News flash: The IHS Colposcopy Courses were just announced

-Basic Colposcopy Course April 26-29, 2004

-Refresher Course April 27-29, 2004

Albuquerque, New Mexico (See Save the dates below, page 20)

OB/GYN Chief Clinical Consultant's Corner

Volume 1, No. 11 December, 2003

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

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

Emergency Contraception: Pharmacy Access in Albuquerque, New Mexico

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

From Burt Attico: Emergency Contraception\*: Semantics is a part of
\"the game.\"

From Burt Attico and Katy Ciacco Palatianos: Possible methods of
preventing cerebral palsy; **Chorioamnionitis and Cerebral Palsy in Term
and Near-Term Infants**

From Katy Ciacco Palatianos: To settle or not to settle?

From Sandra Dodge: 101 Way to ask someone if they are safe

From Bruce Finke: The Elder Care Initiative Office Moves East

From James Galloway and Terry Cullen: Diabetes & Cardiovascular Disease
Review

From Ursula Knoki-Wilson: \'Nurse Run Clinic\' models

From Kelly Moore: New Pediatric Chief Clinical Consultant: Steve Holve,
MD, Tuba City

From Chuck North: Redux -Chaperone Use by Family Physicians During the
Collection of a Pap Smear; Clarification: Non clean catch urine sampling
terminology

###### From Darrell Pratt: Looking for an OB/GYN?

**From Oida Vincent:** Are we required to obtain sensitivities on GBBS
for PCN allergic patients? Eager for Native American and Alaskan Native
applicants to Ph.D. program in the biomedical sciences.

**[Hot Topics:]{.underline}** **Page 10**

##### Obstetrics: Management of diabetes mellitus complicating pregnancy; Thrombophilic disorders and fetal loss: a meta-analysis; Screening for Congenital Cardiovascular Malformations; Can Eating More DHA Increase Duration of Pregnancy? Immunity to CMV Reduces Risk of Congenital Infection; Postpartum Depression Linked to Later Violence in Children;

###### Gynecology: Primary and Secondary Syphilis \-\-- United States, 2002; The 2001 Bethesda System Terminology; Depression in Older Women with Urinary Incontinence; Factors Affecting Accuracy of Mammography Screening; Multidose vs. Single-Dose Therapy in Ectopic Pregnancy; Weekly Therapy Is Effective in Prevention of Osteoporosis; Low-Dose Mifepristone Shrinks Uterine Fibroids; Low BMD Is Associated with Cognitive Decline in Women; Breast Cyst Aspiration

###### Child Health: Prophylaxis for Infants of Mothers with Hepatitis B; Evaluation of Bone Mass in Young Female Athletes; Hearing Assessment in Infants and Children; High School Students in BIA Schools: Tobacco, Alcohol, and other Drug Use; Adolescent's level of linguistic acculturation and their well-being

**Chronic Illness and Disease:** Diabetes Among Young American Indians
\-\-- Montana and Wyoming; Increases in HIV Diagnoses - 29 States,
1999---2002; Secondary Prevention in Women with Heart Disease; Fish Oil
Stabilizes Atherosclerotic Plaques

###### Other: Health Status of American Indians Compared with Other Racial/Ethnic Minority 

Populations \-\-- Selected States, 2001---2002; Common Problems in
Patients Recovering from Chemical Dependency

[Features:]{.underline} Page 12

###### AFP: POEMS HPV Triage for ASC-US Pap Results Makes Sense; Even Low Levels of Lead Can Lower IQ; False-Positive Mammograms Do Not Deter Women; Short-Interval Follow-up Mammography Is Low Yield; Oxybutynin or Tolterodine for Overactive Bladder? Use of Iron in Nonanemic, Fatigued Women; 

Other AFP Topics: Common Hyperpigmentation Disorders in Adults: Part I
Diagnostic Approach, Cafe au Lait, Macules, Diffuse Hyperpigmentation,
Sun Exposure, and Phototoxic Reactions; Common Hyperpigmentation
Disorders in Adults: Part II. Melanoma, Seborrheic Common
Hyperpigmentation Disorders in Adults: Part II. Melanoma, Seborrheic

Keratoses, Acanthosis Nigricans, Melasma, Diabetic Dermopathy, Tinea
Versicolor, and Postinflammatory Hyperpigmentation; Topical NSAIDs
Relieve the Pain of Mastalgia; Routine Vitamin Supplementation to
Prevent Cancer and Cardiovascular Disease: Recommendations and Rationale

**Annals of Family Medicine:** Women's Experiences of Abnormal Cervical
Cytology: Illness Representations, Care Processes, and Outcomes;
Periodic Abstinence From Pap (PAP) Smear Study: Women's Perceptions of
Pap Smear Screening; Factors Affecting the Detection Rate of Human
Papillomavirus; Cervical Cancer Screening

**ACOG:** ACOG Opinion Addresses Elective Cesarean Controversy; Use of
progesterone to reduce preterm birth; Dystocia and Augmentation of Labor
(ACOG Practice Bulletin)

AHRQ: Screening for High Blood Pressure: Recommendations and Rationale

**Breastfeeding:** Breastfeeding and Risk for Respiratory Disease in
Infants

Elder Care News: Influenza Vaccination; Anticoagulation in patients with
atrial fibrillation

**Hormone Replacement Update**: Minimizing Menopausal Symptoms From
Endocrine Therapy; Gabapentin Reduces Hot Flushes; Raloxifene Therapy
Does Not Affect Sexual Functioning

**Information Technology:** AHRQ to support patient safety and quality
of care through health information technology projects

International Health: A guide for health professionals working with
Aboriginal peoples

MCH Alert: Postpartum counseling perceptions and practices; Cost
estimates for Adolescent pregnancy and adolescent pregnancy prevention;

Web site offers one-stop shopping for information about federal grants

#### Medscape: Depressed Women Have More Sexual Dysfunction Than Depressed Men

#### Office of Women's Health, CDC: What's new in Women's Health Newsletter, CDC

Patient Education; [Funding opportunities]{.underline} Youth Violence
Prevention Through Community-Level Change; Sociocultural and Community
Risk and Protective Factors for Child Maltreatment and Youth Violence

#### Patient Education: How to prevent a stroke

**Primary Care Discussion Forum:** Cervical Cancer Screening: New
Guidelines and New Technologies; Emergency Contraception

#### What's new on the ITU MCH web pages Page 19

###### Save the Dates: Upcoming events of interest Page 20

**Did you miss something in the last OB/GYN Chief Clinical**

**Consultant (CCC) Corner? Page 21**

# 

# [Abstract of the Month]{.underline}

###### Emergency Contraception: Pharmacy Access in Albuquerque, New Mexico 

Eve Espey, MD, MPH, Tony Ogburn, MD, Deanna Howard, Clifford Qualls,
PhD, and Jane Ogburn Obstetrics and Gynecology November 2003 Volume 102,
Number 5, Part 1\
Pages 918 - 921

**Objective**: Emergency contraception could reduce the approximately 3
million unintended pregnancies that occur annually in the United States.
Dedicated emergency contraception products may be particularly useful
because instructions are easy to understand and simple to follow.
However, they must be available within a few days to women who have had
unprotected intercourse. The goal of this study was to investigate
whether women presenting to pharmacies in a moderately sized
metropolitan area with a prescription for Plan B or Preven could get it
filled.

**Methods**: Two research assistants posed as women needing emergency
contraception. They visited 89 pharmacies in Albuquerque, New Mexico,
presenting a prescription for either Plan B or Preven. The assistants
recorded the availability of the products in the pharmacies. When the
product was not in stock, the research assistants asked pharmacy
providers why the products were not carried. Fisher exact test was
performed to compare categoric data.

**Results**: Plan B and Preven were in stock at only 19 visits (11%). Of
the pharmacies that did not stock the products, 53% reported they could
obtain Plan B or Preven within 24 hours. The most common reason cited by
pharmacy providers for not stocking Plan B or Preven was the lack of
prescriptions received for them (65%).

**Conclusion**: Plan B and Preven were not in stock at the majority of
pharmacies in a moderately sized metropolitan area. Lack of availability
at the pharmacy constitutes a major barrier to emergency contraception
access.

Non-ACOG members

<https://www.acog.com/from_home/publications/green_journal/wrapper.cfm?document=2003/ong14713fla.htm>

<https://www.acog.com/from_home/publications/press_releases/nr10-31-03-5.cfm>

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

As stated in Chapter 13 of the IHS Manual, the Indian Health system is
authorized to provide FDA approved contraceptive methods. The above
article suggests that there are access issues in the greater Albuquerque
area for the general population. On the other hand, emergency
contraception methods are FDA approved and should be readily available
to American Indian and Alaska Native patients, nation-wide. Also see Dr.
Attico's comments below.

See MCH FAQs: Emergency Contraception

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

See August OB/GYN CCC Corner: Hot Topics

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/CCCCorner81703C.doc>

A good web site for other Emergency Contraception resources,
Not-2-Late.com

<http://ec.princeton.edu/info/ecminip.html>

Emergency Contraception was a matter of lively discussion on the
**Primary Care Discussion Forum** this month. If you want to join the
Primary Care Discussion Forum, please contact Jason Crim at:
<jason.crim@mail.ihs.gov>

By the way......

Drs. Espey and Ogburn are former IHS OB/GYNs who worked at Gallup Indian
Medical Center. Both are now on the faculty of the University of New
Mexico. They are key contributors to best practices in women's health in
Indian Health. Both are regular faculty at the ACOG / IHS OB/GYN
Postgraduate Course. In addition, Dr. Ogburn is the ACOG / IHS
Postgraduate Course Director.

A few other contraception related articles by Drs. Espey and Ogburn

Espey E, Ogburn T, Espey D, Etsitty V. IUD-related knowledge, attitudes
and practices among Navajo Area Indian Health Service providers.
Perspect Sex Reprod Health. 2003 Jul-Aug;35(4):169-73

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12941649&dopt=Abstract>

Espey E, Ogburn T. Perpetuating negative attitudes about the
intrauterine device: textbooks lag behind the evidence. Contraception.
2002 Jun;65(6):389-95.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12127635&dopt=Abstract>

Espey E, Steinhart J, Ogburn T, Qualls C. Depo-provera associated with
weight gain in Navajo women. Contraception. 2000 Aug;62(2):55-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11102587&dopt=Abstract>

## From your colleagues:

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

###### Emergency Contraception\*: Semantics is a part of \"the game.\" 

ACOG defines pregnancy as beginning at implantation. We also know from
the sensitive pregnancy tests, and IVF work, that a large percentage of
fertilizations do not implant, that they dissolve, and/or spontaneously
abort - either way, they terminate spontaneously. That is why 3-5
embryos are routinely inserted (it was 4-8 at one time previously), so
that at least 1 embryo might potentially implant (and often doesn\'t).
With Plan B, which is only progestin, part of its action is:

-inhibit ovulation

-changing cervical permeability

-influencing tubal motility

-influence the endometrium

We really don\'t always know how it works in each case, except for
Hatcher\'s theories on Emergency contraception. This is a very
controversial subject, with latest word being that the expert committee
voted today to approve OTC sale of Plan B.

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

Emergency contraception (EC) can prevent a significant number of
unintended pregnancies.

EC works by a variety of mechanisms. The mechanisms appear to occur in
order listed above, e.g., more common to least common - inhibit
ovulation, changing cervical permeability, influencing tubal motility,
and influencing the endometrium. As the medical definition of pregnancy
begins with implantation, EC is not an abortifacient.

Clinically EC is most effective if used within the first 24 hours after
unprotected coitus. It is marketed for use up to 72 hours after
unprotected coitus, though it's effectiveness declines rapidly with
time.

By some non-medical definitions, if EC hasn't worked by one of the above
3 other mechanisms already, then EC could effect implantation. Those who
believe that pregnancy begins with fertilization may choose to refer a
patient seeking EC to another provider. In any case, all providers
should be able to present the patient a non-directive informed consent
and a facile and timely treatment alternative.

The ethical question, however, is no matter what your belief system
is....rather, have you adequately counseled the patient about the 4
mechanisms, so that the patient can make a non-directed informed
consent? We should leave it up to the values of the patient herself as
to whether she wants to use EC based on the best information we can
offer.

\*Any comments regarding EC 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.

Contact Jason Crim at:
[jason.crim@mail.ihs.gov](mailto:jason.crim@mail.his.gov)

#### [From Burt Attico, Phoenix, and Katy Ciacco Palatianos, HQE]{.underline}

**Cerebral Palsy: Possible methods of preventing cerebral palsy in
full-term and premature**

**Collaborative Group Effect of Magnesium Sulfate Given for
Neuroprotection Before Preterm Birth: A Randomized Controlled Trial**

[Conclusions]{.underline}

Magnesium sulfate given to women immediately before very preterm birth
may improve important pediatric outcomes. No serious harmful effects
were seen.

Caroline A. Crowther, MD, FRANZCOG; Janet E. Hiller, PhD; Lex W. Doyle,
MD, FRACP; Ross R. Haslam, FRACP; for the Australasian Collaborative
Trial of Magnesium Sulphate (ACTOMgSO4) Collaborative Group Effect of
Magnesium Sulfate Given for Neuroprotection Before Preterm Birth: A
Randomized Controlled Trial *JAMA.* 2003;290:2669-2676

<http://jama.ama-assn.org/cgi/content/abstract/290/20/2669>

###### Chorioamnionitis and Cerebral Palsy in Term and Near-Term Infants

[Conclusion]{.underline}

Our data suggest that chorioamnionitis is an independent risk factor for
CP among term and near-term infants.

Yvonne W. Wu, MD, MPH; Gabriel J. Escobar, MD; Judith K. Grether, PhD;
Lisa A. Croen, PhD; John D. Greene, MA; Thomas B. Newman, MD, MPH

Chorioamnionitis and Cerebral Palsy in Term and Near-Term Infants
*JAMA.* 2003;290:2677-2684.
<http://jama.ama-assn.org/cgi/content/abstract/290/20/2677>

##### Katy Ciacco Palatianos, HQE

##### To settle or not to settle?

**Q.** We have a significant lawsuit and a real dilemma with one of our
providers. It\'s a serious case and which, although defensible, could
result in high damages because it involves a cerebral palsy baby. The
physician asserts that she/he didn\'t do anything wrong. However, we
feel the case has to be settled. Any advice?

A. Attorneys who defend providers run into this dilemma all too
frequently. The defense attorney must assess the risk at multiple levels
and be realistic about what will happen in front of the jury. On the
most basic level, your attorney will [consider these
questions]{.underline}:

Can the jury be convinced that the provider was not responsible for the
harm she allegedly caused?

-How sympathetic will the jury feel toward the plaintiff and his or her
family? In a cerebral palsy case, the jury will likely feel very sorry
for the plaintiff.

-Who is the plaintiff\'s attorney?

-How do our experts and witnesses stack up against the plaintiff\'s
experts?

-Do we have any documentation issues that the plaintiff can exploit?

-Will our defendant provider appear caring and thoughtful to the jury?
This is far more important than many people realize.

-The answers will help you determine how to address the claim. As you
can see, it goes beyond whether the provider did the right thing.

-A second level of analysis requires you to think about the possible
damages that could result. The verdict in a cerebral palsy case can be
quite high and possibly place the provider\'s assets at risk. (NB: This
is not an issue in federal tort claim cases)

-When meeting with the provider and hospital to discuss how to proceed,
I often approach the conversation similarly to how a provider would
approach the process of obtaining informed consent for a surgical
procedure. I inform all involved parties about the trial process, the
risks, the pros and the cons, and the alternatives. Then, we discuss how
the provider and the hospital would like to proceed, such as whether to
arbitrate or mediate.

-Finally, you should consider how the case would affect the provider.
Has the provider had prior claims and will this one additional
settlement materially affect her/his credentials or insurance?

Defending a case is not as straightforward as finding out whether
someone breached the standard of care. Many factors come into play. Only
when you have complete information can you make the very important
decision of how to proceed.

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

These are some helpful perspectives on how the legal profession
addresses tort claims. It is also written from a private practice
standpoint, so not all the issues apply to the federal Tort Claim
setting. Please contact Katy Ciacco Palatianos directly for any
questions at
[Katy.CiaccoPalatianos@MAIL.IHS.GOV](mailto:Katy.CiaccoPalatianos@IHS.GOV)

##### From Sandra Dodge, Crownpoint

###### 101 Way to ask someone if they are safe

<http://www.ihs.gov/MedicalPrograms/MCH/W/Dv03.cfm#101ways>

**[From Bruce Finke (Nashville Area)]{.underline}**

###### The Elder Care Initiative Office Moves East

In August Dr. Bruce Finke and the office of the IHS Elder Care
Initiative moved from the Zuni-Ramah Service Unit of the Albuquerque
Area to the Nashville Area. The work of the Elder Care Initiative will
remain much the same, with national scope. Major areas of effort for the
Elder Care

Initiative are to strengthen and support the Indian Health elder care
network, to support clinical sites as they strive to provide excellence
in clinical care, and to work with AIAN communities in the development
of long term care systems and services. Contact information for the new
Elder Care Initiative office: IHS Elder Care Initiative Bruce Finke, MD
45 Vernon Street Northampton, MA 01060 413-584-0790
<bruce.finke@mail.ihs.gov>

##### From James Galloway (Flagstaff) and Terry Cullen (Tucson)

**Diabetes & Cardiovascular Disease Review**

is an American Diabetes Association/American College of Cardiology
newsletter featuring information on treatment guidelines, research
advances, and patient education tools

<http://www.diabetes.org/info/link_healthprof.jsp> (Index page)

Issue 1. Diabetes: Redefining Control

<http://www.diabetes.org/uedocuments/DCVDissue1.pdf>

Issue 2. Diabetes and Hypertension

<http://www.diabetes.org/uedocuments/ADACardioReview_2.pdf>

Issue 3. Diabetes and Dyslipidemia

<http://www.diabetes.org/uedocuments/ADACardioReview3.pdf>

Issue 4. Diabetes: Nutrition and CVD

<http://www.diabetes.org/uedocuments/ADACardioReview4.pdf>

# [From Ursula Knoki-Wilson]{.underline}

# \'Nurse Run Clinic\' models

# I am assisting NCON to get information on \'Nurse Run Clinic\' models either in IHS or in neighborhoods/areas where you work.  Or if you\'ve ever had experience working within a Nurse Run Clinic model, please give me information on contacts or references.  Thank you. Ursula Knoki-Wilson, CNM, Chief Clincial Consultant/APNs. [**Ursula.knoki-wilson@ihs.gov**](mailto:Ursula.knoki-wilson@ihs.gov)

# 

# [From Kelly Moore, Albuquerque]{.underline}

###### New Pediatric Chief Clinical Consultant: Steve Holve, MD, Tuba City

Dr. Moore announced that the new IHS Pediatric Chief Clinical Consultant
is now Steve Holve, MD, Tuba City. Dr. Holve can be reached at
<sholve@tcimc.ihs.gov> or 928 283 2679

We would like to thank Dr. Moore for all her efforts as the former IHS
Pediatric Chief Clinical Consultant.

**[From Chuck North, Albuquerque]{.underline}**

Dr. North raised this issue in the July OB/GYN CCC Corner.
<http://www.ihs.gov/medicalprograms/mch/m/mchdownloads/ccccorner71803.doc>

Here is an article that was just released on the same topic

**Chaperone Use by Family Physicians During the Collection of a Pap
Smear**

The use of chaperones during gynecologic examinations remains a
controversial issue with no formal guidelines or legal mandates. The
topic is poorly addressed by the medical literature and by our current
medical education system. No consensus is found among state medical and
osteopathic boards on the use of a chaperone. From the legal
perspective, the recommendations are nearly unanimous in strongly
supporting the use of chaperones. Many questions related to this issue
are unanswered. Does chaperone use decrease malpractice claims? Does
chaperone use have an impact on clinical efficiency, as the inverse
relationship with the volume of Pap smears performed suggests? What are
the regional influences contributing to the geographic variation in
reported use of a chaperone? We believe the question with highest
priority is, What is the perspective of patients?

Chaperone Use by Family Physicians During the Collection of a Pap Smear

Pamela Rockwell, DO, Terrence E. Steyer, MD and Mack T. Ruffin, IV, MD,
MPH

*Annals of Family Medicine* 1:218-220 (2003)
<http://www.annfammed.org/cgi/content/full/1/4/218>

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

After the 2002 Biennial OB/GYN Meeting there should be no controversy in
the Indian Health System about the use of chaperones during examinations
of the breasts or genitals.

It is the standard of care.

If your current staffing does not encourage this practice, then your
staffing needs to modified accordingly. Please also see the ACOG
benchmark statement below.

**ACOG's Ethics in Gynecology: Sexual Misconduct in the Practice of
Obstetrics and Gynecology: Ethical Considerations**

\"....The request by either a patient or a physician to have a chaperon
present during a physical examination should be accommodated
irrespective of the physician\'s gender. . Local practices and
expectations differ with regard to the use of chaperons, but the
presence of a third person in the examination room can confer benefits
for both patient and physician, regardless of the gender of the chaperon
....."

<https://www.acog.com/from_home/publications/ethics/ethics89.cfm>

**Clarification: Non clean catch urine sampling terminology\
**Dr. North wanted to add a clarification to comments in the October
OB/GYN CCC Corner and November IHS Primary Care Provider about non-clean
catch urine specimens obtained in pregnancy.

The term 'non-clean catch urine' sampling referred to a method of urine
collection. A non-clean catch specimen is a urine sample that was not
intended to be a clean catch specimen. It is a descriptive term, e.g.,
fasting versus non-fasting or random blood glucose testing**.** None of
Dr. North's comments were meant to make any implications about the
practices of the staff obtaining those types of specimen.

**[From Darrell Pratt, HQE]{.underline}**

###### Looking for an OB/GYN?

I talked with an OB/GYN doc this morning who has been out of practice
for 3 years (of his own accord, he says) and is thinking of starting
again. If you wish to talk with him, he is Dr. Dan Gelb and his home
phone number is 603-399-7184 (New Hampshire) or <dgelb@worldpath.net>

Other questions about professional recruiting can be directed to Darrell
Pratt at 301 443 5710 or
[darrell.pratt@mail.ihs.gov](mailto:darrel.pratt@mail.his.gov)

**[From Oida Vincent, Gallup]{.underline}**

###### Are we required to obtain sensitivities on GBBS for PCN allergic patients before giving Clindamycin or can we use Clindamycin empirically?

The answer is yes and no.

Yes, if it picked up during prenatal care... and no, if the patient
presents in labor without the workup done.

Here is a discussion of two main scenarios in which this seems to come
up the most:

#1 **During prenatal care** (the best time).

The CDC says "For penicillin-allergic women at high risk for
anaphylaxis, testing of GBS isolates from prenatal screening for
susceptibility to clindamycin and erythromycin is recommended **[if
feasible]{.underline}**"

The main issue is the increasing antibiotic resistance, hence a higher
use of vancomycin.

"Thirty isolates (29 percent) were resistant to erythromycin, and 22 (21
percent) were resistant to clindamycin. All of the clindamycin-resistant
isolates were also resistant to erythromycin. Eight isolates were
resistant only to erythromycin. The isolates were susceptible to the
other antibiotics tested, but in eight cases, resistance to penicillin
was intermediate. The most common GBS serotypes were V (21 cases), III
(20 cases), and Ia (19 cases). Women carrying serotype V strains were 13
times more likely to have an erythromycin- or clindamycin-resistant
strain than women carrying serotype II strains (41 versus 3 percent)."

*Manning SD, et al. Correlates of antibiotic-resistant group B
streptococcus isolated from pregnant women. Obstet Gynecol January
2003;101:74-9.*

<http://www.aafp.org/afp/20030715/tips/12.html>

Your local sensitivities may vary.

###### GBS Strains Are Increasingly Resistant to Antibiotics 

<http://www.aafp.org/afp/20030715/tips/12.html>

In most facilities, the GBS culture takes 2 days. If you tell the lab
you have a PCN allergic patient, then they will put the sensitivity
discs on, so that will take a 3^rd^ day. This is not a problem if the
patient is getting her GBS culture done at 35-37 weeks.

Here is the suggested manner

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5111a1.htm#box1>

So.....if one has a reported PCN 'allergic' patient, then that patient
should be assessed to determine their risk for anaphylaxis. Persons at
high risk for anaphylaxis are those who have had immediate
hypersensitivity reactions to penicillin (e.g., anaphylaxis, angioedema,
or urticaria) or who have a history of asthma or other conditions that
would make anaphylaxis more dangerous.

The nature of the 'PCN allergy' is important to determine because of the
increasing prevalence of resistance to clindamycin, erythromycin, or
both. Because the efficacy of recommended alternatives to penicillin or
ampicillin has not been measured in controlled trials, and because some
of the recommended alternatives have a broad spectrum of activity and
may be more complicated and costly to administer, verification of a
reported history of penicillin allergy is important.

An estimated 10% of persons with penicillin allergy also have immediate
hypersensitivity reactions to cephalosporins. Please note most of these
reactions are a mild rash, not anaphylaxis.

NB: Among penicillin-allergic women not at high risk for anaphylaxis,
cefazolin, because of its narrow spectrum of activity and ability to
achieve high intraamniotic concentrations, is the agent of choice for
intrapartum chemoprophylaxis.

If penicillin allergy occurs in approximately 10% of adults, and 25% of
parturients are colonized with GBS prenatally, approximately 100,000 of
the 4 million annual deliveries would require prophylaxis with
vancomycin in the absence of clindamycin and erythromycin susceptibility
testing of GBS prenatal isolates. This represents a 7% increase in the
number of patients exposed to vancomycin. The total grams of vancomycin
used annually would increase by less than 1% if all penicillin-allergic
colonized women received vancomycin prophylaxis.

Women who are not at high risk for anaphylaxis should be given
cefazolin, 2 g intravenously initial dose, then 1 g intravenously every
8 hours until delivery. For women at high risk for anaphylaxis,
clindamycin and erythromycin susceptibility testing, if available,
should be performed on isolates obtained during GBS prenatal carriage
screening. Women with clindamycin- and erythromycin-susceptible isolates
should be given either clindamycin, 900 mg intravenously every 8 hours
until delivery; OR erythromycin, 500 mg intravenously every 6 hours
until delivery. If susceptibility testing is not possible,
susceptibility results are not known, or isolates are resistant to
erythromycin or clindamycin, the following regimen can be used for women
with immediate penicillin hypersensitivity: vancomycin, 1 g
intravenously every 12 hours until delivery.

#2 On the other hand....

.....if somehow this issue has **fallen through the cracks in prenatal
care** and the patient presents to L/D without this all worked up, then
no, it is too late to get the work up started and you should

-determine if it is actually a PCN immediate hypersensitivity patient

-If history of mild reaction(rash) then treat empirically with cefazolin
2 gm initially and 1 gm q 8 until delivery

-if history of anaphlaxis, treat empirically with clindamycin or
vancomycin as discussed above

**Eager for Native American and Alaskan Native applicants to Ph.D.
program**

in the biomedical sciences.

The recruitment consultant to the Dean of the Weill Cornell Graduate
School of Medical Sciences in New York City is especially eager to
attract Native American and Alaskan Native applicants to our Ph.D.
program in the biomedical sciences. For accepted applicants, both
programs generously and fully cover the costs of attending, including
travel costs and living expenses.

 

These seven programs specifically are:

Biochemistry & Structural Biology

Cell Biology & Genetics

Immunology

Molecular Biology

Neuroscience

Pharmacology

Physiology, Biophysics, and Molecular Medicine

 

The programs run 5-6 years in length depending on the program and the
type of research undertaken.  Half of the faculty of our school are
shared jointly with Memorial Sloan-Kettering Cancer Center  \--
recognized as the foremost cancer research and treatment center in the
country. More information is available at:
[www.med.cornell.edu/gradschool](http://www.med.cornell.edu/gradschool)

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

**[Obstetrics]{.underline}**

###### 

**Management of diabetes mellitus complicating pregnancy**

###### Diabetes mellitus complicates 3-5% of all pregnancies and is a major cause of perinatal morbidity and mortality, as well as maternal morbidity. The availability of a variety of new insulins, the insulin pump, and self-monitoring of blood glucose have revolutionized the care of the pregnancy complicated by diabetes mellitus. However, challenges remain in caring for the pregnant patient with pregestational diabetes. Relatively few women receive preconceptional counseling, and major fetal malformations as a result of poor glucose control before and during the early weeks of gestation have emerged as the major cause of perinatal mortality. When the patient has diabetic vasculopathy, the obstetrician, maternal-fetal specialist, and/or endocrinologist and other members of the health care team must perform a challenging balancing act that promotes fetal health while minimizing maternal risk. As obesity increases in this country and our population becomes more diversified, the rate of gestational diabetes mellitus (GDM) will rise. Although there is controversy regarding which diagnostic standards to use for GDM, there is agreement that excellent blood glucose control, with diet and, when necessary, insulin will result in improved perinatal outcome. Finally, the goal of our educational programs should be not only to improve pregnancy outcome but also to promote healthy lifestyle changes for the mother that will last long after delivery.

Gabbe SG, Graves CR. Management of diabetes mellitus complicating
pregnancy. Obstet Gynecol. 2003 Oct;102(4):857-68.

[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14551019&dopt=Abstract]{.underline}

###### 

###### Thrombophilic disorders and fetal loss: a meta-analysis

The authors conclude that only certain thrombophilic conditions are
associated with recurrent fetal loss, and that the association differs
for losses occurring early and later in gestation. First-trimester
losses are associated with factor V Leiden, activated protein C
resistance, and prothrombin G20210A mutation. For the most common factor
in most U.S. populations, factor V Leiden, the risk of late recurrent
loss is even higher than that of early miscarriage. Factor V Leiden,
prothrombin G20210A mutation, and protein S deficiency are associated
with nonrecurrent loss late in pregnancy. The mechanism of these
associations is believed to involve excessive thrombosis of placental
vessels, but much remains to be studied.

Rey E, Kahn SR, David M, Shrier I.Thrombophilic disorders and fetal
loss: a meta-analysis. Lancet. 2003 Mar 15;361(9361):901-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12648968&dopt=Abstract>

**Screening for Congenital Cardiovascular Malformations**

<http://www.aafp.org/afp/20031015/tips/21.html>

**Can Eating More docosahexaenoic acid (DHA) Increase Duration of
Pregnancy?**

<http://www.aafp.org/afp/20031001/tips/18.html>

**Immunity to CMV Reduces Risk of Congenital Infection**

<http://www.aafp.org/afp/20030815/tips/16.html>

###### Postpartum Depression Linked to Later Violence in Children\*

<http://www.medscape.com/viewarticle/463951?mpid=20940>

\*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.

**[Gynecology]{.underline}**

###### Primary and Secondary Syphilis \-\-- United States, 2002

###### [**http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5246a1.htm**](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5246a1.htm)

###### 

###### The 2001 Bethesda System Terminology

<http://www.aafp.org/afp/20031115/1992.html>

**Depression in Older Women with Urinary Incontinence**

<http://www.aafp.org/afp/20030715/tips/11.html>

###### 

###### Factors Affecting Accuracy of Mammography Screening

<http://www.aafp.org/afp/20030915/tips/17.html>

**Multidose vs. Single-Dose Therapy in Ectopic Pregnancy**

<http://www.aafp.org/afp/20030915/tips/18.html>

###### Weekly Therapy Is Effective in Prevention of Osteoporosis

<http://www.aafp.org/afp/20030915/tips/19.html>

**Low-Dose Mifepristone Shrinks Uterine Fibroids**

<http://www.aafp.org/afp/20030901/tips/8.html>

**Low BMD Is Associated with Cognitive Decline in Women**

<http://www.aafp.org/afp/20030815/tips/14.html>

###### Breast Cyst Aspiration

<http://www.aafp.org/afp/20031115/1983.html>

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

###### Prophylaxis for Infants of Mothers with Hepatitis B 

<http://www.aafp.org/afp/20030801/tips/11.html>

###### Evaluation of Bone Mass in Young Female Athletes

<http://www.aafp.org/afp/20030801/tips/12.html>

###### Hearing Assessment in Infants and Children

<http://www.aafp.org/afp/20031001/tips/15.html>

######### High School Students in BIA Schools: Tobacco, Alcohol, and other Drug Use

<http://www.ihs.gov/MedicalPrograms/MCH/W/Whsubst.asp#HighSchoolStudents>

###### ADOLESCENTS\' LEVEL OF LINGUISTIC ACCULTURATION AND THEIR WELL-BEING

Adolescents of all racial and ethnic groups from a non-English
\[speaking\] home environment are at higher risk of a range of
psychosocial and parental risk factors than the majority population of
non-Hispanic white English-speakers.

Yu SM, Huang ZJ, Schwalberg RH, Overpeck M, Kogan MD. 2003.
Acculturation and the health and well-being of U.S. immigrant
adolescents. Journal of Adolescent Health 33(6):479-488.

<http://www.mchlibrary.info/databases/bibmenu.html>

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

###### Diabetes Among Young American Indians \-\-- Montana and Wyoming

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5246a4.htm>

###### Increases in HIV Diagnoses \-\-- 29 States, 1999\--2002

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5247a2.htm>

**Secondary Prevention in Women with Heart Disease**

<http://www.aafp.org/afp/20030815/tips/17.html>

**Fish Oil Stabilizes Atherosclerotic Plaques**

<http://www.aafp.org/afp/20030815/tips/7.html>

##### Other

###### Health Status of American Indians Compared with Other Racial/Ethnic Minority 

###### Populations \-\-- Selected States, 2001\--2002

###### [**http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5247a3.htm**](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5247a3.htm)

###### Common Problems in Patients Recovering from Chemical Dependency 

<http://www.aafp.org/afp/20031115/1971.html>

##### Features

## American Family Physician

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

**HPV Triage for ASC-US Pap Results Makes Sense** (POEM Level of
Evidence: 1b)

[Bottom Line:]{.underline} In women whose cervical cytology results
reveal ASC-US and who test positive for high-risk types of HPV,
colposcopy should be performed. If HPV testing is not positive for
high-risk types, colposcopy is not necessary.
<http://www.aafp.org/afp/20031101/tips/8.html>

**Even Low Levels of Lead Can Lower IQ** (POEM Level of Evidence: 1b)

Bottom Line: Even low levels of lead are strongly associated with a
decline in intellectual capacity as measured by IQ test results. Efforts
to eliminate environmental lead should be redoubled.

<http://www.aafp.org/afp/20030815/tips/1.html>

**False-Positive Mammograms Do Not Deter Women** (POEM Level of
Evidence: 1b)

[Bottom Line:]{.underline} False-positive mammography results actually
increase a woman\'s likelihood of returning for subsequent mammography
screening. Rather than feeling angry about medical care that induces
unnecessary anxiety, increases medical costs, and results in additional
work-up, women seem relieved that they \"dodged a bullet\" after the
false-positive result is refuted, although they also become more, rather
than less, worried about breast cancer. While in this case poor
performance is actually good for business, we must get better at
providing accurate mammography screening.
<http://www.aafp.org/afp/20030815/tips/13.html>

**Short-Interval Follow-up Mammography Is Low Yield** (POEM Level of
Evidence: 1b-)

[Bottom Line:]{.underline} When a radiologist recommends short-interval
follow-up mammography, the rate of developing breast cancer within two
years, although higher than when the findings are normal, is
approximately 1 percent. Because the growth of breast cancer in
postmenopausal women is typically slower than in younger women, the
two-year follow-up in this study may be too short.

<http://www.aafp.org/afp/20030715/tips/10.html>

**Oxybutynin or Tolterodine for Overactive Bladder?** (POEM Level of
Evidence: 1c)

[Bottom Line:]{.underline} After three months of treatment,
approximately one in four women receiving extended-release oxybutynin
and one in six women receiving extended-release tolterodine were
completely continent. Overall, both drugs similarly decreased the
average number of episodes of urge urinary incontinence and total
incontinence. More women reported dry mouth while taking oxybutynin.
These results are similar to those seen with immediate-release forms of
both drugs.

<http://www.aafp.org/afp/20031101/tips/9.html>

###### Use of Iron in Nonanemic, Fatigued Women (POEM Level of Evidence: 1c)

[Bottom Line:]{.underline} Women with unexplained fatigue, especially
those with low-normal levels of serum ferritin, report a small clinical
improvement after receiving iron supplementation for four weeks. Iron is
not a panacea; fatigue levels were still reported as 4.5 out of 10 after
one month of treatment. <http://www.aafp.org/afp/20031115/tips/16.html>

###### \*POEM Rating system: [**http://www.infopoems.com/levels.html**](http://www.infopoems.com/levels.html) POEM Definition: [**http://www.aafp.org/x19976.xml**](http://www.aafp.org/x19976.xml)

###### [Other topics]{.underline}

**Common Hyperpigmentation Disorders in Adults: Part I Diagnostic
Approach, Cafe au Lait** Macules, Diffuse Hyperpigmentation, Sun
Exposure, and Phototoxic Reactions

<http://www.aafp.org/afp/20031115/1955.html>

Common Hyperpigmentation Disorders in Adults: Part II. Melanoma,
Seborrheic

Keratoses, Acanthosis Nigricans, Melasma, Diabetic Dermopathy, Tinea
Versicolor, and Postinflammatory Hyperpigmentation

<http://www.aafp.org/afp/20031115/1963.html>

###### 

###### Topical NSAIDs Relieve the Pain of Mastalgia 

<http://www.aafp.org/afp/20031215/tips/8.html>

**Routine Vitamin Supplementation to Prevent Cancer and Cardiovascular
Disease: Recommendations and Rationale**

<http://www.aafp.org/afp/20031215/us.html>

##### Annals of Family Medicine

**Women's Experiences of Abnormal Cervical Cytology: Illness
Representations,**

Care Processes, and Outcomes, Annals of Family Medicine *1:196-202
(2003)*

Alison Karasz, PhD, M. Diane McKee, MD and Krista Roybal, MD

##### [**http://www.annfammed.org/cgi/content/full/1/4/196**](http://www.annfammed.org/cgi/content/full/1/4/196)

**Periodic Abstinence From Pap (PAP) Smear Study: Women's Perceptions of
Pap Smear** Screening, Annals of Family Medicine *1:203-208 (2003)*
Mindy Smith, MD, MS, Linda French, MD and Henry C. Barry, MD, MS
<http://www.annfammed.org/cgi/content/full/1/4/203>

**Screening Mammography and Pap Tests Among Older American Women
1996--2000:** Results from the Health and Retirement Study (HRS) and
Asset and Health Dynamics Among the Oldest Old (AHEAD), Annals of Family
Medicine *1:209-217 (2003)* Truls Østbye, MD, MPH, MBA, PhD, Gary N.
Greenberg, MD, MPH, Donald H. Taylor, Jr, MPA, PhD and Ann Marie M. Lee,
MPH, CHES <http://www.annfammed.org/cgi/content/full/1/4/209>

###### Factors Affecting the Detection Rate of Human Papillomavirus 

*Annals of Family Medicine* 1:221-227 (2003) Diane M. Harper, MD,
MPH^1,2^, Meghan R. Longacre, PhD^1^, Walter W. Noll, MD^3^, Dorothy R.
Belloni, BS^3^ and Bernard F. Cole, PhD^2^

<http://www.annfammed.org/cgi/content/full/1/4/221>

**Cervical Cancer Screening** (Editorial on all the above Annals
articles)

Louise S. Acheson, MD, MS

<http://www.annfammed.org/cgi/content/full/1/4/194>

##### ACOG

**New ACOG Opinion Addresses Elective Cesarean Controversy**

Although informed refusal of care by the patient is a familiar situation
for most clinicians in both obstetrics and gynecology, acknowledgment of
the importance of patient autonomy and increased patient access to
information (such as on the internet) has prompted more
patient-generated requests for surgical interventions not necessarily
recommended by their physicians. A patient request for elective cesarean
delivery, prompted by a perception of lower risk to the woman (of pelvic
floor and sexual dysfunction) and fetus with cesarean birth, is an
obstetric example. Other examples include requests for prophylactic
oophorectomy to reduce risk of ovarian cancer in otherwise healthy,
low-risk women.

The response to such requests must begin with the physician having a
good understanding of the scientific evidence for and against the
requested procedure. With that information, the physician should counsel
the patient within the framework of the ethical principles of autonomy,
beneficence, nonmaleficence, veracity, and justice. The ethical models
described in this document provide an approach for using these
principles. The physician should use the opportunity that this kind of
request presents to explore the patient\'s concerns. In most cases,
providing information and careful counseling will allow patients and
their physicians to reach a mutually acceptable decision. If an
acceptable balance cannot be reached by the patient and physician, the
patient may choose to continue care with another provider.

Surgery and patient choice: the ethics of decision making. ACOG
Committee Opinion No. 289. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2003;102:1101-06.

For ACOG members

<http://www.acog.com/publications/committee_opinions/co289.cfm>

For non-ACOG members

[https://www.acog.com/from_home/publications/press_releases/nr10-31-03-1.cfm]{.underline}

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

Traditionally cesarean delivery rates in Indian Health have been the
lowest in the US. Elective cesarean birth is an option in Indian Health
and is open to Native women if the proper counseling has been provided
and documented, though at this time there is no data to support
"immediate and compelling medical need".

ACOG: "An increasing number of women are requesting elective cesarean
instead of vaginal delivery in the belief that the surgery will prevent
future pelvic support or sexual dysfunction problems, or for other
reasons. A number of physicians believe that such surgery should not be
selected over a natural process without immediate and compelling medical
need.

ACOG cautions that \"both sides to this debate\" must recognize that
evidence to support the benefit of elective cesarean is still incomplete
and that there are not yet extensive morbidity and mortality data to
compare elective cesarean delivery with vaginal birth in healthy women."

The above information from ACOG forms a helpful benchmark to work from.

This will be a topic of discussion at the 2004 OB/GYN Biennial meeting.
**The meeting is open to** **all Indian Health providers and staff.**

Please plan on attending, August 4-6, 2004 in Albuquerque.

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004>

######### Use of progesterone to reduce preterm birth

ABSTRACT: Preterm birth affects 12% of all births in the United States.
Recent studies support the hypothesis that progesterone supplementation
reduces preterm birth in a select group of women (ie, those with a prior
spontaneous birth at \<37 weeks of gestation). Despite the apparent
benefits of progesterone in this high-risk population, the ideal
progesterone formulation is unknown. The American College of
Obstetricians and Gynecologists Committee on Obstetric Practice believes
that further studies are needed to evaluate the use of progesterone in
patients with other high-risk obstetric factors, such as multiple
gestations, short cervical length, or positive test results for
cervicovaginal fetal fibronectin. When progesterone is used, it is
important to restrict its use to only women with a documented history of
a previous spontaneous birth at less than 37 weeks of gestation because
unresolved issues remain, such as optimal route of drug delivery and
long-term safety of the drug.

Use of progesterone to reduce preterm birth. ACOG Committee Opinion No.
291. American College of Obstetricians and Gynecologists. Obstet Gynecol
2003;102:1115-6.

ACOG members

[http://www.acog.com/publications/committee_opinions/co291.cfm]{.underline}

Non-ACOG members

<https://www.acog.com/from_home/publications/press_releases/nr10-31-03-2.cfm>

Largely based on

Meis PJ, Klebanoff M, Thom E, Dombrowski MP, Sibai B, Moawad AH, et al.
Prevention of recurrent preterm delivery by 17 alpha-hydroxyprogesterone
caproate. N Engl J Med 2003;348:2379-85.

[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12802023&dopt=Abstract]{.underline}

da Fonseca EB, Bittar RE, Carvalho MH, Zugaib M. Prophylactic
administration of progesterone by vaginal suppository to reduce the
incidence of spontaneous preterm birth in women at increased risk: a
randomized placebo-controlled double-blind study. Am J Obstet Gynecol
2003;188:419-24.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12592250&dopt=Abstract>

**Dystocia and Augmentation of Labor**

#### ACOG Practice Bulletin NUMBER 49, DECEMBER 2003

**Summary of Recommendations**

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

Patients should be counseled that walking during labor does not enhance
or improve progress in labor nor is it harmful.

Continuous support during labor from caregivers should be encouraged
because it is beneficial for women and their newborns

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

Active management of labor may shorten labor in nulliparous women,
although it has not consistently been shown to reduce the rate of
cesarean delivery.

Amniotomy may be used to enhance progress in active labor, but may
increase the risk of maternal fever.

X-ray pelvimetry alone as a predictor of dystocia has not been shown to
have benefit, and, therefore, is not recommended.

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

Intrauterine pressure catheters may be helpful in the management of
dystocia in selected patients, such as those who are obese.

Women with twin gestations may undergo augmentation of labor.

Dystocia and augmentation of labor. ACOG Practice Bulletin No. 49.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2003;102:1445--54.

Non-ACOG members

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14662243&dopt=Abstract>

For ACOG Members

<http://www.acog.com/publications/educational_bulletins/pb049.cfm>

##### AHRQ: U.S. PREVENTIVE SERVICES TASK FORCE

**Screening for High Blood Pressure: Recommendations and Rationale**

<http://www.aafp.org/afp/20031115/us.html>

**A recommendation**\*

The USPSTF strongly recommends that clinicians screen adults aged 18 and
older for high blood pressure.

The USPSTF found good evidence that blood pressure measurement can
identify adults at increased risk for cardiovascular disease due to high
blood pressure, and good evidence that treatment of high blood pressure
substantially decreases the incidence of cardiovascular disease and
causes few major harms. The USPSTF concludes that the benefits of
screening for and treating high blood pressure in adults substantially
outweigh the harms.

I recommendation\*\*

The USPSTF concludes that the evidence is insufficient to recommend for
or against routine screening for high blood pressure in children and
adolescents to reduce the risk of cardiovascular disease.

The USPSTF found poor evidence that routine blood pressure measurement
accurately identifies children and adolescents at increased risk for
cardiovascular disease, and poor evidence to determine whether treatment
of elevated blood pressure in children or adolescents decreases the
incidence of cardiovascular disease. As a result, the USPSTF could not
determine the balance of benefits and harms of routine screening for
high blood pressure in children and adolescents.

**\*A recommendation**.

The USPSTF strongly recommends that clinicians routinely provide \[the
service\] to eligible patients. The USPSTF found good evidence that
\[the service\] improves important health outcomes and concludes that
benefits substantially outweigh harms.

**\*\*I recommendation.**

The USPSTF concludes that the evidence is insufficient to recommend for
or against routinely providing \[the service\]. Evidence that \[the
service\] is effective is lacking, of poor quality, or conflicting, and
the balance of benefits and harms cannot be determined.

##### Breastfeeding

**Breastfeeding and Risk for Respiratory Disease in Infants**

<http://www.aafp.org/afp/20031001/tips/16.html>

**[Elder Care News]{.underline} by Bruce Finke, MD**

###### Pearls from the Literature: November

###### Influenza Vaccination 

Comparing vaccinated to non-vaccinated persons aged 65 and older over
two influenza seasons, researchers found a 20% reduction in
hospitalization for cardiovascular and cerebrovascular events in
addition to a 30% reduced hospitalization for influenza and a 50%
reduction in death from all causes. Elders who get influenza are at
increased risk of hospitalization and death

from cardiac disease and stroke. Vaccination reduces that risk. We need
to be sure our elders know this!

Nichol KL et al. Influenza vaccination and reduction in hospitalizations
for cardiac disease and stroke among the elderly. NEJM 2003 Apr
3;348:1322-32

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12672859&dopt=Abstract>

###### Pearls from the Literature: December

###### Anticoagulation in patients with atrial fibrillation

A number of studies have shown the benefit of anticoagulation in
patients with atrial fibrillation (including older patients). Two new
studies emphasize this and add to our understanding. Anticoagulation to
an INR of 2.0 in those with nonvalvular atrial fibrillation and no
contraindications reduces frequency and severity of stroke and saves
lives.

In a \"real world\" setting, Go et al followed over 11,000 persons, mean
age of 71, with nonvalvular atrial fibrillation and no contraindication
to anticoagulation, for up to 3 years. Those on warfarin anticoagulation
had a reduction in risk of stroke and thromboembolism of 64% and a
reduction in

all cause mortality of 31%. Intracranial bleeding was \"uncommon\" but
increased in those on warfarin, while there was no increased risk of
extracranial hemorrhage.

In the second study, in the same cohort of patients, Hylek et al
evaluated the outcome of anticoagulation based on intensity of
treatment. There was a clear benefit for those patients with nonvalvular
atrial fibrillation whose INR was above 2.0 compared to those with INR
1.5-1.9, with a reduction in both frequency and severity of stroke.
There was no increased risk of intracranial bleeding in those with INR
under 3.9.

Go AS, Hylek EM, Chang Y, Phillips KA, Henault LE, Capra AM, Jensvold
NG, Selby JV, Singer DE.

Anticoagulation therapy for stroke prevention in atrial fibrillation:
how well do randomized trials translate into clinical practice?
JAMA.2003Nov26;290(20):2685-92.

<http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14645310&dopt=Abstract>

Hylek EM, Go AS, Chang Y, Jensvold NG, Henault LE, Selby JV, Singer DE.

Effect of intensity of oral anticoagulation on stroke severity and
mortality in atrial fibrillation.

N Engl J Med. 2003 Sep 11;349(11):1019-26.

<http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12968085&dopt=Abstract>

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

###### Minimizing Menopausal Symptoms From Endocrine Therapy

###### A 44-year-old woman with estrogen receptor-positive, progesterone-positive, HER2/*neu*

###### negative breast cancer underwent resection of 4 out of 16 metastatic axillary nodes. The breast and axilla were irradiated, and therapy with tamoxifen and goserelin was started. However, the therapy induced menopausal symptoms that were extremely difficult to bear, and the medication was stopped 2 months ago. What would you recommend at this point?

###### A. Briefly, antidepressant including venlafaxine, and more recently gabapentin, estrogen cream, and vaginal lubricants like Astroglide. 

###### See the Medscape URL below for complete reply\*

[http://www.medscape.com/viewarticle/463762?mpid=21225&WebLogicSession=P8oNuh3PeOrcDWsOnU5pEonM12e8KnJk0VIyLEG5dbKd7uHJTimW\|2440607199949746570/184161394/6/7001/7001/7002/7002/7001/-1](http://www.medscape.com/viewarticle/463762?mpid=21225&WebLogicSession=P8oNuh3PeOrcDWsOnU5pEonM12e8KnJk0VIyLEG5dbKd7uHJTimW|2440607199949746570/184161394/6/7001/7001/7002/7002/7001/-1)

###### 

###### \*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.

###### Gabapentin Reduces Hot Flushes

<http://www.aafp.org/afp/20030901/tips/7.html>

**Raloxifene Therapy Does Not Affect Sexual Functioning**

<http://www.aafp.org/afp/20030815/tips/15.html>

# [Information Technology]{.underline}

AHRQ TO SUPPORT PATIENT SAFETY AND QUALITY OF CARE THROUGH HEALTH
INFORMATION TECHNOLOGY PROJECTS\
As part of a larger initiative to support investments in information
technology in the nation\'s health care delivery system, the Agency for
Healthcare Research and Quality today announced that it is seeking
applications for approximately 100 grants to plan, implement, and
demonstrate the value of health information technology to improve
patient safety and quality of care. These grants will be part of a \$50
million portfolio of grants, contracts, and other activities to
demonstrate the role of health information technology to improve patient
safety and the quality of care.
[http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-04-011.html]{.underline}

# [International Health Update]{.underline}

###### A guide for health professionals working with Aboriginal peoples

The Sociocultural context of Aboriginal Peoples in Canada. This policy
statement has been reviewed by the Aboriginal Health Issues Committee
and approved by Executive and Council of the Society of Obstetricians
and Gynaecologists of Canada.

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHacogAIA.asp#ComprehensiveMCH>

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

#### POSTPARTUM COUNSELING PERCEPTIONS AND PRACTICES

#### There is greater concordance today between pediatricians\' and mothers\' perceptions of educational priorities and actual counseling practices than there was a generation ago

Callaghan P, Greenberg L, Brasseaux C, et al. 2003. Postpartum
counseling perceptions and practices: What\'s new? Ambulatory Pediatrics
3(6):284-287.

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14616048&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14616048&dopt=Abstract)

**COST ESTIMATES FOR ADOLESCENT PREGNANCY AND ADOLESCENT PREGNANCY**
PREVENTION

A related policy brief, National Costs of Teen Pregnancy and Teen
Pregnancy Prevention: What We Know, and report, Estimating the Cost of
Effective Teen Pregnancy Prevention Programs, are also available from
the Joint Center at
<http://www.jointcenter.org/publications/details/health/TPP.html>.

The report features a costing worksheet that can be used to calculate
per-client cost for a program, as well as examples of cost estimates for
selected programs. More information about adolescent pregnancy
prevention is available from the MCH Library knowledge path at
<http://www.mchlibrary.info/KnowledgePaths/kp_adolpreg.html>

# WEB SITE OFFERS ONE-STOP SHOPPING FOR INFORMATION ABOUT FEDERAL GRANTS

[http://www.grants.gov](http://www.grants.gov/) is a single source for
information about finding and applying for grants across the federal
government. Development of the cross-agency Web site was led by the U.S.
Department of Health and Human Services (HHS) in collaboration with
other federal agencies and the National Science Foundation, and with
input from organizations that apply for and receive federal grants. The
Web site is available at [http://www.grants.gov](http://www.grants.gov/)

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

###### Depressed Women Have More Sexual Dysfunction Than Depressed Men

<http://www.medscape.com/viewarticle/464156?mpid=21225>

\*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}**

###### What's new in Women's Health Newsletter, CDC

<http://www.ihs.gov/MedicalPrograms/MCH/M/PROG02.cfm#CDCnws>

**Funding opportunities**

###### Youth Violence Prevention Through Community-Level Change

<http://www.cdc.gov/od/pgo/funding/04054.htm>   

 

Sociocultural and Community Risk and Protective Factors for Child
Maltreatment and Youth Violence
[**http://www.cdc.gov/od/pgo/funding/04056.htm**](http://www.cdc.gov/od/pgo/funding/04056.htm)

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

###### How to prevent a stroke (American Family Physician)

<http://lyris.aafp.org/t/50776/5913807/127688/0/>

###### [Primary Care Discussion Forum, Indian Health]{.underline}

###### Learn from national experts and your colleagues

The Indian Health Primary Care Discussion Forum is an e-mail based
discussion quarterly forum open to all staff interested in Indian Health
Primary Care issues.

The two discussions this month were:

-Cervical Cancer Screening: New Guidelines and New Technologies, lead by
Alan Waxman, MD

-Emergency Contraception (spontaneous)

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

Even though I have a full time clinical OB/GYN practice and really try
to keep on the issues, I still learned from the other providers by
participating in this discussion forum. I will modify my practice
accordingly.

You can expect 20-30 e-mails on each topic. The full discussion and a
summary by the Discussion Leader will be posted on the MCH website in
the near future. I am investigating a simultaneous Web Board approach,
but most providers seem to prefer an e-mail based listserv at this time.

If you want to join the Primary Care Discussion Forum, please contact
Jason Crim at: [jason.crim@mail.ihs.gov](mailto:jason.crim@mail.his.gov)

The next discussion, planned to begin February 1, 2004, will be lead by
Bruce Finke, MD, IHS Elder Care Initiative. Among other issues, Dr.
Finke will lead a discussion about the yearly preventive care exam for
elderly, list the recommended contents of the exam, and relate this to
the new Medicare legislation that will pay for it.

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

There has been a yeoman's effort to catch the MCH Web sites up in the 4
weeks there are 3+ pages of just new posting titles alone. Here are just
a few

###### Preventing Violence: Early Childhood Home Visitation and Firearms Laws

<http://www.ihs.gov/MedicalPrograms/MCH/W/Dv03.cfm#PreventingViolence>

###### Early childhood home visitation for the prevention of child abuse and neglect

###### [**http://www.ihs.gov/MedicalPrograms/MCH/W/Dv08.cfm#Earlychildhoodhome**](http://www.ihs.gov/MedicalPrograms/MCH/W/Dv08.cfm#Earlychildhoodhome)

###### 

###### Growing Stronger: Strength Training for Older Adults

###### [**http://www.ihs.gov/MedicalPrograms/MCH/W/Whmature.asp#GrowingStronger**](http://www.ihs.gov/MedicalPrograms/MCH/W/Whmature.asp#GrowingStronger)

###### HIV increasing in women

###### [**http://www.ihs.gov/MedicalPrograms/MCH/W/Whhiv.asp#HIVincreasing**](http://www.ihs.gov/MedicalPrograms/MCH/W/Whhiv.asp#HIVincreasing)

###### Postmenopausal hormone therapy and breast cancer

###### [**http://www.ihs.gov/MedicalPrograms/MCH/W/Whmature.asp#postmen**](http://www.ihs.gov/MedicalPrograms/MCH/W/Whmature.asp#postmen)

###### Preventing skin cancer: increase protective behaviors

###### [**http://www.ihs.gov/MedicalPrograms/MCH/W/Whcancer.asp#PreventingSkinCancer**](http://www.ihs.gov/MedicalPrograms/MCH/W/Whcancer.asp#PreventingSkinCancer)

###### 

###### CDC in interested in hearing from AI/AN Women: The Futures Initiative

<http://www.ihs.gov/MedicalPrograms/MCH/W/Whaccess.asp#CDCisinterested>

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/WN08.asp#top>

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

**19^th^ Annual Midwinter Conference for providers caring for Native
women and children**

Jan 30 -- Feb 1, 2004, Telluride, CO

2004 brochure = pending

See Conference Archives in February 2003 for information on last year's
conference

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

IHS Basic Colposcopy Course April 26-29, 2004

IHS Refresher Course April 27-29, 2004

Albuquerque, New Mexico

Brochure will be posted at this web site soon:

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#April2004>

Contact Roberta Paisano, Cancer Epidemiology Program, IHS Headquarters
West, 5300 Homestead Road, NE, Albuquerque, New Mexico 87110; telephone
(505) 248-4132

<Roberta.paisano@ihs.gov>

**3rd National Sexual Violence Prevention Conference, CDC **

May 25 - 28, 2004 

Los Angeles, California 

 <http://www.cdc.gov/ncipc/2004nsvpc.htm> 

#### National IHS PA / APN Annual Meeting

June 7-11, 2004

Scottsdale, Arizona

[**http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#June2004**](http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#June2004)

Contact Judy Whitecrane for questions <judy.whitecrane@mail.ihs.gov>

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

-   June 13-17, 2004

-   Denver, CO

-   Contact Barbara Fine at 301 443 1840

-   2003 brochure below. 2004 brochure will be available soon

<http://www.ihs.gov/MedicalPrograms/MCH/M/ConfDnlds/ACOGpostgradBroch-2002.doc>

**2004 Biennial OB/GYN meeting**

August 4-6, 2004

Albuquerque, New Mexico

**This meeting is open to all Indian Health providers and staff.**
Location and brochure to follow

Contact Neil Murphy for questions <nmurphy@anmc.org>

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004>

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

The **November 2003 OB/GYN CCC Corner** is available at:\
<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/CCCCorner11103C.doc>

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

**[Abstract of the Month]{.underline}**

From Aberdeen Area, IHS: Characteristics of mothers who have children
with fetal alcohol syndrome

[From your colleagues:]{.underline}

From Sandra Dodge: High School Students in BIA-Funded Schools Tobacco,
Alcohol, and Other Drug Use, CDC is interested in hearing from AI/AN
women, HIV increasing in women, AIDS diagnoses increased 7% among women,
Growing Stronger: Strength Training for Older Adults, Preventing Skin
Cancer

From Jean Howe: Have you ever heard of a low risk VBAC? Minutes from the
2003 Navajo Area Women's Health Provider Meeting

##### From Chuck North and Bob Newcombe: Are liquid prep pap smears the standard of care now?

##### From Rick Olson: Join your Indian Health colleagues in helping the women of Afghanistan

**From Dan Szekely:** Can you use HRT in post menopausal breast cancer
patients? How effective is the clinical breast exam?

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

##### Obstetrics: Helping Pregnant Women Cope With Smoking Cessation

Gynecology: Is colposcopic biopsy overused among women with a
cytological diagnosis of atypical squamous cells of undetermined
significance (ASCUS)?

**Child Health:** A Neonatal Nightmare: The Misread Label,
Cardiovascular risk factors are identifiable in childhood and are
predictive of adulthood, Report compares health of adolescents in the US
to other countries

**Chronic Illness and Disease:** New broader diagnostic criteria for
pre-diabetes, National Diabetes Awareness Month \-\-- November 2003,
Rheumatoid Arthritis: Clinical Evidence, Blood cultures for women with
uncomplicated acute pyelonephritis: are they necessary? Treatment of
Tuberculosis: Updated Recommendations

**Other:** Great American Smokeout \-\-- November 20, 2003, November\'s
National American Indian Heritage Month: Health Disparities exist

Features:

##### AFP: Management of Gestational Diabetes Mellitus, Antidepressants for Anxiety Disorder

ACOG: Cervical Insufficiency

Breastfeeding: Guide to Breastfeeding for American Indian and Alaska
Native Families

**Cochrane Library:** Metformin: First choice in anovulation in PCOS,
effective for metabolic syndrome

**Hormone Replacement Update**: Estradiol levels should be monitored and
therapy adjusted

**Information Technology:** New PCC+ Prenatal Flow Sheet

#### MCH Alert: School based vs Hospital based prenatal care for pregnant adolescents, Indicators related to smoking among women and girls

Office of Women's Health, CDC: Updated Mortality Tables Available on the
Healthy Women Web Site; Maternal Behaviors and Experiences Before,
During, and After Pregnancy

**Patient Education:** Gestational Diabetes Mellitus

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) 12/20/03