed?

-Sacred Circle Handouts, Slides, and Training Materials available

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

#### What's new on the ITU MCH web pages page 51

[Breastfeeding: US Breastfeeding Committee Strategic
Plan](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm)

The past CCC Corners are archived at:

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN02.cfm>

The CCC Corner is good way to inform ITU providers about recent updates,
while decreasing the number of e-mail messages.

Let me know if you want to add something to next month's CCC Corner at
<nmurphy@scf.cc>

or 907 729 3154 (with voicemail)

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

4/24/08njm