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OB/GYN Chief Clinical Consultant's Corner

Volume 4, No. 4, April 2006

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

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

**Protein to Creatinine Ratio in Pre-eclampsia: Is the data preceding
the U.S. benchmarks?**

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

Carolyn Aoyama:

-Pap screening: Great review of various types of interventions

-Breast Cancer Research Program Releases Program Announcements, 2006

#### -Emergency guide for older adults and their caregivers {#emergency-guide-for-older-adults-and-their-caregivers .Style-Heading-4-+-Arial-14-pt-Underline}

Terry Cullen:

-All-or-None Measurement Raises the Bar on Performance: April 19, 2006

#### -Suicide Prevention Grants Available for Tribes and States {#suicide-prevention-grants-available-for-tribes-and-states .Style-Heading-4-+-Arial-14-pt-Underline}

Chuck North:

RCTs: do they have external validity for patients with multiple
co-morbidities

Judy Thierry:

-Child and Youth Projects (CYP) Cooperative Agreement Grant Announcement

-Failure Mode Analysis (FMA) - Improving Perinatal Care

-Looking Ahead -- Institute for Healthcare Improvement: Phase II

-CDC release: Sudden Unexplained Infant Death Investigation (SUIDI)
Reporting Form

-National Women's Health Indicators Data Base

and more...

**Shelley Thorkelson:**

-Gestational Diabetes Mellitus [Tracking
Sheet](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/GDMtrackingsheete.doc) 

-Program Review and Case Management - Diabetes in Pregnancy

**Alan Waxman:**

FDA Approves New Imaging System to Help Detect Cervical Pre-Cancer

**Judy Whitecrane:**

-2006 Physician Assistant/Advanced Practice Nurse CE Seminar

-Exposure to Mumps During Air Travel \-\-- United States, April 2006

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

##### Obstetrics: page 13

-Glyburide is at least as effective as insulin therapy in treating
gestational diabetes

-Use the 'talk but not sing' rule: Physical activity predicts GDM risk\
-Calcium reduced severity, maternal morbidity, and neonatal mortality in
preeclampsia

-Increasing Angle of Episiotomy Reduces Third-Degree Tear Risk

-Bed Rest Not Be Helpful for Threatened Miscarriage

and more...

**Gynecology: page 18**

-Extensive condyloma acuminata treated with imiquimod 5% cream

-Urinary incontinence: Substantial economic costs and decrement in
quality of life

-Sexual activity and function in middle-aged and older women

-Connection Between Obesity and Pelvic Organ Dysfunction

-LLETZ and cold knife conization: Similar effects on pregnancy-related
morbidity

and more...

**Child Health: page 19**

-New article from Aberdeen Area - Infant Mortality Reviews

-Adverse Childhood Events: Impact on chronic adult illness / Risk taking

#### -Anti-tobacco Advertising Has Positive Effect on Adolescents {#anti-tobacco-advertising-has-positive-effect-on-adolescents .Style-Heading-4-+-Arial-14-pt-Underline}

-Shifts in the sexual behavior of adolescent males: It's a Guy Thing

-Too Much TV Put Extra Pounds on Your Preschooler

and more...

**Chronic Illness and Disease: page 23**

-Breast cancer study from PIMC

-Estrogen use after menopause does not increase breast cancer risk

-Newly identified risk factor for death, MI: Pregnancy complications

-Differences Between Painless and Painful Constipation Among Community
Women

-Women and Heart Disease Fact Sheet

#### Features: page 27 {#features-page-27 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician 

## -Active Treatment for Partial Small Bowel Obstruction {#active-treatment-for-partial-small-bowel-obstruction .Style-Heading-2-+-14-pt}

-Sequential Testing Best Detects Down Syndrome

-Effect of Caffeine Intake on Risk of Hypertension

-Embolization Usually Successful to Treat Fibroids

American College of Obstetricians and Gynecologists

-Less Invasive Management of Cervical Cytology Abnormalities in
Adolescents

-New Guidelines Call for Restricted Use of Episiotomies

-Safe Use of Medication

**Agency for Healthcare Research and Quality**

-Estimates of cervical cancers that may be missed by extending screening
time

-Noninvasive tests may miss breast cancer

-Hospital type and location influence discharge of adolescents
hospitalized for suicide

-Light therapy: Improves sleep, mood, and energy in women with
non-seasonal depression

-Changes in the delivery of care needed to reduce the burden of diabetes
among minorities

**Ask a Librarian**

Great Resource: Library Services for the Indian Health Service via NIH

**Breastfeeding**

-Early feeding choice and obesity

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

-New Quarterly Medical Journal on Breastfeeding Launched

**CCC Corner Digest**

#### -March 2006 Highlights include {#march-2006-highlights-include .Style-Heading-4-+-Arial-14-pt-Underline}

\-[Tired of hearing only bad news from the WHI? Here is some good
news](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_AOM.cfm)

\-[Sample templates for guidelines: IUDs, Manual Vacuum Aspiration (MVA)
for SAB,
etc...](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Coll.cfm)

\-[GDM: Can we proceed directly to one step screening / diagnosis in AI
/ AN
women?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_HT.cfm#ob)

\-[Diet and Exercise Reduce Incontinence in Women at Risk of
Diabetes](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_HT.cfm#gyn)

\-[FDA Warns Parents About Contaminated Teething
Rings](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_HT.cfm#child)

\-[Colon cancer rates: Increased in AI/AN women -- March is Colon Cancer
Month](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_HT.cfm#chrIll)

\-[Are you aware of the vast amount of Library Services available to the
Indian Health
System?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#AskLib)

\-[Results raise doubts about the value of the bimanual pelvic exam in
routine
screening](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#ahrq)

\-[Breastfeeding as a Pain
Reliever](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#breast)

\-[Fatal infection without fever: Sepsis and Medical Abortion - FDA
Public Health
Advisory](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#fp)

\-[Two New Perinatology Corner
Modules](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#webSite)

[-Twins: Antepartum assessment and Intrapartum management: Double
Trouble?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#webSite)

[-Antibody Screen Positive:
Rh](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#webSite)
/ Other Antibodies:  Kell kills, Duffy dies, and Lewis lives?

\-[The case of the wandering spleen - Desperate Housewives - 'As seen on
TV'](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#mmtour)

\-[Should we continue to draw Rubella titers as part of the prenatal
panel?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#MidWives)

\-[Do Birth Certificate Data Reflect the Number of CNM-Attended
Births?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#MidWives)

\-[VZIG No Longer Available: Protect non-immune women against
Chickenpox](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#navajo)

\-[Nurse Education Loan Repayment Program: Deadline March
30](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#nurseCorner)

\-[Metformin and Polycystic Ovarian
Syndrome](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#okie)

\-[Move beyond 'integrated' screening to 'contingency'
screening](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#periPicks)

\-[Incorrect use of condoms, not product failure may account for lack of
effectiveness](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#std)

\-[Statin Therapy for Type 2\'s Regardless of LDL Levels and
CVD](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#stillW)

**Domestic Violence**

-Native women, violence, substance abuse and HIV risk

-Safety, permanency, and well-being of AI/AN children: New publication

-Child Maltreatment Institute

-Sexual Violence Prevention: Beginning the Dialogue

-April 2006 is National Child Abuse and Prevention month

**Elder Care News**

-Can you read your patients\' palms and predict their health?

-Older Adult Drivers with Cognitive Impairment

**Family Planning**

#### -Depo Provera Increase Diabetes Risk in Women {#depo-provera-increase-diabetes-risk-in-women .Style-Heading-4-+-Arial-14-pt-Underline}

-Low educational status 2+ times risk of unintended pregnancy 1 year
after delivery

**Featured Website**

The MCH Frequently Asked Question (FAQ) site

**Frequently asked questions**

-Can we use a protein to creatinine ratio instead of a 24 urine protein
in preeclampsia?

-Is cord blood stem cell storage a viable option in Indian Country?

-Ever had problems with a stenotic cervix? E.G., for an IUD placement or
EmBx?

-When should we change the estimated date of delivery (EDD) based on
ultrasound?

-Is my first trimester patient always hyperthyroid if her labs are
abnormal?

and more...

**Indian Child Health Notes**

-In medical school that 50% of what you will learn will turn out to be
wrong\
-Ventilating tubes for Otitis Media with effusion turned out to be in
the bad 50%\
-Dr. Esposito says Indian Health deserves more money and here is how to
get it.\
-Helicobacter pylori is everywhere, especially in AI/AN children. What
should we do - or not do

**Information Technology**

National Release Graphical User Interface Clinical Scheduling System,
Version 1.0

International Health

-Global Warming May Be a Graver Public Health Threat Than Nuclear War

-Prenatal Care Has Not Lowered Perinatal Mortality in Minorities

#### MCH Alert

Injury Reporting: Cautiously interpret injury data, esp. with stressful
life circumstances

#### Medical Mystery Tour

#### What is the common theme? {#what-is-the-common-theme .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

######### Do You Know The AHA Guidelines for CVD Prevention in Women?

**Menopause Management**

Gabapentin Reduces Hot Flashes in Breast Cancer Survivors

**Midwives Corner**

-Liability in triage: management of EMTALA regulations and common
obstetric risks

-All-fours maneuver effective for reducing shoulder dystocia during
labor

-\"Hands off\" versus \"hands on\" for decreasing perineal lacerations:
No difference

-Does Vaginal Birth Increase the Risk for Incontinence?

-Diagnosis and Management of Candida of the Nipple and Breast

and more...

**Navajo News**

Methamphetamine abuse among women on Navajo: Part 1

**Nurses Corner**

-Journey to Magnet

#### -Nominations: \"Integrating Cultural Competency into Nursing Education and Practice\"  {#nominations-integrating-cultural-competency-into-nursing-education-and-practice .Style-Heading-4-+-Arial-14-pt-Underline}

#### -For commissioned officers or those considering switching\... {#for-commissioned-officers-or-those-considering-switching... .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Improving Perinatal Care: Nurses encouraged to attend, IHI {#improving-perinatal-care-nurses-encouraged-to-attend-ihi .Style-Heading-4-+-Arial-14-pt-Underline}

-Scholarship Opportunity for American Indian Commission Corps Officers

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

Cigarette smoking among those who have spent \>24 hours on the streets,
in a shelter

**Oklahoma Perspective**

Peripartum Cardiomyopathy

Osteoporosis

Role and Importance of Calcium in Preventing and Managing Osteoporosis

Patient Education

#### -Vulvodynia: What You Should Know {#vulvodynia-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### -What You Should Know About Worrying Too Much {#what-you-should-know-about-worrying-too-much .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Driving and Dementia: What You Should Know {#driving-and-dementia-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

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

Perinatology Picks

-No increase risk in neurodevelopment at 2 years of age: Vaginal breech
\< 3, 500 g

-Valacyclovir at 36 weeks reduced the number of women with clinical HSV
recurrences

-3 manuscripts that examine the timing and cesarean rate with epidural
analgesia

\-[Is clinical research
overrated?](http://www.contemporaryobgyn.net/obgyn/article/articleDetail.jsp?id=312700)

Primary Care Discussion Forum

Adverse Childhood Events: Impact on chronic adult illness / Risk taking

STD Corner

-New CDC Fact Sheet on HPV in Men

-Announcing New Program Manager for the IHS National STD Program

-Funding opportunities announced. Applications due May 19th

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

-"Clinical inertia\" - Providers not intensifying diabetes therapy when
indicated

-Eating Potatoes May Increase Risk for Type 2 Diabetes

-Cutting Calories Helps You Live Longer

-Join for the WOMAN Challenge

###### Save the Dates: Upcoming events of interest page 50

#### What's new on the ITU MCH web pages page 50

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

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

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

**Protein to Creatinine Ratio in Pre-eclampsia: Is the data preceding
the U.S. benchmarks?**

BACKGROUND: Proteinuria is recognized as an independent risk factor for
cardiovascular and renal disease and as a predictor of end organ damage.
The reference test, a 24-h urine protein estimation, is known to be
unreliable. A random urine protein:creatinine ratio has been shown to
correlate with a 24-h estimation, but it is not clear whether it can be
used to reliably predict the presence of significant proteinuria.

METHODS: We performed a systematic review of the literature on
measurement of the protein:creatinine ratio on a random urine compared
with the respective 24-h protein excretion. Likelihood ratios were used
to determine the ability of a random urine protein:creatinine ratio to
predict the presence or absence of proteinuria.

RESULTS: Data were extracted from 16 studies investigating proteinuria
in several settings; patient groups studied were primarily those with
preeclampsia or renal disease. Sensitivities and specificities for the
tests ranged between 69% and 96% and 41% and 97%, respectively, whereas
the positive and negative predictive values ranged between 46% and 95%
and 45% and 98%, respectively. The positive likelihood ratios ranged
between 1.8 and 16.5, and the negative likelihood ratios between 0.06
and 0.35. The cumulative negative likelihood ratio for 10 studies on
proteinuria in preeclampsia was 0.14 (95% confidence interval,
0.09-0.24).

CONCLUSION: The protein:creatinine ratio on a random urine specimen
provides evidence to \"rule out\" the presence of significant
proteinuria as defined by a 24-h urine excretion measurement.

[Price
CP](http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Price+CP"%5BAuthor%5D),
[Newall
RG](http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Newall+RG"%5BAuthor%5D),
[Boyd
JC](http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Boyd+JC"%5BAuthor%5D).
Use of protein:creatinine ratio measurements on random urine samples for
prediction of significant proteinuria: a systematic review. [Clin
Chem.](javascript:AL_get(this, 'jour', 'Clin Chem.');) 2005
Sep;51(9):1577-86.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16020501>

#### [OB/GYN CCC Editorial comment:]{.underline} with Jonathan Steinhart, Shiprock and

#### Jean Howe, Chinle

What would you do if you worked in an Indian Health facility that was 2
hours away from a Level III nursery and a 30 week EGA patient presented
with a blood pressure of slightly greater than 140 / 90 x 2 separated by
6 hours, a clean catch urine dipstick of 1+, and a mild headache?

One of the possible scenarios would include hospitalizing the patient in
your facility and beginning a 24 hour urine collection for protein.
Unfortunately the 24 hour urine collection is one of the most
notoriously incomplete samples that we routinely encounter, especially
in the outpatient setting. It is estimated that 10-20% of specimens are
incomplete and should be discarded because of the difficulties
associated with obtaining a complete collection, particularly in the
outpatient setting. In addition, in some of our remote facilities a 24
hour protein test is a 'send out' test and it only gets sent out at noon
on weekdays. Invariably, the collection for your patient is finished on
Friday afternoon or Saturday morning.

The second issue is that pre-eclampsia can have a rapidly progressive
course and waiting 24-36 hours for a diagnosis when definitive neonatal
care is a 2 hour transport time away can mean the difference between an
orderly transport of a stable maternal / fetal unit versus the emergent
delivery of significantly preterm infant in a remote facility without
adequate neonatal support.

Another scenario for the same patient would include performing a random
spot urine protein to creatinine (P:C) ratio and triaging the patient
based on that estimate. As Price et al note above, the P:C ratio on a
random urine specimen provides evidence to \"rule out\" the presence of
significant proteinuria as defined by a 24-h urine excretion
measurement.

In this clinical situation the International community and the data has
preceded the U.S. national benchmark organizations. In 2001 the
International Society for the Study of Hypertension in Pregnancy
Statement on the classification and diagnosis of the hypertensive
disorders of pregnancy recommended either a P:C of \> 30 mg / mmol
(calculates to 0.26 mg/mg creatinine), or a 24 hour urine value of 300
mg/ day for the baseline diagnosis of pre-eclampsia.

In 2005 the pre-eclampsia community guideline (PRECOG), following the
National Institute for Clinical Excellence\'s recommendations for the
development of guidelines, issued similar recommendations about a P:C of
\> 30 mg / mmol (calculates to 0.26 mg/mg creatinine). PRECOG is
supported by the Royal College of Obstetricians and Gynaecologists, the
Royal College of Midwives, and the Royal College of General
Practitioners.

On the other hand, neither the National Kidney Foundation, nor the
American College of Obstetricians and Gynecologists recommends the use
of the P:C in pregnancy. Perhaps after these two U.S. groups re-examine
the data, including the Price et al systematic review, and the
international acceptance of P:C, then the U.S. recommendations may
change.

Another disadvantage is that there is not complete agreement in the
nephrology community on how to convert the P:C ratio to a similar 24
hour urine protein result. The prevailing view is that the P:C roughly
correlates on a one for one basis with a 24 hour specimen, e. g., a P:C
of 3.5 roughly correlates to a 24 hour urine protein of 3.5 grams. On
the other hand, other nephrologists feel the ratio on a random urine
specimen correlates closely with daily protein excretion in g/1.73 m2 of
body surface area, when used in mild to moderate pre-eclampsia.

In addition, while a P:C of 0.2 appears to be the most commonly used
cut-off there is disagreement among the various authors about their
cut-offs. The various cut-offs create a gray zone in the P:C range of
0.2 - 0.3 for a possible screening cut-off.

On balance as the urine P:C appears to be a unit-less measure (mg/dl
divided by mg/dl causes the units to cancel out) usually expressed as mg
of protein per mg of creatinine.  Hence if one knows the total amount of
creatinine that a pregnant excretes per day, then one can estimate the
24 hour urine protein excretion. The minimum diagnosis of pre-eclampsia,
based on proteinuria, can be made at a P:C of 0.2 and further
conversions can be made on a 1:1 basis, e. g., a P:C of 5.0 correlates
to a 24 hour protein of 5.0 grams.

As one should not base their entire management of pre-eclampsia on the
degree of proteinuria, the P:C ratio result may at least provide help in
triaging the patient to the proper level of care. Once at the proper
care level, a 24 hour protein can be completed if necessary. The
decision to intervene in severe pre-eclampsia should be made based on
the whole clinical presentation, not on the degree of proteinuria alone.
Another scenario involves the triage of a chronic hypertensive patient
who can perhaps be monitored as an outpatient versus inpatient.

A 24 hour protein may still be indicated in some cases of severe
pre-eclampsia, if time permits, as both the present and future
pregnancies may be affected. Future pregnancies would be impacted as we
currently recommend the use of daily aspirin therapy in patients with
previous severe pre-eclampsia.

In summary, the use of the spot urine P:C has supplanted most of the 24
hour urine estimations done in both pediatric and adult nephrologist's
clinical practice.  Yet, the practice is not endorsed for use in
pregnancy by the National Kidney Foundation, ACOG, or any U.S. national
benchmark organization. This mismatch of U.S. benchmarks and clinical
recommendations leads to confusion in the clinical care of U.S. pregnant
women.

The P:C offers significant advantages to pregnant Indian Health patients
and should be explored for use at your facility. Considering the long
track record of successful use of the P:C in adults with chronic renal
disease, the endorsement the several major international professional
organizations, plus the Price et al systematic review, the time may have
come for our clinical practice to precede the U.S. national benchmarks.

After discussion among your medical staff, plus local maternal fetal
medicine and nephrology consultants, the P:C will offer significant
advantages in the triage of AI/AN women with hypertensive disorders of
pregnancy.

**Resources**

**Frequently Asked Question: MCH web page**

Can we use a protein to creatinine ratio instead of a 24 urine protein
in pre-eclampsia?

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/PCratio4306.doc>

(with an exhaustive set of Resources)

[Milne
F](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Milne+F"%5BAuthor%5D),
et al The pre-eclampsia community guideline (PRECOG): how to screen for
and detect onset of pre-eclampsia in the community.
[BMJ.](javascript:AL_get(this, 'jour', 'BMJ.');) 2005 Mar
12;330(7491):576-80.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15760998>

Brown M et al. The classification and diagnosis of the hypertensive
disorders of pregnancy: Statement from the International Society for the
Study of Hypertension in Pregnancy. Hypertens Pregnancy 2001:20(1)ix --
xiv

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12044323>

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

#### Carolyn Aoymana, HQE {#carolyn-aoymana-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**Pap screening: Great review of various types of interventions**

The authors review a model for intervention actions to increase
screening. They do a great review of various types of interventions,
which almost all fail miserably. A great review of what has been tried
and gives us a framework from which to work.

#### RE: Each January, the American Cancer Society (ACS) publishes a summary of its recommendations for early cancer detection, including guideline updates, emerging issues that are relevant to screening for cancer, and a summary of the most current data on cancer screening rates for US adults. In 2005, there were no updates to ACS guidelines. ACS summarizes the guidelines, discuss recent evidence and policy changes that have implications for cancer screening, and provide an update of the most recent data pertaining to participation rates in cancer screening by age, sex, and insurance status from the Centers for Disease Control and Prevention\'s Behavioral Risk Factor Surveillance System. {#re-each-january-the-american-cancer-society-acs-publishes-a-summary-of-its-recommendations-for-early-cancer-detection-including-guideline-updates-emerging-issues-that-are-relevant-to-screening-for-cancer-and-a-summary-of-the-most-current-data-on-cancer-screening-rates-for-us-adults.-in-2005-there-were-no-updates-to-acs-guidelines.-acs-summarizes-the-guidelines-discuss-recent-evidence-and-policy-changes-that-have-implications-for-cancer-screening-and-provide-an-update-of-the-most-recent-data-pertaining-to-participation-rates-in-cancer-screening-by-age-sex-and-insurance-status-from-the-centers-for-disease-control-and-preventions-behavioral-risk-factor-surveillance-system. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Smith RA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Smith+RA"%5BAuthor%5D), [Cokkinides V](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Cokkinides+V"%5BAuthor%5D), [Eyre HJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Eyre+HJ"%5BAuthor%5D). American Cancer Society guidelines for the early detection of cancer, 2006. [CA Cancer J Clin.](javascript:AL_get(this, 'jour', 'CA Cancer J Clin.');) 2006 Jan-Feb;56(1):11-25; quiz 49-50 [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16449183**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16449183) {#smith-ra-cokkinides-v-eyre-hj.-american-cancer-society-guidelines-for-the-early-detection-of-cancer-2006.-ca-cancer-j-clin.-2006-jan-feb56111-25-quiz-49-50-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids16449183 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Breast Cancer Research Program Releases Program Announcements, 2006 {#breast-cancer-research-program-releases-program-announcements-2006 .Style-Heading-4-+-Arial-14-pt-Underline}

The Department of Defense FY06 Breast Cancer Research Program
Announcements

(PA) were released on February 17th, 2006 with receipt of proposals due
on

May 23th and July 25th, 2006. A summary of the program is on the
website.

Detailed descriptions of each of the mechanisms, evaluation criteria,
and

submission requirements can be found in the FY06 BCRP Program
Announcement

for each mechanism. [http://cdmrp.army.mil](http://cdmrp.army.mil/)

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

#### Emergency guide for older adults and their caregivers {#emergency-guide-for-older-adults-and-their-caregivers-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### I\' have notes and resource for older adults and their caregivers regarding emergency/disaster readiness, plus an emergency guide for older adults and their caregivers.  {#i-have-notes-and-resource-for-older-adults-and-their-caregivers-regarding-emergencydisaster-readiness-plus-an-emergency-guide-for-older-adults-and-their-caregivers. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Contact [**Jennifer.Klocinski@aoa.hhs.gov**](mailto:Jennifer.Klocinski@aoa.hhs.gov) {#contact-jennifer.klocinskiaoa.hhs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Theresa Cullen, Tucson {#theresa-cullen-tucson .Style-Heading-4-+-Arial-14-pt-Underline}

**All-or-None Measurement Raises the Bar on Performance: April 19,
2006 - IHI**

Join The Institute for Healthcare Improvement (IHI) and The Journal of
the American Medical Association (JAMA) Wednesday, April 19, 2006, from
2pm - 3pm Eastern Time for \"Author in the Room,\" an interactive
conference call aimed at closing the gap between knowledge - what is
published in an article - and action - how much of this knowledge is put
into practice to improve care. The interactive call will help readers
consider the implications of the study results for improving their
practice.

On April 19, \"Author in the Room\" features Donald Berwick, MD, MPP,
FRCP, and Thomas Nolan, PhD, authors of \"All-or-None Measurement Raises
the Bar on Performance.\" To read more and access the article, please
visit
[<http://www.ihi.org/IHI/Programs/ConferencesAndTraining/Author+in+the+Roo>m.htm]{.underline}

Key points suggested by the article to be discussed during the call
include:

\* All or none measurement more closely reflects the interests and
likely desires of patients than other approaches to measurement such as
composite or item-by-item

\* All or none measurement forces a system perspective

\* All or none measurement offers a more sensitive scale for assessing
improvements

IHI and JAMA plan to study the degree to which \"Author in the Room\"
participants incorporate clinical improvements suggested by our experts
and the impact these changes have on clinical care.

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

#### Suicide Prevention Grants Available for Tribes and States {#suicide-prevention-grants-available-for-tribes-and-states-1 .Style-Heading-4-+-Arial-14-pt-Underline}

We would very much appreciate your circulating this information to all
tribal contacts who may be interested in applying for suicide prevention
grants. With a May 16 application deadline, we need everyone\'s help in
spreading the word as quickly as possible.

The State/Tribal Youth Suicide Prevention awards will be funded up to
\$400,000/year for up to 3 years.

The Campus Suicide Prevention awards will be funded up to \$75,000/year
in total costs plus an equivalent match from the applicant organization,
for up to 3 years.

SAMHSA has scheduled a series to technical assistance conference calls
for potential grant applicants. Information about these calls are on the
grants Web pages. Applicants are welcome, but are NOT required to
participate. All Frequently Asked Questions will be posted on the Web
sites. Applicants are also free to call or e-mail the contact people
listed in the RFA with questions.

#### For the State/Tribal Youth Suicide Prevention Program, contact [**eileen.zeller@samhsa.hhs.gov**](mailto:eileen.zeller@samhsa.hhs.gov) {#for-the-statetribal-youth-suicide-prevention-program-contact-eileen.zellersamhsa.hhs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

In addition to two conference calls for all interested applicants,
SAMHSA has scheduled a call specifically for Tribes and tribal
organizations:

Thursday, April 20; 4 - 5 pm (Eastern time)

Passcode: Tribe

1-888-455-1517

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

#### Chuck North, Albuquerque {#chuck-north-albuquerque .Style-Heading-4-+-Arial-14-pt-Underline}

**RCTs: do they have external validity for patients with multiple
co-morbidities**

CONCLUSIONS: Results from this study suggest that RCTs targeting a
chronic medical condition such as hypertension could find that, in a
sample taken from family practice, most eligible patients have comorbid
conditions. Whether these patients are sampled or excluded should be
reported. Research results intended to be applied in medical practice
should take the complex reality of effective treatment of these patients
into consideration.

[Fortin
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Fortin+M"%5BAuthor%5D),
et al Randomized controlled trials: do they have external validity for
patients with multiple comorbidities? [Ann Fam
Med.](javascript:AL_get(this, 'jour', 'Ann Fam Med.');) 2006
Mar-Apr;4(2):104-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16569712>

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

#### [Starfield B](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Starfield+B"%5BAuthor%5D). Threads and yarns: weaving the tapestry of comorbidity. [Ann Fam Med.](javascript:AL_get(this, 'jour', 'Ann Fam Med.');) 2006 Mar-Apr;4(2):101-3. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16569711&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16569711&dopt=Abstract) {#starfield-b.-threads-and-yarns-weaving-the-tapestry-of-comorbidity.-ann-fam-med.-2006-mar-apr42101-3.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids16569711doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [Family Medicine CCC Editorial comment:]{.underline} {#family-medicine-ccc-editorial-comment .Style-Heading-4-+-Arial-14-pt-Underline}

#### This issues raised are relevant to our use of guidelines to assess physician performance in diabetes, heart disease and other GPRA type measurements including "pay for performance".  Starfield discusses the role of specialists vs. primary care clinician's use of guidelines. The issues raised deserve attention by our clinical leaders as we continue to develop measurable improvements in the practice of medicine, especially in primary care. I would appreciate your comments. [**Charles.North@ihs.gov**](mailto:Charles.North@ihs.gov) {#this-issues-raised-are-relevant-to-our-use-of-guidelines-to-assess-physician-performance-in-diabetes-heart-disease-and-other-gpra-type-measurements-including-pay-for-performance.-starfield-discusses-the-role-of-specialists-vs.-primary-care-clinicians-use-of-guidelines.-the-issues-raised-deserve-attention-by-our-clinical-leaders-as-we-continue-to-develop-measurable-improvements-in-the-practice-of-medicine-especially-in-primary-care.-i-would-appreciate-your-comments.-charles.northihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Child and Youth Projects (CYP) Cooperative Agreement Grant
Announcement**

(fax to 301-594-6213 attn: Judy Thierry -- see details in the
announcement)

It is not binding, meaning that you don\'t have to actually go ahead and
complete an application, but a letter of intent will be required prior
to submission of the full application. 

Announcement posted on grants.gov web site shortly:
[[www.grants.gov]{.underline}](http://www.grants.gov/)

Remember electronic submissions now!

A Letter of Intent is mandatory and due asap  

Projects will be of two types, Category I or small projects and Category
II or large projects. 

General program goals are aligned with 2010 goals
[[http://www.healthypeople.gov/Search/objectives.htm]{.underline}](http://www.healthypeople.gov/Search/objectives.htm)

 

Award Information

TYPE OF AWARDS:  Cooperative Agreement (CA).

ESTIMATED FUNDS AVAILABLE:  The total amount identified for fiscal year
(FY) 2006 is \$650,000. 

There will be three funded project years of 12 month duration. 

The average award is approximately \$5,000 to \$75,000 to fund up to
approximately 15 awards based on progress and availability of funds.

(Federal Register notice) was published, March 30th, 2006. 

**Failure Mode Analysis (FMA) - Improving Perinatal Care**

A brief definition: a SYSTEMATIC way to analyze care \'pre incident\' by
starting at t-0 and moving forward in time to understand where things
could go wrong versus waiting for an untoward event or sentinel event
and then doing a root cause analysis.

Improving Perinatal Care White Paper 

<http://www.ihi.org/IHI/Results/WhitePapers/IdealizedDesignofPerinatalCareWhitePaper.htm>

Link to 58 minute discussion on Improving Perinatal Care

<http://www.ihi.org/IHI/Programs/IMPACTNetwork/> \
Excerpt from the final page of the 14 page White Page with some terms
developed both in the full text and in the audio.

Lastly: [Conference call]{.underline} with presentation and discussion

See how this could apply to your work no matter the setting. Bring your
examples from your professional experience to the discussion. May 4 --
Thursday -- 1 -- 3 pm ET

Contact <Judith.Thierry@ihs.gov>

**Looking Ahead -- Institute for Healthcare Improvement: Phase II**

During Phase II, teams will continue to work on applying IHI's
reliability model to the implementation of the perinatal care bundles.
In addition, Phase II will focus on developing systems to ensure that a
mother's preferences are known and honored. Teams will also focus on
testing their response to crisis situations by simulating these
situations and making changes to improve those processes. The Idealized
Design project also focuses on improving the safety culture of the
perinatal unit, which will be measured using available safety attitude
survey tools. A Perinatal Trigger Tool will be used to determine rate of
perinatal harm. Another component of the model, the handoff to a
receiving unit, is in development. Additional work in this project will
focus on management of second stage labor and increasing the reliability
of the selected processes.

**Impact Network**
<http://www.ihi.org/IHI/Programs/IMPACTNetwork/IMPACTNetwork.htm>                                                     

**CDC release: Sudden Unexplained Infant Death Investigation (SUIDI)
Reporting Form**

The newly designed form, while voluntary, can be used to gather
consistent information about the circumstances surrounding all sudden,
unexplained infant deaths. Each year in the United States, more than
4,500 infants die suddenly, with no obvious cause at the time of death.
Approximately half of these sudden infant deaths are reported as sudden
infant death syndrome (SIDS). The diagnosis of SIDS should be reserved
for those cases in which the cause of death remains unexplained after
thorough examination of the death scene, a complete autopsy, and a
review of the infant\'s medical history. [Note:]{.underline} In SUIDI
interviews are not focused on the mother. In deference to the National
Fetal Infant Mortality Review (NFIMR) wherein grief and supportive
counseling are provided the mother is the focus -- and the interview
begins with where the mother "is at" versus being forensic in nature.
The form, designed as a questionnaire, ensures that all information is
collected in a consistent, sensitive manner.
[[http://www.cdc.gov/sids/SUIDHowtoUseForm.htm]{.underline}](http://www.cdc.gov/sids/SUIDHowtoUseForm.htm)

Kay Tomashek <kct9@CDC.GOV> at CDC for details.

**National Women's Health Indicators Data Base**

You will want to use this quick reference to build your own tables on
key populations.

Age buckets are 0-15, 16-19, 20-24, 25-44, 45-64, 65-84, 65 and over.

You can build a table by selecting 1) category, 2) demographics, and 3)
geography.

I have attached the table that lists the tribes that are identified in
the 2000 census -- which allows for more tribal specific, detailed data.
Health issues that you can find below:

Data (from several sources) in the system are organized into the
following categories:

  ---------------------------------------------- ------------------------
       - Codes and Status                        \- Demographics

       - Mortality                               \- Access to Care

       - Infectious/Chronic Disease              \- Reproductive Health

       - Maternal Health                         \- Mental Health

       - Violence and Abuse                      \- Prevention
  ---------------------------------------------- ------------------------

Thanks to Gordon Belcourt who sent this link. Let me know if you have
questions, what you think and how you use this.
<http://www.healthstatus2010.com/owh/>

**Kaiser DATA on Women: Health Insurance Coverage of Women Ages 18-64,
by State**

This fact sheet provides state-by-state data on the uninsured rate, as
well as rates of private insurance coverage and Medicaid coverage, among
women nationally, in the 50 states and the District of Columbia. Thank
you to Gordon Belcourt <http://www.kff.org/womenshealth/1613.cfm>

**Healthy People 2010: Related MCH Objectives**

Thorough list of objectives from multiple sources

<http://www.mchlibrary.info/hp2010related.html>

**[Shelley Thorkelson](mailto:Shelley.Thorkelson@ihs.gov), Shiprock**

**Gestational Diabetes Mellitus [Tracking
Sheet](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/GDMtrackingsheete.doc)** 

Diabetes and Pregnancy Program Flowsheet, Northern Navajo Medical Center

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

**Program Review and Case Management - Diabetes in Pregnancy**

Processes of tracking case files using hard copy as well as RPMS and CMS
computer systems

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/gdmcasemanagement(3).ppt>

**Alan Waxman, Albuquerque**

**FDA Approves New Imaging System to Help Detect Cervical Pre-Cancer**

The Food and Drug Administration today approved a new imaging system
that can help detect a cervical cancer precursor, an indication of
possible cancer development, by identifying sites on the cervix that may
contain pre-cancerous cells.

The LUMA Cervical Imaging System, manufactured by MediSpectra, Inc. of
Lexington, Mass., is intended to be used along with colposcopy, a high
magnification evaluation of the cervix for women who have recently had
an abnormal Pap test. The firm\'s study showed that the new device can
detect additional cancer precursors missed by colposcopy. Of the 50
cases of pre-cancer detected in the study, colposcopy caught 41 cases of
cervical pre-cancer and LUMA caught an additional 9 cases of cervical
pre-cancer that colposcopy had missed.

\"Cervical cancer is one of the few highly preventable cancers. The
early detection and removal of pre-cancerous cervical lesions reduces
the risk of developing invasive cervical cancer,\" said Daniel Schultz,
M.D., Director, Center for Devices and Radiological Health. \"The
approval of this imaging system gives health care providers an
additional tool to help detect cervical cancer precursors and identify
pre-disease that may have been missed by a colposcopy.\"

The LUMA Cervical Imaging System shines a light on the cervix and
analyzes how different areas of the cervix respond to this light. The
LUMA Systems assigns a score to tiny areas of the cervix and produces a
color map that helps the doctor decide where to biopsy. The colors and
patterns on the map help the doctor distinguish between healthy tissue,
and potentially diseased tissue.

[[http://www.medispectra.com/detection/detection.html]{.underline}](http://www.medispectra.com/detection/detection.html)

A doctor will first perform a colposcopy and identify areas on the
cervix to biopsy. The doctor will then evaluate the LUMA image to see
whether or not there are additional areas of the cervix that should be
biopsied. Only after both the colposcopy and LUMA procedures are
completed does the doctor perform the biopsies.

FDA\'s approval was based on data from the firm\'s clinical study of 193
women who underwent colposcopy, followed by LUMA. FDA\'s analysis showed
that the device is safe and effective and that - when used along with
colposcopy - the LUMA system will help detect additional cervical cancer
precursors. Use of the LUMA device is not a substitute for a thorough
colposcopic exam.

<http://www.medgadget.com/archives/2006/03/luma_cervical_i_1.html>

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

A number of companies have been working on spectroscopy devices as an
adjunct to cervical cancer screening. MediSpectra is the first to have
FDA approval. The rationale for such a device is the less than desired
sensitivity or colposcopy. The NCI-sponsored ALTS study found the
sensitivity of colposcopy to be disappointing.^1^ Other studies
published in the past few years have also called into question our
ability to find the worst lesion on colposcopy.^2^ An adjunct procedure
that uses objective measures to map out the cervix therefore has appeal.
The LUMA system uses algorithms that integrate reflectance and
florescence spectroscopy with video imaging to highlight areas the
colposcopist may not have noted. Frequently a lesion is too small to
detect visually.

The principle on which the system is based is that light has a
characteristic spectroscopic signature when reflected from diseased
tissues or as it causes tissue florescence from diseased tissues. The
role of this product, its cost and cost-effectiveness still remain to be
seen, but it\'s an exciting prospect that we may be able to increase the
sensitivity of our ability to diagnose cervical dysplasia.

1\. The ASCUS-LSIL Triage Study (ALTS) Group. Results of a randomized
trial on the management of cytology interpretations of atypical squamous
cells of undetermined significance. Am J Obstet Gynecol
2003;188:1383-92.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12824967>

2\. Pretorius RG, Zhang W, Belinson JL, et.al. Colposcopically directed
biopsy, random cervical biopsy, and endocervical curettage in the
diagnosis of cervical intraepithelial neoplasia II or worse. Am J Obstet
Gynecol 2004;191:430-4.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15343217>

**Judy Whitecrane, Phoenix**

**2006 Physician Assistant/Advanced Practice Nurse CE Seminar**

May 22-26, 2006

Scottsdale, Arizona

Here is the latest info on our annual Advanced Practice Nurses Business
Meeting.  This Business meeting is for all APN\'s-not just managers or
policy makers.  We want you to share your practice highlights and get
ideas from others!   This is a good way to network with others in the
field about possible job opportunities elsewhere also!

This year we will have one full day with our APN headquarters
representative, Carolyn Aoyama CNM, MPH. She will be at the business
meeting on Monday, May 22, from 8:30AM to 4PM.

 Please see the links below to register and obtain hotel reservations.  

Scottsdale is a great place for shopping, dining, and family
entertainment.  The hotel provides a wonderful breakfast each day,
included in the price.
<http://www.ihs.gov/MedicalPrograms/ClinicalSupportCenter/>

**Exposure to Mumps During Air Travel \-\-- United States, April 2006**

IDPH has identified two persons who had mumps diagnosed and were
potentially infectious during travel on nine different commercial
flights involving two airlines during March 26\--April 2, 2006.

Persons on the flights listed on the website below who have symptoms
consistent with mumps within 21 days of travel should be evaluated for
mumps by a health-care provider. Health-care providers should remain
vigilant for mumps among persons with parotitis or other salivary gland
inflammation. Cases of suspected mumps should be reported immediately to
public health officials.
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm55d411a1.htm>

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

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

**Glyburide is at least as effective as insulin therapy in treating
gestational diabetes**

CONCLUSION: In a large managed care organization, glyburide was at least
as effective as insulin in achieving glycemic control and similar birth
weights in women with GDM who failed diet therapy. The increased risk of
preeclampsia and phototherapy in the glyburide group warrant further
study.

[Jacobson
GF](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Jacobson+GF"%5BAuthor%5D)
et al Comparison of glyburide and insulin for the management of
gestational diabetes in a large managed care organization. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2005
Jul;193(1):118-24.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16021069>

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

Despite 2000 Langer's results, and that recent expert opinion has
recommended glyburide as an alternative treatment, only 13 percent of
physicians in a 2003 study reported using this medication as first-line
therapy. Jacobson and associates evaluated the use of glyburide versus
insulin in the treatment of women with gestational diabetes mellitus
that has been unresponsive to diet therapy. A retrospective chart audit
of women with gestational diabetes who required medication for control
was performed for two years before the introduction of a glyburide
protocol and for two years after the protocol was used.

Jacobson study mirrors our positive experience with glyburide since
Langer's 2000 study. It is still important to document that glyburide is
not FDA approved in your initial discussion with your patient.

**Use the 'talk but not sing' rule: Physical activity predicts GDM
risk**\
Women who are physically active before pregnancy are less likely to
develop gestational diabetes mellitus (GDM). GDM risk also rises with
the amount of pre-pregnancy television viewing. From the public health
view, it is important for women of reproductive age to keep an active
lifestyle.

Most studies of exercise have looked at its effects on chronic disease
in middle-age and elderly women. Given that GDM is a risk factor for
developing type 2 diabetes, the findings underscore the importance of
physical activity for younger women as well. There\'s also evidence that
GDM can increase a child\'s later risk of obesity and diabetes.

CONCLUSION: Our prospective study provides strong evidence that regular
physical activity before pregnancy is associated with lower GDM risk.

[Zhang
C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Zhang+C"%5BAuthor%5D),
et al A prospective study of pre-gravid physical activity and sedentary
behaviors in relation to the risk for gestational diabetes mellitus.
Arch Intern Med 2006;166:543-548.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16534041>

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

**Use the 'talk, but not sing' rule**

As there is no randomized data on diet in the literature, then what
other evidence-based helpful interventions are there? Exercise has
randomized data to support its benefit in control of fasting and
postprandial glucose. ([Bung et
al](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8515355&dopt=Abstract),
[Jovanovic-Peterson et
al](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2764059&dopt=Abstract))

Roland [Dyck et
al](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10093309&dopt=Abstract)
describe a successful exercise program in Aboriginal women in Saskatoon,
Saskatchewan. Alaska Native Medical Center has also instituted a
successful exercise in pregnancy program.

An "exercise prescription" is something from which women with GDM should
benefit. Something as simple as walking at a comfortable pace for 20-30
minutes after meals will usually favorably impact post-prandial glucose
values and result in lower birth weight if done as part of a regular
regimen. The patient's exercise activity level should allow the patient
to 'talk, but not sing'.

**Reference:**

[Bung P, Bung C, Artal R, Khodiguian N, Fallenstein F, Spätling
L](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8515355&dopt=Abstract).
Therapeutic exercise for insulin-requiring gestational diabetics:
effects on the fetus---results of a randomized prospective longitudinal
study. J Perinat Med 1993;21:125--137 (Level II-2)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8515355&dopt=Abstract>

[Dyck RF, Sheppard MS, Cassidy H, Chad K, Tan L, Van Vliet
SH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10093309&dopt=Abstract).
Preventing NIDDM among aboriginal people: is exercise the answer?
Description of a pilot project using exercise to prevent gestational
diabetes. Int J Circumpolar Health 1998;57 Suppl 1:375-8 (Level III)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10093309&dopt=Abstract>

[Jovanovic-Peterson L, Durak EP, Peterson
CM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2764059&dopt=Abstract).
Randomized trial of diet versus diet plus cardiovascular conditioning on
glucose levels in gestational diabetes. Am J Obstet Gynecol
1989;161:415--419 (Level II-1)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2764059&dopt=Abstract>

**Calcium reduced severity, maternal morbidity, and neonatal mortality
in preeclampsia**

CONCLUSION: A 1.5-g calcium/day supplement did not prevent preeclampsia
but did reduce its severity, maternal morbidity, and neonatal mortality,
albeit these were secondary outcomes

[Villar
J](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Villar+J"%5BAuthor%5D),
et al World Health Organization randomized trial of calcium
supplementation among low calcium intake pregnant women. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Mar;194(3):639-49.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16522392>

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

This is confirmation of previous MCH webpage recommendations and
Cochrane Library\* reviews that patients from low calcium intake regions
(Read as: Many AI/AN women) consider calcium supplementation to mitigate
pre-eclampsia complications. The WHO study, above, now gives us a
successful dosage range.

\*Authors\' conclusions: Calcium supplementation appears to reduce the
risk of high blood pressure in pregnancy, particularly for women at high
risk of gestational hypertension and in communities with low-dietary
calcium intake. Optimum dosage and the effect on more substantive
outcomes requires further investigation.

Citation: Atallah AN, Hofmeyr GJ, Duley L. Calcium supplementation
during pregnancy for preventing hypertensive disorders and related
problems. The Cochrane Database of Systematic Reviews 2002, Issue 1.
Art. No.: CD001059. DOI: 10.1002/14651858.CD001059.

**Increasing Angle of Episiotomy Reduces Third-Degree Tear Risk**

CONCLUSIONS: These results show that a larger angle of episiotomy is
associated with a lower risk of third-degree tear and mediolateral
episiotomy incisions should be made at as large an angle as possible to
minimise the risk of sphincter disruption.

[Eogan
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Eogan+M"%5BAuthor%5D),
et al Does the angle of episiotomy affect the incidence of anal
sphincter injury? [BJOG.](javascript:AL_get(this, 'jour', 'BJOG.');)
2006 Feb;113(2):190-4.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16411997>

**Bed Rest Not Be Helpful for Threatened Miscarriage**

A recent Medscape review article highlighted a controversial issue in
obstetrics: the value of bed rest for threatened miscarriage. Although
this intervention is widely prescribed, evidence of its efficacy is
limited or absent, and some experts suggest that there may be
deleterious effects.

Two small randomized controlled trials (RCTs) from the early 1990s
showed overall lack of effect. In one of these studies, 61 women with
viable pregnancies and vaginal bleeding at less than 8 gestational weeks
were randomized to receive injections of human chorionic gonadotropin,
injections of placebo, or bed rest. Abortion rates were 30%, 48%, and
75%, respectively (*Int J Fertil Menopausal Stud* 1993;38:160-165).\
\
In addition, because Cochrane reviews rely primarily on data from RCTs,
they have rated antepartum bed rest to prevent threatened miscarriage as
a \"form of care unlikely to be beneficial.\" Evidence from current RCTs
shows no significant difference in maternal-fetal outcomes for women
with twin and triplet gestations treated with hospital bed rest and
those allowed to ambulate at home (Cochrane database\*).

Apart from the lack of evidence supporting the efficacy of antepartum
bed rest for threatened abortion, there are potentially adverse effects
to consider. Muscle atrophy and cardiovascular deconditioning are well
documented effects of bed rest in men and nonpregnant women. Antepartum
symptoms may include musculoskeletal and cardiovascular deconditioning,
sleep disturbances, and other changes in circadian rhythms. Additional
problems may include insufficient weight gain and low birth weights.\
\
The effects vary by the severity of activity restriction and length of
bed rest.\"Bathroom privileges do not offset the side effects of bed
rest. Psychosocial adverse effects include increased depression, stress,
and family functioning difficulties.

<http://www.medscape.com/viewarticle/529232?src=mp>

\* Authors\' conclusions: There is insufficient evidence of high quality
that supports a policy of bed rest in order to prevent miscarriage in
women with confirmed fetal viability and vaginal bleeding in first half
of pregnancy.

Citation: Aleman A, Althabe F, Belizán J, Bergel E. Bed rest during
pregnancy for preventing miscarriage. *The Cochrane Database of
Systematic Reviews* 2005, Issue 2. Art. No.: CD003576.pub2. DOI:
10.1002/14651858.CD003576.pub2.

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

**Amnioinfusion Not Effective in Meconium Aspiration Syndrome**

CONCLUSIONS: For women in labor who have thick meconium staining of the
amniotic fluid, amnioinfusion did not reduce the risk of moderate or
severe meconium aspiration syndrome, perinatal death, or other major
maternal or neonatal disorders.

Fraser WD, et al. Amnioinfusion for the prevention of the meconium
aspiration syndrome. N Engl J Med September 1, 2005;353:909-17.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16135835>

**Gestational Diabetes Linked to Later Development of Types 1 and 2
Diabetes**

CONCLUSIONS: Pregnancy seems to identify women who are at risk of
developing diabetes later in life. About 10% of Finnish women with GDM
will develop diabetes over the next 6 years; nearly half of them develop
type 1 diabetes and the other half type 2 diabetes. Age \< or =30 years,
the need for insulin treatment during pregnancy, and positivity for ICAs
and GADAs confer a high risk of subsequent progression to type 1
diabetes in women affected by GDM

[Jarvela
IY](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Jarvela+IY"%5BAuthor%5D)
et al Gestational diabetes identifies women at risk for permanent type 1
and type 2 diabetes in fertile age: predictive role of autoantibodies.
[Diabetes Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');)
2006 Mar;29(3):607-12.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16505514>

**Risk of placenta previa and abruption: Multiparous women who have had
a cesarean**

CONCLUSION: A cesarean first birth is associated with increased risks of
previa and abruption in the second pregnancy. There is a dose-response
pattern in the risk of previa, with increasing number of prior cesarean
deliveries. A short interpregnancy interval is associated with increased
risks of previa and abruption. LEVEL OF EVIDENCE: II-2

[Getahun
D](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Getahun+D"%5BAuthor%5D),
et al Previous Cesarean Delivery and Risks of Placenta Previa and
Placental Abruption. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Apr;107(4):771-778.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16582111&dopt=Abstract>

**Selective serotonin-reuptake inhibitors**

CONCLUSIONS: These data support an association between the maternal use
of SSRIs in late pregnancy and PPHN in the offspring; further study of
this association is warranted. These findings should be taken into
account in decisions as to whether to continue the use of SSRIs during
pregnancy.

[Chambers
CD](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Chambers+CD"%5BAuthor%5D)
et al Selective serotonin-reuptake inhibitors and risk of persistent
pulmonary hypertension of the newborn. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2006 Feb
9;354(6):579-87.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16467545>

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

Chambers et al presents yet another reason we should utilize behavioral
counseling methods in mild to moderate depression before considering
SSRIs in pregnancy.

This Review article is also helpful

[Koren
G](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Koren+G"%5BAuthor%5D),
et al Is maternal use of selective serotonin reuptake inhibitors in the
third trimester of pregnancy harmful to neonates?
[CMAJ.](javascript:AL_get(this, 'jour', 'CMAJ.');) 2005 May
24;172(11):1457-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15911861>

**Abnormal placentation outcomes: Imaging, planning and a
multidisciplinary team**

Small studies suggest that, when the placenta to cervical os distance is
greater than 2 cm, women may safely have a vaginal delivery. Regional
anesthesia for cesarean delivery in women with placenta previa is safe.
Delivery should take place at an institution with adequate blood banking
facilities. The incidence of placenta accreta is rising, primarily
because of the rise in cesarean delivery rates. This condition can be
associated with massive blood loss at delivery. Prenatal diagnosis by
imaging, followed by planning of peripartum management by a
multidisciplinary team, may help reduce morbidity and mortality. Women
known to have placenta accreta should be delivered by cesarean, and no
attempt should be made to separate the placenta at the time of delivery.
The majority of women with significant degrees of placenta accreta will
require a hysterectomy. Although successful conservative management has
been described, there are currently insufficient data to recommend this
approach to management routinely. Vasa previa carries a risk of fetal
exsanguination and death when the membranes rupture. The condition can
be diagnosed prenatally by ultrasound examination. Good outcomes depend
on prenatal diagnosis and cesarean delivery before the membranes
rupture.

[Oyelese
Y](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Oyelese+Y"%5BAuthor%5D),
[Smulian
JC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Smulian+JC"%5BAuthor%5D)
Placenta previa, placenta accreta, and vasa previa. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Apr;107(4):927-41.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16582134&dopt=Abstract>

**Macrosomia: High incidence of 2nd vaginal delivery despite recurrence
of macrosomia**

CONCLUSION: Despite a one-third recurrence of macrosomia, first vaginal
delivery of a macrosomic infant was associated with a high incidence of
second vaginal delivery. Conversely, primiparous macrosomic cesarean
delivery conveyed a high risk (56%) for repeat intrapartum cesarean
whether macrosomia recurred or not. LEVEL OF EVIDENCE: II-2

[Mahony
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Mahony+R"%5BAuthor%5D),
et al Outcome of second delivery after prior macrosomic infant in women
with normal glucose tolerance. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Apr;107(4):857-62

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16582123&dopt=Abstract>

**MRI Accurately Rules out Appendicitis in Pregnant Patients**

RESULTS: MR images were positive for appendicitis in four patients and
inconclusive in three. In the three patients with inconclusive results,
the appendix was not seen in two patients and was borderline enlarged (7
mm in diameter) in the third. The overall sensitivity, specificity,
prevalence-adjusted positive and negative predictive values, and
accuracy for MR imaging was 100%, 93.6%, 1.4%, 100%, and 94.0%,
respectively. CONCLUSION: MR imaging is an excellent modality for use in
excluding acute appendicitis in pregnant women who present with acute
abdominal pain and in whom a normal appendix is not visualized at US

[Pedrosa
I](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Pedrosa+I"%5BAuthor%5D),
et al MR imaging evaluation of acute appendicitis in pregnancy.
[Radiology.](javascript:AL_get(this, 'jour', 'Radiology.');) 2006
Mar;238(3):891-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16505393>

**Risk During Pregnancy and Birth After Assisted Reproductive
Technologies**

The data collected here clearly demonstrate the increased risk for
couples who became pregnant after infertility treatment. However,
similar risks are prevalent from couples with a longer time to pregnancy
(\> 12 months). The risks seem to be lower in fertile women who undergo
infertility treatment (such as surrogate mothers). This also confirms
the risk of infertility for pregnancy course and obstetric outcome.

[Ludwig
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ludwig+M"%5BAuthor%5D).
Risk during pregnancy and birth after assisted reproductive
technologies: an integral view of the problem. [Semin Reprod
Med.](javascript:AL_get(this, 'jour', 'Semin Reprod Med.');) 2005
Nov;23(4):363-70.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16317625>

**Metformin use and diabetic pregnancy - has its time come?**\
Although the use of metformin in gestational diabetes is not yet
accepted as treatment in gestational diabetes, evidence is accumulating
that it may be a useful treatment. The prevalence of Type 2 diabetes in
women of childbearing age continues to grow as the incidence of Type 2
diabetes increases. Recent evidence shows that treatment of gestational
diabetes ensures the best possible outcome for pregnancy complicated by
gestational diabetes. Metformin is a logical treatment in these
circumstances but there has always been concern about its safety for the
fetus, particularly as it crosses the placenta and it may increase the
risk of teratogenesis. Although evidence is accumulating that metformin
is useful and has a role in polycystic ovary syndrome, a condition of
insulin resistance, it is not yet accepted as treatment for Type 2
diabetes in pregnancy and gestational diabetes.

Observational data supports the use of metformin in Type 2 diabetes in
pregnancy and its role in gestational diabetes is currently under
investigation. Metformin may become an important treatment for women
with either gestational or Type 2 diabetes in pregnancy and indeed may
have additional important benefits for women, including reducing insulin
resistance, body weight and long-term risk of diabetes.

[Conclusions]{.underline}: Pregnant women with Type 2 DM who were
treated with metformin had more risk factors for adverse pregnancy
outcomes, but no differences in outcomes were seen compared with women
not taking metformin. There is a need for a randomized controlled trial
in women with Type 2 diabetes in pregnancy with long-term follow-up of
both mothers and children. Until then the best advice remains that
optimized glycemic control prior to conception and during pregnancy is
the most important

[Hawthorne
G](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Hawthorne+G"%5BAuthor%5D).
Metformin use and diabetic pregnancy-has its time come? [Diabet
Med.](javascript:AL_get(this, 'jour', 'Diabet Med.');) 2006
Mar;23(3):223-7.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16492202]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16492202)

**Preventing Postpartum Hemorrhage: Managing the Third Stage of Labor**

Postpartum hemorrhage is a significant cause of maternal morbidity and
mortality. Most postpartum hemorrhages are caused by uterine atony and
occur in the immediate postpartum period. Expectant or physiologic
management of the third stage of labor has been compared with active
management in several studies. Active management involves administration
of uterotonic medication after the delivery of the baby, early cord
clamping and cutting, and controlled traction of the umbilical cord
while awaiting placental separation and delivery. Good evidence shows
that active management of the third stage of labor provides a better
balance of benefits and harms and should be practiced routinely to
decrease the risk of postpartum hemorrhage. Oxytocin, ergot alkaloids,
and prostaglandins have been compared, as have timing and route of
administration of these uterotonic medications. Oxytocin is the
uterotonic agent of choice; it can be administered as 10 units
intramuscularly or as 20 units diluted in 500 mL normal saline as an
intravenous bolus, and can safely and effectively be given to the mother
with the delivery of the baby or after the delivery of the placenta. Am
Fam Physician 2006;73:1025-8.

<http://www.aafp.org/afp/20060315/1025.html>

**Use of acupressure at the P6 point slightly reduced hospital days, but
not other outcomes**

CONCLUSION: The use of acupressure at the P6 point does not reduce the
amount of antiemetic medication that is required, the requirement for
intravenous fluid, and median duration of in-patient stay more than the
use of placebo. A small reduction was seen in the number of women who
required \> or =4 days in the hospital

[Heazell
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Heazell+A"%5BAuthor%5D),
et al Acupressure for the in-patient treatment of nausea and vomiting in
early pregnancy: a randomized control trial. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Mar;194(3):815-20\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16522418>

**Hypertension in Pregnancy Review**

Solomon CG, Seely EW. Hypertension in Pregnancy Endocrinology and
Metabolism Clinics Volume 35 • Number 1 • March 2006

<http://home.mdconsult.com/das/journal/view/56825077-2/N/15894890?ja=506421&PAGE=1.html&ANCHOR=top&source=MI>

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

**Extensive condyloma acuminata treated with imiquimod 5% cream**

Genital warts are one of the most common sexually transmitted
infections, and are caused by human papillomavirus (HPV) types 6 and 11.
Standard treatments for genital warts include cryotherapy, laser
therapy, trichloroacetic acid and podophyllotoxin. We report the case of
a 21-year-old female with extensive genital warts. A patient-applied,
non-destructive therapy was considered to be the most appropriate
treatment in this case, due to the extent of the disease and the
resulting psychological distress experienced by the patient. She applied
imiquimod 5% cream three times per week for a period of 5 weeks, which
resulted in complete clearance of all the warts. Minor inflammatory
changes were observed during treatment; however, no significant pain was
by reported the patient. No recurrences were reported during 2 years of
follow-up.

[Cox
JT](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Cox+JT"%5BAuthor%5D)
Extensive condyloma acuminata treated with imiquimod 5% cream: a case
report. [Clin Exp
Dermatol.](javascript:AL_get(this, 'jour', 'Clin Exp Dermatol.');) 2003
Nov;28 Suppl 1:51-4.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14616817>

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

Questions have also arisen about the treatment of vaginal condyloma
which do not lend themselves easily to topical or laser treatment. One
provider relates the use of a vaginal applicator with one sachet of
imiquimod 5% (0.25 g) once weekly for 3 doses and had fairly good
response to condyloma or VAIN 1. with minimal side effects.

**Urinary incontinence: Substantial economic costs and decrement in
quality of life**

METHODS: In a cross-sectional study at 5 U.S. sites, 293 incontinent
women quantified supplies, laundry, and dry cleaning specifically for
incontinence. Costs were calculated by multiplying resources used by
national resource costs and presented in 2005 United States dollars
(\$2005).

CONCLUSION: Women with severe urinary incontinence pay \$900 annually
for incontinence routine care, and incontinence is associated with a
significant decrement in health-related quality of life. Effective
incontinence treatment may decrease costs and improve quality of life.
LEVEL OF EVIDENCE: III. [Subak
LL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Subak+LL"%5BAuthor%5D)
et al The \"Costs\" of Urinary Incontinence for Women. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Apr;107(4):908-916.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16582131&dopt=Abstract>

**Sexual activity and function in middle-aged and older women**

Satisfaction with sexual activity was associated with African-American
race, lower BMI, and higher mental health score (all P \< .05). More
sexual dysfunction was associated with having a college degree or
greater, poor health, being in a significant relationship, and a low
mental health score (all P \< .05). LEVEL OF EVIDENCE: II-3

CONCLUSION: Middle-aged and older women engage in satisfying sexual
activity, and one third reported problems with sexual function.
Demographic factors as well as some issues associated with aging can
adversely affect sexual frequency, satisfaction, and function.

[Addis
IB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Addis+IB"%5BAuthor%5D),
et al Sexual activity and function in middle-aged and older women.
[Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');)
2006 Apr;107(4):755-64.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16582109&dopt=Abstract>

**Connection Between Obesity and Pelvic Organ Dysfunction**

CONCLUSION: Prevalence of urinary and anal incontinence is high in this
group of morbidly obese women as compared with the general population.
Studies are needed to determine the effect of weight loss on urinary and
anal incontinence symptoms in the morbidly obese woman.

[Richter
HE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Richter+HE"%5BAuthor%5D),
et al Urinary and anal incontinence in morbidly obese women considering
weight loss surgery. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2005
Dec;106(6):1272-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16319252>

**LLETZ and cold knife conization: Similar effects on pregnancy-related
morbidity**

LLETZ has traditionally thought to be less disruptive to the cervical
tissues than cold knife conization. This meta-analysis shows that LLETZ
is equal to cold knife cone in its association with preterm labor and
low birth weight. Careful consideration must be given to the risks and
benefits of an excisional procedure for a patient who still wants to
have children. A premature infant faces many severe medical problems
that can be long term and costly.

INTERPRETATION: All the excisional procedures to treat cervical
intraepithelial neoplasia present similar pregnancy-related morbidity
without apparent neonatal morbidity. Caution in the treatment of young
women with mild cervical abnormalities should be recommended. Clinicians
now have the evidence base to counsel women appropriately.

[Kyrgiou
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Kyrgiou+M"%5BAuthor%5D),
et al Obstetric outcomes after conservative treatment for
intraepithelial or early invasive cervical lesions: systematic review
and meta-analysis.
[Lancet.](javascript:AL_get(this, 'jour', 'Lancet.');) 2006 Feb
11;367(9509):489-98.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16473126>

**Menstrual Cycle Characteristics Correlate With Fertility**

Conception occurred most frequently after menstrual bleeds lasting 5
days, while spontaneous abortion was 60% less likely after bleeds
lasting longer. Shorter cycles are probably due to a shorter follicular
phase, which has been tied to reduced fertility, the researchers note. A
shortened luteal phase might less commonly be the cause, but this could
also lead to reduced oocyte quality, they add. Studies have also shown
that shorter and longer cycles are more likely to be anovulatory.

The link between shorter bleed time and reduced fecundity could be due
to a quick estrogen drop due to follicle deficiency or poor uterine
lining buildup, the researchers suggest.

Menstrual cycles may offer epidemiologists a noninvasive, immediate
measure of reproductive health and may be useful for studying a variety
of host conditions, occupational and environmental exposures.
CONCLUSIONS: Menstrual cycle characteristics appear to be associated
with fertility and spontaneous abortion.

[Small
CM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Small+CM"%5BAuthor%5D)
et al Menstrual cycle characteristics: associations with fertility and
spontaneous abortion.
[Epidemiology.](javascript:AL_get(this, 'jour', 'Epidemiology.');) 2006
Jan;17(1):52-60.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16357595>

**Vulvodynia: Diagnosis and Management**

The diagnosis of vulvodynia is made after taking a careful history,
ruling out infectious or dermatologic abnormalities, and eliciting pain
in response to light pressure on the labia, introitus, or hymenal
remnants. Several treatment options have been used, although the
evidence for many of these treatments is incomplete. Treatments include
oral medications that decrease nerve hypersensitivity (e.g., tricyclic
antidepressants, selective serotonin reuptake inhibitors,
anticonvulsants), pelvic floor biofeedback, cognitive behavioral
therapy, local treatments, and (rarely) surgery. Most women experience
substantial improvement when one or more treatments are used. Am Fam
Physician 2006;73:1231-8, 1239

<http://www.aafp.org/afp/20060401/1231.html>

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

**New article from Aberdeen Area**

**Infant Mortality Reviews in the Aberdeen Area: Strategies and
Outcomes**

The authors set out to determine the cause and manner of deaths in the
Aberdeen Area of the Indian Health Service from 1998 to 2002 and
identify risk markers for infant mortality. They found that Sudden
Infant Death Syndrome was the leading cause of infant death and
accounted for 33% of infant deaths. Prematurity was the second leading
cause and accounted for 22% of infants. The authors also found that
infant mortality was recurrent; 32% of mothers of a deceased infant had
another infant death.

The authors note that participation of tribal team members provides an
important cultural and community perspective. The authors conclude that
the reviews have been very helpful in public education. They say that
quality improvement actions are underway on substance abuse, mental
health/bereavement issues and reviews of fetal deaths.

Eaglestaff, ML et al. Infant Mortality Reviews in the Aberdeen Area of
the Indian Health Service: Strategies and Outcomes. Public Health
Reports. Volume 121 (March/April 2006) pp 140 - 148.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16528946>

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

Kudos to the Aberdeen Area Perinatal and Infant Mortality Review (PIMR)
Team!

Above is another article published in a national peer review journal
that illustrates the excellent work the PIMR team is accomplishing. All
Indian Health Areas and tribes should use the success of the Aberdeen
Area as benchmark for best practice.

An important outcome of the PIMR has been the routine examination of
infant deaths and the realization that patterns of risk factors are
present,\" conclude the authors, adding that \"additional research is
urgently needed to determine why the rate of SIDS remains high in the
AAIHS.\"

\"By examining the data by cause of and age at death, we found
significant differences that may be useful to other groups who are
considering development of an infant death review committee,\" state the
authors of an article published in the March-April 2006 issue of Public
Health Reports. The Aberdeen Area Indian Health Service (AAIHS) has
higher rates of infant mortality, especially of post-neonatal infant
mortality, when compared to the overall U.S. rate and the overall Indian
Health Service (IHS) rate. To improve the classification of the cause
and manner of infant death and to identify preventable causes of infant
death, the Aberdeen Area Perinatal and Infant Mortality Review (PIMR)
was established. The article reports data on 5 consecutive years of
infant death reviews from the AAIHS PIMR. A discussion of the benefits
of a systematic infant mortality review in communities with high infant
mortality rates is also included.

Data for the review were drawn from death certificates sent by the four
states in the AAIHS and from information that IHS service units and
committee members identified by reviewing obituaries from multiple
regional newspapers, death certificates by race, and reports from
regional referral centers. Case reviews for 148 consecutive infant
deaths from 1998 to 2002 were examined as summary data for the total
group, by mortality category, and by three age-of-death categories.

The authors found that

\* Nearly two-thirds of the infants who died were males (ratio: 1.8 to
1).

\* Nearly one-third of the infants (32%) had a previous sibling death.

\* The PIMR attributed 22% of the deaths to prematurity and 33% to SIDS.

\* Infants who died from prematurity had significantly lower
birthweights, shorter gestation, and younger age at death than infants
who died from SIDS or other causes. Mothers of infants who died from
prematurity had significantly fewer prenatal visits than mothers of
infants who died from SIDS or other causes.

\* Mothers of infants who died from SIDS were more likely to have begun
prenatal care after the first trimester than mothers of infants who died
from prematurity or other causes.

\* Birthweights were significantly lower and gestation significantly
shorter for infants who died in the first 3 weeks of life, compared with
infants who died at older ages. Mothers of infants who died in the first
3 weeks of life had significantly fewer prenatal visits.

\* Autopsies and death scene investigations were more likely to have
been completed for older infants.

**Adverse Childhood Events: Impact on chronic adult illness / Risk
taking**

Depression in Moms: Prevalence, Predictors, and Acting Out Among 3^rd^
Grade Children examines factors related to depressive symptoms among
mothers and explores the implications for acting out behavior in their
third grade children. The research brief, produced by Child Trends, is
based on data from the Early Longitudinal Study:

#### Kindergarten Class of 1998-99, a nationally representative study of children who entered kindergarten in the fall of 1998. Earlier findings on maternal depression and child outcomes are highlighted to place the new analyses in a larger context. Analyses of the prevalence of depressive symptoms among mothers, the antecedents to these symptoms, and the intersection of these antecedents and symptoms with parenting and acting out behavior are summarized. Findings from repeat analyses among a subgroup of children from families with low incomes are also presented. [**http://www.childtrends.org/files/MomDepressionRB.pdf**](http://www.childtrends.org/files/MomDepressionRB.pdf) {#kindergarten-class-of-1998-99-a-nationally-representative-study-of-children-who-entered-kindergarten-in-the-fall-of-1998.-earlier-findings-on-maternal-depression-and-child-outcomes-are-highlighted-to-place-the-new-analyses-in-a-larger-context.-analyses-of-the-prevalence-of-depressive-symptoms-among-mothers-the-antecedents-to-these-symptoms-and-the-intersection-of-these-antecedents-and-symptoms-with-parenting-and-acting-out-behavior-are-summarized.-findings-from-repeat-analyses-among-a-subgroup-of-children-from-families-with-low-incomes-are-also-presented.-httpwww.childtrends.orgfilesmomdepressionrb.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

#### 

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

#### Ever noticed how adverse events from childhood can affect risk taking behavior or chronic illnesses (like depression) in later life? {#ever-noticed-how-adverse-events-from-childhood-can-affect-risk-taking-behavior-or-chronic-illnesses-like-depression-in-later-life .Style-Heading-4-+-Arial-14-pt-Underline}

#### If you think that is possible, or if you would ever want to hear more about that concept, then please join us on May 1, 2006 on that topic on the Primary Care Discussion Forum. {#if-you-think-that-is-possible-or-if-you-would-ever-want-to-hear-more-about-that-concept-then-please-join-us-on-may-1-2006-on-that-topic-on-the-primary-care-discussion-forum. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Go here {#go-here .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm#adverse**](http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm#adverse) {#httpwww.ihs.govmedicalprogramsmchfpcdiscforum.cfmadverse .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

#### Anti-tobacco Advertising Has Positive Effect on Adolescents {#anti-tobacco-advertising-has-positive-effect-on-adolescents-1 .Style-Heading-4-+-Arial-14-pt-Underline}

State-sponsored antitobacco advertisement is associated with greater
antitobacco sentiment and reduced rates of smoking among adolescents.
These results are consistent with desired outcomes from the antitobacco
campaigns. The authors add that this information shows that recent cuts
in antitobacco media programs may have negative health and budgetary
consequences in the future.

Emery S, et al. Televised state-sponsored antitobacco advertising and
youth smoking beliefs and behavior in the United States, 1999-2000. Arch
Pediatr Adolesc Med July 2005;159:639-45

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15996997**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15996997) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15996997 .Style-Heading-4-+-Arial-14-pt-Underline}

**Shifts in the sexual behavior of adolescent males: It's a Guy Thing**

It\'s a Guy Thing: Boys, Young Men, and Teen Pregnancy Prevention offers
several key insights regarding adolescent males\' contributions to
recent declines in adolescent pregnancy and birth rates as well as
pertinent implications for those working with adolescent males. The
three-part report was produced as part of the Putting What Works to Work
Project by the National Campaign to Prevent Teen Pregnancy with support
from the Centers for Disease Control and Prevention. Chapter 1 provides
an extensive review of research on the attitudes and behavior of
adolescent males regarding sex, contraception, pregnancy, and related
issues; chapter 2 reviews evaluation research on the effectiveness of
school-based, coeducational programs in reducing risky sexual behavior
among adolescent males; and chapter 3 offers a qualitative look at the
challenges associated with engaging adolescent males in adolescent
pregnancy prevention and some strategies for overcoming these
challenges.
[[http://www.teenpregnancy.org/resources/reading/males.asp]{.underline}](http://www.teenpregnancy.org/resources/reading/males.asp)

**Too Much TV Put Extra Pounds on Your Preschooler**

CONCLUSION: Excessive television exposure is a risk factor for
overweight in preschoolers independent of a number of potential
confounders associated with the quality of the home environment.\
[Lumeng
JC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Lumeng+JC"%5BAuthor%5D),
et al Television exposure and overweight risk in preschoolers. [Arch
Pediatr Adolesc
Med.](javascript:AL_get(this, 'jour', 'Arch Pediatr Adolesc Med.');)
2006 Apr;160(4):417-22.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16585488>

**Adolescent Obesity and Bariatric Surgery**

Morbid obesity in the United States has reached epidemic proportions.
Families, physicians, and the government are finally hearing the message
that obesity is an issue of health and not of appearance. Treating this
epidemic requires a multidisciplinary approach and a commitment on the
part of legislators, health care executives, and medical professionals.
Prevention is critical, and all efforts should be made to support
increasing safe physical activity for children and adolescents. Children
and families also should be educated about appropriate food choices and
portion sizes in schools and by their physicians. Decisions about foods
in the schools and at home should be driven by education and not by
advertising or other outside forces.

The treatment of morbid obesity in adolescence first and foremost should
be based on aggressive behavioral and dietary modification. With only a
small daily increase in caloric expenditure and a relatively small
decrease in caloric intake, many adolescents can achieve and maintain
weight

loss. This goal requires constant encouragement and surveillance on the
part of a "coach," whether that be family, a commercial weight loss
program, or a physician. For adolescents with severe morbid obesity who
have failed attempts at weight loss, the options are medical therapy or
bariatric surgery. Medical therapy is occasionally effective in some
patients and should be considered. Bariatric surgery is currently the
most effective method of weight loss for morbid obesity. Current
indications for bariatric surgery in adolescence are more conservative
than for adults, because the long-term consequences of this surgery in
growing children are not known. The unique psychological and physical
issues of adolescence add another layer of complexity to the management
of these patients. For that reason, morbidly obese teenagers are best
treated in centers with special expertise in the care of adolescents.
Because the long-term outcomes of bariatric surgery in adolescents are
not known, it is ethically and clinically important that these patients
be enrolled, whenever possible, in long-term prospective outcome
studies.

Helmrath MA, Brandt ML, IngeTH. Adolescent Obesity and Bariatric Surgery
[Surg Clin North
Am.](javascript:AL_get(this, 'jour', 'Surg Clin North Am.');) 2006
Apr;86(2):441-54.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16580933>

**Antibiotics Unnecessary for Management of Conjunctivitis**

The authors conclude that symptoms of acute infective conjunctivitis
resolve without topical antibiotic therapy in most children. Although in
this trial children treated with chloramphenicol had an advantage at day
7 in symptoms and bacteriologic eradication, these results were not
clinically or statistically significant. The authors recommend that most
cases of conjunctivitis be managed by parents through good hygiene and
symptom control, thus avoiding use of medical services and antibiotics.

Rose PW, et al. Chloramphenicol treatment for acute infective
conjunctivitis in children in primary care: a randomised double-blind
placebo-controlled trial. Lancet July 2, 2005;366:37-43.

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15993231**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15993231) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15993231 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Metformin Reduces Testosterone Levels in Teens With PCOS {#metformin-reduces-testosterone-levels-in-teens-with-pcos .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Metformin significantly lowered total testosterone concentrations, increased the likelihood of menses, and improved high-density lipoprotein cholesterol levels without affecting measures of insulin sensitivity or body weight. {#conclusion-metformin-significantly-lowered-total-testosterone-concentrations-increased-the-likelihood-of-menses-and-improved-high-density-lipoprotein-cholesterol-levels-without-affecting-measures-of-insulin-sensitivity-or-body-weight. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Bridger T](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Bridger+T"%5BAuthor%5D) et al Randomized placebo-controlled trial of metformin for adolescents with polycystic ovary syndrome. [Arch Pediatr Adolesc Med.](javascript:AL_get(this, 'jour', 'Arch Pediatr Adolesc Med.');) 2006 Mar;160(3):241-6. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16520442**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16520442) {#bridger-t-et-al-randomized-placebo-controlled-trial-of-metformin-for-adolescents-with-polycystic-ovary-syndrome.-arch-pediatr-adolesc-med.-2006-mar1603241-6.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16520442 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Is the presence of ano-genital herpes in children evidence of sexual abuse?  {#is-the-presence-of-ano-genital-herpes-in-children-evidence-of-sexual-abuse .Style-Heading-4-+-Arial-14-pt-Underline}

#### The link between ano-genital herpes and sexual abuse requires an understanding of viral transmission and typing to properly interpret its significance. Ano-genital herpes in children creates serious medical, social, and legal implications. It is important that primary care providers have an understanding of the appearance, mode of transmission, and diagnostic technique of ano-genital herpes. Implications for practice will provide guidelines for diagnosing, evaluating, and properly managing ano-genital herpes in children {#the-link-between-ano-genital-herpes-and-sexual-abuse-requires-an-understanding-of-viral-transmission-and-typing-to-properly-interpret-its-significance.-ano-genital-herpes-in-children-creates-serious-medical-social-and-legal-implications.-it-is-important-that-primary-care-providers-have-an-understanding-of-the-appearance-mode-of-transmission-and-diagnostic-technique-of-ano-genital-herpes.-implications-for-practice-will-provide-guidelines-for-diagnosing-evaluating-and-properly-managing-ano-genital-herpes-in-children .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Hornor G](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Hornor+G"%5BAuthor%5D). Ano-genital herpes in children. [J Pediatr Health Care.](javascript:AL_get(this, 'jour', 'J Pediatr Health Care.');) 2006 Mar-Apr;20(2):106-14. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16522487**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16522487) {#hornor-g.-ano-genital-herpes-in-children.-j-pediatr-health-care.-2006-mar-apr202106-14.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16522487 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Brochures material/SIDS: AAP Reducing the Risk of SIDS brochures {#brochures-materialsids-aap-reducing-the-risk-of-sids-brochures .Style-Heading-4-+-Arial-14-pt-Underline}

The American Academy of Pediatrics (AAP) Early Education and Child Care
program has recently revised the Reducing the Risk of SIDS brochures to
reflect the AAP\'s Policy Statement on SIDS Risk Reduction.  

[[A Child Care Provider\'s Guide to Safe
Sleep]{.underline}](http://www.healthychildcare.org/pdf/SIDSchildcaresafesleep.pdf)\
This easy-to-read brochure provides child care providers with
straightforward information about safe sleep practices, as well as
information about SIDS.

[[A Parents\' Guide to Safe
Sleep]{.underline}](http://www.healthychildcare.org/pdf/SIDSparentsafesleep.pdf)\
This brochure is similar to the Child Care Provider\'s guide, but the
intended audience is parents. It includes information about working with
child care providers to ensure that safe sleep practices are used both
in the home and in child care.

[[Tummy
Time]{.underline}](http://www.healthychildcare.org/pdf/SIDStummytime.pdf)\
Although babies should be placed on their backs to sleep, supervised
tummy time is an important part of healthy development. Read about the
importance of supervised tummy time in this brochure.

If you are interested in receiving these brochures, please email Trisha
M. Calabrese your mailing address along with which brochures and how
many [[TCalabrese@aap.org]{.underline}](mailto:TCalabrese@aap.org)

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

**Obesity Prevention Toolkit for girls and their families**

The Office on Women\'s Health (OWH), have developed the Body Works
Toolkit for Obesity Prevention in Girls and their Families.  This
program consists of 9 sessions for parents /caregivers.  It focuses on
action steps and provides information on ways to change how the family
eats, shops, cooks and moves. The goal is to help families improve their
lifestyles to prevent overweight and obesity.  The program is a train
the trainer model and will require all those who want to use it to have
someone in their organization trained in using the kit.  The kit
contains a video on healthy shopping and cooking, a recipe book, weekly
meal planner, and food and fitness journals as well as magazine-like
books with information and action steps for the parent/caregiver and for
the daughter.  This toolkit has been presented at APHA as well as other
public health gatherings.  It has been very well received as an
important family oriented piece in addressing the rising problem of
obesity in our youth and families.\
If you\'re interested in being trained to be a BodyWorks toolkit
facilitator, please e-mail <bodyworks@hagersharp.com> or
<jrowe@osophs.dhhs.gov>

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

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

**Breast cancer study from PIMC**

BACKGROUND: Breast cancer incidence and survival varies by race and
ethnicity. There are limited data regarding breast cancer in Native
American women. METHODS: A retrospective chart review was performed of
139 women diagnosed with breast cancer and treated at Phoenix Indian
Medical Center in Phoenix, AZ between January 1, 1982 and December 31,
2003. Data points included tribal affiliation, and quantum (percentage
American Indian Heritage) along with patient, tumor, and treatment
characteristics. RESULTS: Most patients (79%) presented initially with
physical symptoms. There were no significant differences based on tribal
affiliation; however, higher quantum predicted both larger tumor size
and more advanced stage at diagnosis. Obesity also significantly
correlated with larger tumor size and more advanced stage. Treatment was
inadequate in 21%; this was attributed to traditional beliefs, patient
refusal, or financial issues. CONCLUSIONS: When compared to national
averages, Native American women presented at a later stage,
underutilized screening, and had greater delays to treatment.\
[Tillman
L](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Tillman+L"%5BAuthor%5D),
et al Breast cancer in Native American women treated at an urban-based
Indian health referral center 1982-2003. [Am J
Surg.](javascript:AL_get(this, 'jour', 'Am J Surg.');) 2005
Dec;190(6):895-902.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16307942>

#### [Editorial comment: Carolyn Aoyama]{.underline} Below is a list of tips for improving mammography screening rates.  I would appreciate it if you would review it and add any other pearls of wisdom that have made a difference in raising mammography screening rates in your setting.  

#### Let me know your thoughts [**Carolyn.Aoyama@ihs.gov**](mailto:Carolyn.Aoyama@ihs.gov)

**Lessons Learned: Improving Mammography Access and Quality of Care**

-   Leadership: One person minimum should be responsible for improving
    mammography screening rates.

-   Identify current practice for getting women in for mammography
    screening and modify current practices first.

-   Where to begin: Begin your efforts by establishing a target group.
    For example, select women aged 50 and over and screen every woman in
    this group. Then move on to women aged 35-40 to get a baseline and
    an annual mammogram after age 40. Another approach would be to
    target a women living in a particular neighborhood or who are coming
    into the clinic for another reason.

-   On-site mammography: Work with the radiology and clinical staff to
    improve access. For example, try not to limit mammography to a
    certain day. Scheduling a mammography clinic is fine, but the policy
    should be that when a woman presents herself for screening
    regardless of the day, she should be screened. With mammography
    on-site, screening should be routine. If you have on-site
    mammography, but are using contractors for radiology coverage,
    screen and save the images for the next time the radiologist is
    available. Good interdepartmental relationships are important to
    making the system work.

-   No on-site mammography: If you do not have mammography on site,
    determine where and when mammography is available, and determine if
    the mammography program is accredited by FDA.

-   Costs and Reimbursement: Determine the cost to the Service Unit of
    mammography screening of women who do not have Medicaid, Medicare or
    private insurance. Be sure to include the cost of co-pays and
    calculate total cost.

-   Medicaid Eligibility: Encourage Service Unit to arrange for a
    Medicaid eligibility worker to be stationed at the clinic as often
    as possible so that women can obtain either Medicaid insurance.

-   Mobile Mammography Units can do about 20 mammograms in a 6 hour time
    frame, so if you are going to use a mobile unit, schedule at least
    30 women. Over-scheduling is necessary because if these mobile
    unites do not do at least 15 patients in a 6 hour period, they will
    be reluctant to serve your site and may not return.

-   When over-scheduling patients (scheduling 30 to be sure you have
    20), use the clinic staff to make up some of the ten extra people
    you need. Because they are already at work, they can always come in
    next time if more patients than anticipated actually show up for
    their appointments. Clinic staff are also good for the first
    appointments in the morning or to fill in gaps in the clinic day.

-   Good personal relationships with patients: Treat each woman with
    dignity and respect. Personalize patient communication by sending
    out a personal letter with each scheduled appointment -- do not use
    a computerized form letter because they are just tossed in the
    trash. Send out some health education with the non-computerized
    letter about breast cancer or related subjects. If you have no
    literature to send, call your local American Cancer Society, or
    write a little something yourself.

-   Policy and Procedure Manuel: Do not wait for a formal policy and
    procedure manual to be written and approved before you begin. There
    are no policy and procedure manuals for doing any other x-rays;
    standard procedure dictates. Certainly a policy can be written, but
    just do not wait for it to begin screening women.

-   Referrals: Medicare does not require a physician's order for
    mammograms. Contract Health does require a referral for each
    procedure done by an outside facility. Use the standard referral
    form or the referral form required by your service unit. Work
    closely with contract health if you must refer outside of your
    service unit.

-   Make it easy for Contract Health: No-shows can be frequent, so do
    not make Contract Health go though all of the required paperwork
    before the patient actually comes in for the mammogram. Have signed
    referrals in advance, but CHS doesn't need to send out the notices.
    Patients with Medicaid, Medicare or other private health insurance
    can be scheduled. No one should be scheduled for CHS payment if they
    are not CHS eligible. Remember that patients can access screening if
    the state has a CDC Breast and Cervical Cancer Program. Again,
    foster good interdepartmental relationships.

-   Contact each and every patient before the mammogram. Explain that
    they are scheduled for the procedure and that it will take about 20
    minutes, that it could detect cancer and ultimately save their life.
    Explain that it is the best tool we have for detecting possible
    breast tumors. Do no wait for them to ask for an appointment. This
    contact is best made in person, but could be over the phone. Work
    with your Public Health Nurses and Community Health Representative
    Programs for personal contact with patients.

-   Encourage the providers to remind patients that a mammogram is
    important. The word of the provider goes a long way in terms of
    compliance.

-   Reward the patient, especially early in your mammogram access
    initiative. This can be as simple as saying thank you or as generous
    as a gift of cosmetics, a rose, a treat from the casino, etc. Look
    for resources for these little incentives. Incentives can be
    controversial; is it nursing to order roses, make perfume sachets,
    work a little arrangement with the casino? No one remembers that
    course. But did you have a course in the benefits of preventive
    health care? Yes!

-   Is it a good use of nursing time to prepare or arrange for these
    incentives? No, not even if the patient does not come in, the roses
    wilt. Your efforts convey your interest and you will eventually get
    where you want to be...each eligible woman with a current mammogram
    in her chart.

-   Why can't patients just come in and request a mammogram, get an
    appointment, keep the appointment and come back again for their
    follow-up? They can, but it is rare, and it is especially rare among
    the vulnerable and impoverished American Indian/Alaska Native
    populations we serve. Many women have competing survival needs, and
    they benefit from the personal contact and coaching nurses provide.

-   Reschedule, reschedule, reschedule. After a certain point, you will
    have a group of ladies who never get their mammogram. Keep their
    names. Schedule at least three times each year. Contact them each
    time. Contact their sisters, their mothers, their aunts. Do not
    breach their privacy.

-   Let family members suggest other relatives who need a mammogram. For
    example, "Do you have a sister who would like to come in for a
    mammogram? Could you encourage your sister, your mother, your friend
    or your neighbor?"

-   Encourage the patient to have a clinical breast exam and a pap, but
    do not make it a requirement for a mammogram.

-   Establish a procedure for follow-up. The physician should get the
    original and the PHN should get a duplicate copy of each report and
    follow-up should be as needed. Including the PHN with a copy of the
    report will help insure that the follow-up gets done and patients
    don't slip through they system.

-   Use every means available to contact patients of an abnormal
    mammogram result; telephone, certified mail, CHR, PHN. The patient
    MUST be notified so that a biopsy can be performed and treatment
    initiated.

-   Do not allow the system to discourage you. Never allow anyone to
    defeat your enthusiasm for healthy women. Do not stand in the way of
    improving access and quality of care by your apathy or frustration
    with the system. Think of the women you are serving as your mother,
    your grandmother, your sister, your aunt, yourself.

-   Document on the PCC. This documentation is the only way that your
    work will be counted and be reflected in the GPRA Mammogram measure.
    Be sure to check all of the boxes, purpose of visit, etc. Work
    closely with data entry. Review your data regularly to catch errors.

-   What does the nurse do? Nurses educate, schedule, encourage, coach,
    reschedule, follow-up on abnormal mammograms, refer to a surgeon for
    biopsy, support breast cancer survivor groups, etc.

-   Enjoy this work. You can make a difference in the lives of the
    people you are serving.

**Estrogen use after menopause does not increase breast cancer risk**

CONCLUSIONS: Treatment with CEE alone for 7.1 years does not increase
breast cancer incidence in postmenopausal women with prior hysterectomy.
However, treatment with CEE increases the frequency of mammography
screening requiring short interval follow-up. Initiation of CEE should
be based on consideration of the individual woman\'s potential risks and
benefits.

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

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

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

This is another important follow-up to last month's Abstract of the
Month entitled Tired of hearing only bad news from the Women's Health
Initiative (WHI)? \*

The Stefanick et al article shows another retrenchment from the initial
series of WHI reports that showed primarily negative associations
between hormone therapy and many chronic conditions. Hormone replacement
is indicated for short term relief of menopausal symptoms, but we should
also be prepared to counsel our patients about some of the positive
effects and the lack of other negative effects of hormone therapy, e.g.,
Stefanik et al.

\* **Tired of hearing only bad news from the Women's Health Initiative
(WHI)?**

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_AOM.cfm>

**Newly identified risk factor for death, MI: Pregnancy complications**

Women who have adverse pregnancy outcomes are at increased risk of
all-cause mortality and early myocardial infarction, occurring at a
median age of 43, Duke University researchers announced Monday at the
ongoing 55th Scientific Sessions of the American College of Cardiology.\
Dr. Mimi S. Biswas and colleagues in Durham, North Carolina, conducted a
retrospective cohort study of 415 patients who had had pregnancies and
were recorded in both the Duke University Perinatal and Health Services
Outcomes Database and the Duke Information System for Cardiovascular
Care. The investigators looked for adverse outcomes of the pregnancy and
for concomitant risk factors for heart disease.\
The median age at delivery was 28 years and median age at first cardiac
catheterization was 41 years. Median age at first documented MI was 43
years and median age at death was 42. The results were similar for
blacks and whites.\
Pregnancy complications occurred in 214 patients, and were more likely
to occur in diabetics, hypertensives, women with unstable angina and
those with coronary artery disease on catheterization (35% compared with
24% of those without complications).\
Factors associated with coronary disease included Caucasian race, which
had an odds ratio of 2.7; diabetes, with an odds ratio of 2.0; and
hyperlipidemia, associated with an odds ratio of 3.8.\
Factors associated with death were congestive heart failure, with a
hazard ratio of 1.9; any adverse pregnancy outcome, with a hazard ratio
of 2.4; current smoking, with a hazard ratio of 2.0 and gestational
diabetes, which was associated with a hazard ratio of 2.5 for all-cause
mortality.\
Dr. Biswas noted that smoking during pregnancy was associated with a
three-fold increase in early MI or death.\
\"Pregnancy complications are an early red flag \-- a novel early risk
factor for cardiovascular disease,\" Dr. Biswas told the audience. \"We
need to incorporate these novel risk factors in screening women with
pregnancy complications.\"\
\"We need to look for thrombotic, clotting and other abnormalities,\"
she noted. A search for genetic factors could also prove helpful.

55th Scientific Sessions of the American College of Cardiology

<http://www.acc.org/2006ann_meeting/home/home.htm>

**Differences Between Painless and Painful Constipation Among Community
Women**

CONCLUSIONS: Patients with painful constipation more closely resemble
those with constipation-predominant irritable bowel syndrome than
painless constipation. Consideration should be given to separating
painful constipation from painless constipation in the Rome criteria and
in therapeutic trials.

[Bharucha
AE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Bharucha+AE"%5BAuthor%5D),
et al Differences between painless and painful constipation among
community women. [Am J
Gastroenterol.](javascript:AL_get(this, 'jour', 'Am J Gastroenterol.');)
2006 Mar;101(3):604-12.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16464225>

**Women and Heart Disease Fact Sheet**

Although heart disease is sometimes thought of as a \"man\'s disease,\"
it is the leading cause of death for both women and men in the United
States with women comprising 51% of the total heart disease deaths.
<http://www.cdc.gov/cvh/library/fs_women_heart.htm>

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

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

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

##  {#section-17 .Style-Heading-2-+-14-pt}

## Active Treatment for Partial Small Bowel Obstruction {#active-treatment-for-partial-small-bowel-obstruction-1 .Style-Heading-2-+-14-pt}

**Clinical Question:** Does oral therapy with magnesium oxide,
*Lactobacillus acidophilus*, and simethicone (Mylanta) improve outcomes
in patients with partial small bowel obstruction?

**Setting:** Inpatient (any location)

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

**Bottom Line:** The combination of magnesium oxide, *L. acidophilus*,
and simethicone appears to reduce length of stay and the need for
surgery in patients with partial small bowel obstruction, although this
study was limited by a failure to completely blind patients and their
caregivers. (Level of Evidence: 1b).

**Study Reference:** Chen SC, et al. Nonsurgical management of partial
adhesive small-bowel obstruction with oral therapy: a randomized
controlled trial. CMAJ November 8, 2005;173:1165-9.

###### [**http://www.aafp.org/afp/20060315/tips/9.html**](http://www.aafp.org/afp/20060315/tips/9.html)

Sequential Testing Best Detects Down Syndrome

**Clinical Question:** What is the most accurate screening approach for
detecting Down syndrome during pregnancy?

**Setting:** Outpatient (specialty)

**Study Design:** Cohort (prospective)

**Bottom Line:** The most accurate screening approach was sequential
testing, which detected 95 percent of patients with Down syndrome with a
2.5 percent false-positive rate. The process: perform combined screening
during the first trimester. If the screening result is positive, offer
genetic testing; if negative, perform the quadruple test in the second
trimester, and then offer genetic testing if that yields a positive
result. Fully integrated testing (second-trimester quadruple test plus
first-trimester nuchal translucency) is almost as accurate (95 percent
detection and 4 percent false-positive results). The skill of the
ultrasonographer in measuring nuchal translucency is key to these
approaches.

(Level of Evidence: 1b)

**Study Reference:** Malone FD, et al. First-trimester or
second-trimester screening, or both, for Down\'s syndrome. N Engl J Med
November 10, 2005;353:2001-11

###### [**http://www.aafp.org/afp/20060315/tips/10.html**](http://www.aafp.org/afp/20060315/tips/10.html)

Effect of Caffeine Intake on Risk of Hypertension

**Clinical Question:** Does habitual caffeine intake increase the risk
of hypertension in women?

**Setting:** Population-based

**Study Design:** Cohort (prospective)

**Bottom Line:** Habitual caffeine consumption does not appear to
increase the risk of hypertension in women. In particular, coffee and
tea are not associated with increased risk. The development of
hypertension is, however, significantly associated with the intake of
cola drinks, including sugared and diet versions. (Level of Evidence:
2b)

**Study Reference:** Winkelmayer WC, et al. Habitual caffeine intake and
the risk of hypertension in women. JAMA November 9, 2005;294:2330-5.

<http://www.aafp.org/afp/20060315/tips/11.html>

Embolization Usually Successful to Treat Fibroids

**Clinical Question:** What are the long-term outcomes for uterine
artery embolization to treat uterine fibroids?

**Setting:** Outpatient (specialty)

**Study Design:** Cohort (prospective)

**Allocation:** Concealed

**Bottom Line:** Uterine artery embolization for the treatment of
symptomatic uterine fibroids has a long-term success rate of 75 percent
over the five years following treatment. This approach has the potential
to avoid most hysterectomies for fibroid-caused symptoms and deserves
futher study. (Level of Evidence: 2b)

**Study Reference:** Spies JB, et al. Long-term outcome of uterine
artery embolization of leiomymata. Obstet Gynecol November
2005;106:933-9.

<http://www.aafp.org/afp/20060315/tips/12.html>

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

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

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

**Less Invasive Management of Cervical Cytology Abnormalities in
Adolescents**

ABSTRACT: The management of abnormal cervical cytology in adolescents
differs from that for the adult population in many cases. Certain
characteristics of adolescents may warrant special management
considerations. It is important to avoid aggressive management of benign
lesions in adolescents because most cervical intraepithelial neoplasia
grades 1 and 2 regress. Surgical excision or destruction of cervical
tissue in a nulliparous adolescent may be detrimental to future
fertility and cervical competency. Care should be given to minimize
destruction of normal cervical tissue whenever possible. A compliant,
health-conscious adolescent may be adequately served with observation in
many situations.

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

Here is more about three of the key elements of the ACOG recommendations

**What is an adolescent?**

In regard to cervical cancer screening, based on the natural history
data and the rarity of cervical cancer in the population of women
younger than 21 years are considered adolescents.

**Why should we treat adolescents differently than adults?**

In natural history studies of adolescents with newly acquired HPV
infection, the average length of detectable HPV is 13 months. In most
adolescent patients with an intact immune system, an HPV infection will
resolve within 24 months. Further evidence that the HPV infection will
resolve without treatment comes from the high rates of resolution of CIN
1 and CIN 2, 70% and 50% respectively.

**What is the recommendation on Cervical Intraepithelial Neoplasia 2 ?**

Cervical intraepithelial neoplasia 2 is a significant abnormality that
has classically required therapy. A variety of studies, including the
ALTS trial, have demonstrated that this lesion may have a significant
rate of resolution (up to 40%) in adults. This rate of resolution is
suspected to be higher in adolescents. Based on these data and expert
opinion, CIN 2 can be managed in adolescents with either observation or
ablative or excision therapy. The adolescent patient who is monitored
without therapy should be an individual deemed to be reliable regarding
follow-up and have a good understanding of the nature of the abnormality
and its risks. Follow-up can be individualized, with colposcopy or
cytology every 4--6 months being a very conservative approach.

Evaluation and management of abnormal cervical cytology and histology in
the adolescent. ACOG Committee Opinion No. 330. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2006;107:963--8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16582143>

**New Guidelines Call for Restricted Use of Episiotomies**

**Summary of Recommendations and Conclusions**

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

-   Restricted use of episiotomy is preferable to routine use of
    episiotomy.

-   Median episiotomy is associated with higher rates of injury to the
    anal sphincter and rectum than is mediolateral episiotomy.

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

-   Mediolateral episiotomy may be preferable to median episiotomy in
    selected cases.

-   Routine episiotomy does not prevent pelvic floor damage leading to
    incontinence.

Episiotomy. ACOG Practice Bulletin No. 71. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2006;107:957--62.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16582142>

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

**Here is more perspective from ACOG**

The use of episiotomy during labor should be restricted, with physicians
encouraged to use clinical judgment to decide when the procedure is
necessary. \"The best available data do not support the liberal or
routine use of episiotomy. Nonetheless, there is a place for episiotomy
for maternal or fetal indications such as avoiding severe maternal
lacerations or facilitating or expediting difficult deliveries.\"

Episiotomy is a surgical incision made into the perineum---the region
between the vagina and the anus---to widen the vaginal opening for
delivery. Episiotomy was performed in more than one-fourth of all
vaginal deliveries in 2002. Although rates of episiotomy have decreased
in recent years, it is still one of the most commonly performed
procedures in obstetrics.

Recent studies show that common indications for episiotomy were based on
limited data. Additionally, there was a general underestimation of
potential adverse consequences associated with the procedure, including
extension to a third- or fourth-degree tear, anal sphincter dysfunction,
and painful sex. Data suggest that women who have an episiotomy do not
have significantly improved labor, delivery, and recovery compared with
those who do not have one. Without sufficient data to develop
evidence-based criteria for performing episiotomies, clinical judgment
remains the best guide to determine when its use is warranted, according
to ACOG.

Historically, the procedure has been indicated in circumstances such as
abnormal labor progression, non-reassuring fetal heart rate pattern,
vacuum- or forceps-assisted vaginal delivery, and shoulder dystocia. It
also was believed to hasten the second stage of labor and reduce the
risk of spontaneous perineal tearing, subsequent pelvic floor
dysfunction, urinary and fecal incontinence, and sexual dysfunction.

\"In the case of episiotomy, as with all medical and surgical therapies,
we need to continually evaluate what we do and make appropriate changes
based on the best and most current evidence available,\" said the
document\'s author, ACOG Fellow John T. Repke, MD. \"We should avoid the
pitfall of letting anything in medicine become \'routine\' and
therefore, outside the realm of review and critical analysis.\"

**Safe Use of Medication**

ABSTRACT: Medication use errors are the largest single source of
preventable adverse events. To minimize the risk of medication use
errors, obstetrician--gynecologists should focus on several elements of
medication order writing, such as the appropriate use of decimals and
zeros, standard abbreviations, and assuring legibility. Additionally, it
is important to assist the patient in understanding the medical
condition for which a medication is prescribed. Focusing on elements
that may prevent prescription errors and helping patients understand how
to use prescribed medication properly may help lower the occurrence of
medication use errors.

Safe use of medication. ACOG Committee Opinion No. 331. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2006;107:969--72.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16582144>

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

**Study provides estimates of cervical cancers that may be missed by
extending screening time after consecutive negative Pap smears**

<http://www.ahrq.gov/research/feb06/0206RA7.htm>

**Noninvasive tests may miss breast cancer**

<http://www.ahrq.gov/research/feb06/0206RA1.htm>

**Hospital type and location influence discharge disposition of
adolescents hospitalized for suicide attempts**

<http://www.ahrq.gov/research/feb06/0206RA13.htm>

**Light therapy appears to improve sleep, mood, and energy among women
with non-seasonal depression**

<http://www.ahrq.gov/research/feb06/0206RA29.htm>

**Changes in the delivery of care are needed to reduce the burden of
diabetes among ethnic minorities**

<http://www.ahrq.gov/research/feb06/0206RA15.htm>

#### Ask a Librarian Diane Cooper, M.S.L.S. / NIH {#ask-a-librarian-diane-cooper-m.s.l.s.-nih .Style-Heading-4-+-Arial-14-pt-Underline}

![](media/image2.jpeg){width="4.041666666666667in"
height="1.6458333333333333in"}![](media/image3.png){width="2.7416666666666667in"
height="0.9083333333333333in"}

**Library Services for the Indian Health Service**

**[Your library contact:]{.underline}**

Diane Cooper, MSLS

Informationist for the Indian Health Service

National Institutes of Health (NIH) Library

<cooperd@mail.nih.gov>

301 594-2449

As your library contact, I am here to help you meet your information
needs. If you need to find information at either patient point-of-care
or to provide background for a specific project, I can help. I am here
to save you time and ensure you get the information you need.

As your direct link to HSRL, I can support you in the following ways:

-   Help with complex and difficult literature searches to support
    direct patient care and patient care activities

-   Participate and help with IHS projects and development team
    activities

-   Assist in manuscript preparation (verify references; editing)

-   Set up current awareness alerts in your field of interest

-   Create customized databases in bibliographic software programs to
    organize your information for easy retrieval when you need it

-   Provide instruction on how to search literature databases and other
    information resources

**[Other Services]{.underline}**

**[Website]{.underline}**: The library's website - located at
[http://hsrl.nihlibrary.nih.gov](http://hsrl.nihlibrary.nih.gov/),
provides access to electronic resources that are critical to the work of
HHS staff. These resources include:

-   **Online Journals** -- access to full-text articles

-   **Databases** -- MEDLINE, Web of Science, PsycINFO, and more

-   **Research Updates** -- Porpoise Alert Service developed at NIH

-   **Online Catalog** -- search for books and journals held by the HSRL

-   **Document Requests** -- journal articles delivered by email

**[Document Delivery]{.underline}**: The library provides document
delivery of journal articles and books. Items not available in the
library's collection are obtained from another library. You can submit a
request via the library's website.

##### 

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

**Early feeding choice and obesity**

Obesity has increased dramatically in all age groups throughout the
United States, including our children. In 1999, the prevalence of
childhood obesity and overweight in American Indian and Alaska Native
(AI/AN) communities was estimated to be almost 2.5 times greater than
general population. Recently, an I.H.S. study reported obesity rates
among Northern Plains American Indian children to be almost half of all
5 year olds, and nearly one quarter for all children between the ages of
5-17. (1)

The long-term impact obesity is profound. Type 2 diabetes and other
obesity related health problems have become common in schools. Other
likely but unmeasured consequences of obesity like poor self esteem and
depression are linked with numerous social and academic problems. Sadly,
researchers suggest that children born today could have a shorter life
expectancy than their parents because of this epidemic and its impact.

There are many programs working toward leaner tomorrows. One method
supported by research is to encourage breastfeeding as the early infant
feeding choice. Examples of studies include research by CDC reporting a
30% reduction in risk for 4 year olds if breastfeeding continued for 6
months or longer (2). Another large study of the US general population
reported a 25% risk reduction in middle school age children who were
mostly breastfed compared to those who were mostly formula fed in the
first year. (3). While there are many possible confounders such as
maternal smoking, parental obesity, low/large birth weight, with
infrequent exception, breastfeeding duration and exclusivity is
inversely related to risk of obesity/overweight.

Another way of looking at early feeding choices is that formula feeding
may increase risk of obesity. So, for families who decide to formula
feed, it may be especially important to provide counter measures to
reduce risk -- like being careful to avoid early overfeeding and
encouraging healthy food and activity choices for their children.

1\. Zephier, E et al. Increasing prevalences of overweight and obesity
in Northern Plains American Indian children. *Arch Pediatr Adolesc Med*.
2006 Jan; 160(1):34:9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16389208>

2\. Grummer-Strawn LM et al. Does breastfeeding protect against
pediatric overweight? Analysis of longitudinal data from the Centers of
Disease Control and Prevention Pediatric Nutrition Surveillance System.
*Pediatrics*. 2004; 113:e81-e86.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14754976>

3\. Gillman, MW et al. Risk of overweight among adolescents who had been
breast fed as infants. *JAMA*. 2001; 285:2461-2467.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11368698>

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

To obtain current estimates of racial and economic disparities in
breastfeeding among U.S. children, CDC analyzed data from the 2004
National Immunization Survey. This report describes the results of that
analysis, which indicated that 71.5% of non-Hispanic white children were
ever breastfed compared with 50.1% of non-Hispanic black children. Among
those ever breastfed, 53.9% of non-Hispanic white and 43.2% of
non-Hispanic black children continued breastfeeding until at least age 6
months. Disparities between black and white children existed within most
socioeconomic subgroups studied.

[[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5512a3.htm?s_cid=mm5512a3_e]{.underline}](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5512a3.htm?s_cid=mm5512a3_e)

**New Quarterly Medical Journal on Breastfeeding Launched**

Breastfeeding Medicine is a new peer-reviewed journal about the
complexities and benefits of breastfeeding. The journal, launched this
month by the Academy of Breastfeeding Medicine (ABM), will be published
on a quarterly basis. Topics will include epidemiologic and physiologic
benefits of breastfeeding; health risks of artificial feeding; impact of
breastfeeding on physical and psychological health; breastfeeding
management in health and disease; indications and contraindications of
breastfeeding; use of medications by the breastfeeding mother; and
related social, cultural, and economic issues. More information about
the journal is available at
[[http://www.liebertpub.com/publication.aspx?pub_id=173&crit=breastfeeding]{.underline}](http://www.liebertpub.com/publication.aspx?pub_id=173&crit=breastfeeding)

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

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

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

#### -March 2006 Highlights include {#march-2006-highlights-include-1 .Style-Heading-4-+-Arial-14-pt-Underline}

\-[Tired of hearing only bad news from the WHI? Here is some good
news](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_AOM.cfm)

\-[Sample templates for guidelines: IUDs, Manual Vacuum Aspiration (MVA)
for SAB,
etc...](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Coll.cfm)

\-[GDM: Can we proceed directly to one step screening / diagnosis in AI
/ AN
women?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_HT.cfm#ob)

\-[Diet and Exercise Reduce Incontinence in Women at Risk of
Diabetes](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_HT.cfm#gyn)

\-[FDA Warns Parents About Contaminated Teething
Rings](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_HT.cfm#child)

\-[Colon cancer rates: Increased in AI/AN women -- March is Colon Cancer
Month](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_HT.cfm#chrIll)

\-[Are you aware of the vast amount of Library Services available to the
Indian Health
System?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#AskLib)

\-[Results raise doubts about the value of the bimanual pelvic exam in
routine
screening](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#ahrq)

\-[Breastfeeding as a Pain
Reliever](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#breast)

\-[Fatal infection without fever: Sepsis and Medical Abortion - FDA
Public Health
Advisory](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#fp)

\-[Two New Perinatology Corner
Modules](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#webSite)

[-Twins: Antepartum assessment and Intrapartum management: Double
Trouble?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#webSite)

[-Antibody Screen Positive:
Rh](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#webSite)
/ Other Antibodies:  Kell kills, Duffy dies, and Lewis lives?

\-[The case of the wandering spleen - Desperate Housewives - 'As seen on
TV'](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#mmtour)

\-[Should we continue to draw Rubella titers as part of the prenatal
panel?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#MidWives)

\-[Do Birth Certificate Data Reflect the Number of CNM-Attended
Births?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#MidWives)

\-[VZIG No Longer Available: Protect non-immune women against
Chickenpox](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#navajo)

\-[Nurse Education Loan Repayment Program: Deadline March
30](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#nurseCorner)

\-[Metformin and Polycystic Ovarian
Syndrome](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#okie)

\-[Move beyond 'integrated' screening to 'contingency'
screening](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#periPicks)

\-[Incorrect use of condoms, not product failure may account for lack of
effectiveness](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#std)

\-[Statin Therapy for Type 2\'s Regardless of LDL Levels and
CVD](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#stillW)

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

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

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

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

**Native women, violence, substance abuse and HIV risk**

Violence has become a critical public health issue in the United States.
It has had a particularly devastating impact on the health and well
being of Native American women and children. The relationship between
aggression and substance use is an intrinsic one: Native women often
bear the brunt of violence in drinking situations, which places them and
their children at extremely high risk for physical and sexual abuse. In
urban environments, many Native American women find themselves in adult
relationships that mirror the abuse they experienced and witnessed as
children or adolescents. Not only does violence often occur while
substances are being used, but conversely, substance use is a frequent
consequence of sexual abuse. Clearly, the mental health repercussions of
physical or sexual abuse are often severe. Trauma is associated not only
with psychological distress, but also with risky behavior and social
role impairment. Traumatized women engaging in substance abuse and
unsafe sex are at high risk for contracting HIV/AIDS. This article
explores the intersection of substance abuse, sexual and physical abuse,
and increased HIV risk among urban Native American women in the San
Francisco Bay Area.

[Saylors
K](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Saylors+K"%5BAuthor%5D),
[Daliparthy
N](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Daliparthy+N"%5BAuthor%5D).
Native women, violence, substance abuse and HIV risk. [J Psychoactive
Drugs.](javascript:AL_get(this, 'jour', 'J Psychoactive Drugs.');) 2005
Sep;37(3):273-80.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16295010>

**Safety, permanency, and well-being of AI/AN children: New
publication**

The National Clearinghouse on Child Abuse and Neglect Information has
released a new publication on how States and Tribes can work together
more effectively to protect the safety, permanency, and well-being of
American Indian/Alaska Native children.  This issue brief was developed
in partnership with the National Indian Child Welfare Association

The issue brief, Tribal-State Relations, examines:

-   Factors affecting Tribal-State relations in child welfare

-   Components of successful Tribal-State relations

-   Examples of promising practices in Tribal-State relations

 <http://nccanch.acf.hhs.gov/pubs/issue_briefs/tribal_state/index.cfm>
 <http://www.acf.hhs.gov/programs/cb/current_initiatives/index.htm>  

**Child Maltreatment Institute**

The 2006-2007 PREVENT Child Maltreatment Institute, sponsored by the
Centers for Disease Control and Prevention and the Injury Prevention
Research Center at the University of North Carolina at Chapel Hill, is
accepting applications through April 30, 2006. The Institute offers
public health leadership training to experienced teams from across the
country that are working to stop child maltreatment before the first
victimization or perpetration occurs. Team participants can expect to
enhance core competencies in the primary prevention of child
maltreatment, including: planning and evaluating effective programs;
stimulating organizational and social change; enhancing leadership
skills; critically evaluating the literature and translating science
into practice; effectively communicating with media and policy makers;
and implementing promising practices.

The PREVENT Child Maltreatment Institute will include two three-day
in-person sessions and eight months of coaching at homes sites on a
team-developed project. The first three-day session will be held July
17-19 in Chapel Hill, North Carolina. The second session will be
conducted in March, 2007. Tuition, room and board are supported by
funding from the Centers for Disease Control. Travel stipends are
available. For more information and to submit an application, please see
the attached flyer and visit <http://prevent.unc.edu/education/>.

Feel free to contact Liz Knight at UNC if you have any questions.

Liz Knight, MSW (919) 843-1472 Email: <LKNIGHT@med.unc.edu>

**Sexual Violence Prevention: Beginning the Dialogue**

Sexual Violence is a serious public health problem with extensive short-
and long-term health consequences. Sexual Violence Prevention: Beginning
the Dialogue identifies concepts and strategies that may be used as a
foundation for planning, implementing, and evaluating sexual violence
prevention activities. <http://www.cdc.gov/ncipc/dvp/SVPrevention.htm>

**April 2006 is National Child Abuse and Prevention month**

The 2006 Child Abuse Prevention Community Resource Packet, which
contains one prevention poster, is available at no cost. Section on
methamphetamine and child maltreatment also.

[[http://nccanch.acf.hhs.gov/topics/prevention/index.cfm]{.underline}](http://nccanch.acf.hhs.gov/topics/prevention/index.cfm)

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

**Can you read your patients\' palms and predict their health?**

Assessing the Hands and Wrists in Elderly People

Medscape Free CME

<http://www.medscape.com/viewprogram/5202?src=mp>

**Older Adult Drivers with Cognitive Impairment**

As the number of drivers with cognitive impairment increases, family
physicians are more likely to become involved in decisions about
cessation of driving privileges in older patients. Physicians who care
for cognitively impaired older adults should routinely ask about driving
status. In patients who continue to drive, physicians should assess
pertinent cognitive domains, determine the severity and etiology of the
dementia, and screen for risky driving behaviors. Cognitive impairment
detected by office-based tests may indicate that the patient is at risk
of a motor vehicle crash. Referral for performance-based road testing
may further clarify risk and assist in making driving recommendations.
Physicians should assist families in the difficult process of driving
cessation, including providing information about Web sites and other
resources and clarifying the appropriate state regulations. Some states
require reporting of specific medical conditions to their departments of
motor vehicles. Am Fam Physician 2006;73:1029-34, 1035-6

<http://www.aafp.org/afp/20060315/1029.html>

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

#### Depo Provera Increase Diabetes Risk in Women {#depo-provera-increase-diabetes-risk-in-women-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The finding that DMPA and breast-feeding or DMPA and high triglycerides was associated with increased risk of diabetes in these women was from observational data. {#the-finding-that-dmpa-and-breast-feeding-or-dmpa-and-high-triglycerides-was-associated-with-increased-risk-of-diabetes-in-these-women-was-from-observational-data. .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: DMPA use was associated with an increased risk of diabetes that appeared to be explained by three factors: 1) use in women with increased baseline diabetes risk, 2) weight gain during use, and 3) use with high baseline triglycerides and/or during breast-feeding {#conclusions-dmpa-use-was-associated-with-an-increased-risk-of-diabetes-that-appeared-to-be-explained-by-three-factors-1-use-in-women-with-increased-baseline-diabetes-risk-2-weight-gain-during-use-and-3-use-with-high-baseline-triglycerides-andor-during-breast-feeding .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Xiang AH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Xiang+AH"%5BAuthor%5D) et al Long-acting injectable progestin contraception and risk of type 2 diabetes in Latino women with prior gestational diabetes mellitus. [Diabetes Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');) 2006 Mar;29(3):613-7. {#xiang-ah-et-al-long-acting-injectable-progestin-contraception-and-risk-of-type-2-diabetes-in-latino-women-with-prior-gestational-diabetes-mellitus.-diabetes-care.-2006-mar293613-7. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16505515**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16505515) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16505515 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Low educational status 2+ times risk of unintended pregnancy 1 year after delivery RESULTS: Low educational status (odds ratio, 2.32; 95% CI, 1.25-4.33) and less effective contraceptive use (odds ratio, 2.31; 95% CI, 1.05-4.51) were associated with unintended pregnancy. Neither depressive symptoms nor contraceptive use reduced the risk of pregnancy that was associated with low educational status {#low-educational-status-2-times-risk-of-unintended-pregnancy-1-year-after-delivery-results-low-educational-status-odds-ratio-2.32-95-ci-1.25-4.33-and-less-effective-contraceptive-use-odds-ratio-2.31-95-ci-1.05-4.51-were-associated-with-unintended-pregnancy.-neither-depressive-symptoms-nor-contraceptive-use-reduced-the-risk-of-pregnancy-that-was-associated-with-low-educational-status .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Low educational status was associated with more than twice the risk of unintended pregnancy 1 year after delivery. We found no evidence that depression or poor contraceptive use mediate this relationship. {#conclusion-low-educational-status-was-associated-with-more-than-twice-the-risk-of-unintended-pregnancy-1-year-after-delivery.-we-found-no-evidence-that-depression-or-poor-contraceptive-use-mediate-this-relationship. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Bennett IM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Bennett+IM"%5BAuthor%5D), et al Unintended rapid repeat pregnancy and low education status: any role for depression and contraceptive use? [Am J Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006 Mar;194(3):749-54. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16522408**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16522408) {#bennett-im-et-al-unintended-rapid-repeat-pregnancy-and-low-education-status-any-role-for-depression-and-contraceptive-use-am-j-obstet-gynecol.-2006-mar1943749-54.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16522408 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

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

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

Go here to explore the frequently asked question page

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

Finally, if the particular question you have is not already posted, then
please contact the OB/GYN Chief Clinical Consultant directly. You can
get an answer at <nmurphy@scf.cc>

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

**Q. Can we use a protein to creatinine ratio instead of a 24 urine
protein in preeclampsia?**

P:C is a standard metric for chronic renal disease. Here are the details
in the OB setting

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/PCratio4306.doc>

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

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

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

**Q. Ever had problems with a stenotic cervix? E.G., for an IUD
placement or EmBx?**

A. Cervical priming with misoprostol can be helpful in non-pregnant
women. See Details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/MisoIUD4306.doc>

**Q. When should we change the estimated date of delivery (EDD) based on
ultrasound?**

A. There are various criteria, but once you determine an EDD, stick with
it. See these helpful tips

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/USdating4606.doc>

**Q. Is my first trimester patient always hyperthyroid if her labs are
abnormal?**

A. No, not necessarily. If she is clinically stable, then wait till
18-20 weeks to decide. See details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Hyperthy4706.doc>

**Q. Are there any \_\_\_\_\_\_ (forms, guidelines, pt. ed materials,
etc) I can use as templates?**

A. Yes, the Indian Health website has sites for all those. See details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Forms4706.doc>

**Q. My patient with bacterial vaginosis is allergic to metronidazole.
What else can I use?**

A. First make sure it is bacterial vaginosis, and then consider one of
these other regimens.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/BValtRX4406.doc>

**Q. How do I get clinical privileges in deliveries, ultrasound,
colposcopy, etc...**

A. It requires documentation of training, experience, and current
competence. See details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CredPriv4406.doc>

**Q. How do you manage retinal detachment in pregnancy?**

Management depends on which of the types of retinal detachment. See
details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Retina4206.doc>

**Q. What does the Essure sterilization procedure entail?**

A. A coil is placed in the fallopian tube / is 99.8 % effective. It
needs a post-op HSG. See details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Essure4706.doc>

**Q. Is cholestasis in pregnancy significant in American Indians and
Alaska Natives?**

Yes, cholestasis can be associated with infant mortality and maternal
discomfort. See details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Cholestas4206.doc>

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

**April 2006 --highlights**

-Remember when they told you in medical school that 50% of what you will
learn will turn out to be wrong?  (at least I remembered that from
medical school and I know it is in the 50% that is still true)\
-Ventilating tubes for Otitis Media with effusion turned out to be in
the bad 50%. Children with ventilating tubes have worse long term
outcomes than medical management\
-Dr. Esposito says Indian Health deserves more money and here is how to
get it.\
-Helicobacter pylori is everywhere, especially in AI/AN children. What
should we do - or not do?

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN406.doc>

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

**National Release Graphical User Interface Clinical Scheduling System,
Version 1.0**

The new release of this software is located on the IHS Web site:
<http://www.ihs.gov/Cio/RPMS/appselect.cfm> or ITSC National Program
system, cmbsyb, in the /usr/spool/uucppublic/DIST/2006cert directory.

#### International Health Update {#international-health-update .Style-Heading-4-+-Arial-14-pt-Underline}

**Global Warming May Be a Graver Public Health Threat Than Nuclear War**

Part 1 \-- Getting Your Attention

Would the forecast of billions of premature human deaths seem like a
medical and public health issue to you?
<http://www.medscape.com/viewarticle/525105?src=mp>

**Prenatal Care Has Not Lowered Perinatal Mortality in Minorities**

CONCLUSION: Racial disparities in perinatal mortality persist in
contemporary obstetric practice despite early access to prenatal care.
LEVEL OF EVIDENCE: II-2.

[Healy
AJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Healy+AJ"%5BAuthor%5D),
et al Early Access to Prenatal Care: Implications for Racial Disparity
in Perinatal Mortality. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Mar;107(3):625-631.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16507934>

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

**Injury Reporting: Cautiously interpret injury data, esp. with
stressful life circumstances**

\"To our knowledge, our study is the first to quantify how many injuries
may be missed when medical records are used as the only data source.\"
The article presents findings from a study to assess agreement of
unintentional injury reporting in the first 3 years of life between
primary care medical records and maternal interviews in a
population-based sample of families at risk for child abuse and neglect.
The authors found that

\* The two data sources combined reported 490 injuries; 148 injuries
(30%) were documented in both primary care medical records and maternal
interviews, 245 (50%) in medical records only, and 97 (20%) in maternal
interviews only.

\* Significantly more children were reported injured in medical records
than in maternal interviews (51% vs. 39%).

\* The mean number of injuries per child reported was significantly
higher in primary care medical records than in maternal interviews.

\* The strength of agreement between medical record and maternal
interview reports of child injury status was 0.47 (fair agreement).

\* Agreement between medical records and maternal interviews was no
better for children who received home visiting services or had the same
primary care provider for the first 3 years of life, compared with other
children.

\"Caution should be used when interpreting injury data from one source,
especially individuals with stressful life circumstances.\" Further
research on barriers to communication across sites of care may help to
increase completeness of data and improve both research and quality of
care.

Stone KE, Burrell L, Higman SM, et al. 2006. Agreement of injury
reporting between primary care medical record and maternal interview for
children aged 0-3 years: Implications for research and clinical care.
Ambulatory Pediatrics 6(2):91-95.
[[http://www.ambulatorypediatrics.org/article/PIIS1530156705000158/abstract]{.underline}](http://www.ambulatorypediatrics.org/article/PIIS1530156705000158/abstract)

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

#### What is the common theme? {#what-is-the-common-theme-1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### This 35 year old G 2 P1001 was originally scheduled for elective repeat cesarean delivery at 36 2/7 pending results of fetal lung maturity studies. The patient's prenatal course was significant for a first visit at 8 weeks. The gestational age was confirmed by a 10 week ultrasound. The patient was offered a quad screen and /or amniocentesis and declined both. The patient had gastroesophageal reflux disease and received omeprazole 20 mg per day orally. {#this-35-year-old-g-2-p1001-was-originally-scheduled-for-elective-repeat-cesarean-delivery-at-36-27-pending-results-of-fetal-lung-maturity-studies.-the-patients-prenatal-course-was-significant-for-a-first-visit-at-8-weeks.-the-gestational-age-was-confirmed-by-a-10-week-ultrasound.-the-patient-was-offered-a-quad-screen-and-or-amniocentesis-and-declined-both.-the-patient-had-gastroesophageal-reflux-disease-and-received-omeprazole-20-mg-per-day-orally. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The patient's previous delivery was significant for a low transverse cesarean delivery for an abruption placenta at term. She otherwise had a history of mild endometriosis and laparoscopy for an ovarian cystectomy. {#the-patients-previous-delivery-was-significant-for-a-low-transverse-cesarean-delivery-for-an-abruption-placenta-at-term.-she-otherwise-had-a-history-of-mild-endometriosis-and-laparoscopy-for-an-ovarian-cystectomy. .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### This 20 year old G 3 P 0020 at 40 2/7 presented with good early dating for an outpatient cervical ripening regimen. The patient had uncomplicated Class A~1~ gestational diabetes mellitus. The patient weighed 193 lbs with a fetus in a cephalic presentation. Her cervical exam was 50% effaced, 1 cm dilation at the external os, firm, and posterior with the presenting part at -3 station. {#this-20-year-old-g-3-p-0020-at-40-27-presented-with-good-early-dating-for-an-outpatient-cervical-ripening-regimen.-the-patient-had-uncomplicated-class-a1-gestational-diabetes-mellitus.-the-patient-weighed-193-lbs-with-a-fetus-in-a-cephalic-presentation.-her-cervical-exam-was-50-effaced-1-cm-dilation-at-the-external-os-firm-and-posterior-with-the-presenting-part-at--3-station. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### What do these two patients have in common? {#what-do-these-two-patients-have-in-common .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Stay tuned next month for the rest of the story {#stay-tuned-next-month-for-the-rest-of-the-story .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-28 .Style-Heading-4-+-Arial-14-pt-Underline}

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

######### Do You Know The AHA Guidelines for CVD Prevention in Women?

######### Women\'s Agenda Targeting Cholesterol in Heart Disease (W.A.T.C.H.) 

######### Case Studies Series: Interaction for Improved Intervention 

######### (Archived Web Conference -- Free CME)

<http://www.medscape.com/viewprogram/4081?sssdmh=dm1.187324&src=0_mp_cmenl_0>

######### 

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

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

######### 

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

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

**Clinical Discussion Board Index, Medscape**

Hundreds of ongoing clinical discussions available

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

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

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

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

**Menopause Management**

Gabapentin Reduces Hot Flashes in Breast Cancer Survivors

Hot flashes are among the most common symptoms reported by women during
and after therapy for breast cancer. Conventional therapy for hot
flashes using estrogen and progesterone has been reported to increase
the risk of cancer recurrence, leading to a search for alternative
therapies. Because the g-aminobutyric analogue gabapentin (Neurontin)
has been effective in controlling menopausal hot flashes,

Gabapentin at dosages of at least 900 mg is effective in reducing
symptoms of hot flashes in women with breast cancer. These results
correlate with studies in postmenopausal women indicating that higher
dosages of gabapentin are required for clinical effect. In this study,
the reductions obtained with gabapentin are somewhat lower than those
reported with other agents, but gabapentin may have advantages over
other treatments because it does not inhibit cytochrome P450 enzymes
that are significant in the metabolism of tamoxifen and other drugs.

Pandya KJ, et al. Gabapentin for hot flashes in 420 women with breast
cancer: a randomised double-blind placebo-controlled trial. Lancet
September 3, 2005;366:818-24.

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16139656**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16139656) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16139656 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Midwives Corner Jenny Glifort, Anchorage {#midwives-corner-jenny-glifort-anchorage .Style-Heading-4-+-Arial-14-pt-Underline}

**Liability in triage: management of EMTALA regulations and common
obstetric risks**

To clear up any misconceptions, I am following up on this topic from the
December and February CCC Corners. The following information is
paraphrased from [Angelini
DJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Angelini+DJ"%5BAuthor%5D),
[Mahlmeister
LR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Mahlmeister+LR"%5BAuthor%5D).
Liability in triage: management of EMTALA regulations and common
obstetric risks. [J Midwifery Womens
Health.](javascript:AL_get(this, 'jour', 'J Midwifery Womens Health.');)
2005 Nov-Dec;50(6):472-8. It is not necessarily the opinion of the
Indian Health system or other agencies, unless otherwise stated.

Two key points:

According to Angelini in the EMTALA setting a physician has to certify
that a patient is in 'false labor'. With careful consultation a
'qualified medical person' can sign that certification after consulting
with a physician who authorizes the patient's care. The physician must
countersign the certification as contemporaneously as possible, e. g.,
24 hours, under certain conditions. (see below)

Further, it is the hospital that designates who is a 'qualified medical
person' to provide appropriate medical screening. The 'qualified medical
person' can be a non-physician, e.g., CNM, or RN, etc... If properly
applied, then a system of cooperation between the nurses, CNMs, and
physicians can easily be devised and be within compliance with the
EMTALA directives.

Adequate documentation is the key to success. Each facility should
review the Resources below. The L/D or Triage team should come to
agreement, and then implement a cohesive plan. In the meantime, the ACNM
is working on changing the Federal regulations to allow CNMs to be able
to directly diagnose 'false labor' in EMTALA settings.

The ACNM is actively pursuing a revision of the above regulations. The
Technical Advisory Committee met on June 15-17, 2005. The Minutes
reflect the ACNM proposed changes. The complete minutes can be found
below or contact Deanne Williams, Exec. Director, ACNM

<http://new.cms.hhs.gov/FACA/07_emtalatag.asp>

**[CCC Editorial Comment:]{.underline}**

The regulations make no specific provision for how or whether the
physician may certify false labor by telephone based on information
received from the qualified medical personnel by telephone. Hence, you
should consult your administrative staff, plus all stakeholders at your
facility and then develop thorough guidelines to support your local
process....and then live by those guidelines, e.g., document, document,
document.

**Resources:**

G. Freeman, Final EMTALA rule lessens risk, yet getting docs on-call
still a problem, Healthcare Risk Manage **25** (2004), pp. 109--113.

D. Glass, J. Rebstock and E. Handberg, Emergency treatment and labor act
(EMTALA). Avoiding the pitfalls, J Perinat Neonatal Nurs **18** (2004),
pp. 103--114

Emergency Medical Treatment and Labor Act. Definitions: Emergency
medical condition. 42 C.F.R. § 489.24 (b) (1). Available from:
[[http://www.emtala.com/law/index.html]{.underline}](http://ezproxyhhs.nihlibrary.nih.gov:2079/science?_ob=RedirectURL&_method=externObjLink&_locator=url&_cdi=6605&_plusSign=%2B&_targetURL=http%253A%252F%252Fwww.emtala.com%252Flaw%252Findex.html)

Department of Health and Human Services Centers for Medicare and
Medicaid Services C42 CFR Parts 413, 482, and 489, Clarifying policies
related to the responsibilities of medicare participating hospitals
treating individuals with emergency medical conditions: Final rule. Part
II. Federal Register **Vol 68** (2003) September 9, No 174.

Emergency Medical Treatment and Labor Act. Examinations and treatment
for emergency medical conditions and women in labor. 42 U.S.C. § 1395dd
(1).

CENTERS FOR MEDICARE & MEDICAID SERVICES website
[[http://new.cms.hhs.gov/]{.underline}](http://new.cms.hhs.gov/)

**All-fours maneuver effective for reducing shoulder dystocia during
labor**

OBJECTIVE: To report on a large amount of clinical experience with
shoulder dystocia managed primarily with the all-fours maneuver. STUDY
DESIGN: The all-fours maneuver consists of moving the laboring patient
to her hands and knees. Eighty-two consecutive cases of shoulder
dystocia managed with this technique were reported to a registry through
January 1996. RESULTS: The incidence of shoulder dystocia was 1.8%, and
half of the newborns weighed \> or = 4,000 g. Sixty-eight women (83%)
delivered without the need for any additional maneuvers. The mean
diagnosis-to-delivery interval was 2.3 +/- 1.0 (SD) minutes (range,
1-6). No maternal or perinatal mortality occurred. Morbidity was noted
in only four deliveries: a single case of postpartum hemorrhage that did
not require transfusion (maternal morbidity, 1.2%), one infant with a
fractured humerus and three with low Apgar scores (neonatal morbidity,
4.9%). All morbidity occurred in cases with a birth weight \> 4,500 g (P
= .0009). CONCLUSION: The all-fours maneuver appears to be a rapid, safe
and effective technique for reducing shoulder dystocia in laboring
women.\
[Bruner
JP](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Bruner+JP"%5BAuthor%5D),
[Drummond
SB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Drummond+SB"%5BAuthor%5D),
[Meenan
AL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Meenan+AL"%5BAuthor%5D),
[Gaskin
IM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Gaskin+IM"%5BAuthor%5D).
All-fours maneuver for reducing shoulder dystocia during labor. [J
Reprod Med.](javascript:AL_get(this, 'jour', 'J Reprod Med.');) 1998
May;43(5):439-43.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9610468>

**\"Hands off\" versus \"hands on\" for decreasing perineal lacerations:
No difference**

Lacerations in the anterior and posterior regions of the perineum
occurred with similar frequencies. Laceration rates did not differ
between the \"hands off\" and \"hands on\" groups (P \> .05). Neonatal
outcomes were similar in both groups. The use of \"hands off\" technique
of perineal protection does not alter the frequency or degree of
perineal lacerations in childbirth, relative to a \"hands on\"
technique.

[de Souza Caroci da Costa
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="de+Souza+Caroci+da+Costa+A"%5BAuthor%5D),
[Gonzalez Riesco
ML](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Gonzalez+Riesco+ML"%5BAuthor%5D).
A comparison of \"hands off\" versus \"hands on\" techniques for
decreasing perineal lacerations during birth. [J Midwifery Womens
Health.](javascript:AL_get(this, 'jour', 'J Midwifery Womens Health.');)
2006 Mar-Apr;51(2):106-11.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16504907>

**Does Vaginal Birth Increase the Risk for Incontinence?**

RESULTS: Among this sample of biological sisters, urinary incontinence
was reported by 47.6% of nulliparous women and by 49.7% of parous women
(P = .782). We found no difference in the severity or type of urinary
incontinence between these 2 groups. There was a high concordance in
continence status, however, within biological sisters. CONCLUSION:
Vaginal birth does not seem to be associated with urinary incontinence
in postmenopausal women. Considering the high concordance in continence
status between sister pairs, and considering that the majority of parous
women are continent, an underlying familial predisposition toward the
development of urinary incontinence may be present.

[Buchsbaum
GM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Buchsbaum+GM"%5BAuthor%5D),
et al Urinary incontinence in nulliparous women and their parous
sisters. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2005
Dec;106(6):1253-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16319249>

**Medscape Editorial**

The results suggest vaginal delivery may not be as harmful to continence
as many contend. This is a perfect example of how trying to do the best
thing for our patients may in the end be more harmful if appropriate
studies are not conducted to evaluate the hypothesis. As many cesarean
deliveries are likely performed in an attempt to \"preserve\"
continence, and vaginal delivery has not yet been conclusively
demonstrated as a cause of incontinence, one should exercise caution
until more scientific support is available.

<http://www.medscape.com/viewarticle/523743>

**Diagnosis and Management of Candida of the Nipple and Breast**

Diagnosis and treatment are based on history, physical exam, and
presenting symptoms because cultures of breast milk are often
inconclusive. Differential diagnoses and treatment options are reviewed.

Early recognition and treatment for candida of the nipple and/or breast
is essential to supporting successful long-term breastfeeding. Despite
the National Breastfeeding Awareness Campaign to promote exclusive
breastfeeding for 6 months, the majority of women in the United States
stop breastfeeding early because of pain. Without microbiologic testing
to confirm a diagnosis of mammary candida, we must use excellent
systematic clinical skills to make the presumptive diagnosis. A team
approach, including a lactation consultant and a clinician, is ideal.
Prospective research studies and clinical trials are needed to improve
our diagnosis and management of mammary candida. In the absence of
medical protocols and guidelines, a conservative approach to prescribing
medications is recommended. The use of fluconazole (Diflucan) for
long-term therapy needs to be considered only after a thorough history
is taken and physical examination is completed.

[Wiener
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Wiener+S"%5BAuthor%5D).
Diagnosis and management of Candida of the nipple and breast. [J
Midwifery Womens
Health.](javascript:AL_get(this, 'jour', 'J Midwifery Womens Health.');)
2006 Mar-Apr;51(2):125-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16504910>

**Can shoulder dystocia be resolved without fetal injury when it does
occur?**

<http://www.shoulderdystociainfo.com/resolvedwithoutfetal.htm>

## Navajo News Kathleen Harner, Tuba City

Methamphetamine abuse among women on Navajo

*This begins a four part series on the recognition and treatment of
pregnant methamphetamine abusers.*

PART I

**HEADLINE:** *March 28, 2006, The Navajo Nation* "Navajo Nation Police
arrest three meth dealers in Dilkon, Family of three includes
81-year-old grandmother, mother, daughter."

Unfortunately, this is not an aberration on Navajo or anywhere else in
the country for that matter. Methamphetamine (MA) abuse is a real and
growing problem. According to the U.S. Department of Health and Human
Services\' *Results from the 2002 National Survey on Drug Use and
Health: National Findings,* more than 12 million people age 12 and older
(5.3%) reported that they had used MA at least once in their lifetime.
Of those surveyed, 597,000 persons age 12 and older (0.3%) reported past
month use of MA. Statistics for Navajo are difficult to come by, but
Tuba City, a town of 10,000 saw 14 meth related deaths in 2002. A local
health department study found that 12% of Tuba City's teens were using
meth as were 17% of the residents between the ages of 27 to 45 years.
One third of patients screened in the emergency room are positive for
the drug. The Tuba City Regional Health Care Corporation (TCRHCC)
obstetrical service had its first maternal death in eight years last
April and it was directly attributable to MA use.

MA is a potent sympathomimetic agent that causes a massive release of
dopamine in the brain, thereby inducing euphoria, increased alertness
and a sense of confidence in users. It can be injected, smoked or
ingested orally or anally. The timing and intensity of the "rush" is
related to the method of administration. MA is readily available and
relatively inexpensive. A 250 mg. Packet can supply 3 -- 4 users for 24
hours and costs only \$25.00. This is about 75% less than cocaine users
spend for their drug of choice. Negative effects of the drug include
stroke, cardiac arrhthmia, stomach cramps, shaking, increased anxiety,
aggression, paranoia, hallucinations and death. Prolonged use results in
tolerance. Abusers are more likely than others to engage in risky
behaviors such as sharing needles or unsafe sexual practices.

The toxic effects of dopamine and catecholamine release caused by MA
have potentially serious effects on the pregnant woman and her fetus.
For the mother these may include severe hypertension, hypertensive
crisis, cerebrovascular accident, intracranial hemorrhage, cardiac
arrhythmia, pulmonary edema, agitation, confusion, seizure, hyperpyrexia
and cardiovascular collapse. Effects of long-term use may include
anorexia, weight loss, aggressive behavior, psychosis and cerebral
arteritis. Fetal effects are more problematic. Animal studies suggest
there may be a teratogenic effect but that is not yet established in
humans. Mothers who abuse meth have significantly smaller infants than
women who are drug free. MA abuse in pregnancy has been associated with
increased rates of premature birth, fetal distress and placental
abruption. . Perinatal exposure can lead to developmental disorders in
neonates. Children of MA abusers are at high risk for neglect and abuse.

Late entry to prenatal care or missed prenatal visits is often an
indication that a pregnant woman may be abusing drugs or alcohol.
Cigarette smoking and a current or past history of other drug abuse
might indicate MA abuse. Unfortunately, most pregnant women abusing MA
never seek prenatal care and are often seen for the first time in the
hospital in labor or experiencing side effects of the drug. The chronic
MA abuser exhibits marked physical changes which include weight loss,
poor dentition and signs of aging, however these changes appear late in
the course of addiction. Abusers are tirelessly hyperactive and stay
awake for long periods of time. They often have abrupt personality
changes including argumentative and disrespectful behavior (unusual in
the Navajo population), incessant talking and newfound
self-assertiveness. Borrowing or stealing money or the sudden onset of
lying is often a clue to drug use. Drug paraphernalia such as high
temperature butane lighters, glass pipes and empty drug packets may
alert family members to MA abuse.

*Next Month: Identifying MA abusers and suggestions for the treatment of
the abusing Gravida*

**References:**

-Anglin MD, Burke C, Perrochet B, Stamper E, et al. History of the
Methamphetamine problem. Journal of Psychoactive Drugs. Vol. 32 (2)
April-June 2000 pages 137-141.

-Buchi KF, Zone S, Langheinrich K, and Varner MW. Changing Prevalence of
Prenatal Substance Abuse in Utah. The American College of Obstetricians
and Gynecologists, Vol.102, No 1 July 2003 Pages 27 -- 30.

-Cantanzarite VA, Stein DA. 'Crystal' and
Pregnancy-Methamphetamine-Associated Maternal Deaths. West j Med
1995;162:454-457.

-Frosch, D., ( Nov. 9, 2004). Reservation Blues. AlterNet,
<http://www.alternet.org/module/printversion/20456>.

-Holve, S (February 8, 2005). Methamphetamine Use. Indian and Rural
Health Special Interest Groups.
<http://www.aap.org/nach/methsummary.htm>

-Little BB, Snell LM, Gilstrap LC. Methamphetamine Abuse During
Pregnancy: Outcome and Fetal Effects. Obstetrics and Gynecology Vol 72,
No. 4, October 1988 pages 541-44.

-NIDA NIDA Infofacts: Pregnancy and Drug Use Trends.

[http://www.nida.nih.gov/infofacts/pregnancy
trends.html](http://www.nida.nih.gov/infofacts/pregnancy trends.html)

-Prevention Alert. American Indians/Alaska Natives and Substance Abuse.
Vol 5 Number 16. November 22, 2002.
<http://ncadi.samhsa.gov/govpubs/prevalert/v5/10.aspx>

-Slutsker L, Smith R, Higginson G, Fleming D. Recognizing Illicit Drug
Use by Pregnant Women: Reports from Oregon Birth Attendants. American
Journal of Public Health 1993 Jan; 83 (1) Pages 61-64.

-Smith L, Yonekura ML, Wallace T, Berman N, et al. Effects of Prenatal
Methamphetamine Exposure on Fetal Growth and Drug Withdrawal Symptoms in
Infants Born at Term. Developmental and Behavioral Pediatrics. Vol 24
No. 1 Feb 2003 pages 17-23

####  [OB/GYN CCC Editorial comment]{.underline} {#obgyn-ccc-editorial-comment-7 .Style-Heading-4-+-Arial-14-pt-Underline}

#### I want to personally thank Kathleen Harner from Tuba City this excellent 4 part series, of which this is this first installment. {#i-want-to-personally-thank-kathleen-harner-from-tuba-city-this-excellent-4-part-series-of-which-this-is-this-first-installment. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Kathleen Harner, an Ob/Gyn at Tuba City, wrote her Master's thesis on creating a Methamphetamine clinic for pregnant women in Tuba City, 'Methamphetamine Abuse among Pregnant women in Tuba City: A Multi-dimensional, Culturally Sensitive Approach to Prevention, Identification and Treatment'. The planned fourth installment of the series will be on dealing with the methamphetamine abuser who presents to L&D with no prenatal care. {#kathleen-harner-an-obgyn-at-tuba-city-wrote-her-masters-thesis-on-creating-a-methamphetamine-clinic-for-pregnant-women-in-tuba-city-methamphetamine-abuse-among-pregnant-women-in-tuba-city-a-multi-dimensional-culturally-sensitive-approach-to-prevention-identification-and-treatment.-the-planned-fourth-installment-of-the-series-will-be-on-dealing-with-the-methamphetamine-abuser-who-presents-to-ld-with-no-prenatal-care. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-33 .Style-Heading-4-+-Arial-14-pt-Underline}

Steve Holve, Tuba City, hosted an excellent discussion forum on this
topic through our own Indian Health Primary Care Discussion Forum. That
Forum generated considerable discussion, plus a complete set of
resources which are posted at the url below.

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

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

**Nurses Corner Sandra Haldane, HQE**

**Journey to Magnet**

In 2003 Alaska Native Medical Center (ANMC) received the coveted
designation of Magnet Status. This designation is about achieving
nursing excellence. A hospital that has Magnet Status usually has small
turnover rates and high nurse satisfaction, thus, is a magnet for nurses
seeking employment. Nurses have autonomy in clinical practice
decision-making; there is higher job satisfaction and enhanced
nurse-physician collaboration in most Magnet hospitals. But most
important there is high quality care provided to patients and patient
satisfaction is high. Several Nurse Executives traveled to ANMC for a
magnet conference in October of 2005 and have joined together to assist
each other on the road to Magnet Status. Although not every facility
will apply for the designation, there are aspects of the forces of
magnetism that can be applied independent of the others. The Chief Nurse
Officer, Sandra Haldane, is extending an invitation for all interested
IHS Service Units to join the journey to adapting/adopting some of the
forces of magnetism. Conference calls are held on the first Friday of
every month <Sandra.Haldane@ihs.gov>

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

#### Nominations: \"Integrating Cultural Competency into Nursing Education and Practice\"  {#nominations-integrating-cultural-competency-into-nursing-education-and-practice-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The California Endowment seeks your assistance in nominating individuals to be invited to a convening, Integrating Cultural Competency into Nursing Education and Practice, to be held on May 23 and 24, 2006 at our Center for Healthy Communities conference facilities at our new headquarters in downtown Los Angeles. Issues regarding Cultural Competency into Nursing Education and Practice are critical for improving the quality and effectiveness of nursing care generally and in women\'s health specifically. Please review, and, if you choose, consider nominating yourself to participate. [**gzamora@calendow.org**](mailto:gzamora@calendow.org) {#the-california-endowment-seeks-your-assistance-in-nominating-individuals-to-be-invited-to-a-convening-integrating-cultural-competency-into-nursing-education-and-practice-to-be-held-on-may-23-and-24-2006-at-our-center-for-healthy-communities-conference-facilities-at-our-new-headquarters-in-downtown-los-angeles.-issues-regarding-cultural-competency-into-nursing-education-and-practice-are-critical-for-improving-the-quality-and-effectiveness-of-nursing-care-generally-and-in-womens-health-specifically.-please-review-and-if-you-choose-consider-nominating-yourself-to-participate.-gzamoracalendow.org .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### For commissioned officers or those considering switching\... {#for-commissioned-officers-or-those-considering-switching...-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### COMMISSIONED COPRS POLICY: Nurse Accession Bonus AND Incentive Special Pay for CRNAs and others! [**Judy.Whitecrane@IHS.GOV**](mailto:Judy.Whitecrane@IHS.GOV) {#commissioned-coprs-policy-nurse-accession-bonus-and-incentive-special-pay-for-crnas-and-others-judy.whitecraneihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Improving Perinatal Care: Nurses encouraged to attend, IHI {#improving-perinatal-care-nurses-encouraged-to-attend-ihi-1 .Style-Heading-4-+-Arial-14-pt-Underline}

This Spring, the Institute for Healthcare Improvement is beginning a new
Learning & Innovation Community, "Improving Perinatal Care." Meeting for
the first time June 6-7, participants in this Community will actively
test changes aimed at achieving ambitious design targets, including:

-   Reduction in birth trauma to a maximum of 3.3 adverse events per
    1,000 live births

-   Patients state that 95 percent of the time their wishes are known to
    the entire team and their wishes are respected

-   Perinatal units will report a 50 percent improvement in their
    culture survey scores

-   All claims or allegations may be defended because they meet each
    institution's internal standards for defense

To learn more about this Community, including areas for focus and
options for participation, please visit our website at:

<http://www.ihi.org/IHI/Programs/CollaborativeLearning/IMPACTICImprovingPerinatalCare2006.htm>

Additionally, a White Paper on Perinatal Care providing further detail
on work that has been done to date is also posted at our website:

<http://www.ihi.org/IHI/Results/WhitePapers/IdealizedDesignofPerinatalCareWhitePaper.htm>

Please also feel free to contact me directly by return email or phone at
(617) 301-4871.

Best regards, Denise D'Aunno

####  {#section-38 .Style-Heading-4-+-Arial-14-pt-Underline}

**Scholarship Opportunity for American Indian Commission Corps
Officers**

I am writing to you about a scholarship opportunity for American Indian
and Native Alaskan (AI/NA) Commission Corps Officers through the Native
Nurses Career Opportunity Program.  We are a small grant-based
scholarship program funded by IHS at the University of Minnesota -
School of Nursing.  We award scholarships to AI/NA registered nurses
pursuing their Master degree at the University of Minnesota School of
Nursing.  It is our goal to increase the number of Masters prepared
AI/NA nurses.  We have several scholarship recipients who are currently
Commission Corps Officers and would like to get the word out to other
Officers who might also benefit from our program.  The U of MN offers
courses online and we encourage our students to stay and serve in their
current communities.  We also understand the nature of being a
Commission Corps Officer and understand that our students need to
respond when called to duty.

I would appreciate it if you would forward this e-mail to the
appropriate person.  We would like to send your office information
regarding our scholarship program and would appreciate it if you could
share the information with any American Indian and Native Alaskan
officers looking to increase further their education. Web site
[www.nursing.umn.edu/NNCOP](../www.nursing.umn.edu/NNCOP)

Contact Karly Turner <NativeRN@umn.edu> or Carolyn Aoyama
<Carolyn.Aoyama@ihs.gov>

####  {#section-39 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**QuickStats: Cigarette Smoking Prevalence Among Adults Aged \>18 Years
Who Have Ever Spent \>24 Hours on the Streets, in a Shelter, or in a
Jail or Prison**

In 2004, an estimated 9.5 million adults (4.5% of the adult population;
6.8% of men and 2.3% of women) had ever spent \>24 hours on the streets,
in a shelter, or in a jail or prison. The prevalence of cigarette
smoking for both men and women in this population was more than twice
that observed among the overall adult population.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5510a7.htm>

####  {#section-40 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Oklahoma Perspective Greggory Woitte -- Hastings Indian Medical Center {#oklahoma-perspective-greggory-woitte-hastings-indian-medical-center .Style-Heading-4-+-Arial-14-pt-Underline}

**Peripartum Cardiomyopathy**

Peripartum cardiomyopathy develops in the last month of pregnancy or in
the 5 months post delivery with no identifiable cause for heart failure
in the absence of heart disease. It is the fifth leading cause of
maternal mortality and may be fatal 20-50% of patients. Diagnosis may be
difficult as many of the presenting symptoms are common complaints in
pregnant women. However, prompt intervention when peripartum
cardimyopathy is suspected by consultation of medicine and anesthesia,
along with treatment aimed at heart failure can be potentially life
saving.

[Murali
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Murali+S"%5BAuthor%5D),
[Baldisseri
MR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Baldisseri+MR"%5BAuthor%5D).
Peripartum cardiomyopathy. [Crit Care
Med.](javascript:AL_get(this, 'jour', 'Crit Care Med.');) 2005 Oct;33(10
Suppl):S340-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16215357>

[Tidswell
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Tidswell+M"%5BAuthor%5D).
Peripartum cardiomyopathy. [Crit Care
Clin.](javascript:AL_get(this, 'jour', 'Crit Care Clin.');) 2004
Oct;20(4):777-88, xi.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15388202>

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

**Role and Importance of Calcium in Preventing and Managing
Osteoporosis**

The Gap Between Knowledge and Action -- Medscape CME

<http://www.medscape.com/viewprogram/5237?src=mp>

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

#### Vulvodynia: What You Should Know {#vulvodynia-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060401/1239ph.html**](http://www.aafp.org/afp/20060401/1239ph.html) {#httpwww.aafp.orgafp200604011239ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-41 .Style-Heading-4-+-Arial-14-pt-Underline}

#### What You Should Know About Worrying Too Much {#what-you-should-know-about-worrying-too-much-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060315/1057ph.html**](http://www.aafp.org/afp/20060315/1057ph.html) {#httpwww.aafp.orgafp200603151057ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-42 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Driving and Dementia: What You Should Know {#driving-and-dementia-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060315/1035ph.html**](http://www.aafp.org/afp/20060315/1035ph.html) {#httpwww.aafp.orgafp200603151035ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-43 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Perinatology Picks George Gilson, MFM, ANMC {#perinatology-picks-george-gilson-mfm-anmc .Style-Heading-4-+-Arial-14-pt-Underline}

**No increase risk in neurodevelopment at 2 years of age: Vaginal breech
\< 3, 500 g**

RESULTS: An Ages and Stages Questionnaire at 2 years of age was obtained
in 183 of 203 children (90.1%). Twenty-eight percent of these children
showed 1 or more abnormal Ages and Stages Questionnaire domains. There
were no differences in the risk of having abnormal Ages and Stages
Questionnaire domains between planned vaginal delivery and planned
cesarean section (P = .99). There was, however, evidence of interaction
between mode of delivery and birth weight, with significantly higher
risk in neurodevelopmental delay in children with birth weight greater
than 3500 g with planned vaginal birth (adjusted odds ratio for
interaction term 3.37; 95% confidence interval 1.14 to 9.95).
CONCLUSION: Based on the Ages and Stages Questionnaire results at 2
years of age, planned vaginal delivery is associated with an increased
risk of neurodevelopmental delay at 2 years of age in term breech
children with a birth weight greater than 3500 g.

[Molkenboer
JF](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Molkenboer+JF"%5BAuthor%5D)
et al Birth weight and neurodevelopmental outcome of children at 2 years
of age after planned vaginal delivery for breech presentation at term.
[Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Mar;194(3):624-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16522389>

**[Editorial comment: George Gilson]{.underline}**

As the pendulum swings back toward breech vaginal delivery, now 6 years
after the Hannah large multicenter breech RCT (Lancet 2000;
356:1375-83), one can take some satisfaction reading [Molkenboer
JF](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Molkenboer+JF"%5BAuthor%5D)
et al, can't one. The 2000 Hannah et al study concentrated only on short
term effects and now 5 years later, it is beginning to appear the long
term data shows a different trend.

[Molkenboer
JF](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Molkenboer+JF"%5BAuthor%5D)
et al combines with:

-Whyte et al's 2 year f/u study of Hannah ([Whyte
H](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Whyte+H"%5BAuthor%5D)
et al AJOG 2004;191:864-71)

-Glezerman's 5 year analysis ([Glezerman
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Glezerman+M"%5BAuthor%5D)
AJOG 2006; 194:20-5)

\-[Eide
MG](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Eide+MG"%5BAuthor%5D),
et al's 18 year follow up data (Eide MG Obstet Gynecol 2005; 105:4-11)

\-[Goffinet
F](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Goffinet+F"%5BAuthor%5D),
et al's 138 French and 36 Belgian maternity units (AJOG 2006
194(4):1002-11)

....to form a pattern in the literature which supports breech vaginal
delivery in selected cases.

**References:**

INTERPRETATION: Planned caesarean section is better than planned vaginal
birth for the term fetus in the breech presentation; serious maternal
complications are similar between the groups.

[Hannah
ME](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Hannah+ME"%5BAuthor%5D)
et al Planned caesarean section versus planned vaginal birth for breech
presentation at term: a randomised multicentre trial. Term Breech Trial
Collaborative Group.
[Lancet.](javascript:AL_get(this, 'jour', 'Lancet.');) 2000 Oct
21;356(9239):1375-83.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11052579>

CONCLUSION: Planned cesarean delivery is not associated with a reduction
in risk of death or neurodevelopmental delay in children at 2 years of
age.

[Whyte
H](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Whyte+H"%5BAuthor%5D)
et al Outcomes of children at 2 years after planned cesarean birth
versus planned vaginal birth for breech presentation at term: the
International Randomized Term Breech Trial. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2004
Sep;191(3):864-71.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15467555>

### 

### [Conclusion]{.underline} The original term breech trial recommendations should be withdrawn

[Glezerman
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Glezerman+M"%5BAuthor%5D)
Five years to the term breech trial: the rise and fall of a randomized
controlled trial. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Jan;194(1):20-5.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16389006>

### 

### CONCLUSION: Presentation at birth did not affect adult intellectual performance. Cesarean delivery of breech-presented infants did not improve adult intellectual performance when compared with a vaginal delivery. The excess perinatal hazards of breech-presented infants with a vaginal delivery were not reflected in adult intellectual performance [Eide MG](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Eide+MG"%5BAuthor%5D), et al Breech delivery and intelligence: a population-based study of 8,738 breech infants. [Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2005 Jan;105(1):4-11. <http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15625134&dopt=Abstract>

CONCLUSION: In places where planned vaginal delivery is a common
practice and when strict criteria are met before and during labor,
planned vaginal delivery of singleton fetuses in breech presentation at
term remains a safe option that can be offered to women.

[Goffinet
F](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Goffinet+F"%5BAuthor%5D),
et al Is planned vaginal delivery for breech presentation at term still
an option? Results of an observational prospective survey in France and
Belgium. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Apr;194(4):1002-11.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16580289>

**Valacyclovir at 36 weeks reduced the number of women with clinical HSV
recurrences**

No neonates had symptomatic congenital HSV infection before discharge or
up to 2 weeks\' postpartum, and no clinical or laboratory safety
concerns were identified.

CONCLUSION: Administration of valacyclovir beginning at 36 weeks\'
gestation to women with a history of recurrent genital HSV reduced the
number of women with subsequent clinical HSV recurrences.\
[Andrews
WW](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Andrews+WW"%5BAuthor%5D),
et al Valacyclovir therapy to reduce recurrent genital herpes in
pregnant women. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Mar;194(3):774-81.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16522412>

**[Editorial comment: George Gilson]{.underline}**

Here\'s this issue again. Interestingly, while the recurrences were
less, the incidence of shedding, lesions when in labor, and cesareans
was not different. No babies were affected but the power was too low to
detect. They cite 8 references looking at acyclovir for this purpose
which likewise did not decrease shedding. Just to remind the readership
that this may not be a panacea and to still be vigilant with the
babies\...

**3 manuscripts that examine the timing and cesarean rate with epidural
analgesia**

CONCLUSION: Initiation of epidural analgesia in early labor, following
the first request for epidural, did not result in increased cesarean
deliveries, instrumental vaginal deliveries, and other adverse effects;
furthermore, it was associated with shorter duration of the first stage
of labor and was clearly preferred by the women

[Ohel
G](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ohel+G"%5BAuthor%5D)
et al Early versus late initiation of epidural analgesia in labor: does
it increase the risk of cesarean section? A randomized trial. [Am J
Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Mar;194(3):600-5.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16522386>

CONCLUSION: Randomized trials showing no effect of EA on cesarean
section (CS) rate lack external validity in much of North American
practice. The limited data available suggest EA and low-dose oxytocin
used together increase the CS rate. Early detection of dystocia and
high-dose oxytocin augmentation should be considered for women receiving
EA; those delivering in low-dose oxytocin settings should be advised of
a probable increase in the likelihood of CS.\
[Kotaska
AJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Kotaska+AJ"%5BAuthor%5D),
et al Epidural analgesia associated with low-dose oxytocin augmentation
increases cesarean births: a critical look at the external validity of
randomized trials. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Mar;194(3):809-14.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16522417>

**Editorial - Timing of conduction analgesia in labor**

In this issue of the Journal, Ohel et al, from Haifa, Israel, report a
prospective randomized study of early versus late epidural analgesia in
laboring nulliparous women at
term.[9](http://ezproxyhhs.nihlibrary.nih.gov:2079/science?_ob=ArticleURL&_udi=B6W9P-4JDTJ3P-6&_user=2391895&_handle=V-WA-A-W-ZV-MsSAYWW-UUA-U-AAVZEDYVAU-AAVVCCEWAU-DYBUWDBWU-ZV-U&_fmt=full&_coverDate=03%2F31%2F2006&_rdoc=6&_orig=browse&_srch=%23toc%236688%232006%23998059996%23618262!&_cdi=6688&view=c&_acct=C000000150&_version=1&_urlVersion=0&_userid=2391895&md5=5f117bef58751fd5b39162344c219b6c#bib9%23bib9)
Using conventional continuous epidural infusion, women randomized to the
early group received epidural immediately upon request if their cervix
was less than 3 cm dilated (mean dilation 2.4 cm). Women randomized to
the late group received intravenous narcotics until they achieved
cervical dilation of 4 to 5 cm, at which time epidural analgesia was
initiated (mean dilation 4.6 cm). Results included a significantly
shorter time from study randomization to full dilation in the early
epidural group. There were no significant differences between the groups
in rates of cesarean section, indications for cesarean section, rates of
instrumentation, duration of the second stage, or neonatal or maternal
outcomes. Although overall patient satisfaction was the same,
significantly more women would prefer to be in the early epidural group
with their next labor. This important study follows a publication by
Wong et al that reported no difference between early and late neuraxial
analgesia.[10](http://ezproxyhhs.nihlibrary.nih.gov:2079/science?_ob=ArticleURL&_udi=B6W9P-4JDTJ3P-6&_user=2391895&_handle=V-WA-A-W-ZV-MsSAYWW-UUA-U-AAVZEDYVAU-AAVVCCEWAU-DYBUWDBWU-ZV-U&_fmt=full&_coverDate=03%2F31%2F2006&_rdoc=6&_orig=browse&_srch=%23toc%236688%232006%23998059996%23618262!&_cdi=6688&view=c&_acct=C000000150&_version=1&_urlVersion=0&_userid=2391895&md5=5f117bef58751fd5b39162344c219b6c#bib10%23bib10)
In Wong\'s study, women were randomized to early intrathecal with later
epidural analgesia versus systemic analgesia with later epidural. This
is a different protocol than that used by Ohel et al but was again an
effort to evaluate the issue of timing of conduction analgesia. Wong was
similarly unable to demonstrate any difference in cesarean delivery rate
or other outcomes between their 2 groups. Previous reports from Chestnut
et al, although somewhat methodologically challenged, reached similar
conclusions to these recent
studies.[11](http://ezproxyhhs.nihlibrary.nih.gov:2079/science?_ob=ArticleURL&_udi=B6W9P-4JDTJ3P-6&_user=2391895&_handle=V-WA-A-W-ZV-MsSAYWW-UUA-U-AAVZEDYVAU-AAVVCCEWAU-DYBUWDBWU-ZV-U&_fmt=full&_coverDate=03%2F31%2F2006&_rdoc=6&_orig=browse&_srch=%23toc%236688%232006%23998059996%23618262!&_cdi=6688&view=c&_acct=C000000150&_version=1&_urlVersion=0&_userid=2391895&md5=5f117bef58751fd5b39162344c219b6c#bib11%23bib11)
and
[12](http://ezproxyhhs.nihlibrary.nih.gov:2079/science?_ob=ArticleURL&_udi=B6W9P-4JDTJ3P-6&_user=2391895&_handle=V-WA-A-W-ZV-MsSAYWW-UUA-U-AAVZEDYVAU-AAVVCCEWAU-DYBUWDBWU-ZV-U&_fmt=full&_coverDate=03%2F31%2F2006&_rdoc=6&_orig=browse&_srch=%23toc%236688%232006%23998059996%23618262!&_cdi=6688&view=c&_acct=C000000150&_version=1&_urlVersion=0&_userid=2391895&md5=5f117bef58751fd5b39162344c219b6c#bib12%23bib12)
That is, early versus late conduction analgesia in nulliparous women
does not appear to have an effect on the rate of cesarean delivery.

Where does this leave us and how should we counsel our patients
regarding this important therapeutic modality? In light of these
excellent studies, it is difficult to argue that epidural analgesia
should be withheld from a woman who is requesting pain relief in labor.
While such decisions should always be individualized, there should no
longer be an arbitrary degree of cervical dilation necessary before such
a decision is considered. No longer should a patient be made to feel
guilty about her wish for pain relief early in labor, powerless in her
choices or conflicted about the consequences of such a choice. Women
should receive adequate pain relief when needed, as determined by the
patient herself. What a concept---pain relief of real pain when
requested. We all should now feel comfortable supporting this position
for the patient in labor.

[Nageotte
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Nageotte+M"%5BAuthor%5D).
Timing of conduction analgesia in labor. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Mar;194(3):598-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16522385>

**[Editorial comment: George Gilson]{.underline}**

Our Indian Health facilities need to be able to maintain a certain level
of deliveries to maintain staff competence. In addition to honoring
patient autonomy, offering epidural analgesia, when appropriate, is one
way to improve a facility's appeal to our pregnant patients in a
competitive market.

The 2 RCT manuscripts above also allude to the \"external validity\" or
clinical applicability in practice. The evaluation of clinical
application is important, especially in our small rural Indian Health
facilities that are struggling with declining deliveries. You may also
find this article from Contemporary OB/GYN, Mar 1, 2006 helpful

[**Is clinical research
overrated?**](http://www.contemporaryobgyn.net/obgyn/article/articleDetail.jsp?id=312700)

For all the talk about the importance of rigorous medical research and
randomized double-blind trials, many physicians still put more faith in
clinical experience than clinical experiment. Is it possible to strike a
reasonable balance between the two?

Cerrato PL, Lockwood CJ [Is clinical research
overrated?](http://www.contemporaryobgyn.net/obgyn/article/articleDetail.jsp?id=312700)
Contemporary OB/GYN, Mar 1, 2006

<http://www.contemporaryobgyn.net/obgyn/article/articleDetail.jsp?id=312700>

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

**Adverse Childhood Events: Impact on chronic adult illness / Risk
taking**

**May 1, 2006 Moderator:       Andrew Hsi, M.D, University of New
Mexico**

Have you ever wondered where some untoward adult behaviors and chronic
illness(s) come from?....perhaps they have roots in childhood?

We are lucky to have Andrew Hsi M.D., University of New Mexico, moderate
a discussion on:

-Parental obesity and inactivity: Impact on childhood obesity

-Past sexual abuse: Effect on adult obesity

-Many other examples will be discussed

We will also be joined by the Indian Health Special Interest Group, AAP
for this discussion

**Cardiology Discussion Close Out**

I want to take this opportunity to extend my warmest thanks to Dr. Jim
Galloway for his hard work and patience (he lost full access to the
listerv at one point) in moderating the Cardiology Topics for Primary
Care Providers discussion.

Dr. Galloway's Summary is here

<http://www.ihs.gov/MedicalPrograms/MCH/F/documents/CardioSum4406.doc>

The full captured Discussion is here

<http://www.ihs.gov/MedicalPrograms/MCH/F/documents/CardioDiscus4406.doc>

All the presentations and other resources are here

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

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

Subscribe to the Primary Care listserv

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

Unsubscribe from the Primary Care listserv

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

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

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

**New CDC Fact Sheet on HPV in Men**

In March, CDC produced an informative fact sheet on HPV in men that can
be downloaded for distribution to patients from the CDC Division of STD
Prevention's website at
<http://www.cdc.gov/std/HPV/STDFact-HPV-and-men.htm>

**Announcing New Program Manager for the IHS National STD Program**

Scott Tulloch has joined the IHS National STD Program as its new Program
Manager. He replaces Laura Shelby, who served in this capacity for nine
years until her departure last year to attend graduate school in London.
Scott brings with him a wealth of STD program management expertise; he
is the former STD Director in the state of Maryland and has worked for
state STD programs in Georgia, North Carolina, Chicago, and Maryland. He
joins Lori de Ravello, Public Health Advisor; Dr. David Wong, Medical
Epidemiologist; Cleora Chicharello, Stop Chlamydia Coordinator; and
Yolanda Savage, Public Health Prevention Specialist. Scott, like Lori
and David, is a CDC assignee to IHS. Scott can be reached at
505-248-4344 or <scott.tulloch@ihs.gov>

####  {#section-46 .Style-Heading-4-+-Arial-14-pt-Underline}

**Funding opportunities announced. Applications due May 19th**

Please spread the word about these new funding opportunities:\
This RFA is expected to fund research that will expand our knowledge and
understanding in the areas of cancer, reproductive health, child and
adolescent health, and adult health. Individual project descriptions are
contained in Section IX. Special Interest Projects (SIPs) Descriptions
of this announcement. SIP descriptions are grouped by the following
topical areas:

**Cancer**\
**SIP 1:** Inventory and Assessment of National Breast and Cervical
Cancer Early Detection Program (NBCCEDP) Interventions (\$250,000)

**SIP 2:** Integration and Evaluation of an Existing Cancer Survivorship
Educational Material into a Clinical Setting (\$200,000)

**Reproductive Health**\
**SIP 3:** Identifying intervention needs of youth living in communities
with high rates of teen pregnancy (\$300,000)\
**SIP 4:** Intervention Research on Youth Development to Prevent Teen
Pregnancy (\$350,000)\
**Child and Adolescent Health**\
**SIP 5:** Building Capacity for Community Monitoring System to Track
Indicators of Child and Adolescent Well-being (\$200,000 to fund two
projects)

**Adult Health**\
**SIP 6:** Reliability Study of the \"Actions to Control High Blood
Pressure\" Module in the Behavioral Risk Factor Surveillance System
(\$100,000)

**SIP 7:** Intervention Research on Home-based Depression Treatment in
People with Epilepsy (\$200,000)\
**SIP 8:** Identification and Development of Prevention Opportunities to
Promote or Maintain Brain Health in Older Adults (\$250,000)

All estimated funding amounts are subject to availability of funds.\
CDC will accept and review applications with budgets greater than the
listed funding amount for the SIP.\
Each SIP has specific anticipated outcomes and/or expected deliverables.
Please refer to the Project Activities of the SIP description in Section
IX. Special Interest Projects (SIPs) Descriptions of this announcement.
<http://www.grants.gov/search/search.do?oppId=8933&mode=VIEW>

####  {#section-47 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Barbara Stillwater Alaska State Diabetes Program  {#barbara-stillwater-alaska-state-diabetes-program .Style-Heading-4-+-Arial-14-pt-Underline}

**"Clinical inertia\" - Providers not intensifying diabetes therapy when
indicated**

A computerized system that tells primary care physicians how well they
are managing blood glucose levels in their patients seems to improve
diabetes control. Physician Performance Feedback Improves Diabetes
Control

CONCLUSIONS: Feedback on performance given to medical resident primary
care providers improved provider behavior and lowered HbA1c levels.
Similar approaches may aid health care provider behavior and improve
diabetes outcomes in other primary care settings.

[Ziemer
DC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ziemer+DC"%5BAuthor%5D),
et al An intervention to overcome clinical inertia and improve diabetes
mellitus control in a primary care setting: Improving Primary Care of
African Americans with Diabetes (IPCAAD) 8. [Arch Intern
Med.](javascript:AL_get(this, 'jour', 'Arch Intern Med.');) 2006 Mar
13;166(5):507-13.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16534036>

**Eating Potatoes May Increase Risk for Type 2 Diabetes**

Our findings suggest a modest positive association between the
consumption of potatoes and the risk of type 2 diabetes in women,\" the
authors write. \"This association was more pronounced when potatoes were
substituted for whole grains.\"

A limitation of this study is the inability to completely separate the
effects of potatoes and french fries from the effects of the overall
Western dietary pattern.

[Halton
TL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Halton+TL"%5BAuthor%5D),
et al Potato and french fry consumption and risk of type 2 diabetes in
women. [Am J Clin
Nutr.](javascript:AL_get(this, 'jour', 'Am J Clin Nutr.');) 2006
Feb;83(2):284-90.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16469985>

**Cutting Calories Helps You Live Longer**

CONCLUSIONS: Our findings suggest that 2 biomarkers of longevity
(fasting insulin level and body temperature) are decreased by prolonged
calorie restriction in humans and support the theory that metabolic rate
is reduced beyond the level expected from reduced metabolic body mass.
Studies of longer duration are required to determine if calorie
restriction attenuates the aging process in humans.\
[Heilbronn
LK](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Heilbronn+LK"%5BAuthor%5D)
et al Effect of 6-month calorie restriction on biomarkers of longevity,
metabolic adaptation, and oxidative stress in overweight individuals: a
randomized controlled trial.
[JAMA.](javascript:AL_get(this, 'jour', 'JAMA.');) 2006 Apr
5;295(13):1539-48.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16595757>

**Join for the WOMAN Challenge**

an 8-week challenge to increase your physical activity beginning Sunday,
May 14^th^, Mother\'s Day, to kick off National Women\'s Health Week

**SIGN UP NOW\... It\'s quick and easy!**
[womenshealth.gov/whw/woman](http://www.womenshealth.gov/whw/woman)

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

**Advances in Indian Health, 6^th^ Annual**

-   May 2-6, 2006

-   Albuquerque, NM

-   Save the dates brochure

> <http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#May06>

**Native Peoples of North America HIV/AIDS Conference**

-   May 3--6, 2006

-   Anchorage, Alaska

-   Embracing Our Traditions, Values, and Teachings
    [www.embracingourtraditions.org](http://www.embracingourtraditions.org/)

-   [National Institutes of Health (NIH),
    DHHS](http://www.embracingourtraditions.org/conf_info.htm)
    <http://www.ou.edu/rec/pdf/Native_Fact_Sheet.pdf>

**ACOG 2006 Annual Clinical Meeting (ACM)**

-   May 6-10, 2006

-   Washington, DC

-   Save the dates brochure
    [http://www.acog.org/abstract%2Dsubmission/](http://www.acog.org/abstract-submission/)

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

-   September 17 -- 21, 2006

-   Denver, CO

-   Contact <YMalloy@acog.org> or call Yvonne Malloy at 202-863-2580

-   Neonatal Resuscitation Program available

-   Brochure

> <http://www.ihs.gov/MedicalPrograms/MCH/F/documents/ACOG_06brochR1_1.pdf>

**PUBLIC'S HEALTH & THE LAW IN THE 21^ST^ CENTURY**

-   June 12-14, 2006

-   Atlanta, Georgia

<http://www2a.cdc.gov/phlp/conference2006.asp>

# What's new on the ITU MCH web pages? {#whats-new-on-the-itu-mch-web-pages .Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5%)}

**New Discussion: May 1, 2006 - Adverse Childhood Events: Impact on
chronic adult illness / Risk taking**
<http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm#adverse>

**Gestational Diabetes Mellitus [Tracking
Sheet](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/GDMtrackingsheete.doc)** 

Diabetes and Pregnancy Program Flowsheet, Northern Navajo Medical Center

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

**Program Review and Case Management - Diabetes in Pregnancy**

Processes of tracking case files using hard copy as well as RPMS and CMS
computer systems

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/gdmcasemanagement(3).ppt>

There are several upcoming **Conferences**

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

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

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

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

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

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

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

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn0306.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

####  Abstract of the Month: page 5 {#abstract-of-the-month-page-5-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Tired of hearing only bad news from the Women's Health Initiative
(WHI)?**

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

Carolyn Aoyama:

-Deadline Extended: Special AI/AN issue of the Maternal and Child Health
Journal

-Three Women\'s Health Awards

Burt Attico:

-Calcium Supplementation May Reduce the Severity of Pre-eclampsia

#### -Low-Dose Aspirin in the Primary Prevention of Cardiovascular Disease in Women {#low-dose-aspirin-in-the-primary-prevention-of-cardiovascular-disease-in-women .Style-Heading-4-+-Arial-14-pt-Underline}

Terry Cullen:

Indian Health Service Medical Provider Best Practice Conference

Costs Are Too High: Improving Perinatal Care -New Learning & Innovation
Community from IHI

Eve Espey

Sample templates for guidelines: IUDs, [Manual Vacuum Aspiration (MVA)
for SAB](http://www.ihs.gov/NonMedicalPrograms/NC4/nc4-clinguid.cfm#m),
etc...

Chuck North

Keams Canyon 1979: Have you ever noticed that some things never seem to
change?

####  {#section-48 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Frances Placide {#frances-placide .Style-Heading-4-+-Arial-14-pt-Underline}

#### Please Welcome Frances Placide, new Chief Clinical Consultant for Physician Assistants {#please-welcome-frances-placide-new-chief-clinical-consultant-for-physician-assistants .Style-Heading-4-+-Arial-14-pt-Underline}

Jane Powers

New Child Abuse Website from IHS and Office for Victims of Crimes: Child
Abuse Training

Judy Thierry:

-What is the evidence on school health promotion in improving health?

-Meeting the needs of our native children in special education

Sara Thomas

#### Is a low fat diet not good idea? Comments on recent research? {#is-a-low-fat-diet-not-good-idea-comments-on-recent-research .Style-Heading-4-+-Arial-14-pt-Underline}

Roberta Ward

-New Information on Paxil and Congenital Malformations

#### -For Your Reading Pleasure . . . Asthma in Pregnancy {#for-your-reading-pleasure-.-.-.-asthma-in-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

Judy Whitecrane

-Needed: PHS Nurses with OB experience

#### -2006 Clinical Update on Substance Abuse and Dependency  {#clinical-update-on-substance-abuse-and-dependency .Style-Heading-4-+-Arial-14-pt-Underline}

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

##### Obstetrics: page 13

#### -GDM: Can we proceed directly to one step screening / diagnosis in AI / AN women?

-Link between GDM and Type 2 DM can be broken: Update

-Gestational Glucose Tolerance Risk of Type 2 Diabetes in Young Pima
Indian Offspring

-Is Influenza Vaccination Safe for Pregnant Women?

-Membrane sweeping at induction increases vaginal delivery rate and
patient satisfaction

and more...

**Gynecology: page 18**

-Diet and Exercise Reduce Incontinence in Women at Risk of Diabetes

-Hysterectomy increases resource use significantly, but increases
quality-of-life too

-Atypical glandular cells: High risk - several markers put patients at
more substantial risk

-Laparoscopic assistance not useful in performing vaginal hysterectomies
w/ BSO

-Psychosocial Stress May Raise Risk of Bacterial Vaginosis

and more...

**Child Health: page 19**

-Maternal cholestasis and neonatal respiratory distress syndrome

-FDA Warns Parents About Contaminated Teething Rings

#### -Incidence of a Type AB Infant Born to a Type O Mother  {#incidence-of-a-type-ab-infant-born-to-a-type-o-mother .Style-Heading-4-+-Arial-14-pt-Underline}

-CDC Releases Guidelines on Identifying and Referring Persons with FAS

-Prevalence of overweight among children entering school

and more...

**Chronic Illness and Disease: page 21**

-Colon cancer rates: Significantly increased in AI/AN women -- Colon
Cancer Month

-American Heart Association Updates Guidelines for Blood Pressure
Management

-Prenatal setting represents a missed opportunity for Tuberculosis
treatment completion

-Anyone snore in your house: Oral Appliances for Obstructive Sleep
Apnea?

-Statins and beta-blockers may reduce severity of first coronary event

and more...

#### Features: page 24 {#features-page-24 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician

Steroids Before Cesarean Delivery May Reduce RDS

American College of Obstetricians and Gynecologists

-LAY MIDWIFERY: Statement of Policy

-Tracking and Reminder Systems

**Agency for Healthcare Research and Quality**

Results raise doubts about the value of the bimanual pelvic exam in
routine screening

**Ask a Librarian**

I have a great resource for you: Diane Cooper, NIH

**Breastfeeding**

Breastfeeding as a Pain Reliever

**CCC Corner Digest**

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

\-[Results of a Well-Defined Protocol for a Trial of Labor After
Cesarean](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_AOM.cfm)

\-[Oral misoprostol for cervical priming in non-pregnant
women](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Coll.cfm)

\-[The term breech trial recommendations should be
re-evaluated](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_HT.cfm#ob)

\-[Superiority of Liquid-Based Cytology for Cervical Screening
Questioned](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_HT.cfm#gyn)

\-[Broad-spectrum antibiotics in labor linked to serious late-onset
neonatal
infections](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_HT.cfm#child)

\-[Dietary intervention alone of little benefit in preventing
disease](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_HT.cfm#chrIll)

\-[Vaginal Birth after Cesarean: Evidence Based
Recommendations](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#afp)

\-[Nearly half of urban AI/AN travel back to their reservation to visit
during the
year](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#ahrq)

\-[Birth News Highlights: Young mothers, VBACs down, Early Care? Low
birth
weight](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#AskLib)

\-[Maternal Child Health Website Gets a
Facelift](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#webSite)

\-[What is the latest on an OB/GYN solution for the PCC, PCC+ and EHR in
Indian
Health?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#it)

\-[Listen up any parents or grandparents: How NOT to give
Acetaminophen](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#mmtour)

\-[When Should We Clamp the Umbilical Cord? Preterm vs Term
Infants](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#MidWives)

\-[Liability in triage: management of EMTALA regulations and common
obstetric
risks](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#MidWives)

\-[Focus on preventable causes of stillbirth: 3
articles](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#periPicks)

\-[Efficacy and safety of azithromycin for treatment of C. trachomatis
in
pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#std)

\-[Women with pain, but w/o coronary artery disease: Coronary
microvascular
dysfunction](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Feat.cfm#stillW)

\-[Vaginal Birth after Cesarean  - New Perinatology Corner
Module](http://www.ihs.gov/MedicalPrograms/MCH/M/VB01.cfm)

**Domestic Violence**

Survey queries women and men about their experiences as victims of rape

**Elder Care News**

-Not too Late: Funding Available for Palliative Care Training - April
3 - 5, 2006

-Screen for cognitive impairment with many non-English speaking elders 

**Family Planning**

#### -Fatal infection without fever: Sepsis and Medical Abortion - FDA Public Health Advisory -Pharmacists\' Knowledge, Attitudes, and Beliefs Toward Prescribing EC {#fatal-infection-without-fever-sepsis-and-medical-abortion---fda-public-health-advisory--pharmacists-knowledge-attitudes-and-beliefs-toward-prescribing-ec .Style-Heading-4-+-Arial-14-pt-Underline}

-Are continuous and extended-cycle combined contraceptives safe and
effective?

#### -Continuous OCPs with norethindrone: More bleeding-free days than levonorgestrel preps {#continuous-ocps-with-norethindrone-more-bleeding-free-days-than-levonorgestrel-preps .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

Two New Perinatology Corner Modules

-Twins: Antepartum assessment and Intrapartum management - Double
Trouble?

-Antibody Screen Positive: Rh Disease and Other Atypical Antibodies:

Kell kills, Duffy dies, and Lewis lives?

**Frequently asked questions**

-How do the EMTALA regulations effect the evaluation of patient with
false labor?

-Can we perform one step GDM screening in AI/AN?

-What is the best screening cut-off for gestational diabetes mellitus?

-What are some of the issues about viability in the range of 23-25 EGA
weeks?

**Indian Child Health Notes**

**Highlights for March 2006**

-Cardiovascular screening for high school athletes - a summary of the
appropriately named \"Sudden Death\" Committee of the American Heart
Association

-Medico legal Implications of Cardiovascular Screening of Athletes -
Yes, you can say \"No\"

-The new Rotavirus vaccine is on the way

-Doug Esposito: Race, genetics, social construct and political
correctness - read it if you dare

**Information Technology**

-UpToDate 14.1 is now available: Evidence based recommendations added
now

-IHS received an "effective" rating: buried in President Bush's fiscal
2007 budget

-Evaluation of IHI work within IHS

International Health

-Combating poverty and social exclusion

-Quinacrine sterilization (From Yolanda Meza)

-How to expand the reach of successful programs by replicating effective
ones

#### MCH Alert

Reducing substance uptake among younger adolescents

#### Medical Mystery Tour

As seen on TV- Desperate Housewives: Wandering spleen

#### Medscape

######### [Increasing Diversity in the Medical Workforce Is Way to Prevent Disparities in Healthcare](http://mp.medscape.com/cgi-bin1/DM/y/hyxu0G875W0Dzc0HJ760Gv)

**Menopause Management**

Hormone Therapy: Predictor of worsening insulin sensitivity in
postmenopausal women

**Midwives Corner**

-Should we continue to draw Rubella titers as part of the prenatal
panel?

-Do Birth Certificate Data Reflect the Number of CNM-Attended
Births**?**

**Navajo News**

VZIG No Longer Available: Protect non-immune women against Chickenpox
(pre-pregnancy)

**Nurses Corner**

#### -Nurse Education Loan Repayment Program: Deadline March 30 {#nurse-education-loan-repayment-program-deadline-march-30 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Idealized Design of Perinatal Care - Institute for Healthcare Improvement {#idealized-design-of-perinatal-care---institute-for-healthcare-improvement .Style-Heading-4-+-Arial-14-pt-Underline}

-Sign up for the 'Every Woman' quarterly magazine

-NNLC Award Announcement

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

-Global Tobacco Use in Young People: Future Chronic Disease Burden in
Adults

#### -National Women\'s Health Week, May 14-20, 2006 {#national-womens-health-week-may-14-20-2006 .Style-Heading-4-+-Arial-14-pt-Underline}

**Oklahoma Perspective**

Metformin and Polycystic Ovarian Syndrome

Osteoporosis

Nutritional Influences on Bone Health: Update on Research and Clinical
Implications

Patient Education

#### -Preterm Premature Rupture of Membranes: What it Means to You {#preterm-premature-rupture-of-membranes-what-it-means-to-you .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Behavior Problems in a Family Member with Dementia: What You Should Know {#behavior-problems-in-a-family-member-with-dementia-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Caring for Your New Baby {#caring-for-your-new-baby .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Move beyond 'integrated' screening to 'contingency' screening

-Misoprostol for postpartum hemorrhage

Primary Care Discussion Forum

Cardiology Topics for Primary Care Providers -- Ongoing, 'not too late
to join in

STD Corner

#### -Incorrect use of condoms not product failure may account for the lack of effectiveness {#incorrect-use-of-condoms-not-product-failure-may-account-for-the-lack-of-effectiveness .Style-Heading-4-+-Arial-14-pt-Underline}

-Expedited Partner Therapy in the Management of Sexually Transmitted
Diseases

-Chlamydia screening and management: Primary care providers in
California

-Raise Awareness of Impact of HIV /AIDS on Women and Girls

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

Statin Therapy for Type 2\'s Regardless of LDL Levels and CVD

###### Save the Dates: Upcoming events of interest page 51

The past CCC Corners are archived at:

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

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

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

or 907 729 3154 (with voicemail)

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

<http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm>

4/14/06njm

4/19/06njm