**News Flash: The basics of all AI/AN women's health, plus a good
update**

**I.H.S. / A.C.O.G. Postgraduate Course: Obstetric, Neonatal, and
Gynecologic Care Start planning now**

-   June 19 - 23, 2005

-   Denver, CO

-   Contact [Yvonne Malloy](mailto:YMalloy@acog.org) <YMalloy@acog.org>
    or 202-863-2580

-   Save the date info below and online

OB/GYN Chief Clinical Consultant's Corner

Volume 2, No. 11, November, 2004

**[Contents:]{.underline}**

**[Abstract of the Month]{.underline}:** **page 3**

## Results of the National Study of Vaginal Birth After Cesarean in Birth Centers 

[From your colleagues:]{.underline} page 4

**From Burt Attico:** Glycemic Control in Diabetic Women Fosters
Delivery of Normal Weight Infants; Health Disparities in Women's Health

From Bonnie Bishop-Stark: Total Cr/P useful for ruling out preeclampsia,
but not at diagnosing

**From Mark Carroll:** Opportunities for local/regional collaboration
between IHS and VA

**From Diane Cooper:** Ask a Medical Librarian - New service available
to all Indian Health Staff

**From Terry Cullen:** UpToDate Subscriber Newsletter - *UpToDate*
Version 12.3 Now Available

From Sandra Dodge: **Smoking During Pregnancy;** Trends in national
estimates of mean weight, height, and body mass index; **Access to
care**

**From Doug Eby:** Asthma prevalence, hospitalization, and
corticosteroid use: Alaska Natives

**From Kat Franklin:** Easy access to Patient Education materials

From Steve Holve: November Child Health Notes highlights

**From Bob Laliberte:** LOCUM TENENS AVAILABILITY

**From Kelly Moore**: Best practices for diabetes programs and care in
pregnancy

**From Kelton Oliver:** IHS Patient Education codes can make your life
easier

**From Ty Reidhead:** Easier access to Clinical Guidelines in Indian
Health

From Judy Thierry: Overweight and obese women had a significantly slower
labor ; 4 in 10 people who start drinking before age 15 eventually
become alcohol dependent

From Alan Waxman: Conference on Women's and Children's Healthcare-20th
Annual

**From Pat Yee-Spencer:** There is an OB/GYN physician interested in IHS

**[Hot Topics:]{.underline}**

**Obstetrics**: **page 10**

3 Articles on CenteringPregnancy; Fetal Manipulation Often Best for
Shoulder Dystocia; Data support the routine use of antibiotics for women
with PROM; AFI offers no advantage over single deepest pocket when
performed with the BPP; Mercury Levels in Young Children and
Childbearing-Aged Women; Vaginal-perianal compared with vaginal-rectal
cultures for group B; Perinatal infections due to group B streptococci;
Treatment of Bacterial Vaginosis in Pregnancy; Pregnancy Nutrition
Surveillance System / Pediatric Nutrition Surveillance websites; Blunt
Trauma in Pregnancy; Seat belt use during pregnancy; Pregnancy
Prevention in Adolescents; Teenage Pregnancy Prevention: What Can We Do?
Introduction of Routine HIV Testing in Prenatal Care

**Gynecology:** **page 13**

Colposcopy Possibly Unjustified for Screening Young Women for Cervical
Cancer; Women With Atypical Glandular Cells: A Long-Term Study in a
High-Risk Population; Pessary Test May Predict Urinary Incontinence
After Hysterectomy; Many older patients are bothered by night sweats,
day sweats, and hot flashes; Pelvic symptoms in women with pelvic organ
prolapse; Incontinence Products and Devices for the Elderly; Urinary
incontinence strategies for frail elderly women; Physiotherapy Helpful
for Persistent Postnatal Stress Urinary Incontinence; Laparoscopic vs.
Abdominal Hysterectomy: a Comparison; Add-back therapy plus GnRH-a
improves treatment of endometriosis pain; Cognitive Behavior Therapy
Should Be First-Line Therapy for Sleep-Onset Insomnia; Do your patients
complain of poor sleep? Is it hormonal? Or something else? Laparoscopic
Excision Often Helpful for Endometriosis; Ultrasound Therapy Effective
for Vulvar Dystrophy; Stress urinary incontinence -- An excellent review
of management; Management of Cervical Cytologic Abnormalities; The 2001
ASCCP Management Guidelines for Cervical Cytology, Editorial

**Child Health:** **page 15**

Cholestasis of pregnancy - Bile acid pneumonia: a \"new\" form of
neonatal respiratory distress syndrome? AHRQ and its partners launch new
tools to help combat childhood obesity; AAP to Issue Advisory to Help
Diagnose, Treat and Monitor Depressed Children; Childhood Bullying:
Implications for Physicians; Bullying: Patient Education

**Chronic Illness and Disease:** **page 16**

A novel specific prophylaxis for menstrual-associated migraine;
Identifying patients who require a change in their current acute
migraine treatment; National Diabetes Awareness Month; Acne patients
should include attention to anger and other chronic emotional states;
Prevalence of Overweight and Obesity Among Adults with Diagnosed
Diabetes; The colon is a pelvic organ too: taking the Couric challenge;
Aggressive statin strategy best for patients with heart disease; Is
Antibiotic Use Associated with Breast Cancer Risk? Caloric Restriction
Decreases Incidence of Breast Cancer; Vioxx Pulled From Global Market -
Potential Mechanisms for Cardiovascular Risk; Outcomes After Cardiac
Catheterization in Women; Common Dietary Supplements for Weight Loss

[Features:]{.underline} page 18

AFP: Isoflavones Do Not Reduce Menopausal Symptoms; Trial of Labor After
Cesarean Section Is Relatively Safe; Ultrapotent Topical Steroids for
Vulvar Lichen Sclerosus; Screening for Syphilis Infection:
Recommendation Statement;

**ACOG:** Gynecologic Herpes Simplex Virus Infections; Prenatal and
Perinatal Human Immunodeficiency Virus Testing: Expanded; Influenza
Vaccination and Treatment During Pregnancy; ACOG Issues State-of-the-Art
Guide to Hormone Therapy

**AHRQ:** Study finds that some pregnant women are prescribed drugs that
may be considered unsafe during pregnancy; Quality-of-life benefits of
short-term hormone therapy may outweigh the risks for some menopausal
women; After more than 20 years, quality of life is similar for women
who had a hysterectomy or went through natural menopause; Instruments
that measure the health status of children: Impact of race, ethnicity,
and income on health

**Breastfeeding:** Breastfeeding reduced risk of leukemia; New Brochure:
Nursing Mothers Room\'s

**Domestic Violence:** Intimate Partner Violence: What Are Physicians\'
Perceptions with older patients? Abuse in childhood and adolescence as
predictor of future victimization

**Elder Care News:** Use of Traditional Foods in a Healthy Diet in
Alaska: Risks in Perspective; Metabolic syndrome plus inflammation
increases risk of cognitive decline

**Family Planning:** Depo Provera: Loss of significant bone mineral
density; Effectiveness of Spermicides Containing Nonoxynol-9;
Contraception for Adolescents

**Frequently asked questions:** Does IHS have any policy on distribution
of the morning after pill? Is exercise actually recommended in
pregnancy? What do you use to treat pregnant women with migraines? Is
routine antenatal surveillance indicated with an elevated maternal serum
alpha-fetoprotein? Can we use misoprostol for labor induction in asthma
patients? Using weekly 17-OH-progesterone caproate in your patient
population for PTL? What are some of the issues involving rapid cesarean
delivery [+]{.underline} local anesthesia? What is the best antenatal
surveillance regimen for twin gestations?

**Hormone Replacement Update**: Effect of Hormone Therapy on Cognition
in Elderly Women

**Information Technology:** Prenatal care: a strategic first step toward
EMR acceptance; Designated provider management system, version 1.0
released

**International Health**: 100,000 Excess Civilian Iraqi Deaths Since
War; Health policy summer internship available to minority college
students; Applied Epidemiology Fellowship in Maternal and Child Health

**MCH Alert:** New Web site to support the education and training of
those working in the MCH; Economic factors explain weight outcomes

**Medscape**: Cultural Differences in Diet and Heart Health Among Women

**Office of Women's Health, CDC**: Intervention and Evaluation Trials to
Prevent Intimate Partner Violence: Funding

**Osteoporosis**: Pharmacologic Prevention of Osteoporotic Fractures;
Osteoporosis Management: Out of Subspecialty Practice and into Primary
Care

**Patient Education:** Timing of pregnancy, and pre-pregnancy health
habits and important issues; Seat Belt Use During Pregnancy; Bullying:
Patient Education

Primary Care Discussion Forum: Domestic violence -- now; Gastric
stapling surgery -- Feb. 05

#### Barbara Stillwater, Alaska Diabetes Prevention and Control: Obesity and Diabetes Independently Increase Cesarean Delivery Risk; Even Without Diabetes, High Blood Sugar Ups Death, Heart Disease Risk; Western\' Diet Linked to Type 2 Diabetes in Women; Average American is 1 Inch Taller, 25 Pounds Heavier Than 40 Years Ago; MAJOR GAINS IN HEALTH CARE QUALITY, BUT ONLY FOR 1/4th OF THE SYSTEM; Cultural Sensitivity and Its Impact on Care

**What's new on the ITU MCH web pages: page 28**

###### Save the Dates: Upcoming events of interest page 28

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

# 

# [Abstract of the Month]{.underline}

## Results of the National Study of Vaginal Birth After Cesarean in Birth Centers 

**OBJECTIVE:** Some women wish to avoid a repeat cesarean delivery and
believe that a midwife-supported vaginal birth after cesarean (VBAC) in
a nonhospital setting represents their best chance to do so; there is a
small, persistent demand for out-of-hospital VBACs. We conducted a study
to obtain the data necessary to formulate an evidence-based policy on
this practice.

**METHODS.:** We prospectively collected data on pregnancy outcomes of
1,913 women intending to attempt VBACs in 41 participating birth centers
between 1990 and 2000.

**RESULTS:** A total of 1,453 of the 1,913 women presented to the birth
center in labor. Twenty-four percent of them were transferred to
hospitals during labor; 87% of these had vaginal births. There were 6
uterine ruptures (0.4%), 1 hysterectomy (0.1%), 15 infants with 5-minute
Apgar scores less than 7 (1.0%), and 7 fetal/neonatal deaths (0.5%).
Most fetal deaths (5/7) occurred in women who did not have uterine
ruptures. Half of uterine ruptures and 57% of perinatal deaths involved
the 10% of women with more than 1 previous cesarean delivery or who had
reached a gestational age of 42 weeks. Rates of uterine rupture and
fetal/neonatal death were 0.2% each in women with neither of these
risks.

**CONCLUSION:** Despite a high rate of vaginal births and few uterine
ruptures among women attempting VBACs in birth centers, a
cesarean-scarred uterus was associated with increases in complications
that require hospital management. Therefore, birth centers should refer
women who have undergone previous cesarean deliveries to hospitals for
delivery. Hospitals should increase access to in-hospital care provided
by midwife/obstetrician teams during VBACs*.*

Lieberman E, Ernst EK, Rooks JP, Stapleton S, Flamm B Results of the
national study of vaginal birth after cesarean in birth centers. Obstet
Gynecol. 2004 Nov;104(5):933-42.\
Non-ACOG Members

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15516382&dopt=Abstract>

**ACOG Members**

<http://www.greenjournal.org/cgi/content/abstract/104/5/933>

#### 

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

I realize you don't necessarily work in a 'birthing center', but many
Indian Health System deliveries occur in remote low risk centers, so
this applies to many of our patients / staff.

The Indian Health Biennial Women's Health and MCH meeting presented
several venues for discussion of VBAC and its application in Indian
Country. I highly recommend reviewing the material the Dr. Michele
Lauria has allowed us to post on our MCH web site.\*

[Low risk:]{.underline}

Spontaneous onset of labor, normal tracing, 1 prior cesarean delivery

[Medium risk]{.underline}

Augmented labor, 2 prior cesarean deliveries, induction of labor, prior
CD \< 18 months prior

[High risk]{.underline}

Abnormal FHR -- not resolving, no change despite 2 hours of adequate
labor, bleeding like an abruption

A discussion is presented about possible management options for each
category, above\*
<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/NewMexico.ppt#272,55,Protocol>
(1 MB ppt)

Another area of discussion was how to approach emergency delivery of any
etiology, e.g., uterine rupture, etc...The consensus is that each L/D
unit should perform drills to evaluate/train all staff \*

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/Talk.ppt#288,3,Objectives>
(728 K ppt)

## From your colleagues:

#### [From Burt Attico, Phoenix]{.underline}

**Glycemic Control in Diabetic Women Fosters Delivery of Normal Weight
Infants**

"Our colleagues are emphasizing and proving what we\'ve been saying -
never let the fetus know that it\'s in an unfriendly environment. Tight
control is the key."

CONCLUSION: Anthropometric measurements of infants of mothers with
well-controlled gestational diabetes do not differ from infants of
nondiabetic mothers. EVIDENCE: II-2.\
Salim R, Hasanein J, Nachum Z, Shalev E. Anthropometric Parameters in
Infants of Gestational Diabetic Women With Strict Glycemic Control.
Obstet Gynecol. 2004 Nov;104(5):1021-1024.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15516395>

**Health Disparities in Women's Health**

John Molina & I were presenters at the local NCCJ Health Disparities
Conference in September. My PowerPoint presentation is at
[[http://www.nccjaz.org/documents/HealthcarePPPres_000.ppt]{.underline}](http://www.nccjaz.org/documents/HealthcarePPPres_000.ppt)

**[From Bonnie Bishop-Stark, Anchorage]{.underline}**

**Total Cr/P useful for ruling out preeclampsia, but not at diagnosing
significant protienuria**\
OBJECTIVE: The aim of this study was to evaluate the diagnostic accuracy
of random urine protein-creatinine ratio for prediction of significant
proteinuria (\> or = 300 mg/24 h) in patients with new-onset mild
hypertension in late pregnancy. METHODS: Medical records of 185
consecutive pregnant patients with new onset of mild hypertension in
late pregnancy were reviewed. Random urine samples were taken before
24-hour urine collection. The predictive values of the random urine
protein-creatinine ratio for diagnosis of significant proteinuria were
estimated by using at least a 300-mg protein level within the collected
24-hour urine as the gold standard. RESULTS: Thirty-nine patients (21%)
had significant proteinuria. There was a significant association between
24-hour protein excretion and the random urine protein-creatinine ratio
(rs = 0.56, P \<.01). With a cutoff protein-creatinine ratio greater
than 0.19 as a predictor of significant proteinuria, sensitivity and
specificity were 85% and 73%, respectively. Positive and negative
predictive values of the test were 46% and 95%, respectively.
CONCLUSION: The random urine protein-creatinine ratio was a poor
predictor for significant proteinuria in patients with new-onset mild
hypertension in late pregnancy.

Al RA, Baykal C, Karacay O, Geyik PO, Altun S, Dolen I. Random urine
protein-creatinine ratio to predict proteinuria in new-onset mild
hypertension in late pregnancy. Obstet Gynecol. 2004 Aug;104(2):367-71.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15292013&dopt=Abstract>

#### 

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

At this juncture in our understanding, the key to the use of this test
in pregnancy is that the total Cr / P accurately excludes significant
proteinuria and may be useful for ruling out preeclampsia. On the whole,
the random urine protein-creatinine ratio was a poor predictor for
significant proteinuria in patients with new-onset mild hypertension in
late pregnancy.

For example, with use of a 0.19 cut-off, the test had a good negative
predictive value (95%) in excluding significant proteinuria. However,
the positive predictive value of the test was only 46%, and a test
result above the cutoff point was not diagnostic for significant
proteinuria. njm

**[From Mark Carroll, Navajo Area]{.underline}**

**Opportunities for local/regional collaboration between IHS and VA**

The IHS and the VA are very much hoping to identify folks who might
attend this meeting and identify specific opportunities for
local/regional collaboration between IHS and VHA - which could translate
into pilot activities and cooperative efforts with the Department of
Veterans Affairs.

-You are invitted to present at the Second Annual VHA Care Coordination
& Telehealth Leadership Forum to be held in Salt Lake City April 5-7,
2005. www.va.gov/telehealth

-You are invited to submit your proposals, due November 30, 2004.\
This applies to Indian Health clinical, technical, administrative, and
research colleagues who may have an interest in presenting or
participating during the conference next April.

Contact Ms. Rita Kobb (386) 754-6437 or John Peters
<john.peters@hq.med.va.gov>

**[From Diane Cooper, NIH-Bethesda]{.underline}**

**Ask a Medical Librarian - New service available to all Indian Health
Staff**

-   Find quality clinical information and studies you need for patient
    care, research, presentations, and manuscripts

-   Receive pertinent clinical literature, filtered citations; and
    focused packets of information on any clinical topic to improve your
    efficiency and save you time

Email your informationist-a specially trained medical librarian:

Diane Cooper, MSLS\
Biomedical Librarian / Informationist for the Indian Health Service\
Health Services Research Library (a branch of the NIH Library)
[http://nihlibrary.nih.gov](http://nihlibrary.nih.gov/)\
Bethesda, MD <cooperd@mail.nih.gov>

This posting is available on the Clinical Information Resources page at

<http://www.ihs.gov/medicalprograms/CIR/cir-medical-library-sercives.asp>

#### 

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

Diane Cooper will have a regular column in the OB/GYN CCC Corner
starting next month njm

**[From Terry Cullen, Tucson]{.underline}**

**UpToDate Subscriber Newsletter - *UpToDate* Version 12.3 Now
Available**

What's New in Obstetrics and Gynecology

<http://www.uptodateonline.com/application/topic.asp?file=whatsnew/2369>

What's New, overall content

[http://www.uptodateonline.com/application/toc.asp?toc=what%27s_new&title=What%27s%20New](http://www.uptodateonline.com/application/toc.asp?toc=what's_new&title=What's New)

The following is an update on what\'s new with *UpToDate*

<http://www.uptodate.com/img/newsletter.pdf>

**[From Sandra Dodge, Crownpoint]{.underline}**

**Smoking During Pregnancy**
-<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5339a1.htm>

**Diabetes** This report presents trends in national estimates of mean
weight, height, and body mass index between 1960 and 2002.
<http://www.cdc.gov/od/oc/media/pressrel/r041027>

**Access to care** Improved conceptual data on how the social
environment impacts the health of populations.
<http://www.cdc.gov/cvh/library/data_set_directory/index.htm>

 

**[From Doug Eby and Richard Mandsager]{.underline}**

**Asthma prevalence, hospitalization, and inhaled corticosteroid use
among Alaska Natives**

Most of you know, or remember, Richard Mandsager.  He was the CEO of
ANMC under Indian health Service and then Pediatrics Medical Director
for Southcentral Foundation for awhile.  He is now the Alaska State
Director of Public Health. 

If you look at the data on the Epidemiology Bulletin below you will see:

\- From 1999 to 2002 you will see that the Anchorage Native pediatric
use of inhaled steroids increased 3X and the hospitalization rate over
the same time for asthma decreased to one third.  The Native rates for
the rest of the state did not change much and the non-Native rates also
did not change very much.

\- We started our relationship based, open access system in late
1999/early 2000 in Anchorage.  The real significant change was to move a
system that did everything to optimize relationship, care coordination,
build trust, expand self-care, etc.

\- During this time there was some good work on asthma protocols and
standardizing the approach within our primary care relationship based
clinics.

-The data is State produced from the Medicaid portion of the population.

-Would seem to support out claim that by moving to a relationship based
system with many barriers to relationship removed as much as possible
you can get outcomes that exceed the usual from disease specific or just
protocol driven approaches!!!  Of course it is hard to separate out that
from the protocol/standardization, etc. approach\... ANYWAY \-\-\--
GREAT WORK !!!!!!!!

Trends in asthma prevalence, hospitalization, and inhaled corticosteroid
use among Alaska Native and non-Native Medicaid recipients less than 20
years of age, 10/25/2004, State of Alaska Epid. Bulletin
<http://www.ihs.gov/generalweb/webapps/sitelink/site.asp?link=http://www.epi.hss.state.ak.us/default.jsp>

**[From Kat Franklin, Sante Fe, and Marsha Tahquechi,
GIMC]{.underline}**

**Easy access to Patient Education materials**

How would you like to improve the nation wide Indian Health access to
patient education material? A great deal of this work already exists,
but we seek your help to improve the access. Isn't that a good idea?
Contact <Marsha.Tahquechi@ihs.gov> or <kfranklin@abq.ihs.gov>

[From Steve Holve, Tuba City]{.underline}

**November Child Health Notes: Here are some highlights**

Winter is Coming: The shocking answer of what to do about all those
coughing infants and children

Obesity Prevention: The results of a multi-million dollar project to
reduce obesity in Native American school children. The results are\....I
guess you\'ll have to go to the website to find out.

-Meetings of Interest
<http://www.ihs.gov/MedicalPrograms/MCH/C/documents/ICHN1104.doc>

[From Bob Laliberte, Phoenix]{.underline}

**LOCUM TENENS AVAILABILITY**

Dr. Robert Laliberte is a board certified obstetrician/gynecologist
currently stationed at Phoenix Indian Medical Center (PIMC).  He will be
retiring from the Commissioned Corps of the Public Health Service and
from PIMC on January 1, 2005 after more than 20 years service.  He plans
to do locum tenens work and plans to work 6 months a year.  His history
with the IHS began at Crow Agency, Montana and is concluding at PIMC; he
would like to continue working in IHS facilities with Native patients. 
Should any facilities want or need a locum Ob/Gyn for a one time
assignment or for a recurring assignment, Dr. Laliberte would like to
speak with you and can be reached at the numbers or e-mail that follow.

 Robert C. Laliberte, MD, FACOG

W (602) 263-1550 H (480) 987-0938

E-mail:  <LBLALIB@AOL.COM>

**[From Kelly Moore, ABQ]{.underline}**

**What are some best practices for diabetes in pregnancy?**

Here are few thoughts about best practices for diabetes programs in
pregnancy

<http://www.ihs.gov/MedicalPrograms/diabetes/resources/Diab&Preg.PDF>

Here is a clinically oriented resource

<http://www.ihs.gov/MedicalPrograms/MCH/w/documents/DMPreg102504_000.doc>

**[From Kelton Oliver and Michale Ratzlaff, Anchorage]{.underline}**

**Did you know that the IHS Patient Education codes can make your life
easier?**

The codes are really just a short hand way to say you spent a fair
amount of time educating your patient on this, or that, issue. If used
properly they can also increase your billing for that encounter. As
short hand code, they will make your charting life easier and inform
JCAHO and IHS about your efforts at education. They are quite dry to
look at, but think of them as a shortcut.

Contact for questions: <kholiver@anmc.org> or <mdratzlaff@anmc.org>

**Prenatal objectives / codes**

<http://www.ihs.gov/NonMedicalPrograms/HealthEd/Pepctopics/PN_2004.pdf>

**Women's Health objectives / codes**

<http://www.ihs.gov/NonMedicalPrograms/HealthEd/Pepctopics/WH_2004.pdf>

All systems objectives / codes on the IHS Patient Education main page

<http://www.ihs.gov/NonMedicalPrograms/HealthEd/index.cfm?module=initiative&option=protocols&newquery=dsp_NatlPatientEd_Protocols.cfm>

Here is a PCC+ form that has the codes on the back of it already

<http://www.ihs.gov/MedicalPrograms/MCH/M/mchdownloads/pnvfu_template_5.doc>

**[From Ty Reidhead, Whiteriver]{.underline}**

**Easier access to Clinical Guidelines in Indian Health**

Same message as above about Patient Education materials, but now about
Clinical Guidelines.

A great deal of this work already exists (see site below) but we seek
your help to improve the existing Clinical Guidelines page. Do you have
clinical guidelines you want to share? Can you think of any clinical
guidelines that are a 'must' to be posted on the Indian Health website?

Contact Ty Reidhead <Charles.Reidhead@ihs.gov>

**Here is the existing IHS Clinical Guidelines page**

Individual guidelines: Specific System or Event Oriented (alphabetical
order)

<http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-clinguid.cfm#event>

Clearinghouses, Agencies, or compendiums of Clinical Guidelines
(alphabetical order)

<http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-clinguid.cfm#clear>

**Recent new additions**

Hemoglobin A1C Patient Handout

<http://www.ihs.gov/NonMedicalPrograms/nc4/documents/PCAOrderandFlowCombo31.doc>

Heparin Standing Orders

<http://www.ihs.gov/NonMedicalPrograms/nc4/documents/Heparin2.doc>

Parenteral Nutrition Order sheet

<http://www.ihs.gov/NonMedicalPrograms/nc4/documents/parenteralnutritionordersheet.doc>

Patient Controlled Analgesia Orders and Flow sheet

<http://www.ihs.gov/NonMedicalPrograms/nc4/documents/HbA1CPtHandout.xls>

**[From Judy Thierry, HQE]{.underline}**

**Overweight and obese women had a significantly slower labor (see also
Stillwater below)**

Overweight and obese women had a significantly slower labor from 4 to 10
cm, compared with that of normal-weight women. The prevalence of
overweight and obesity is increasing among women of childbearing age,
yet few studies have explored in depth the effect of maternal overweight
and obesity on labor progression.

-Compared with normal-weight women, both overweight and obese women were
admitted earlier to labor and delivery, more frequently reported no or
irregular uterine contractions, more frequently had their labor induced,
and received oxytocin more often.

-Primary emergent cesarean delivery rates were higher for overweight and
obese women compared with normal-weight women. The majority of these
deliveries were performed during the first stage of labor because of an
indication of dystocia and fetal distress.

-Overweight and obese women had a significantly longer median duration
of labor from 4 to 10 cm compared with normal-weight women (7.5, 7.9,
and 6.2 hours, respectively), after adjusting for maternal height, net
weight gain, labor induction, membrane rupture, the timing and use of
epidural analgesia, oxytocin use, and fetal size.

-Compared with normal-weight women, the trend of a slower labor from 4
to 6 cm persisted in overweight women, and the trend of a slower labor
before 7 cm persisted in obese women.

-Given that nearly one half of women of childbearing age are either
overweight or obese, it is critical to consider differences in labor
progression by maternal prepregnancy BMI before additional interventions
are performed

Vahratian A, Zhang J, Troendle JF, et al. 2004. Maternal prepregnancy
overweight and obesity and the pattern of labor progression in term
nulliparous women. Obstetrics and Gynecology 104(5, Part 1):943-951.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15516383>

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

This article and Ehrenberg HM, et al., see Stillwater below, report on
the detrimental effects of maternal obesity on the normal labor process.
In Ehrenberg HM, et al., records for 12,303 deliveries showed pregravid
obesity and diabetes independently increase the risk for CD. Given the
disparate prevalence of obesity and diabetes in the United States, body
habitus has a significantly larger impact on CD risk.

Along with ACOG we should encourage strongly recommend exercise to our
pregnant patients, especially those with pregravid obesity and diabetes
in pregnancy. In the absence of medical or obstetrical complications,
pregnant women should be encouraged to continue and maintain an active
lifestyle during their pregnancies. Some modification in exercise
routines or activity patterns may be necessary because of maternal
physiological changes and fetal requirements.

Basically only moderate exercise is needed. As a rough rule of thumb,
just use the **"talk-sing test"** may be used -- the patient should be
able to talk while exercising; if she can sing, the pace can be
increased. The current guidelines for diabetes in pregnancy give an
example of a tested exercise program successfully used in AI/AN pregnant
women. See Appendix F, page 18 below

<http://www.ihs.gov/MedicalPrograms/MCH/w/documents/DMPreg102504_000.doc>

For optimal outcome, the Institute of Medicine advises a weight gain of

Underweight women (BMI\<19.8) 12.5 to 18 kg (28 to 40 lb)

Average weight (BMI 19.8 to 26.0) 11.5 to 16 kg (25 to 35 lb)

Overweight women
(BMI![](media/image1.png){width="8.333333333333333e-2in"
height="9.236111111111112e-2in"}26), 7 to 11.5 kg (15 to 25 lb)

These can be achieved with an additional 300 Kcal per day for average
weight women njm

**ACOG**

**Exercise During Pregnancy and the Postpartum Period Committee
Opinion** Number 267, January 2002

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11777528>

**UpToDate**

**Physiologic principles of exercise during pregnancy**

<http://www.uptodateonline.com/application/topic.asp?file=antenatl/12515>

**Recommendations for exercise during pregnancy and the postpartum
period**

<http://www.uptodateonline.com/application/topic.asp?file=antenatl/12055>

**Nutrition in pregnancy**

<http://www.uptodateonline.com/application/topic.asp?file=antenatl/6112>

**[Appendix F]{.underline}**

# [Exercise guidelines to improve glucose control]{.underline}

Type of activities:

Aerobic activities such as walking, stationary cycling, or swimming

Frequency:

At least 3 days per week

Duration:

20-45 minutes per session

Intensity:

Moderate. **The "talk-sing test"** may be used -- the patient should be
able to talk while

exercising; if she can sing, the pace can be increased. If using rating
of perceived

exertion (RPE) exertion level should feel "fairly light" to "somewhat
hard".

Patient should warm-up before and cool down after exercise, drink plenty
of water, and

have snacks nearby if needed.

Initial exercise consult:

> Assessment of current physical activities and level of readiness for
> exercise
>
> Education/Information on exercise and GDM
>
> Individualized exercise plan

Supervised exercise:

> Measure blood glucose pre and post exercise
>
> Exercise on treadmill and/or recumbent cycle
>
> Monitor perceived exertion
>
> Monitor blood pressure and/or heart rate as needed

<http://www.ihs.gov/MedicalPrograms/MCH/w/documents/DMPreg102504_000.doc>

**4 in 10 people who start drinking before age 15 eventually become
alcohol dependent**

The National Institute on Alcohol Abuse and Alcoholism (NIAAA), has
released a new version of \"The Cool Spot,\" the institute\'s website
for middle school (11- to 13-year-old) children. It\'s vital to reach
this age group, because the younger people are when they start to drink,
the higher their chances of developing an alcohol problem at some point
in their lives.\" Research shows that more than 4 in 10 people who start
drinking before age 15 eventually become alcohol dependent.

[http://www.thecoolspot.gov](../../../../../../../../exchweb/bin/redir.asp%3FURL=http://www.thecoolspot.gov)

**[From Alan Waxman, Albuquerque]{.underline}**

**20th Annual Conference on Women's and Children's Healthcare**

-   For providers caring for Native women and children

-   February 25 - 27, 2005

-   First announcement details
    <http://www.ihs.gov/MedicalPrograms/MCH/M/documents/tldr20051stnotice.doc>

-   Telluride, CO
    <http://www.ihs.gov/MedicalPrograms/MCH/M/ConfDnlds/Tellurideagenda10-2004.doc>

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

**[From Pat Yee-Spencer, HQE]{.underline}**

**There is an OB/GYN physician interested in IHS**

She wants service from July 2005 through April 2006 only.  If you have a
position, please contact her directly.  The information is as follows:

Summer Khan (Guerra), M.D. LSU Dept of OB/GYN

New Orleans, LA  70003 Pager:  504-423-3308

Cell:  504-723-8575 <summerguerra@yahoo.com>

**[Hot Topics:]{.underline}**

**[Obstetrics]{.underline}**

**3 Articles on CenteringPregnancy**

**\# 1 CenteringPregnancy and the Current State of Prenatal Care**

Prenatal care is often credited with improving pregnancy outcomes. Yet
rates of low birthweight (LBW) and prematurity have risen in recent
decades, calling into question the efficacy of traditional prenatal
routines. Proposals have included broadening the objectives of prenatal
care beyond prevention of LBW and enriching care to provide education
and support for pregnant women. CenteringPregnancy, an innovative model
of prenatal care that integrates extensive health education and group
support with the standard prenatal exam, incorporates many of these
elements. Impediments to wider implementation of CenteringPregnancy are
explored, as well as proposals for addressing these challenges.

Novick G. CenteringPregnancy and the current state of prenatal care. J
Midwifery Womens Health. 2004 Sep-Oct;49(5):405-11.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15351330>

Or

<http://www.medscape.com/viewarticle/489498_1>

**\# 2 Pregnancy Outcomes of Adolescents Enrolled in a
CenteringPregnancy Program**

Adolescent pregnancy remains a significant social, economic, and health
issue in the United States. The unique developmental needs of the
pregnant adolescent require attention when designing prenatal care
services. The CenteringPregnancy model of group prenatal care provides
education and support for young women in an active and developmentally
appropriate environment. Thirteen groups of adolescents (N = 124) have
completed the Centering program at the Teen Pregnancy Center at Barnes
Jewish Hospital in St. Louis, Missouri. Evaluation data suggest that the
model has encouraged excellent health care compliance, satisfaction with
prenatal care, and low rates of preterm birth and low birth weight
infants.

**Grady MA, Bloom KC. Pregnancy outcomes of adolescents enrolled in a
CenteringPregnancy program.** J Midwifery Womens Health. 2004
Sep-Oct;49(5):412-20.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15351331>

Or

<http://www.medscape.com/viewarticle/489499?src=mp>

**\# 3 Redesigning prenatal care through CenteringPregnancy**

CenteringPregnancy is a model of group prenatal care that provides more
than 20 hours of contact time between the childbearing care provider and
a cohort of pregnant women with similar due dates. During this time,
each woman has the opportunity to build community with other pregnant
women, learn self-care skills, get assurance about the progression of
her pregnancy, and gain knowledge about pregnancy, birth, and parenting.
Ten essential elements have been defined, which contribute to the
success of this model of prenatal care delivery. These elements
correspond with the Institute of Medicine\'s 2001 challenge to improve
the quality of health care in the United States. Foundational
perspectives provide potential explanations for the model\'s growing
influence and success. Implications for clinical practice and further
research to link it with perinatal health outcomes are suggested.\
Rising SS, Kennedy HP, Klima CS. Redesigning prenatal care through
CenteringPregnancy**.** J Midwifery Womens Health. 2004
Sep-Oct;49(5):398-404.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15351329>

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

CenteringPregnancy has been used successfully throughout the Indian
Health System, as well as the University of New Mexico. To date the
paucity of funded and published research on Centering is one of the
great impediments to demonstrating its value, as well as to
disseminating the model. Despite the lack of evidence that traditional,
one-on-one prenatal care is effective, as a challenger to the status
quo, a burden of demonstrating effectiveness rests on Centering\'s
shoulders. Other innovative approaches to care have faced this challenge
too, such as freestanding birth centers compared to hospital birth.

I encourage randomized studies in the AI/AN population. If you are
interested in further discussion about CenteringPregnancy in Indian
Health, then contact Yolanda Meza, CNM, (ANMC) <ymeza@anmc.org> or Judy
Whitecrane (PIMC) <Judy.Whitecrane@ihs.gov>

**Fetal Manipulation Often Best for Shoulder Dystocia **

A study suggests that episiotomy offers no benefit over fetal
manipulation unless the episiotomy is made specifically to assist the
infant through manipulation.

CONCLUSION: In severe shoulder dystocia, if fetal manipulation can be
performed without episiotomy, severe perineal trauma can be averted
without incurring greater risk of brachial plexus palsy. Gurewitsch ED
et al Episiotomy versus fetal manipulation in managing severe shoulder
dystocia: a comparison of outcomes**.** Am J Obstet Gynecol. 2004
Sep;191(3):911-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15467564>

**Data support the routine use of antibiotics for women with PROM.
Amoxicillin/clavulanate should be avoided due to increased risk of
neonatal necrotizing enterocolitis**

CONCLUSION: The administration of antibiotics after PROM is associated
with a delay in delivery and a reduction in maternal and neonatal
morbidity. These data support the routine use of antibiotics for women
with PROM. Penicillins and erythromycin were associated with similar
benefits, but erythromycin was used in larger trials and, thus, the
results are more robust. Amoxicillin/clavulanate should be avoided in
women at risk of preterm delivery because of the increased risk of
neonatal necrotizing enterocolitis. Antibiotic administration after PROM
is beneficial for both women and neonates.

Kenyon S, Boulvain M, Neilson J. Antibiotics for preterm rupture of the
membranes: a systematic review. Obstet Gynecol. 2004 Nov;104(5):1051-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15516401&dopt=Abstract>

**AFI offers no advantage over single deepest pocket when performed with
the BPP**

CONCLUSION: The AFI offers no advantage in detecting adverse outcomes
compared with the single deepest pocket when performed with the BPP. The
AFI may cause more interventions by labeling twice as many at-risk
pregnancies as having oligohydramnios than with the single deepest
pocket

Magann EF, Doherty DA, Field K, Chauhan SP, Muffley PE, Morrison JC.
Biophysical profile with amniotic fluid volume assessments. Obstet
Gynecol. 2004 Jul;104(1):5-10

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15228994>

**Blood Mercury Levels in Young Children and Childbearing-Aged Women**

This report updates NHANES 1999\--2000 estimates of blood Hg levels, the
first nationally representative estimates of U.S. women\'s and
children\'s exposures to Hg based on biologic measures. The findings
indicate that blood Hg levels in young children and childbearing-aged
women usually are below levels of concern.

Fish are an important part of a diet, high in protein and nutrients and
low in saturated fatty acids and cholesterol. The short-term strategy to
reduce Hg exposure is to eat fish with low Hg levels and avoid or reduce
consumption of fish with high Hg levels. Because exposure to methyl-Hg
can harm fetuses, the Food and Drug Administration (FDA) advises that
women who are or might become pregnant not eat shark, swordfish, king
mackerel, and tile fish (*9*). In addition, EPA and the Agency for Toxic
Substances and Disease Registry have established daily consumption
levels of Hg considered to be without harm. State-based fish advisories
and bans identify fish species contaminated by Hg and their locations
and provide safety advice. The NHANES program continues to collect Hg
measurements in human tissue to monitor the effectiveness of efforts to
reduce Hg exposure in the U.S. population.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5343a5.htm>

**Vaginal-perianal compared with vaginal-rectal cultures for group B
streptococci**

CONCLUSION: The group B streptococci detection rate from
vaginal-perianal specimens is not significantly different from the
detection rate from vaginal-rectal specimens. Therefore, pregnant women
do not need to be subjected to the discomfort of collection of a rectal
specimen. LEVEL OF EVIDENCE: II-2

Jamie WE, Edwards RK, Duff P. Vaginal-perianal compared with
vaginal-rectal cultures for identification of group B streptococci.
Obstet Gynecol. 2004 Nov;104(5):1058-61.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15516402&dopt=Abstract>

**Perinatal infections due to group B streptococci**

Group B streptococci (GBS) emerged dramatically in the 1970s as the
leading cause of neonatal infection and as an important cause of
maternal uterine infection. We review the epidemiology, diagnosis, and
therapy of GBS perinatal infection. In 1996, the first national
consensus guidelines were released. Since then, there has been a 70%
reduction in early-onset neonatal GBS infection, but no decrease in
late-onset neonatal GBS disease. In 2002, new national guidelines were
released recommending 1) solely a screen-based prevention strategy, 2) a
new algorithm for patients with penicillin allergy, and 3) more specific
practices in certain clinical scenarios. Yet many clinical issues
remain, including implementation of new diagnostic techniques,
management of preterm rupture of membranes, use of alternative
antibiotic approaches, improvement of compliance, prevention of low
birth weight infants, emergence of resistant organisms, and vaccine
development.

Gibbs RS, Schrag S, Schuchat A. Perinatal infections due to group B
streptococci. Obstet Gynecol. 2004 Nov;104(5):1062-76.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15516403&dopt=Abstract>

**Treatment of Bacterial Vaginosis in Pregnancy**\
CONCLUSION: The effectiveness of metronidazole therapy of bacterial
vaginosis persists for \> or =10 weeks. Women who underwent placebo
therapy had significant remission of bacterial vaginosis over \> or =10
weeks. Remission was more common when the initial vaginal microbiologic
disturbances were less severe.

Klebanoff MA, et al. Time course of the regression of asymptomatic
bacterial vaginosis in pregnancy with and without treatment. Am J Obstet
Gynecol. 2004 Feb;190(2):363-70.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14981375>

**Pregnancy Nutrition Surveillance System / Pediatric Nutrition
Surveillance websites**

CDC is pleased to announce the availability of new Web site for the
Pediatric Nutrition Surveillance System (PedNSS) and the Pregnancy
Nutrition Surveillance System (PNSS) This Web site provides access to
the most recent national data on prevalence data for overweight,
breastfeeding initiation and duration for low-income populations and
detailed information about the program-based surveillance systems. Also
included at the site is training on reading the data tables, an
epidemiologic approach to interpreting the data, and application of the
data.

PedNSS and PNSS monitor the nutritional status of low-income infants,
children and women in federally funded maternal and child health
programs. PedNSS data represent more than 5 million children from birth
to age 5. PNSS data represent approximately 750,000 pregnant and
postpartum women. <http://www.cdc.gov/pednss/>

**Blunt Trauma in Pregnancy**

<http://www.aafp.org/afp/20041001/1303.html>

**Seat Belt Use During Pregnancy: Patient Education**

<http://www.aafp.org/afp/20041001/1313ph.html>

**Pregnancy Prevention in Adolescents**

<http://www.aafp.org/afp/20041015/1517.html>

**Teenage Pregnancy Prevention: What Can We Do? - Editorial**

<http://www.aafp.org/afp/20041015/editorials.html>

**Introduction of Routine HIV Testing in Prenatal Care**

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5346a2.htm>

**[Gynecology]{.underline}**

**Colposcopy Possibly Unjustified for Screening Young Women for Cervical
Cancer **

INTERPRETATION: The high rate of regression recorded in this study lends
support to observation by cytology in the management of LSIL in female
adolescents. Negative HPV status was associated with regression,
suggesting that HPV testing could be helpful in monitoring LSIL.

Moscicki AB, et al Regression of low-grade squamous intra-epithelial
lesions in young women. Lancet. 2004 Nov 6;364(9446):1678-83.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15530628>

**Women With Atypical Glandular Cells: A Long-Term Study in a High-Risk
Population**

Patients with AGCs are at risk of harboring clinically significant
uterine lesions and should be followed up for a substantial period
despite initial negative findings.

**Chhieng DC, et al Women with atypical glandular cells: a long-term
follow-up study in a high-risk population.** Am J Clin Pathol. 2004
Oct;122(4):575-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15487456>

**Pessary Test May Predict Urinary Incontinence After Hysterectomy **

CONCLUSION: Continent patients suffering from severe pelvic organ
prolapse but with a positive pessary test are considered to be at high
risk of developing postoperative symptomatic stress urinary
incontinence. Among the patients in our medium-range study, TVT
effectively prevented postsurgical urinary incontinence. LEVEL OF
EVIDENCE: II-1\
Liang CC, et al Pessary test to predict postoperative urinary
incontinence in women undergoing hysterectomy for prolapse**.** Obstet
Gynecol. 2004 Oct;104(4):795-800.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15458904>

**Many older patients are bothered by night sweats, day sweats, and hot
flashes**

CONCLUSION: Though these symptoms are similar and related, they have
somewhat different associations with other variables. Clinical
evaluation should include questions about febrile illnesses, sensory
deficits, anxiety, depression, pain, muscle cramps, and restless legs
syndrome

Mold JW, Roberts M, Aboshady HM. Prevalence and predictors of night
sweats, day sweats, and hot flashes in older primary care patients: an
OKPRN study. Ann Fam Med. 2004 Sep-Oct;2(5):391-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15506569>

**Pelvic symptoms in women with pelvic organ prolapse**

CONCLUSION: Women with more advanced prolapse were less likely to have
stress incontinence and more likely to manually reduce prolapse to void;
however, prolapse severity was not associated with sexual or bowel
symptoms. LEVEL OF EVIDENCE: II-2.

Burrows LJ, et al Pelvic symptoms in women with pelvic organ prolapse.
Obstet Gynecol. 2004 Nov;104(5):982-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15516388&dopt=Abstract>

**Incontinence Products and Devices for the Elderly**

Devices and products to contain or collect the urine are part of the
management of bladder dysfunction, particularly urinary incontinence
(UI). The aim of continence nurse experts and those who care for
incontinent individuals during the past decade has been to greatly
decrease the indiscriminate use of absorbent pads and garments, external
collecting devices, and indwelling catheterization, through the
successful treatment of urinary incontinence (UI) with behavioral
interventions, drug therapies, and new surgical procedures. However,
these products and devices can be beneficial for persons who are
elderly, fail treatment and remain incontinent, who are too ill or
disabled to participate in behavioral programs, who cannot be helped by
medications, or who have a type of UI that cannot be alleviated by other
interventions. The judicious use of products to contain urine loss and
maintain skin integrity is a first-line defense for these patients
(Fantl et al., 1996). Urinary collection devices and products that are
appropriate for elderly patients, that are used by nurses in all
clinical settings, and are available at local pharmacies, retail stores,
medical equipment dealers or directly from manufacturers are discussed.
Newman DK. Incontinence products and devices for the elderly. Urol Nurs.
2004 Aug;24(4):316-33
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15446380>

**Urinary incontinence strategies for frail elderly women**

Among the majority of frail older women, urinary incontinence has not
been adequately assessed or treated, with resultant negative impact on
quality of life. An assessment and intervention model based on type of
incontinence, evidence-based interventions, and the influence of patient
preference and capacity to carry out interventions are described.

Lekan-Rutledge D Urinary incontinence strategies for frail elderly
women. Urol Nurs. 2004 Aug;24(4):281-3, 287-301\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15446378>

**Physiotherapy Helpful for Persistent Postnatal Stress Urinary
Incontinence **

CONCLUSION: Multimodal supervised pelvic floor physiotherapy is an
effective treatment for persistent postnatal stress urinary
incontinence.

Dumoulin C, et al Physiotherapy for persistent postnatal stress urinary
incontinence: a randomized controlled trial. Obstet Gynecol. 2004
Sep;104(3):504-10.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15339760>

**Laparoscopic vs. Abdominal Hysterectomy: a Comparison**

CONCLUSIONS: Laparoscopic hysterectomy was associated with a
significantly higher rate of major complications than abdominal
hysterectomy. It also took longer to perform but was associated with
less pain, quicker recovery, and better short term quality of life. The
trial comparing vaginal hysterectomy with laparoscopic hysterectomy was
underpowered and is inconclusive on the rate of major complications;
however, vaginal hysterectomy took less time.\
Garry R, Fountain et al The eVALuate study: two parallel randomised
trials, one comparing laparoscopic with abdominal hysterectomy, the
other comparing laparoscopic with vaginal hysterectomy. BMJ. 2004 Jan
17;328(7432):129\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14711749>

and

CONCLUSIONS: Laparoscopic hysterectomy is not cost effective relative to
vaginal hysterectomy. Its cost effectiveness relative to the abdominal
procedure is finely balanced.

Sculpher M, et al Cost effectiveness analysis of laparoscopic
hysterectomy compared with standard hysterectomy: results from a
randomised trial. BMJ. 2004 Jan 17;328(7432):134.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14711748>

**Add-back therapy plus GnRH-a improves treatment of endometriosis
pain**

CONCLUSION(S): Add-back therapy allows the treatment of women with
relapse of endometriosis-associated pain for a longer period, with
reduced bone mineral density loss, good control of pain symptoms, and
better patient quality of life compared with GnRH analogue alone or oral
contraceptive. Zupi E, et al Add-back therapy in the treatment of
endometriosis-associated pain. Fertil Steril. 2004 Nov;82(5):1303-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15533351>

**Cognitive Behavior Therapy Should Be First-Line Therapy for
Sleep-Onset Insomnia**

CONCLUSIONS: These findings suggest that young and middle-age patients
with sleep-onset insomnia can derive significantly greater benefit from
CBT than pharmacotherapy and that CBT should be considered a first-line
intervention for chronic insomnia. Increased recognition of the efficacy
of CBT and more widespread recommendations for its use could improve the
quality of life of a large numbers of patients with insomnia.

Jacobs GD, et al Cognitive behavior therapy and pharmacotherapy for
insomnia: a randomized controlled trial and direct comparison**.** Arch
Intern Med. 2004 Sep 27;164(17):1888-96.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15451764>

**Do your patients complain of poor sleep? Is it hormonal? Or something
else?**

Excessive daytime sleepiness (EDS) or somnolence is common in our
patients and in society in general. The most common cause of EDS is
\"voluntary\" sleep restriction. Other common causes include
sleep-fragmenting disorders such as the obstructive sleep apnea
syndrome. Somewhat less familiar to the clinician are EDS conditions
arising from central nervous system dysfunction. Of these so-called
primary disorders of somnolence, narcolepsy is the most well known and
extensively studied, yet often misunderstood and misdiagnosed.
Idiopathic hypersomnia, the recurrent hypersomnias, and EDS associated
with nervous system disorders also must be well-understood to provide
appropriate evaluation and management of the patient with EDS. This
review summarizes the distinguishing features of these clinical
syndromes of primary EDS. A brief overview of the pharmacological
management of primary EDS is included.

Black JE, Brooks SN, Nishino S. Narcolepsy and syndromes of primary
excessive daytime somnolence. Semin Neurol. 2004 Sep;24(3):271-82.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15449220>

Or

<http://www.medscape.com/viewarticle/491437?src=mp>

**Laparoscopic Excision Often Helpful for Endometriosis**

CONCLUSION(S): Laparoscopic excision of endometriosis is more effective
than placebo at reducing pain and improving quality of life. Surgery is
associated with a 30% placebo response rate that is not dependent on
severity of disease. Approximately 20% of women do not report an
improvement after surgery for endometriosis.\
Abbott J, et al Laparoscopic excision of endometriosis: a randomized,
placebo-controlled trial. Fertil Steril. 2004 Oct;82(4):878-84.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15482763>

or

<http://www.medscape.com/viewarticle/491783?src=mp>

**Ultrasound Therapy Effective for Vulvar Dystrophy**

CONCLUSION: Vulvar dystrophy could be effectively treated with focused
ultrasound therapy. This approach appears to be a new promising
treatment method, although further studies are still needed. LEVEL OF
EVIDENCE II-3: Li C, et al Focused Ultrasound Therapy of Vulvar
Dystrophies: A Feasibility Study. Obstet Gynecol. 2004
Nov;104(5):915-921.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15516378>

**Stress urinary incontinence -- An excellent review of management**

Nygaard IE, Heit M. Stress urinary incontinence. Obstet Gynecol. 2004
Sep;104(3):607-20.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15339776>

**Management of Cervical Cytologic Abnormalities**

<http://www.aafp.org/afp/20041115/1905.html>

The 2001 ASCCP Management Guidelines for Cervical Cytology: Editorial

<http://www.aafp.org/afp/20041115/editorials.html>

**[Child Health]{.underline}**

**Cholestasis of pregnancy - Bile acid pneumonia: a \"new\" form of
neonatal respiratory distress syndrome?**

Our experience suggests that a high level of attention in the management
of newborn infants (even near-term infants) born from women with
intrahepatic cholestasis of pregnancy is necessary to detect as soon as
possible signs and symptoms of this \"unexpected\" RDS, which can assume
a very severe clinical picture. In such instances, we recommend that the
diagnosis of BA pneumonia be kept in mind and that exogenous surfactant
be given as soon as possible, even in the presence of indices of normal
lung maturity in the amniotic fluid. Finding high levels of BA and
lysophosphatidylcholines in the bronchoalveolar lavage of affected
infants would aid in support of the diagnosis Zecca E, Costa S, Lauriola
V, Vento G, Papacci P, Romagnoli C.

Bile acid pneumonia: a \"new\" form of neonatal respiratory distress
syndrome? Pediatrics. 2004 Jul;114(1):269-72\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15231944>

**AHRQ and its partners launch new tools to help combat childhood
obesity**

<http://www.ahrq.gov/research/oct04/1004RA1.htm>

**AAP to Issue Advisory to Help Diagnose, Treat and Monitor Depressed
Children**

Since the Food and Drug Administration\'s (FDA) Oct. 15 announcement
that all antidepressants prescribed to children must be marked with a
\"black box\" warning due to increased risk of suicidal thinking and
behavior, the AAP has been working to address the questions and concerns
of pediatricians. These include the appropriateness of the proposed
monitoring schedule and any liability issues. While the drugs are not
contraindicated, FDA instructs prescribers to balance the risk with
clinical need.

The AAP supports the FDA\'s action, but additional guidance is being
given to help pediatricians and other health professionals meet the
needs of their patients with depression. The AAP is currently working
with the American Psychiatric Association, the American Academy of Child
and Adolescent Psychiatry and the American Academy of Family Physicians
to develop an advisory for health professionals to help diagnose, treat
and monitor depressed children. It is expected to be ready for
distribution early in 2005.

The AAP is also calling on the FDA to clarify and modify its proposed
monitoring schedule. The December AAP News issue has an article
explaining the AAP action, along with suggested clinical advice
[[http://aapnews.aappublications.org/cgi/content/full/e2004146v1]{.underline}](http://aapnews.aappublications.org/cgi/content/full/e2004146v1)

FDA information on this issue can be found at:
[[http://www.fda.gov/cder/drug/antidepressants]{.underline}](http://www.fda.gov/cder/drug/antidepressants)

**Childhood Bullying: Implications for Physicians**

<http://www.aafp.org/afp/20041101/1723.html>

**Bullying: Patient Education**

<http://www.aafp.org/afp/20041101/1729ph.html>

**[Chronic disease and Illness]{.underline}**

**A novel specific prophylaxis for menstrual-associated migraine.**

CONCLUSIONS: All currently available estrogen-containing oral
contraceptives produce a premenstrual fall in ethinyl estradiol
concentration equal to or greater than 20 microg. Estrogen
supplementation during the placebo week can reduce the magnitude of this
fall to less than 20 microg. When the decline is limited to the
equivalent of 10 microg ethinyl estradiol, menstrual-associated migraine
is prevented. At an average cost of six dollars per headache-day
prevented, this represents an effective and inexpensive strategy for a
common migraine trigger.

Calhoun AH. A novel specific prophylaxis for menstrual-associated
migraine. South Med J. 2004 Sep;97(9):819-22.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15455962>

**Identifying patients who require a change in their current acute
migraine treatment**

Results: The test-retest reliability of the 27 Migraine-ACT questions
ranged from good to excellent, and correlation coefficients were highly
significant for all items. The consistency of reporting the yes and no
answers was also excellent. Correlations of Migraine-ACT items with
SF-36 and MIDAS items and SF-36, MIDAS and MTAQ total scores indicated
that the following were the most discriminating items, in the respective
four domains, and constitute the final Migraine-ACT questionnaire:

Dowson AJ, et al Identifying patients who require a change in their
current acute migraine treatment: the Migraine Assessment of Current
Therapy (Migraine-ACT) questionnaire. Neurol Sci. 2004 Oct;25 Suppl
3:S276-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15549559>

**National Diabetes Awareness Month \-\-- November 2004**

November is National Diabetes Awareness Month. An estimated 18.2 million
persons in the United States (i.e., 6.3% of the population) have
diabetes. However, 5.2 million (29%) of these persons have not had their
condition diagnosed. Persons with diabetes have a risk of premature
death that is approximately two times greater than that of persons
without the disease. From 1980 to 2002, the number of persons with
diabetes in the United States more than doubled. In 2000, diabetes was
the sixth leading cause of death in the United States and cost the
nation more than \$132 billion dollars in health-care expenditures.
Additional information about diabetes is available from CDC at
<http://www.cdc.gov/diabetes>.

**Acne patients should include attention to anger and other chronic
emotional states**

CONCLUSIONS: Anger is associated with the quality of patients\' lives
and with their satisfaction with treatment. Care of acne patients should
include attention to anger and other chronic emotional states, quality
of life, as well as to clinical severity. Simple guidelines are
suggested for how clinicians might approach this important aspect of
care

Rapp DA, et al Anger and acne: implications for quality of life, patient
satisfaction and clinical care. Br J Dermatol. 2004 Jul;151(1):183-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15270889>

**Prevalence of Overweight and Obesity Among Adults with Diagnosed
Diabetes**

The prevalence of obesity among adults overall in the United States
increased from 22.9% during 1988\--1994 to 30.5% during 1999\--2002
(*5,6*); the prevalence of obesity among adults with diagnosed diabetes
remained high, at 45.7% during 1988\--1994 and 54.8% during 1999---2002

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5345a2.htm>

**The colon is a pelvic organ too: taking the Couric challenge**

Through her position and passion, Katie Couric has been able to motivate
legions of viewers to talk about their bowels, to learn about their
colon cancer risks, and in many cases, to take action and undergo
screening. Well, the colon is a pelvic organ and
obstetricians--gynecologists should play an active role in preventing
death from colon cancer..

Karlan BY. The colon is a pelvic organ too: taking the couric challenge.
Obstet Gynecol. 2004 Nov;104(5):907-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15516375&dopt=Abstract>

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

As we struggle to rediscover a place for the 'Annual Exam' in our
practices please consider that colon cancer is increased among AI/AN
women.

At The American College of Obstetricians and Gynecologists' 2004 Annual
Clinical Meeting, Katie Couric of NBC\'s Today Show challenged us to
increase the number of women screened for colon cancer. Colorectal
cancer currently ranks third among cancer-related deaths in women and
takes twice as many lives as ovarian cancer. Although our patients are
eager to be screened for ovarian cancer, less than half are screened for
colorectal cancer. Ironically, we have reliable techniques to detect
early-stage colorectal cancer, which have been proven to reduce
mortality; in contrast, diagnosing early-stage ovarian cancer has been
an elusive goal.

Most organizations, including ACOG and the American Cancer Society, have
issued evidence-based guidelines that recommend screening for colon
cancer, beginning at age 50 in average-risk individuals.

Sigmoidoscopy and colonoscopy directly visualize colonic tumors,
although accuracy depends on the skill of the operator and on the size
and location of abnormalities. Flexible sigmoidoscopy is easier, safer,
and less costly than colonoscopy, but only visualizes the distal third
of the colon, thereby missing all proximal lesions. It has been argued
that sigmoidoscopy identifies those patients most likely to benefit from
colonoscopy. However, in a large study performed at 13 Veterans
Administration medical centers, more than half of the patients with
advanced proximal neoplasia had no distal lesions; these cancers would
not have been identified if patients had been screened with
sigmoidoscopy alone. Colonoscopy is often considered the \"gold
standard\" for colorectal cancer screening. On the other hand, its
accuracy is only 90% for large polyps and 75% for polyps under 1 cm.
Persistent or recurrent symptoms, therefore, require further testing and
follow-up. njm

**Aggressive statin strategy best for patients with heart disease**

CONCLUSIONS: An aggressive, focused statin therapy management strategy
outperformed usual care in health maintenance organization and Veterans
Administration clinic patients with CHD. Koren MJ, et al Clinical
outcomes in managed-care patients with coronary heart disease treated
aggressively in lipid-lowering disease management clinics: the alliance
study. J Am Coll Cardiol. 2004 Nov 2;44(9):1772-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15519006>

**Is Antibiotic Use Associated with Breast Cancer Risk?**

CONCLUSIONS: Use of antibiotics is associated with increased risk of
incident and fatal breast cancer. It cannot be determined from this
study whether antibiotic use is causally related to breast cancer, or
whether indication for use, overall weakened immune function, or other
factors are pertinent underlying exposures. Although further studies are
needed, these findings reinforce the need for prudent long-term use of
antibiotics. Velicer CM, et al Antibiotic use in relation to the risk of
breast cancer. JAMA. 2004 Feb 18;291(7):827-35.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14970061>

**Caloric Restriction Decreases Incidence of Breast Cancer**

CONCLUSIONS: Severe caloric restriction in humans may confer protection
from invasive breast cancer. Low caloric intake prior to first birth
followed by a subsequent pregnancy appears to be associated with an even
more pronounced reduction in risk. Michels KB, Ekbom A. Caloric
restriction and incidence of breast cancer. JAMA. 2004 Mar
10;291(10):1226-30.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15010444>

**Vioxx Pulled From Global Market - Potential Mechanisms for
Cardiovascular Risk**

Mechanistically speaking, there are reasons why inhibiting COX-1 and
COX-2 might affect cardiovascular risk. Because COX-1 helps promote
thrombosis and COX-2 helps inhibit it, blocking COX-2 but not COX-1
could theoretically increase the risk of myocardial infarction and other
thrombotic events. On the other hand, inflammation has also been
implicated in cardiovascular events, so controlling inflammation via
COX-2 inhibition could conceivably be protective.
<http://www.fda.gov/cder/drug/infopage/vioxx/default.htm>

**Outcomes After Cardiac Catheterization in Women**

CONCLUSIONS: Sex-based differences in death rates after cardiac
catheterization are time- and treatment-specific. This finding may at
least partially explain the discrepancies in results from earlier
studies on sex differences in outcomes of cardiac care

King KM, et al Sex differences in outcomes after cardiac
catheterization: effect modification by treatment strategy and time.
JAMA. 2004 Mar 10;291(10):1220-5.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15010443>

**Common Dietary Supplements for Weight Loss**

<http://www.aafp.org/afp/20041101/1731.html>

##### Features

## American Family Physician\*\*

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

**Isoflavones Do Not Reduce Menopausal Symptoms**

[Clinical Question]{.underline}: Do isoflavones improve cognitive
function, bone mineral density, and plasma lipid levels in
postmenopausal women?

###### **[Bottom Line:]{.underline}** Postmenopausal supplementation with soy protein containing isoflavones does not improve cognitive function or affect bone mineral density or plasma lipid levels. Previous studies evaluating an effect of isoflavones on postmenopausal hot flushes also have found minimal benefit. (Level of Evidence: 1b-)

<http://www.aafp.org/afp/20041115/tips/16.html>

Trial of Labor After Cesarean Section Is Relatively Safe

[Clinical Question]{.underline}: How risky is a trial of labor after
cesarean delivery for uterine rupture and other patient-oriented
outcomes?

[Bottom Line:]{.underline} Based on the best research, as compared with
trial of labor, approximately 370 elective repeat cesarean sections
would have to be performed to avoid one symptomatic uterine rupture.
More than 7,000 elective repeat cesarean sections would be needed to
prevent one perinatal death associated with uterine rupture, and almost
3,000 elective repeat cesarean sections would be needed to prevent one
hysterectomy. No maternal deaths occurred among women who chose trial of
labor or elective repeat cesarean section in the studies included in
this review. There is insufficient evidence to judge whether induction
of labor with oxytocin or prostaglandins increases the risk of
symptomatic uterine rupture. This information should be included in the
consent process for women who must choose between trial of labor and
elective repeat cesarean section. (Level of Evidence: 2a)

<http://www.aafp.org/afp/20041101/tips/22.html>

Ultrapotent Topical Steroids for Vulvar Lichen Sclerosus

[Clinical Question]{.underline}: What is the response of vulvar lichen
sclerosus to treatment with ultrapotent topical steroids?

[Bottom Line]{.underline}: This study supports the use of an ultrapotent
topical steroid (i.e., 0.05 percent clobetasol propionate ointment) in
women with vulvar lichen sclerosus. Unfortunately, the weak study
design, which lacked a control group, is typical of the literature on
this condition. (Level of Evidence: 4)

<http://www.aafp.org/afp/20041101/tips/23.html>

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

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

Screening for Syphilis Infection: Recommendation Statement

U.S. PREVENTIVE SERVICES TASK FORCE

**Summary of Recommendations**

• The USPSTF strongly recommends that physicians screen persons at
increased risk for syphilis infection. **A recommendation.**

Although the USPSTF found no new direct evidence that screening for
syphilis infection leads to improved health outcomes in persons at
increased risk (see Clinical Considerations), there is adequate evidence
that screening tests can accurately detect syphilis infection and that
antibiotics can cure syphilis. Screening may result in potential harms
(such as clinical evaluation of false-positive results, unnecessary
anxiety to the patient, and harms of antibiotic use). The USPSTF
concludes that the benefits of screening persons at increased risk for
syphilis infection substantially outweigh the potential harms.

• The USPSTF strongly recommends that physicians screen all pregnant
women for syphilis infection. **A recommendation.**

The USPSTF found observational evidence that the universal screening of
pregnant women decreases the proportion of infants with clinical
manifestations of syphilis infection and those with positive serologies.
The USPSTF concludes that the benefits of screening all pregnant women
for syphilis infection substantially outweigh potential harms.

• The USPSTF recommends against routine screening of asymptomatic
persons who are not at increased risk for syphilis infection. **D
recommendation.**

Given the low incidence of syphilis infection in the general population
and the consequent low yield of such screening, the USPSTF concludes
that potential harms of screening (i.e., opportunity cost,
false-positive test results, and labeling) in a low-incident population
outweigh the benefits.

<http://www.aafp.org/afp/20041115/us.html>

##### ACOG

**Gynecologic Herpes Simplex Virus Infections**

**ACOG Practice Bulletin NUMBER 57, NOVEMBER 2004**

**Summary of Recommendations**

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

-   Antiviral therapy should be prescribed at the first clinical episode
    to reduce the duration of symptoms and viral shedding.

-   Women should be offered antiviral treatment for recurrent episodes
    at prodrome or at the beginning of an episode of genital herpes.

-   Women with frequent recurrences should be offered suppressive
    therapy.

-   For couples in which one partner has HSV-2 infection, suppressive
    antiviral therapy should be recommended for the partner with HSV-2
    to reduce the rate of transmission.

-   Topical antivirals are not effective in the treatment of genital
    herpes and should not be used.

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

-   Clinical suspicion of genital herpes should be confirmed using
    reliable laboratory testing.

-   Discordant couples should be counseled that consistent use of
    condoms decreases but does not eliminate the risk of transmission.

**Non- ACOG Members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15516420>

**ACOG Members**

<http://www.acog.org/publications/educational_bulletins/pb057.cfm>

Gynecologic herpes simplex virus infections. ACOG Practice Bulletin No.
57. American College of Obstetricians and Gynecologists. Obstet Gynecol
2004;104:1111--7.

**Prenatal and Perinatal Human Immunodeficiency Virus Testing: Expanded
Recommendations ACOG Committee Opinion** Number 304, November 2004

ABSTRACT: Early identification and treatment of all pregnant women with
human immunodeficiency virus (HIV) is the best way to prevent neonatal
disease. Pregnant women universally should be tested for HIV infection
with patient notification as part of the routine battery of prenatal
blood tests unless they decline the test (ie, opt-out approach). Repeat
testing in the third trimester and rapid HIV testing at labor and
delivery are additional strategies to further reduce the rate of
perinatal HIV transmission.

The Committee on Obstetric Practice [makes the following
recommendations]{.underline}:

-follow an opt-out prenatal HIV testing approach where legally possible

-repeat offer of HIV testing in the third trimester to women

-in areas with high HIV prevalence,

-women known to be at high risk for HIV infection

-women who declined testing earlier in pregnancy

-as allowed by state laws and regulations

-use conventional HIV testing for women who are candidates for
third-trimester testing

-use rapid HIV testing in labor for women with undocumented HIV status

-if a rapid HIV test result is positive, initiate antiretroviral
prophylaxis (with consent) without waiting for the results of the
confirmatory test.

**Non-ACOG Members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15516421>

**ACOG Members**

<http://www.acog.org/publications/committee_opinions/co304.cfm>

Prenatal and perinatal human immunodeficiency virus testing: expanded
recommendations. ACOG Committee Opinion No. 304. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2004;104:1119--24.

**Influenza Vaccination and Treatment During Pregnancy**

**ACOG Committee Opinion** Number 305, November 2004

ABSTRACT: Influenza vaccination is an essential element of prenatal
care. The American College of Obstetricians and Gynecologists\'
Committee on Obstetric Practice supports the Centers for Disease Control
and Prevention\'s expanded recommendation that women who will be
pregnant during the influenza season (October through mid May) should be
vaccinated. The ideal time to administer the vaccine is October and
November; however, it is appropriate to vaccinate patients throughout
the influenza season as long as the vaccine supply lasts. This
intramuscular, inactivated vaccine may be used in all 3 trimesters.
Because of the unknown effects of influenza antiviral drugs on pregnant
women and their fetuses, the Committee on Obstetric Practice recommends
that these antiviral agents should be used during pregnancy only if the
potential benefits justify the potential risks.

**Non-ACOG Members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15516422>

**ACOG Members**

<http://www.acog.org/publications/committee_opinions/co305.cfm>

Influenza vaccination and treatment during pregnancy. ACOG Committee
Opinion No. 305. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2004;104:1125--6.

**ACOG Issues State-of-the-Art Guide to Hormone Therapy**

-Experts Expand Prior Post-WHI Advice on Estrogen

-Herbal Remedies Don\'t Relieve Hot Flashes;\
-Too Soon to Know if Testosterone Enhances Libido

<https://www.acog.com/from_home/publications/press_releases/nr09-30-04-2.cfm>

##### AHRQ

**Study finds that some pregnant women are prescribed drugs that may be
considered unsafe during pregnancy**
<http://www.ahrq.gov/research/sep04/0904RA2.htm#head1>

**Quality-of-life benefits of short-term hormone therapy may outweigh
the risks for some menopausal women**
<http://www.ahrq.gov/research/oct04/1004RA2.htm#head1>

**After more than 20 years, quality of life is similar for women who had
a hysterectomy or went through natural menopause**
<http://www.ahrq.gov/research/oct04/1004RA3.htm#head2>

**Instruments that measure the health status of children: Impact of
race, ethnicity, and income on health**
<http://www.ahrq.gov/research/oct04/1004RA5.htm#head4>

##### Breastfeeding

**Breastfeeding reduced risk of leukemia**

CONCLUSIONS: This meta-analysis showed that both short-term and
long-term breastfeeding reduced the risk of childhood ALL and AML,
suggesting that the protective effect of breastfeeding might not be
limited to ALL as earlier hypothesized. Potential bias introduced by
different participation rates for case and control samples that differed
in SES can be minimized by implementing larger case-control studies with
SES-matched, population-based controls.

Kwan ML, et al Breastfeeding and the risk of childhood leukemia: a
meta-analysis. Public Health Rep. 2004 Nov-Dec;119(6):521-35.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15504444>

**New Brochure available: USDA Nursing Mothers Room\'s**

Supporting nursing mothers means healthier babies, happier mothers, and
more productive employees. Let\'s work together as the USDA community to
help provide that support.

<http://www.usda.gov/oo/broch.htm>

**[Domestic Violence]{.underline}**

**Intimate Partner Violence: What Are Physicians\' Perceptions with
older patients?**

CONCLUSIONS: Continued provider training about IPV should include
information on identifying older victims and appropriate management
options. Participants stressed the importance of community efforts to
raise awareness and improve resources available for older women who are
victims of IPV. Zink T, Regan et al Intimate partner violence: what are
physicians\' perceptions? J Am Board Fam Pract. 2004
Sep-Oct;17(5):332-40.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15355946>

**Abuse in childhood and adolescence as predictor of future
victimization**

Violence Against Women: Identifying Risk Factors summarizes two studies
that used different methodologies and samples to determine the extent to
which physical and sexual abuse during childhood or adolescence
contribute to later victimization. The research brief, published by the
National Institute of Justice, describes the methodologies, limitations,
and findings of the two studies. The first study followed college-age
women and men for 4 years, asking them questions about past and current
victimization each year. In the second study, researchers asked urban,
low-income, mostly black women who had substantiated child sexual abuse
about their adolescent and adult victimization. The brief also presents
information on prevention strategies, and it includes references. It is
intended for use by service providers and counselors working with
adolescents and young adults, victims\' and women\'s advocacy groups,
and researchers.
[[http://www.ncjrs.org/pdffiles1/nij/197019.pdf]{.underline}](http://www.ncjrs.org/pdffiles1/nij/197019.pdf)

**[Elder Care News]{.underline}**

**Use of Traditional Foods in a Healthy Diet in Alaska: Risks in
Perspective**

State of Alaska Epidemiology Bulletin 10/22/04,
<http://epi.alaska.gov/bulletins/docs/rr2004_07.pdf>

Volume 1. PCB's and related compounds

Volume 2. Mercury

Volume 3. Benefits of Native Foods

**Metabolic syndrome plus inflammation increases risk of cognitive
decline**

CONCLUSION: These findings support the hypothesis that the metabolic
syndrome contributes to cognitive impairment in elders, but primarily in
those with high level of inflammation.

Yaffe K, Kanaya et al The metabolic syndrome, inflammation, and risk of
cognitive decline. JAMA. 2004 Nov 10;292(18):2237-42.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15536110>

**[Family Planning]{.underline}**

**Depo Provera: Loss of significant bone mineral density\***

FDA and Pfizer notified healthcare professionals of the addition of a
BOXED WARNING: the loss of significant bone mineral density.

-Depo-Provera Contraceptive Injection is indicated only for the
prevention of pregnancy in women of child-bearing potential.

-Bone loss is greater with increasing duration of use and may not be
completely reversible.

-Depo-Provera Contraceptive should be used as a long-term birth control
method (e.g., longer than 2 years) only if other birth control methods
are inadequate.

[[http://www.fda.gov/medwatch/SAFETY/2004/safety04.htm#Depo]{.underline}](http://www.fda.gov/medwatch/SAFETY/2004/safety04.htm#Depo)

[\*Note from Burt Attico:]{.underline} This seems a very important
clinical item, since DMPA is such a popular contraceptive with IHS
clients. When DMPA was approved for contraception, Pfizer was supposed
to come back with some long term BMD studies, but this has not as yet
been forthcoming. With the high rates of lactose intolerance that we
see, and the virtually unknown prevalence rates of osteoporosis in
AI/AN, this seems even more important.

**Effectiveness of Spermicides Containing Nonoxynol-9**

CONCLUSION: The gel with the lowest amount of nonoxynol-9 was less
effective than the 2 higher-dose gels. Among 3 products containing 100
mg of nonoxynol-9, formulation did not significantly affect pregnancy
risk. All products were safe. LEVEL OF EVIDENCE: I

Raymond EG, et al Contraceptive effectiveness and safety of five
nonoxynol-9 spermicides: a randomized trial. Obstet Gynecol. 2004
Mar;103(3):430-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14990402>

**Contraception for Adolescents**

Part II (below) is a practice guideline on contraception for
adolescents. Part I reviewed general adolescent reproductive health
issues, the use of oral contraceptive pills (OCPs) and the contraceptive
patch. Part II will address a newly-approved formulation of OCPs, the
use of depot medroxyprogesterone acetate (DMPA), emergency contraception
(EC), and the male condom. Condoms, although not as effective in
preventing pregnancy, are important in preventing the transmission of
sexually transmitted infections (STIs), and teenagers who use hormonal
contraceptive methods should be counseled to use condoms as well. For
some teens, condoms may serve the dual purpose of preventing STIs and
pregnancy.

This practice guideline will not include the IUD, vaginal spermicides,
or the group of barrier methods that includes the diaphragm and cervical
cap, which are not used very commonly by adolescents. Nonoxynol-9, the
vaginal spermicide that is used alone in a cream, foam, or suppository
formulation or with the condom, diaphragm, or cervical cap, has been
associated with increased rates of HIV transmission (Centers for Disease
Control and Prevention, 2000).

Cromwell PF, Daley AM, Risser WL. Contraception for adolescents: part
one. J Pediatr Health Care. 2004 May-Jun;18(3):149-52.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15129216>

and

Cromwell PF, Daley AM, Risser WL. Contraception for adolescents: Part
two. J Pediatr Health Care. 2004 Sep-Oct;18(5):250-3.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15337920>

**[Frequently asked questions]{.underline}**

**Q.** Does IHS have any policy on distribution of the morning after
pill?

**A.** Yes, the IHS offers all FDA approved contraceptive agents.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ec112204.doc>

**Q**. Is exercise actually recommended in pregnancy? If so, why?

**A.** Yes, exercise is highly recommended in uncomplicated pregnancy.
It can help a lot.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/exercpreg112104.doc>

**Q**. What do you use to treat pregnant women with migraines?

**A.** First of all make sure these are migraine headaches, then treat
appropriately.

<http://www.ihs.gov/MedicalPrograms/MCH/M/faqdnlds/MigraiPreg102505.doc>

**Q** Is routine antenatal surveillance indicated with an elevated
maternal serum alpha-fetoprotein ?

**A**. #1 No, it is not routinely recommended. #2 There may be a role in
certain high risk patients.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/AFPrisk111504B.doc>

**Q.** Can we use misoprostol for labor induction in asthma patients?
(Medscape)

**A.** Yes, but PG-F2alpha analogs (*Hemabate*) should be avoided if
possible. or used with caution

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHfaq.asp#miso>

**Q**. Using weekly 17-OH-progesterone caproate in your patient
population for PTL?

**A.** Yes, we are using a progesterone regimen in a restricted fashion
for selected patients.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/progestPTL112204.doc>

**Q.** What are some of the issues involving rapid cesarean delivery
[+]{.underline} local anesthesia?

**A**. It can be quite uncomfortable despite local infiltration. Think
about the surgical approach too.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/RapCes111404.doc>

**Q.** What is the best antenatal surveillance regimen for twin
gestations?

**A.** One can consider beginning at 38 weeks, though start earlier in
higher risk groups

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/TwinAnteSurv1122204.doc>

**Q.**  What is known about nurse based breast and cervical cancer
screening in AI/AN(s)?

**A.**  Here are several articles that discuss this method to increase
screening in AI/AN(s).

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/nursScr111404.doc>

**[Hormone Replacement Update]{.underline}**

**Effect of Hormone Therapy on Cognition in Elderly Women**

CONCLUSION: Given equivalent groups of users and nonusers of HRT no
support was found for the hypothesis that use of HRT improves cognitive
performance in older women.

Galen Buckwalter J, et al Hormone use and cognitive performance in women
of advanced age. J Am Geriatr Soc. 2004 Feb;52(2):182-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14728625>

# [Information Technology]{.underline}

**Prenatal care: a strategic first step toward EMR acceptance**

Rather than turn a practice upside-down with a \"big bang\"
implementation or replace old workflows with entirely new ones,
executives must survey and understand those clinical areas where the
needs are real and the value of an electronic medical record (EMR) to
clinicians is immediate and obvious. Obstetrics may be the best place to
test an electronic medical record.

Miller DW Jr. Prenatal care: a strategic first step toward EMR
acceptance. J Healthc Inf Manag. 2003 Spring;17(2):47-50.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12698913>

**Designated provider management system, version 1.0 released**

ITSC wishes to thank for following beta sites for testing this
functionality: Sonoma County Indian Health, Chinle Comprehensive Health
Care Facility, and Mt. Edgecumbe Hospital. 

FEATURES: The new Designated Specialty Provider Management System (BDP)
facilitates assignment of a panel or multiple panels of patients to a
Designated Primary Care Provider.  The System similarly permits
assignment of a panel or panels of patients to one of several Specialty
Care Providers such as a Diabetes Provider, Home Care Provider, Mental
Health Provider, and others. In addition to initial assignment of
patients to Primary Care and Specialty Providers, the system facilitates
easy changing of patients from one provider to another, and addition and
deletion of individual patients from a provider's assigned panel. The
assignment of patient panels to Primary Care Providers and to Specialty
Care Providers is intended to assist a facility's comprehensive care
team in coordinating the overall care of patients.  Additionally, it
permits the display of important statistical information by Provider
Panels. Please contact your site manager for further information about
this package

# [International Health Update]{.underline}

**100,000 Excess Civilian Iraqi Deaths Since War**

Interpretation Making conservative assumptions, we think that about
100?000 excess deaths, or more have happened since the 2003 invasion of
Iraq. Violence accounted for most of the excess deaths and air strikes
from coalition forces accounted for most violent deaths. We have shown
that collection of public-health information is possible even during
periods of extreme violence. Our results need further verification and
should lead to changes to reduce non-combatant deaths from air strikes.
Roberts L, et al Mortality before and after the 2003 invasion of Iraq:
cluster sample survey. Lancet. 2004 Nov 20;364(9448):1857-64.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15555665>

**Health policy summer internship available to minority college
students**\
The Henry J. Kaiser Family Foundation is seeking applications for a
congressional internship program for minority college students, hosted
by Howard University in Washington, D.C. African American, Latino,
Asian/Pacific Islander and American Indian/Alaska Native college
seniors\
and recent graduates interested in the field of health policy are
encouraged to apply for the \"Barbara Jordan Health Policy Scholars
Program,\" which honors the legacy of the late U.S. congresswoman.
Participants in the summer program will receive approximately \$5,000
in\
support, including a stipend, daily expense allowance, airfare, and
lodging. The application deadline is Jan. 7.
<http://www.kff.org/docs/topics/jordanscholars.html>

**Applied Epidemiology Fellowship in Maternal and Child Health**

In response to the need for a skilled workforce in applied epidemiology
at state and local health departments, the Council of State and
Territorial Epidemiologists has established the Applied Epidemiology
Fellowship Program in partnership with the Centers for Disease Control
and Prevention and the Association of Schools of Public Health. The goal
of the fellowship is to provide on-the-job training in applied
epidemiology for recent graduates and to prepare fellows for long-term
career placement. CSTE is currently accepting applications for immediate
placement in maternal and child health positions for doctoral-level
fellows. Adrienne Gil (770) 458-3811

[www.cste.org/Workforcedev/main1.htm](../www.cste.org/Workforcedev/main1.htm)
or <fellowship@cste.org>

#### [MCH Alert]{.underline}

**New Web site to support the education and training of those working in
the MCH**

The Maternal and Child Health (MCH) Training Program of the Maternal and
Child Health Bureau has launched a new Web site to support the education
and training of those working in the MCH professions. The MCH Training
Program supports trainees, faculty, continuing education, and technical
assistance. The new Web site provides information on new funding
opportunities, writing a grant proposal, currently funded projects, and
reporting requirements. The Web site also includes an events calendar,
conference archives, a glossary, a PDF file library, and other resources
relevant to the program.
[[http://www.mchb.hrsa.gov/training]{.underline}](http://www.mchb.hrsa.gov/training)

**Economic factors explain weight outcomes**

The Role of Economics in Eating Choices and Weight Outcomes examines
economic factors that help explain variation in behaviors and attitudes
associated with weight outcomes among U.S. adults. The report includes a
summary, data, and information on particular behaviors and attitudes
that affect an individual\'s risk for
overweight.[[http://www.ers.usda.gov/publications/aib791]{.underline}](http://www.ers.usda.gov/publications/aib791)

#### [Medscape\*]{.underline}

**Cultural Differences in Diet and Heart Health Among Women**\
Heart disease is the leading cause of death in women in the United
States, accounting for more deaths than stroke, lung cancer, and breast
cancer. Cardiovascular diseases account for one third of all deaths in
women worldwide. This third essay on \"Nutrition, Culture, and Women\'s
Health\" focuses on the influence of acculturation on dietary habits of
women.
[http://www.medscape.com/viewarticle/490343?src=mp](http://www.magnetmail.net/ls.cfm?r=12268528&sid=284442&m=58193&u=AHA_HFSF_1&s=http://www.medscape.com/viewarticle/490343?src=mp)

######### 

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

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

######### 

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

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

**Clinical Discussion Board Index, Medscape**

Hundreds of ongoing clinical discussions available

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

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

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

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

**[Office of Women's Health, CDC]{.underline}**

**Intervention and Evaluation Trials to Prevent Intimate Partner
Violence: Funding**

\- Letter of Intent Deadline: November 26, 2004.

\- Application Deadline: January 25, 2005.

The purpose of the program is to conduct efficacy and effectiveness
trials of intervention strategies to prevent intimate partner violence
and/or its negative consequences, particularly studies of strategies
that have not been well studied, for at-risk or underserved populations.
Approximate Number of Awards: 3-6. Approximate Average Award: \$300,000
to \$600,000, with an average award of \$450,000.

<http://a257.g.akamaitech.net/7/257/2422/06jun20041800/edocket.access.gpo.gov/2004/04-24026.htm>

**[Osteoporosis]{.underline}**

**Pharmacologic Prevention of Osteoporotic Fractures: AFP**

<http://www.aafp.org/afp/20041001/1293.html>

**Osteoporosis Management: Out of Subspecialty Practice and into Primary
Care**

<http://www.aafp.org/afp/20041001/editorials.html>

**[Patient Information]{.underline}**

**Timing of pregnancy, and pre-pregnancy health habits and important
issues**

A new consumer brochure from the WA Department of Health addresses
timing of pregnancy, and pre-pregnancy health habits and important
issues to discuss with a doctor about when considering pregnancy. It is
currently available online in pdf format ready to print in English,

Spanish, Ukrainian, Somali, Russian, Korean, Traditional Chinese, and
Vietnamese. 

<http://www.swedishmedical.org/PregnancyForesight/Home.html>

**Seat Belt Use During Pregnancy**

<http://www.aafp.org/afp/20041001/1313ph.html>

**Bullying: Patient Education**

<http://www.aafp.org/afp/20041101/1729ph.html>

**[Primary Care Discussion Forum]{.underline}**

## November 1, 2004:  Violence against Native women 

Moderator: Terry Cullen

This discussion will include:

-scope of violence against Native women

-tools for patient evaluation

-best practice policies and procedures

-ideas about available resources.

**February 1, 2005:  Surgery for obesity?**

Moderator: Hope Baluh

This discussion will include:

-Is it time for Obesity Surgery in the IHS?

-How are primary care providers addressing the obesity epidemic now?

-Would non-surgical programs to address this issue be safer? easier?
more effective?

-Cost effectiveness\... what\'s cheaper? What about results?

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

Subscribe to the Primary Care listserv

<http://www.ihs.gov/generalweb/helpcenter/ihshelpdesk/index.cfm?module=listserv&option=subscribe&newquery=1>

Unsubscribe from the Primary Care listserv

<http://www.ihs.gov/generalweb/helpcenter/ihshelpdesk/index.cfm?module=listserv&option=unsubscribe&newquery=1>

Questions on how to subscribe, contact <nmurphy@anmc.org> directly

**[Barbara Stillwater, Alaska State Diabetes Program]{.underline}**

**Obesity and Diabetes Independently Increase Cesarean Delivery Risk
(see Thierry above)**

CONCLUSION: Pregravid obesity and diabetes independently increase the
risk for CD. Given the disparate prevalence of obesity and diabetes in
the United States, body habitus has a significantly larger impact on CD
risk.

Ehrenberg HM, et al. The influence of obesity and diabetes on the risk
of cesarean delivery. Am J Obstet Gynecol. 2004 Sep;191(3):969-74.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15467574>

**See also CCC Editorial Comment in Thierry above**

**Even Without Diabetes, High Blood Sugar Ups Death, Heart Disease
Risk**

As your blood sugar level goes up, so does your risk of death and heart
disease - even if you don\'t have diabetes. The news comes from two
extraordinary studies appearing in the *Annals of Internal Medicine*.
Both focus on a test called hemoglobin A1c \-- HbA1c \-- which measures
average blood sugar levels over the past three months. Normal HbA1c
levels range from 4% to 6%.

#1 CONCLUSIONS: Pending confirmation from large, ongoing clinical
trials, this analysis shows that observational studies are consistent
with limited clinical trial data and suggests that chronic hyperglycemia
is associated with an increased risk for cardiovascular disease in
persons with diabetes.

Selvin E, et al Meta-analysis: glycosylated hemoglobin and
cardiovascular disease in diabetes mellitus. Ann Intern Med. 2004 Sep
21;141(6):421-31.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15381515>

#2 CONCLUSIONS: The risk for cardiovascular disease and total mortality
associated with hemoglobin A1c concentrations increased continuously
through the sample distribution. Most of the events in the sample
occurred in persons with moderately elevated HbA1c concentrations. These
findings support the need for randomized trials of interventions to
reduce hemoglobin A1c concentrations in persons without diabetes

Khaw KT, et al Association of hemoglobin A1c with cardiovascular disease
and mortality in adults: the European prospective investigation into
cancer in Norfolk. Ann Intern Med. 2004 Sep 21;141(6):413-20.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15381514>

**Western\' Diet Linked to Type 2 Diabetes in Women**

CONCLUSION: The Western pattern, especially a diet higher in processed
meats, may increase the risk of type 2 diabetes in women.

Fung TT, et al Dietary patterns, meat intake, and the risk of type 2
diabetes in women. Arch Intern Med. 2004 Nov 8;164(20):2235-40.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15534160>

**Average American is 1 Inch Taller, 25 Pounds Heavier Than 40 Years
Ago**

In 1960-62, the average man weighed 166.3 pounds. By 1999-2002, the
average had reached 191 pounds, according to the National Center for
Health Statistics - part of the Centers for Disease Control and
Prevention - which issued the report. Similarly, the report said, the
average woman\'s weight rose from 140.2 pounds to 164.3 pounds. The
report, Mean Body Weight, Height and Body Mass Index, United States,
1960-2002, was based on data from the National Health and Nutrition
Examination Survey, which uses actual body measurements.

<http://www.cdc.gov/nchs/hus.htm>

**MAJOR GAINS IN HEALTH CARE QUALITY, BUT ONLY FOR 1/4th OF THE SYSTEM**

Accountable health plans show fifth straight year of gains, but broader
system still plagued by quality gaps; annual toll is 42,000 - 79,000
avoidable deaths, 66.5 million sick days and \$1.8 billion in excess
medical costs. Here are just two examples.

**Avoidable Deaths**

Smoking Cessation (with medication) 5,400 -- 8,100

Breast Cancer Screening 600 -- 1,000

**Avoidable Medical Costs per year**

Smoking Cessation (w/ Medication) \$441 million

Breast Cancer Screening \$48 million

NCQA 2004

<http://www.ncqa.org/Communications/News/sohc2004.htm>

NCQA, The State of Health Care Quality: 2003 - Tables

<http://www.ncqa.org/communications/news/sohc2003-tables.htm>

**Cultural Sensitivity and Its Impact on Care**\
Perceptions of disrespect and of being treated unfairly within
patient-provider relationships affect whether patients heed doctors\'
advice or return for treatment. These consequences are the unwelcome
results of perceived racial discrimination and can be avoided if doctors
strive to be respectful and culturally sensitive to the needs of their
patients, regardless of ethnic or racial background.
<http://www.cmwf.org/publications/publications_show.htm?doc_id=240955>

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

**Updated Diabetes in Pregnancy Guidelines-Now Online**

<http://www.ihs.gov/MedicalPrograms/MCH/w/Documents/DMPreg102504_000.doc>

There are several upcoming **Conferences**

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

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

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

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

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

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

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

### **[Save the dates]{.underline}**

**20th Annual Conference on Women's and Children's Healthcare**

-   For providers caring for Native women and children

-   February 25 - 27, 2005

-   First announcement details
    <http://www.ihs.gov/MedicalPrograms/MCH/M/documents/tldr20051stnotice.doc>

-   Telluride, CO
    <http://www.ihs.gov/MedicalPrograms/MCH/M/ConfDnlds/Tellurideagenda10-2004.doc>

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

**\
17th Annual IHS Research Conference: International Meeting on Inuit and
Native American Child Health: Innovations in clinical care and
research**

> April 29-May 1, 2005, Seattle, WA

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

**American College of Obstetricians and Gynecologists Annual Clinical
Meeting**

-   May 7-11, 2005

-   San Francisco , California

-   53rd Annual ACOG ACM <http://www.acog.org/ACM2005/>

**I.H.S. / A.C.O.G. Postgraduate Course: Obstetric, Neonatal, and
Gynecologic Care**

-   June 19 - 23, 2005

-   Denver, CO

-   Contact [Yvonne Malloy](mailto:YMalloy@acog.org) <YMalloy@acog.org>
    202-863-2580

-   Save the date info
    <http://www.ihs.gov/MedicalPrograms/MCH/M/documents/pgcoursesavethedate.doc>

-   [2004
    Brochure](http://www.ihs.gov/MedicalPrograms/MCH/M/ConfDnlds/Brochure2004.doc)
    (WORD 252k) NB: 2005 brochure is coming soon

> <http://www.ihs.gov/MedicalPrograms/MCH/M/ConfDnlds/Brochure2004.doc>

-   June 19th at 8:00 am: NEONATAL RESUSCITATION PROGRAM

```{=html}
<!-- -->
```
-   NRP Class size limited. Sign up now
    <http://www.ihs.gov/MedicalPrograms/MCH/M/documents/NeonatalResuscitationProvider2.doc>

```{=html}
<!-- -->
```
-   Meeting Website
    <http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#June05>

Did you miss something in the last OB/GYN Chief Clinical Consultant
Corner?

The **October 2004 OB/GYN CCC Corner** is available at:\
<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1004.cfm>

**[Contents:]{.underline}**

**[Abstract of the Month]{.underline}: page 2**

Premenstrual syndrome, premenstrual dysphoric disorder, and beyond: a
clinical primer for practitioners.

[From your colleagues:]{.underline} page 3

**From Biennial Meeting:** Francis Byrn, M.D. Polycystic Ovarian
Syndrome / Insulin Resistance

From Rosemary Bolza: Where is the OB package for new EHR?

From Katy Ciacco Palantinos: "Informed Refusal\" document when patients
decline a procedure

**From Terry Cullen:** Commonwealth Fund/Harvard University Fellowship
in Minority Health Policy

From Lori de Ravello: Eliminating health disparities in pregnancy;
Celebrating Women\'s Health Research\
From Sandra Dodge: Goals for smoking in pregnancy: Healthy People 2010

Helpful lifestyle and diabetes data: mean weight, height, and body mass
index; Access to care

From Sandy Haldane: Please share this with any AN/AI college students
you know 

**From Steve Holve:** November Indian Child Health Notes: Highlights

From Jean Howe: Any solutions that can help the ongoing 'Meth' crisis in
your area?

From Bob Laliberte: LOCUM TENENS AVAILABILITY

From Judy Thierry: Periodontal Disease and Pregnancy Outcomes; Pregnancy
Risk Assessment Monitoring System (PRAMS) National Meeting:

**From Rebecca Werner:** Treatment for migraines in pregnant women

**[Hot Topics:]{.underline}**

##### Obstetrics: page 7

Early delivery associated with severe periodontal disease; Infant
Mortality Rate Doubles with Short Umbilical Cord; Blunt Trauma in
Pregnancy; Seat Belt Use During Pregnancy

**Gynecology:** **page 7**

Which Women Develop Fever Following Hysterectomy? Sacrocolpopexy
consistently resolves vaginal vault prolapse; Primary and Secondary
Syphilis with Oral Sex

**Child Health:** **page 7**

SSRIs for children and adolescents should be prescribed judiciously;
Lack of Progress in physical activity in high school students; Inhalant
Abuse and Dependence Among Adolescents; Newborn Screening for Cystic
Fibrosis; Measures of sexual orientation in adolescent health surveys

**Chronic Illness and Disease:** **page 8**

Complementary Therapies in Primary Care Patients With Arthritis

[Features:]{.underline} page 9

AFP: Postmenopausal Estrogen and Cognitive Function; Blood Loss of 80 mL
or More Poorly Defines Menorrhagia; Many Pap Smears Unnecessary After
HysterectomyProphylactic Cerclage in Women with a Short Cervix;
Misoprostol for Uterine Evacuation in Missed Abortion; Postmenopausal
Estrogen Therapy and Dementia

##### ACOG: Inappropriate Use of the Terms Fetal Distress and Birth Asphyxia;

Cervical Cancer Screening in Adolescents; Multiple Gestation:
Complicated Twin, Triplet, and High-Order Multifetal Pregnancy: Sexually
Transmitted Diseases in Adolescents; Guidelines for Adolescent Health
Research

**AHRQ:** Studies show that obesity affects mammography accuracy and
screening rates; Initial surfactant treatment to prevent respiratory
distress in very premature infants is often delayed in routine practice;
Diagnosis of pain by primary care doctors is influenced by pain
severity, patient sex, and physician practice style

**Breastfeeding:** Workplace lactation program resource kit available

**Domestic Violence:** November 1, 2004:  Violence against Native women
Discussion

**Elder Care News:** Pharmacologic Prevention of Osteoporotic Fractures

**Family Planning:** Accuracy of Early Results with Home Pregnancy Test
Kits

**Frequently asked questions:** Should we perform routine urine dipstick
protein screening in our prenatal clinic? When should antenatal testing
start after an intrauterine fetal demise (IUFD)?

**Hormone Replacement Update**: ACOG Issues State-of-the-Art Guide to
Hormone Therapy

ACOG Frequently Asked Questions About Hormone Therapy for Patients;
Phytoestrogens do not improve hot flushes or other menopausal symptoms

**Information Technology:** Parklawn Library has a new identity**;**
International Health: Effectiveness of Condoms in Reducing Heterosexual
Transmission of HIV

**MCH Alert:** New edition of adolescent pregnancy prevention knowledge
path released

**Office of Women's Health, CDC**: Social Determinants of Health at the
Local Level

**Osteoporosis**: Surgeon General encourages bone health throughout the
lifespan

**Patient Education**: Seat Belt Use During Pregnancy: Patient Education

**Primary Care Discussion Forum:** November 1, 2004:  Violence against
Native women Discussion; February 1, 2005:  Surgery for obesity?

#### Barbara Stillwater, Alaska Diabetes Prevention and Control: Is your diabetic patient non-adherent? Maybe she is depressed? **Doctors\' Interpersonal Skills Valued More than Their Training or Being Up-to-Date**

**What's new on the ITU MCH web pages: page 16**

###### Save the Dates: Upcoming events of interest page 17

The past CCC Corners are archived at:

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN01.cfm#top>

The CCC Corner is good way to inform ITU providers about recent updates,
while decreasing the number of e-mail messages.

Let me know if you want to add something to next month's CCC Corner at
<nmurphy@anmc.org>

or 907 729 3154 (with voicemail)

\*The opinions expressed in the OB/GYN CCC Corner are strictly those of
the authors, and not necessarily those of the Indian Health System, or
the author of this newsletter. If you have any comments, please share
them by joining the Primary Care Discussion Forum where this topic was
recently discussed. To join the Primary Care Listserv, click on
'Subscribe' here
<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdiscuss.asp>

11/25/04njm