**News Flash(s) Plan now**

**-ACOG / IHS -- Total Women's Health and Neonatal Course: June 19-23,
2005**

**-IHS Advanced Colposcopy course / Refresher Workshop: March 30 --
April 1, 2005**

**-17th Annual IHS Research Conference and International**

**Meeting on Inuit and Native American Child Health: April 29-May 1,
2005**

**New Feature:**

**CCC Corner Digest - A print friendly digest of the CCC Corner that can
be mailed to you, or**

> **your colleagues. Just send your address to
> [[nmurphy@scf.cc]{.underline}](mailto:nmurphy@scf.cc)**

**OB/GYN Chief Clinical Consultant's Corner**

**Volume 3, No. 2, February 2005**

**Contents:**

**Abstract of the Month:** **page 3**

**LEEP Treatment Increases Risk of Preterm Delivery in Future
Pregnancies**

**From your colleagues: page 4**

**Elaine Locke:** Free Job Postings for Indian Facilities on ACOG Career
Connection

**Sandra Haldane:** Web portal linking all HHS.gov sites to breast
cancer information

-Women and Medication Safety: Special Journal Issue Is Available Online

**Steve Holve** How common is Methamphetamine use in your area? Feb '05
ICHN available

**:Jean Howe:** Announcing the new Deputy Chief Clinical Consultant

**Yolanda Meza:** Routine suctioning of meconium-stained before delivery
of the shoulders?

**Suzan Murphy:** Methamphetamine abuse and breastfeeding

**Chuck North:** Patients with more than one medical condition: How can
guidelines help?

-Single digit need to treat (NNT) obesity are remarkable statistics -
should spur us on

**Lori de Ravello:** Contraceptive Methods Among Women: Quickstats

**Judy Thierry:** Discourage use of infant car seats as long term sleep
environments

-Training for Nursery Room Nurses on Back to Sleep

-Tony Dekker, M.D. New Addiction Medicine Chief Clinical Consultant
(CCC)

-The Chief Clinical consultants - are available for your consultation

-What is the definition of 'preventable or avoidable maternal death?

**Judy Whitecrane:** It makes it easy for moms to remember: 2 days, 2
weeks, and 2 months

**Hot Topics:**

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

-Severe Preeclampsia and Eclampsia: Systolic Hypertension Is Also
Important

-Progesterone Treatment Decreases Preterm Birth Rate

-Ripening of the Cervix and Risk for Later Preterm Birth

-Ginger May Relieve Nausea During Early Pregnancy

-Effect of Episiotomy on Pelvic Floor Weakness

**Gynecology: page 12**

-Sexual Function After Hysterectomy

-Screening for Ovarian Cancer: Recommendation Statement

-Limitations of Screening Tests for Asymptomatic Chlamydia

-Abnormal Uterine Bleeding: Surgical or Medical Therapy?

-Endometriosis and Subfertility: Is the Relationship Resolved?

**Child Health: page 13**

-Gender bias in child growth evaluations may miss disease in girls

-Recommended Childhood and Adolescent Immunization Schedule, United
States, 2005

-Protective effects of firearm storage practices for children

-Dramatic decline in varicella related mortality: Impact of vaccine

-Oral health is looking to better capture the topical fluoride
applications

**Chronic Illness and Disease: page 14**

-Quality of Care May Decline as Physicians Age

-Chronic disease antecedents arise in utero and infancy

-JAMA Editorialist recommends the \"low fad\" approach

-Diabetes Mellitus in Women: Adolescence Through Pregnancy and Menopause

-Irritable Bowel Syndrome: Clinical Evidence Concise - BMJ

**Features: page 17**

##### **American Family Physician** 

-Radio-Frequency Endometrial Ablation for Menorrhagia

-Esterified Estrogen and Venous Thrombotic Risk

-Physical Therapy and Stress Urinary Incontinence

-Lactobacillus Does Not Prevent Post-Antibiotic Vaginitis

-Antidepressants and Smoking Cessation

**ACOG**

Coping With the Stress of Medical Professional Liability Litigation

**AHRQ**

**-**Computerized Order Entry Leads to Unwanted Testing- Web M + M -
Clinical Ethics

-Women who have given birth only via cesarean are less likely than those
with vaginal -deliveries to report stress incontinence

**Ask a Librarian**

-Infant Mortality: Bad News, Good News

**Breastfeeding**

**-**American Academy of Pediatrics Revised policy on Breastfeeding

**CCC Corner Digest**

-A compact digest of last month's CCC Corner - Highlights include:

Depo Provera and bone loss

Oral rehydration solution -- reverse transfer of technology

What maneuver is in best in shoulder dystocia?

Midwives serving in Indian Country

Marriage may be good for you

Consumer Reports evaluates condoms, and 16 other contraceptive methods

Bariatric surgery may be a viable treatment option in severe obesity,
etc...

**Domestic Violence**

-Intimate Partner Violence During Pregnancy APRIL 2005 MCH EPI GRAND
ROUNDS

-Primary Care Discussion Forum: Domestic Violence in AI/AN - Just
finished

-Assaults during pregnancy: both immediate and long-term adverse
neonatal outcomes

**Elder Care News**

-Caring for elders at home: what is the best bath strategy?

-Cultural Diversity at the End of Life: Issues and Guidelines

-Management of Hypertension in Older Persons

-White House Conference on Aging

**Family Planning**

-Do combination hormonal contraceptives cause weight gain?

-Availability and Use of Publicly Funded Family Planning Clinics

**Frequently asked questions**

What is the Indian Health policy on use of chaperones?

How does one manage possible exposure to hand foot and mouth disease in
pregnancy?

The 'quad' second trimester screening test is expensive. Is it worth it?

.How can you predict if a placenta previa will persist based on US at
15-24 weeks?

**Hormone Replacement Update**

Benefits and Risks of Estrogen in Postmenopausal Women

**Information Technology**

Free CME from Harvard to 60 of our providers

**International Health**

Institute for OneWorld Health \-- A Not-for-Profit Pharmaceutical
Company

#### **MCH Alert** 

-Entire supplement on sleep in children: Cultural impacts

#### **Medscape** 

**Midwives Corner**

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

-Cesarean Rate Highest Ever

**Osteoporosis**

-"Uncertain Role" of Biochemical Markers Use in Osteoporosis Therapy

-Fracture Protection Lost Five Years After Stopping Hormone Replacement
Therapy

-Impact of Intense Exercise on Early Osteopenia in Women

**Patient Education**

-Painful Menstrual Periods

-Urinary Tract Infections

-Pelvic Floor Muscle Exercises

-Microscopic Hematuria

-Heart Palpitations

**Primary Care Discussion Forum**

-April 1, 2005: Methamphetamine use in Indian Country

**STD Corner**

-Men have often been overlooked for routine chlamydia screening

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

-Walk 2000 More Steps a Day and Never Gain Another Pound

-Fit And Fat Not Good Enough

-15-Year Study Shows Link Between Fast Food, Obesity and Insulin
Resistance

-How Well Do Adults Follow Prescriptions for insulin?

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

###### Save the Dates: Upcoming events of interest **page 29** 

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

**Abstract of the Month**

**LEEP Treatment Increases Risk of Preterm Delivery in Future
Pregnancies** [OBJECTIVE]{.underline}: To estimate whether the loop
electrosurgical excision procedure (LEEP) is associated with an adverse
effect on the outcome of subsequent pregnancies.

[METHODS:]{.underline} A retrospective cohort study was performed. The
study group comprised women who had a LEEP in Halifax County between
1992 and 1999 and then had a subsequent singleton pregnancy of greater
than 20 weeks of gestation with delivery at the IWK Health Centre in
Halifax, Nova Scotia. The comparison group comprised women with no
history of cervical surgery who were matched for age, parity, smoking
status, and year of delivery. There were 571 women in each group. The
primary outcome was rate of preterm delivery at less than 37 weeks of
gestation. Secondary outcomes included delivery at less than 34 weeks
and various neonatal and maternal outcomes. The effect of specific LEEP
characteristics was analyzed separately. [RESULTS:]{.underline} Women
who had a LEEP were more likely to deliver preterm overall (7.9% versus
2.5%; odds ratio \[OR\] 3.50, 95% confidence interval \[CI\] 1.90-6.95;
P \< .001) and to deliver preterm after premature rupture of membranes
(PROM) (3.5% versus 0.9%; OR 4.10, 95% CI 1.48-14.09). The increase in
delivery at less than 34 weeks was not statistically significant (1.25%
versus 0.36%; OR 3.50, 95% CI 0.85-23.49; P = .12). Women with LEEP also
delivered more low birth weight (LBW) infants (5.4% versus 1.9%; OR
3.00, 95% CI 1.52-6.46; P = .003). There were no differences in other
neonatal or maternal outcomes. No association was found between the
characteristics of the LEEP, including depth, and the rate of preterm
delivery.

[CONCLUSION]{.underline}: Loop electrosurgical excision procedure is
associated with an increased risk of overall preterm delivery, preterm
delivery after PROM, and LBW infants in subsequent pregnancies at
greater than 20 weeks of gestation. Women who are considering future
pregnancies should be counseled about these risks during informed
consent for LEEP.

LEVEL OF EVIDENCE: II-2.

Samson SL et al The effect of loop electrosurgical excision procedure on
future pregnancy outcome.Obstet Gynecol. 2005 Feb;105(2):325-32.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15684160

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

The above study further develops the literature base that supports that
LEEP is associated with adverse outcomes related to premature delivery
on subsequent pregnancies. See also the CCC Corner 9/04 comments, re:
Sadler 2004.

Patients should be counseled about these risks and providers should
fully outline alternative therapies, which may include careful
observation in many cases. The potential risks of LEEP on future
pregnancies is one more reason that low-grade CIN should followed
closely for a period of time instead of being immediately treated since
most low-grade CIN will spontaneously regress and will not need
treatment (ASCCP). If current therapy is deemed necessary, then
cryotherapy is often a reasonable alternative. njm

**Other resources:**

**ACOG: LEEP Treatment Increases Risk of Preterm Delivery in Future
Pregnancies**

[[https://www.acog.com/from_home/publications/press_releases/nr01-31-05-2.cfm]{.underline}](https://www.acog.com/from_home/publications/press_releases/nr01-31-05-2.cfm)

**CCC Corner 9/04 comments, re: Sadler 2004**

[http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0904_HT.cfm#ob]{.underline}

Sadler L, et al Treatment for cervical intraepithelial neoplasia and
risk of preterm delivery. JAMA. 2004 May 5;291(17):2100-6.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15126438

**Clinical uses of human papillomavirus (HPV) DNA Self Assessment
Booklet: ASCCP**

[[http://www.asccp.org/bookstore.shtml#]{.underline}](http://www.asccp.org/bookstore.shtml)

[[http://www.asccp.org/edu/hpv_testing.shtml]{.underline}](http://www.asccp.org/edu/hpv_testing.shtml)

**From your colleagues:**

**Elaine Locke, ACOG**

**Free Job Postings for Indian Facilities Only on ACOG Career
Connection**

Post your ob-gyn physician jobs for FREE on ACOG's new online career
center. ACOG Career Connection is designed especially for women's health
care professionals and provides job opportunities that are updated
regularly and are targeted specifically to obstetrics and gynecology.
From the ob-gyn's point of view, job searches are free at the ACOG
Career Connection and offer more features and functionality than other
job banks.

Your job posting will be available 24 hours a day, seven days a week to
over 45,000 ACOG members. With ACOG Career Connection you can:

1.  • Post ob-gyn physician jobs for FREE

    • Target your search to women's healthcare professionals

    • Review résumé database

    • Receive candidate responses immediately online

    • Sign up for e-mailed "Résumé Alerts" when résumés meeting your
    criteria are posted

ACOG Career Connection is part of *HEALTH*e**CAREERS** Network, an
integrated Network of healthcare association job banks. You can post
jobs to over 200 disciplines within the Network. This provides a broad
reach for your position to the most qualified candidates -- association
members -- with volume discount pricing. Only ob-gyn physician positions
in AI/AN hospitals listed under the following disciplines will be posted
for free: General Obstetrics & Gynecology; Gynecological Oncology;
Maternal/Fetal Medicine; Reproductive Endocrinology.

Post your jobs today! For more information or to post your ob-gyn
physician position for free, please contact Elaine Locke at 202-863-2596
or e-mail her at [[Elocke@acog.org]{.underline}](mailto:Elocke@acog.org)

**Sandra Haldane, HQE**

**Web portal linking all HHS.gov sites to breast cancer education,
prevention, treatment**

The Dept is developing a web portal linking all HHS.gov sites specific
to breast cancer education, prevention, treatment, etc in accordance
with the Breast Cancer Initiative. The portal will be for providers,
care givers, and those with breast cancer. We need 10 to 12
scenarios/tasks that users will test on the site. For example, in the
Screening and Testing section, a task might be: \'You want to know if
you (or a loved one) can get a free mammography. What information can
you find?\'
[[http://testweb.hhs.gov/breastcancer]{.underline}](http://testweb.hhs.gov/breastcancer)

**Women and Medication Safety: Special Journal Issue Is Available
Online**

The Journal of Women\'s Health has published a special issue on
improving the use and safety of medications in women, which was edited
by Rosaly Correa-de-Araujo, AHRQ\'s Senior Advisor for Women\'s Health.
The articles in this issue were based on discussions at an expert
meeting called by Dr. Correa-de-Araujo to highlight gender differences
in medication use. Topics of the articles include evidence for gender
and racial differences in drug response, the role of biological rhythms
in medication safety for women, geriatric pharmacotherapy, and
strategies for reducing the risk of medication errors in women.
[[http://www.liebertonline.com/toc/jwh/14/1]{.underline}](http://www.liebertonline.com/toc/jwh/14/1)

**Steve Holve, Tuba City**

**February 2005 Indian Child Health Notes - Highlights**

-Well child care was developed to match vaccination schedules

-We agree that well child care is important

-There is unfortunately little data to back up what takes up 25-30% of
our visits

-A review of two articles that suggest it is time to revise well child
care

-Literature review: American Indian children who keep food diaries
[[http://www.ihs.gov/MedicalPrograms/MCH/C/documents/PedNotes0205.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/C/documents/PedNotes0205.doc)

**How common is Methamphetamine use in your area?**

-In your tribal area are there laws that make Methamphetamine production
and use a crime?

-Should all mothers be screened at delivery for Methamphetamine use or
only if medically indicated?

-What resources are available in your community if a pregnant mother is
found

to be using Methamphetamine?

-What resources are available for teenagers and adults who are
Methamphetamine users?

-What programs have shown success in treating Methamphetamine addiction?

There was a moderated discussion on this topic.
[[steve.holve@tcimc.ihs.gov]{.underline}](mailto:steve.holve@tcimc.ihs.gov)

**Background**

[[http://www.ihs.gov/MedicalPrograms/MCH/M/documents/MethPrimer2705.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/MethPrimer2705.doc)

**[Methamphetamine, Word document by Thomas Drouhard,
MD](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/listservmethdocument.rtf)**
[[http://www.ihs.gov/MedicalPrograms/MCH/M/documents/listservmethdocument.rtf]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/listservmethdocument.rtf)

[**Methamphetamine Abuse: Fact or Fiction? PPT by Diana
Hu**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ListservMethPowerpoint.ppt)

[[http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ListservMethPowerpoint.ppt]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ListservMethPowerpoint.ppt)

**Jean Howe, Chinle**

**Announcing the new Deputy Chief Clinical Consultant**

Acting on a directive from the National Council of Chief Clinical
Consultants, we conducted a national search for an OB/GYN Deputy Chief
Clinical Consultant. We had to choose from some excellent candidates,
any of which would have been excellent choices. Kudos to all of them.

I am happy to announce that Jean Howe will become the OB/GYN Deputy
Chief Clinical Consultant. Jean will participate in many of the national
functions of the CCC. I look forward to working her. Originally from
Vermont and trained at the University of Colorado, Dr. Howe has been an
Ob/Gyn at Chinle Hospital for 7 years. She also currently serves as the
Navajo Area Ob/Gyn consultant and will complete an MPH program this May.
Her areas of interest include preventive services, contraception, and
diabetes in pregnancy.
[[Jean.Howe@ihs.gov]{.underline}](mailto:Jean.Howe@ihs.gov)

**Yolanda Meza, Anchorage**

**Routine suctioning of meconium-stained neonates before delivery of
their shoulders?**

[INTERPRETATION]{.underline}: Routine intrapartum oropharyngeal and
nasopharyngeal suctioning of term-gestation infants born through MSAF
does not prevent MAS. Consideration should be given to revision of
present recommendations. Vain NE, et al Oropharyngeal and nasopharyngeal
suctioning of meconium-stained neonates before delivery of their
shoulders: multicentre, randomised controlled trial. Lancet. 2004 Aug
14;364(9434):597-602.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15313360]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15313360)

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

This is the first randomized controlled trial to assess routine
oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates
before delivery of their shoulders. Though the numbers are not large,
each Indian Health facility should re-evaluate this practice as it
reflects on staffing manpower issues at their facility. njm

**[Comments Steve Holve, Pediatric CCC]{.underline}**

Since the report in 1976 by Carson et al the AAP and ACOG have
recommended intrapartum oropharyngeal suctioning of newborns to prevent
meconiium aspiration syndrome. The assumption was that aspiration of
meconium was an intrapartum event. Unfortunately, in recent years there
is good evidence that many, if not all, episodes of severe meconium
aspiration occur in utero and that intrapartum suctioning will not
prevent these infants from developing meconium aspiration syndrome
(MAS).

From the pediatric point of view, there is good evidence (Pediatrics
105:1: 1- 7, 2000\*) that vigorous infants born through meconium stained
fluid are at little risk for MAS and do not need delivery room
intubation by the pediatrican. This study also pointed out that
intubation has risks, though the complications were rare and transient.

**What to do?** Current Neonatal Resuscitation Program guidelines still
recommend intraparutm suctioning of meconium stained infants by the
maternity provider, but no longer recommend delivery room intubation of
meconium stained infants if they are vigorous.

Should the same standard apply to maternity providers? Is there a small
subgroup of infants (those with signs of intrapartum distress such as
flat strips or thick meconium) who might benefit from intrapartum
suctioning of the oropharynx? These issues need to be addressed in the
literature and then applied to local practice guidelines.

\* Wiswell TE, et al Delivery room management of the apparently vigorous
meconium-stained neonate: results of the multicenter, international
collaborative trial. Pediatrics. 2000 Jan;105(1 Pt 1):1-7.
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=10617696&dopt=Abstract]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=10617696&dopt=Abstract)

**Suzan Murphy, Lactation Consultant, PIMC**

**Methamphetamine abuse and breastfeeding**

Dr. Hale et al have indicated that moms with a +UDS for methamphetamine
at delivery may still be able to breastfeed safely because the amount of
methamphetamine that gets into the colostrum is small, and the amount
colostrum that the baby receives is also small, making the
methamphetamine dose negligible. Unfortunately, as the baby grows, the
subsequent use and feedings may be a problem. There has been newspaper
publicity about methamphetamine user's breastfeeding and their babies
dying. It is not yet a clearly understood issue.
[[Suzan.Murphy@ihs.gov]{.underline}](mailto:Suzan.Murphy@ihs.gov)

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

There will be a Primary Care Discussion Forum about Methamphetamine Use
in Indian Country starting April 1, 2005 moderated by Steve Holve. Go
here to subscribe njm

[[http://www.ihs.gov/generalweb/helpcenter/helpdesk/index.cfm?module=listserv&option=subscribe&newquery=1]{.underline}](http://www.ihs.gov/generalweb/helpcenter/helpdesk/index.cfm?module=listserv&option=subscribe&newquery=1)

Or contact [[nmurphy@scf.cc]{.underline}](mailto:nmurphy@scf.cc)

**Chuck North, Albuquerque**

**Patients with more than one medical condition: How can guidelines
help?**

We do pretty well on patients with one disease but increasingly our
patients have multiple diseases as pointed out in the NEJM article
(below). As the number of diseases and conditions increase, the value of
the guidelines decreases and the need for better data is more apparent,
hence our interest in practice based research networks such as RIOS-Net.
AHRQ and Medicare are very interested in the adoption of effective
treatment for the top ten conditions as affecting Medicare
beneficiaries, i.e. heart disease, pneumonia, stroke, diabetes, asthma,
arthritis and depression

[Pitfalls in Disease Specific Guidelines in multiple
conditions](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/guidelinepitfallsnejm.pdf)
, NEJM

[[http://www.ihs.gov/MedicalPrograms/MCH/M/documents/guidelinepitfallsnejm.pdf]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/guidelinepitfallsnejm.pdf)

Other resources.

National Guidelines Clearinghouse
[[www.guidelines.gov]{.underline}](http://www.guidelines.gov/)

Institute for Clinical System Improvement
[[www.icsi.org]{.underline}](http://www.icsi.org/)

[Cochrane Library, clinicially applied topics,
A-Z](http://www.informedhealthonline.org/item.aspx?tabid=3)
[[www.informedhealthonline.org]{.underline}](http://www.informedhealthonline.org/)

Vanderbilt Center for Evidence-Based Medicine
[[www.ebm.vanderbilt.edu]{.underline}](http://www.ebm.vanderbilt.edu/)

Health Affairs, Vol. 24, No.1 devoted to EBM
[[http://www.healthaffairs.org/]{.underline}](http://www.healthaffairs.org/)

**Single digit need to treat (NNT) obesity are remarkable statistics -
should spur us on**

1.  1\. Manage obesity as a chronic relapsing disease

    2\. Use BMI as a vital sign to screen for overweight/obese patients
    and to decide treatment (PPV=97%)

    3\. Modest weight loss (10%) positively affects prevention/treatment
    of hypertension (NNT=3), diabetes (NNT=9) and hyperlipidemia

    4\. Effective treatments exist for overweight/obese patients and a
    combination of diet and exercise provides the best results (NNT=7)

    5\. Counsel patient to achieve a goal of 10% reduction in weight
    (500 to 800 kcal/day decrease to affect 1-2 pound loss/week)

    6\. Counsel patient to exercise to achieve a goal of any increased
    energy expenditure

    7\. Weight loss has an impact on important disease states and risk
    factors. Effective strategies exist for the management of obesity
    when viewed as a chronic relapsing disease.

Orzano AJ, Scott JG.Diagnosis and treatment of obesity in adults: an
applied evidence-based review. J Am Board Fam Pract. 2004
Sep-Oct;17(5):359-69.
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15355950]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15355950)

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

Please note the above resources and many others are available on the
national CCC website and the MCH website njm

Clinical Guidelines: A - Z

[[http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-clinguid.cfm]{.underline}](http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-clinguid.cfm)

Clinical Guidelines: by Organ System

[[http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-organSys.cfm]{.underline}](http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-organSys.cfm)

Clinical Guidelines: Overall Clearinghouses or Agencies

[[http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-clearHouse.cfm]{.underline}](http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-clearHouse.cfm)

Clinical Guidelines: Indian Health Specific

[[http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-guidesA-Z.cfm]{.underline}](http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-guidesA-Z.cfm)

Evidence Based Medicine page -- MCH

[[http://www.ihs.gov/MedicalPrograms/MCH/M/MCHebp.asp]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHebp.asp)

**Lori de Ravello, Albuquerque**

**Contraceptive Methods Among Women: Quickstats**

IThe most frequent contraceptive method among women aged 15\--44 years
was oral contraception. Other leading methods were female sterilization
and the male condom. A smaller, but significant, number of women were
using the newer, long-acting hormonal methods, including injectables,
implants, and the patch.
[[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5406a5.htm]{.underline}](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5406a5.htm)
and

[[http://www.cdc.gov/nchs/nsfg.htm]{.underline}](http://www.cdc.gov/nchs/nsfg.htm).

**Judy Thierry, HQE**

**Discourage use of infant car seats as long term sleep environments**

Although I have not seen the epidemiological data about SIDS deaths
while infants are sitting, it is not uncommon to see an infant in
childcare asleep in the car seat inside the crib.

In keeping with NC child care licensing rules and the legal mandate, we
advise providers to remove infants from the car seat and place the
infants on their back to sleep in the crib.

We also remind providers and ask them to inform the parents:

1\. Sleeping in car seats is a violation of NC child care licensing
rules 2. Car seats were designed for transportation safety, NOT as sleep
environments 3. Car seat manufacturers advise not to leave children
unattended in car seats 4. Not to use the car seat covers (with the hole
cut-out for baby\'s face) made to fit over the entire car seat - dangers
include overheating and suffocation

[Re: respiration]{.underline} 1. We demonstrate how the infant\'s lungs
are compressed when sitting and slumped in a car seat, and do a visual
comparison with back to sleep position on a flat surface in a crib 2. If
the head is leaning forward, the airways are further compressed

Christine O\'Meara, MA, MPH, Campaign Coordinator, North Carolina Back
To Sleep Campaign for SIDS Risk Reduction. North Carolina Healthy Start
Foundation [www.NCHealthyStart.org]{.underline}

**Training for Nursery Room Nurses on Back to Sleep**

The Missouri Department of Health and Senior Services did a survey in
2000 of hospital nursery room nurses to look at how infants were placed
to sleep. The study was published in the May/June 2004 issue of MCN, Vol
29. No. 3.

As a result of this survey, the Department issued an RFP in December
2003 to develop a training for Nursery Room Nurses on Back to Sleep.
CEUs are being given for this program also, and it will also be
available on the internet and on CD Rom. Karen Schenk,
[[SchenK@dhss.mo.gov]{.underline}](mailto:SchenK@dhss.mo.gov)

**Tony Dekker, M.D. New Addiction Medicine Chief Clinical Consultant
(CCC)**

Addiction medicine has just been added as a CCC. Dr. Dekker understands
some of the great burden of substance abuse in the AI/AN community. Dr.
Dekker works at Phoenix Indian Medical Center with Diane Pond who is
also a pain expert Dr. Pond is the Chief of Anesthesia and the IHS Chief
Clinical Consultant for Anesthesia. Here is Dr. Dekker's CCC webpage

[[http://www.ihs.gov/NonMedicalPrograms/NC4/nc4-adctnpn.asp]{.underline}](http://www.ihs.gov/NonMedicalPrograms/NC4/nc4-adctnpn.asp)

**The Chief Clinical consultants - are available for your consultation**

The Chief Clinical consultants - are available for consultation, review
of programs, review of articles, and telephone consultation on their
subject or specialty.

Addiction Medicine, Tony Dekker, PIMC
[[Anthony.Dekker@ihs.gov]{.underline}](mailto:Anthony.Dekker@ihs.gov)

Advance Practice Nurses, Ursula Knoki-Wilson, CNM, Chinle
[[Ursula.Knoki-Wilson@ihs.gov]{.underline}](mailto:Ursula.Knoki-Wilson@ihs.gov)

Anesthesiology, Diane Pond, MD, PIMC
[[Diane.Pond@ihs.gov]{.underline}](mailto:Diane.Pond@ihs.gov)

Family Medicine, Charles North, MD, Albuquerque
[[CNorth@abq.ihs.gov]{.underline}](mailto:CNorth@abq.ihs.gov)

Internal Medicine, Charles (Ty) Reidhead, MD, Whiteriver
[[Charles.Reidhead@ihs.gov]{.underline}](mailto:Charles.Reidhead@ihs.gov)

Nephrology, Andrew Narva, MD, Albuquerque
[[Andrew.Narva@ihs.gov]{.underline}](mailto:Andrew.Narva@ihs.gov)

OB/GYN, Neil Murphy, MD, ANMC [nmurphy@scf.cc]{.underline}

Ophthalmology, James Cox, MD, GIMC
[[James.Cox@ihs.gov]{.underline}](mailto:James.Cox@ihs.gov)

Optometry, Richard Hatch, OD, GIMC
[[Richard.Hatch@ihs.gov]{.underline}](mailto:Richard.Hatch@ihs.gov)

Pediatrics, Steve Holve, MD, Tuba City
[[steve.holve@tcimc.ihs.gov]{.underline}](mailto:steve.holve@tcimc.ihs.gov)

Lois Goode, Physical Therapy, White River
[[Lois.Goode@ihs.gov]{.underline}](mailto:Lois.Goode@ihs.gov)

Physician Assistant, Harry B. Taylor, PA-C, Lawton
[[htaylor@sirinet.net]{.underline}](mailto:htaylor@sirinet.net)

Podiatry, Eugene Dannels, DPM, PIMC
[[Eugene.Dannels@ihs.gov]{.underline}](mailto:Eugene.Dannels@ihs.gov)

Surgery, Hope Baluh, MD, Tahlequah
[[Hope.Baluh@mail.ihs.gov]{.underline}](mailto:Hope.Baluh@mail.ihs.gov)

**What is the definition of 'preventable or avoidable maternal death?**

I am looking for definitions of \"preventable\" or avoidable maternal
death to help guide us in determining how we want to conceptualize
\"preventability\" when it comes to reviewing pregnancy-related deaths.
If any of you have definitions or thoughts you would be willing to share
with me, they would be much appreciated. Judith Thierry
[[Judith.Thierry@ihs.gov]{.underline}](mailto:Judith.Thierry@ihs.gov)

**Native American Outreach: National Partnership to Help Pregnant
Smokers** Women smoke cigarettes for different reasons. Some smoke to
relieve stress or because they think it will help them control their
weight. Younger women may start smoking as a way of rebelling, declaring
their independence, or gaining acceptance by their peers. For Native
American women, tobacco\'s ceremonial role in the community plays a
large part in their decision to begin smoking. American Indians/Alaska
Natives have the highest rates of smoking during pregnancy than any
other ethnic group in the United States. There is a critical need to
reach these women with effective tobacco cessation interventions.

The National Partnership to Help Pregnant Smokers Quit is committed to
reaching out to Native American communities to increase cessation
training for providers and to make resources available where they are
needed the most. Recently, the National Partnership\'s Healthcare
Provider working group completed a needs assessment with American
Indian/Alaska Native healthcare providers to gather information on the
types of culturally appropriate cessation materials they are using.
Contact Catherine Rohweder at
[[rohweder@mail.schsr.unc.edu]{.underline}](mailto:rohweder@mail.schsr.unc.edu)

**SIDS Alliance provides technical assistance: education, outreach and
support**

The National SIDS and Infant Death Program Support Center of First
Candle/SIDS Alliance provides technical assistance to professionals in
managing infant death education, outreach and support. If you are
interested please contact me Judy Thierry 301-443-5070 and I can get you
in touch with Mariam Sokol and Deborah Boyd from First Candle on what we
can do together for a training specific to your area, region. If you
want to contact them directly they can be reached at: FirstCandle
[[http://www.firstcandle.org/about/staff.html]{.underline}](http://www.firstcandle.org/about/staff.html)

**AAP - Child Care provider ppt presentation and manual**

20% access rate of SIDS in Child Care settings. Slides
[[http://www.healthychildcare.org/PPT/256]{.underline}](http://www.healthychildcare.org/PPT/256)

AAP/ NICHD - Child care provider training manual
[[http://www.healthychildcare.org/pdf/SIDSfinal.pdf]{.underline}](http://www.healthychildcare.org/pdf/SIDSfinal.pdf)

**AAP: Child Care providers on back to sleep**

[[http://www.healthychildcare.org/pdf/summer2000hcca.pdf]{.underline}](http://www.healthychildcare.org/pdf/summer2000hcca.pdf)

**[Asthma card - Child
care](http://www.aafa.org/pdfs/childcard_allergyaction_card.pdf),
Allergy and Asthma Foundation of America**

[[http://www.aafa.org/pdfs/childcard_allergyaction_card.pdf]{.underline}](http://www.aafa.org/pdfs/childcard_allergyaction_card.pdf)

**Proper way of infant being placed to sleep -- Avoid SIDS**

CJSIDS foundation has two AI/AN video\'s of infants being placed to
sleep [[www.cjsids.com]{.underline}](http://www.cjsids.com/)

**WONDER now has natality data you can query**

[[http://wonder.cdc.gov/nataJ.html]{.underline}](http://wonder.cdc.gov/nataJ.html)

**NFIMR poster - web site with good PDF**

I sent out a link to the poster that was not as good of quality as these
from the Commonwealth

directly -- I spoke with them by phone. Their walk through the web site
is worth the trip

Click on "ccpc" and then click on "public health education".
[[http://www.vcu.edu/ccpc/]{.underline}](http://www.vcu.edu/ccpc/)

**Judy Whitecrane, Phoenix**

**It makes it easy for moms to remember: 2 days, 2 weeks, and 2 months**

At PIMC, We have a 2 day and 2 week infant check by peds. Then there is
a 2 month Mom-Baby clinic with CNM\'s doing postpartum and pediatricians
doing well-baby.

**Hot Topics:**

**Obstetrics**

**Severe Preeclampsia and Eclampsia: Systolic Hypertension Is Also
Important**

CONCLUSION: In contrast to severe systolic hypertension, severe
diastolic hypertension does not develop before stroke in most patients
with severe preeclampsia and eclampsia. A paradigm shift is needed
toward considering antihypertensive therapy for severely preeclamptic
and eclamptic patients when systolic blood pressure reaches or exceeds
155-160 mm Hg. LEVEL OF EVIDENCE: III. Martin JN Stroke and severe
preeclampsia and eclampsia: a paradigm shift focusing on systolic blood
pressure. Obstet Gynecol. 2005 Feb;105(2):246-54.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684147&dopt=Abstract]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684147&dopt=Abstract)

**Editorial**

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684145&dopt=Abstract]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684145&dopt=Abstract)

**Progesterone Treatment Decreases Preterm Birth Rate**

CONCLUSION: Use of 17P could reduce preterm birth among eligible women,
but would likely have a modest effect on the national preterm birth
rate. Additional research is urgently needed to identify other
populations who might benefit from 17P, evaluate new methods for early
detection of women at risk, and develop additional prevention
strategies. LEVEL OF EVIDENCE: III.

Petrini JR, et al Estimated effect of 17 alpha-hydroxyprogesterone
caproate on preterm birth in the United States. Obstet Gynecol. 2005
Feb;105(2):267-72.
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684150&dopt=Abstract]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684150&dopt=Abstract)

and

CONCLUSION: The use of progestational agents and
17alpha-hydroxyprogesterone caproate reduced the incidence of preterm
birth and low birth weight newborns.

Sanchez-Ramos L et al Progestational agents to prevent preterm birth: a
meta-analysis of randomized controlled trials. Obstet Gynecol. 2005
Feb;105(2):273-9.
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684151&dopt=Abstract]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684151&dopt=Abstract)

and

**ACOG: Progesterone Treatment Decreases Preterm Birth Rate**

[[https://www.acog.com/from_home/publications/press_releases/nr01-31-05-1.cfm]{.underline}](https://www.acog.com/from_home/publications/press_releases/nr01-31-05-1.cfm)

**Ripening of the Cervix and Risk for Later Preterm Birth**

CONCLUSION: The use of the Foley catheter for preinduction cervical
ripening does not appear to increase the risk of preterm birth in a
subsequent pregnancy.

Sciscione A et al Preinduction cervical ripening with the Foley catheter
and the risk of subsequent preterm birth. Am J Obstet Gynecol. 2004
Mar;190(3):751-4.
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15042009]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15042009)

**Ginger May Relieve Nausea During Early Pregnancy**

CONCLUSION: For women looking for relief from their nausea, dry
retching, and vomiting, the use of ginger in early pregnancy will reduce
their symptoms to an equivalent extent as vitamin B6. LEVEL OF EVIDENCE:
I Smith C, et al. A randomized controlled trial of ginger to treat
nausea and vomiting in pregnancy. Obstet Gynecol April 2004;103:639-45.
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15051552]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15051552)

**Effect of Episiotomy on Pelvic Floor Weakness**

CONCLUSION: Mediolateral episiotomy does not protect against urinary and
anal incontinence and genital prolapse and is associated with a lower
pelvic floor muscle strength compared with spontaneous perineal
lacerations and with more dyspareunia and perineal pain. LEVEL OF
EVIDENCE: II-2 Sartore A, et al. The effects of mediolateral episiotomy
on pelvic floor function after vaginal delivery. Obstet Gynecol April
2004;103:669-73.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15051557]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15051557)

**Role of Regular Physical Activity in Preeclampsia Prevention**

Abnormal placental development, predisposing maternal constitutional
factors, oxidative stress, immune maladaptation, and genetic
susceptibility have all been hypothesized to contribute to the
development of preeclampsia. Physical conditioning and preeclampsia have
opposite effects on critical physiological functions. This suggests that
regular prenatal exercise may prevent or oppose the progression of the
disease. Epidemiologic studies show that occupational and leisure-time
physical activity is associated with a reduced incidence of
preeclampsia.

Weissgerber TL et al The role of regular physical activity in
preeclampsia prevention. Med Sci Sports Exerc. 2004 Dec;36(12):2024-31.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15570135]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15570135)

**Subclinical hypothyroidism: should all pregnant women be screened?**

CONCLUSION: We speculate that the previously reported reduction in
intelligence quotient of offspring of women with subclinical
hypothyroidism may be related to the effects of prematurity. LEVEL OF
EVIDENCE: II-2. Casey BM, et al Subclinical hypothyroidism and pregnancy
outcomes. Obstet Gynecol. 2005 Feb;105(2):239-45.
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684146&dopt=Abstract]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684146&dopt=Abstract)

**Editorial**

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684144&dopt=Abstract]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684144&dopt=Abstract)

### **Diagnosis, Prevention, and Management of Eclampsia** 

## The development of eclampsia is associated with increased risk of adverse outcome for both mother and fetus, particularly in the developing nations. Pregnancies complicated by eclampsia require a well-formulated management plan. Women with a history of eclampsia are at increased risk of eclampsia (1-2%) and preeclampsia (22-35%) in subsequent pregnancies. Recommendations for diagnosis, prevention, management, and counseling of these women are provided based on results of recent studies and my own clinical experience. 

Sibai, BM. Diagnosis, Prevention, and Management of Eclampsia Obstet
Gynecol. 2005 Feb;105(2):402-10.
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684172&dopt=Abstract]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684172&dopt=Abstract)

**Pregnancy Outcomes Worsening for Diabetic Women**

CONCLUSIONS: The perinatal outcome of pregnancies in women with type 2
diabetes during 1996-2001 is poor. It is worse than the outcome of
pregnancies in women with type 1 diabetes and the background population
in the same period, as well as in women with type 2 diabetes studied
during 1982-1990. Clausen TD, et al Poor pregnancy outcome in women with
type 2 diabetes. Diabetes Care. 2005 Feb;28(2):323-8

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15677787]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15677787)

**Heavy mother, heavy child**

CONCLUSION: Anthropometric measures were not significantly different
between groups at year 2; weight and lean body mass were greater at
years 4 and 6, and fat mass was greater at year 6 in high-risk children.
Berkowitz RI, et al Growth of children at high risk of obesity during
the first 6 years of life: implications for prevention. Am J Clin Nutr.
2005 Jan;81(1):140-6.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15640473]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15640473)

**Substances Found in Blood May Predict Development of Preeclampsia**

Abnormal levels of two molecules found in the blood appear to predict
the development of preeclampsia. When compared to women who did not have
preeclampsia, women who later developed the condition had elevated blood
levels of a substance known as soluble fms-like tyrosine kinase 1
(sFlt-1), before their preeclampsia occurred. Conversely, beginning
early in their pregnancies, these women had lower levels of a substance
known as placental growth factor (PlGF) in the blood than did women who
did not develop preeclampsia.

[http://www.nichd.nih.gov/new/releases/preeclampsia.cfm#nejm]{.underline}

**Pain Management After Cesarean Delivery**

CONCLUSION: Pain relief was superior with the morphine regimens used and
was positively associated with breastfeeding and infant rooming-in.

Yost NP, et al. A hospital-sponsored quality improvement study of pain
management after cesarean delivery. Am J Obstet Gynecol May
2004;190:1341-6.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15167840]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15167840)

**Neural Tube Defect Risk Persists in Babies of Overweight Mothers**

CONCLUSION: These data emphasize the higher risk of NTD associated with
increased maternal weight, even after universal folic acid flour
fortification. Beyond periconceptional folic acid use, consideration
should be given to testing whether prepregnancy weight reduction is an
independent means of preventing NTD. Ray JG, et al Greater maternal
weight and the ongoing risk of neural tube defects after folic acid
flour fortification. Obstet Gynecol. 2005 Feb;105(2):261-5.
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684149&dopt=Abstract]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684149&dopt=Abstract)

**Gynecology**

**Sexual Function After Hysterectomy**

CONCLUSION: Most patients expected and experienced no change in sexual
desire, orgasm frequency, or orgasm intensity. Hysterectomy appears to
result in decreased pain with sexual relations. Dragisic KG, Milad MP.
Sexual functioning and patient expectations of sexual functioning after
hysterectomy. Am J Obstet Gynecol May 2004;190:1416-8.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15167854]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15167854)

**Screening for Ovarian Cancer: Recommendation Statement**

U.S. PREVENTIVE SERVICES TASK FORCE: SUMMARY OF RECOMMENDATIONS

The USPSTF recommends against routine screening for ovarian cancer. **D
recommendation.**

The USPSTF found fair evidence that screening with serum CA-125 level or
transvaginal ultrasound can detect ovarian cancer at an earlier stage
than it can be detected in the absence of screening; however, the USPSTF
found fair evidence that earlier detection would likely have a small
effect, at best, on mortality from ovarian cancer. Because of the low
prevalence of ovarian cancer and the invasive nature of diagnostic
testing after a positive screening test, there is fair evidence that
screening could likely lead to important harms. The USPSTF concluded
that the potential harms outweigh the potential benefits.

[[HTTP://WWW.AAFP.ORG/AFP/20050215/US.HTML]{.underline}](http://www.aafp.org/afp/20050215/us.html)

**Limitations of Screening Tests for Asymptomatic Chlamydia**

CONCLUSION: When C. trachomatis infection was defined by multiple tests
from different specimen sources, the sensitivity of any 1 test from a
single specimen source was lower than generally reported. The
limitations of the use of a single test to identify C. trachomatis
infection should be considered when test type, specimen source, and
collection method for screening young women is being determined.

Shrier LA, et al. Limitations of screening tests for the detection of
Chlamydia trachomatis in asymptomatic adolescent and young adult women.
Am J Obstet Gynecol March 2004;190:654-62.
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15041995]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15041995)

**Abnormal Uterine Bleeding: Surgical or Medical Therapy?**

CONCLUSIONS: Among women with abnormal uterine bleeding and
dissatisfaction with medroxyprogesterone, hysterectomy was superior to
expanded medical treatment for improving health-related quality-of-life
after 6 months. With longer follow-up, half the women randomized to
medicine elected to undergo hysterectomy, with similar and lasting
quality-of-life improvements; those who continued medical treatment also
reported some improvements.

Kuppermann M, et al., for the Ms Research Group. Effect of hysterectomy
vs medical treatment on health-related quality of life and sexual
functioning. The medicine or surgery (Ms) randomized trial. JAMA March
24/31, 2004;291:1447-55.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15039411]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15039411)

**Endometriosis and Subfertility: Is the Relationship Resolved?**

#### Conclusion: Based on the evidence presented in this article, many arguments support the hypothesis that endometriosis causes subfertility. D\'Hooghe TM et al Endometriosis and subfertility: is the relationship resolved? Semin Reprod Med. 2003 May;21(2):243-54. 

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12917793]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12917793)

**Selecting Medications for the Treatment of Urinary Incontinence (also
Patient Education)**

[[http://www.aafp.org/afp/20050115/315.html]{.underline}](http://www.aafp.org/afp/20050115/315.html)

**Dysmenorrhea (also see Patient Education)**

[[http://www.aafp.org/afp/20050115/285.html]{.underline}](http://www.aafp.org/afp/20050115/285.html)

**Procedural Sedation in the Acute Care Setting**

[[http://www.aafp.org/afp/20050101/85.html]{.underline}](http://www.aafp.org/afp/20050101/85.html)

**Child Health**

**Gender bias in child growth evaluations may miss disease in girls**

CONCLUSIONS: Sex differences in short stature referrals may delay
diagnosis of diseases in girls while promoting overzealous evaluations
of healthy boys who do not appear to be tall enough. Grimberg A, et al
Sex differences in patients referred for evaluation of poor growth. J
Pediatr. 2005 Feb;146(2):212-6.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15689911]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15689911)

**Recommended Childhood and Adolescent Immunization Schedule, United
States, 2005**

CDC National Immunization Program Web site
([[http://www.cdc.gov/nip]{.underline}](http://www.cdc.gov/nip))

AAFP Web site
([[http://www.aafp.org/x10615.xml]{.underline}](http://www.aafp.org/x10615.xml))

Society of Teachers of Family Medicine
([[http://www.immunizationed.org]{.underline}](http://www.immunizationed.org/)),

Immunization Action Coalition Web site
([[http://www.immunize.org]{.underline}](http://www.immunize.org/));

National Network for Immunization Information Web site
([[http://www.immunizationinfo.org]{.underline}](http://www.immunizationinfo.org/)).

**Protective effects of firearm storage practices for children**

The 4 specific practices of keeping a gun locked, unloaded, and storing
ammunition locked and in a separate location were associated with a
protective effect and suggest feasible strategies to reduce these types
of injuries in homes with children and adolescents where guns are
stored.

Grossman DC, Mueller BA, Riedy C, et al. 2005. Gun storage practices and
risk of youth suicide and unintentional firearm injuries. JAMA, The
Journal of the American Medical Association 293(6):707-714.
[[http://jama.ama-assn.org/cgi/content/abstract/293/6/707?etoc]{.underline}](http://jama.ama-assn.org/cgi/content/abstract/293/6/707?etoc).

**Dramatic decline in varicella related mortality: Impact of vaccine**

After the universal childhood varicella vaccination program was
implemented in 1995, the incidence of disease in the United States
declined by 71% to 84% by 2000 in areas of active surveillance and by
67% to 82% by 2001 in areas of passive surveillance

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15689583&dopt=Abstract]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15689583&dopt=Abstract)

**Oral health is looking to better capture the topical fluoride
applications**

Are you and or your non-dental provider staff using this code? If not
which one are you using? Please email Patrick Blahut
[[Patrick.Blahut@ihs.gov]{.underline}](mailto:Patrick.Blahut@ihs.gov)

ICD-9 Code ICD-9 Code Description

V07.31 NEED FOR PROPHYLACTIC FLUORIDE ADMINISTRATION

**Chronic disease and Illness**

**Quality of Care May Decline as Physicians Age**

CONCLUSIONS: Physicians who have been in practice longer may be at risk
for providing lower-quality care. Therefore, this subgroup of physicians
may need quality improvement interventions. Choudhry NK, et al
Systematic review: the relationship between clinical experience and
quality of health care. Ann Intern Med. 2005 Feb 15;142(4):260-73.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15710959]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15710959)

**Chronic disease** **antecedents arise in utero and infancy: The Barker
Hypothesis**

Fetal Infant Mortality (NFIMR) conference in August plenary session by
Dr. Michael Lu presented birth outcomes that you will find provocative
and insightful. It focuses primarily on White and African American
differences and includes AI/AN population in the graphs to a certain
extent.

Dr. Lu introduces a model of life trajactory, \"the weathering factor\",
and the Barker Hypothesis calling attention to the multifactoral nature
of birth outcomes and that there is no one easy fix.
[[http://128.248.232.90/archives/mchb/dpswh/august2004/dpswhaugust2004slides.pdf]{.underline}](http://128.248.232.90/archives/mchb/dpswh/august2004/dpswhaugust2004slides.pdf)

Medscape article on the Barker Hypothesis:

[[http://www.medscape.com/viewarticle/453242_print]{.underline}](http://www.medscape.com/viewarticle/453242_print)

**JAMA Editorialist recommends the \"low fad\" approach**

CONCLUSIONS: Each popular diet modestly reduced body weight and several
cardiac risk factors at 1 year. Overall dietary adherence rates were
low, although increased adherence was associated with greater weight
loss and cardiac risk factor reductions for each diet group.

Dansinger ML et al Comparison of the Atkins, Ornish, Weight Watchers,
and Zone diets for weight loss and heart disease risk reduction: a
randomized trial**.** JAMA. 2005 Jan 5;293(1):43-53.
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15632335]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15632335)

**The dietary approach to obesity: is it the diet or the disorder?**

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15632342]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15632342)

**Book Review**

**Diabetes Mellitus in Women: Adolescence Through Pregnancy and
Menopause**

Third edition. Edited by E. Albert Reece, Donald R. Coustan, and Steven
G. Gabbe. 492 pp., illustrated. Philadelphia, Lippincott Williams &
Wilkins, 2004. \$99. ISBN 0-7817-3861-X.

[[http://content.nejm.org/cgi/content/extract/352/6/638]{.underline}](http://content.nejm.org/cgi/content/extract/352/6/638)

**Irritable Bowel Syndrome: What are the effects of treatments in people
with irritable bowel syndrome (IBS)? Clinical Evidence Concise: A
Publication of BMJ Publishing Group**

**A. Likely to be beneficial**

**Antidepressants** (Amitriptyline, Clomipramine, Desipramine, Doxepin,
Mianserin, Trimipramine). One systematic review found limited evidence
from low to moderate quality randomized controlled trials (RCTs) that
antidepressants (amitriptyline, clomipramine, desipramine, doxepin,
mianserin, trimipramine) reduced symptoms of IBS compared with placebo
in the short term. It was not clear whether the effects on IBS were
independent of the effects on psychological symptoms.

**Smooth Muscle Relaxants** (Cimetropium Bromide, Hyoscine Butyl
Bromide, Mebeverine Hydrochloride, Otilonium Bromide, Pinaverium
Bromide, Trimebutine). One systematic review found limited evidence that
smooth muscle relaxants (cimetropium bromide, hyoscine butyl bromide,
mebeverine hydrochloride, otilonium bromide, pinaverium bromide,
trimebutine) improved symptoms compared with placebo. One subsequent RCT
found no significant difference between alverine and placebo in
improvement in abdominal pain, although the study may have lacked power
to exclude a clinically important effect. One RCT identified by a
systematic review found that mebeverine was less effective for symptoms
than alosetron in women with diarrhea-predominant IBS, although there
are concerns that alosetron may be associated with ischemic colitis.

**B. Trade-off between benefits and harms**

**5HT~4~ Receptor Agonists** (Tegaserod). One systematic review found
that in women with constipation-predominant IBS, tegaserod improved
symptoms compared with placebo. It found insufficient evidence about the
effects of tegaserod in men. Tegaserod was more likely to cause diarrhea
than placebo.

**Alosetron**. One systematic review found that alosetron (a 5HT~3~
receptor antagonist) improved symptoms in women with
diarrhea-predominant IBS compared with placebo or mebeverine. However,
alosetron is associated with adverse effects, particularly constipation,
and has been restricted in some countries because of concerns that it
may be associated with ischemic colitis. The systematic review provided
insufficient evidence about the effects of alosetron in men.

unknown effectiveness

**5HT~3~ Receptor Antagonists** Other Than Alosetron. We found no RCTs
examining 5HT~3~ receptor antagonists other than alosetron.

**Fiber Supplementation**. Small RCTs provided insufficient evidence on
the effects of fiber supplementation on the symptoms of IBS.
[[http://www.aafp.org/afp/20050201/bmj.html]{.underline}](http://www.aafp.org/afp/20050201/bmj.html)

**Definition of Metabolic Syndrome**

There has been disagreement in the medical community over the definition
of the metabolic syndrome. The National Heart, Lung, and Blood Institute
collaborated with the American Heart Association to examine the issues
associated with the definition.

The metabolic syndrome seems to have three potential etiologies: obesity
and disorders of adipose tissue; insulin resistance; and a constellation
of independent factors (e.g., molecules of hepatic, vascular, and
immunologic origin) that mediate specific components of the metabolic
syndrome. Other factors such as aging, proinflammatory state, and
hormonal changes also have been implicated.

The clinical criteria for the diagnosis of metabolic syndrome, as
defined in the National Cholesterol Education Program\'s Adult Treatment
Panel III (ATP III) report, include waist circumference of more than 102
cm (40 in) in men and more than 88 cm (35 in) in women; triglyceride
levels of at least 150 mg per dL (1.70 mmol per L); high-density
lipoprotein cholesterol levels of less than 40 mg per dL (1.04 mmol per
L) in men and less than 50 mg per dL (1.30 mmol per L) in women; blood
pressure of at least 130/85 mm Hg; and fasting glucose levels of at
least 110 mg per dL (6.10 mmol per L).

ATP III did not include impaired glucose tolerance, as detected by an
oral glucose tolerance test (OGTT) or two-hour postglucose challenge, in
the risk factors for metabolic syndrome. Its added value for determining
cardiovascular risk appears small, and the benefit did not outweigh the
inconvenience and cost of administering the OGTT in clinical practice.
However, conference participants suggested adding OGTT at the
physician\'s discretion in patients without diabetes with ATP
III-defined metabolic syndrome or two or more metabolic risk factors. In
the absence of impaired fasting glucose, impaired glucose tolerance
could count as a risk factor to define metabolic syndrome. Their report
is available online at
[[http://www.circulationaha.org]{.underline}](http://www.circulationaha.org/)

**Benefits of Omega-3 Fatty Acids**

Consumption of fish oil can help reduce deaths from heart disease, but
its effects on other outcomes are inconclusive, according to evidence
reports from the Agency for Healthcare Research and Quality (AHRQ).
[http://www.ahrq.gov/clinic/epcindex.htm#dietsup]{.underline}.

An analysis of 10 randomized controlled trials (RCTs) and nine other
studies addressed the effects of omega-3 fatty acids on respiratory
outcomes. The AHRQ could not conclude whether omega-3 fatty acids are an
efficacious adjuvant or monotherapy in improving respiratory outcomes in
adults or children.

Overall, strong evidence shows that fish oils have a strong,
dose-dependent beneficial effect on triglyceride levels. There also is
evidence of possible small beneficial effects on blood pressure and
coronary artery restenosis after angioplasty, exercise capacity in
patients with coronary atherosclerosis, and heart rate variability,
particularly in patients with recent MI. Omega-3 fatty acids do not
appear to affect total cholesterol, high-density lipoprotein
cholesterol, low-density lipoprotein cholesterol, fasting blood sugar,
or glycosylated hemoglobin levels, and they had no effect on plasma
insulin levels and insulin resistance in patients with type 2 diabetes.

[[http://www.aafp.org/afp/20050115/practice.html]{.underline}](http://www.aafp.org/afp/20050115/practice.html)

**Red meat consumption linked to colorectal cancer**

CONCLUSIONS: Our results demonstrate the potential value of examining
long-term meat consumption in assessing cancer risk and strengthen the
evidence that prolonged high consumption of red and processed meat may
increase the risk of cancer in the distal portion of the large
intestine.

Chao A et al Meat consumption and risk of colorectal cancer. JAMA. 2005
Jan 12;293(2):172-82.
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15644544]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15644544)

Comment

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15644551]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15644551)

**Sugar-Sweetened Soft Drinks, Obesity, and Type 2 Diabetes**

CONCLUSION: Higher consumption of sugar-sweetened beverages is
associated with a greater magnitude of weight gain and an increased risk
for development of type 2 diabetes in women, possibly by providing
excessive calories and large amounts of rapidly absorbable sugars.

Schulze MB et al Sugar-sweetened beverages, weight gain, and incidence
of type 2 diabetes in young and middle-aged women. JAMA. 2004 Aug
25;292(8):927-34.
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15328324]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15328324)

[Comment]{.underline}:

Sugar-sweetened soft drinks contribute 7.1% of total energy intake and
represent the largest single food source of calories in the US diet. The
article by Schulze and colleagues in this issue of *JAMA* represents
another link in the chain of evidence. This study provides additional
evidence that excess calories from sugar-sweetened soft drinks are
responsible for the increasing prevalence of obesity among adults and
also implicates sugar-sweetened soft drinks as a cause of type 2
diabetes. Apovian CM. Sugar-sweetened soft drinks, obesity, and type 2
diabetes. JAMA. 2004 Aug 25;292(8):978-9
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15328331]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15328331)

**Nevirapine Alert (Viramune) - Serious liver toxicity with CD4+cell
counts greater than 250**

FDA issued a public health advisory to inform health care providers and
patients about recent

safety-related changes to the nevirapine (Viramune) label and about
appropriate use of HIV triple combination therapy containing nevirapine.
The Indications and Usage section now recommends

against starting nevirapine treatment in women with CD4+cell counts
greater than 250 cells/mm3 unless benefits clearly outweigh risks. This
recommendation is based on a higher observed risk of serious liver
toxicity in patients with higher CD4 cell counts prior to initiation of
therapy.

[http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#viramune]{.underline}

**Mayo Clinic discovers a key to low metabolism \-- and major factor in
obesity**

Obesity occurs when energy intake exceeds energy expenditure. Humans
expend energy through purposeful exercise and through changes in posture
and movement that are associated with the routines of daily life
**\[called nonexercise activity thermogenesis (NEAT)\].** To examine
NEAT\'s role in obesity, we recruited 10 lean and 10 mildly obese
sedentary volunteers and measured their body postures and movements
every half-second for 10 days. Obese individuals were seated, on
average, 2 hours longer per day than lean individuals. Posture
allocation did not change when the obese individuals lost weight or when
lean individuals gained weight, suggesting that it is biologically
determined. If obese individuals adopted the NEAT-enhanced behaviors of
their lean counterparts, they might expend an additional 350 calories
(kcal) per day.

Levine JA, et al Interindividual variation in posture allocation:
possible role in human obesity. Science. 2005 Jan 28;307(5709):584-6.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15681386]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15681386)

**C-Reactive Protein Comparable to LDL as an Indicator**

CONCLUSIONS: Patients who have low CRP levels after statin therapy have
better clinical outcomes than those with higher CRP levels, regardless
of the resultant level of LDL cholesterol. Strategies to lower
cardiovascular risk with statins should include monitoring CRP as well
as cholesterol. Ridker PM, et al C-reactive protein levels and outcomes
after statin therapy. N Engl J Med. 2005 Jan 6;352(1):20-8.
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15635109]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15635109)

**Diagnostic Approach to Palpitations (See Patient Education)**

[[http://www.aafp.org/afp/20050215/743.html]{.underline}](http://www.aafp.org/afp/20050215/743.html)

**ACG Releases Updated Practice Guidelines for Ulcerative Colitis in
Adults**

[[http://www.aafp.org/afp/20050201/practice.html]{.underline}](http://www.aafp.org/afp/20050201/practice.html)

**Guidelines for Cardiovascular Disease Prevention in Women**

[[http://www.aafp.org/afp/20050201/practice.html]{.underline}](http://www.aafp.org/afp/20050201/practice.html)

**Antidepressants and Antiepileptic Drugs for Chronic Non-Cancer Pain**

[[http://www.aafp.org/afp/20050201/483.html]{.underline}](http://www.aafp.org/afp/20050201/483.html)

**Ambulatory Detoxification of Patients with Alcohol Dependence (See
Patient Education)**

[[http://www.aafp.org/afp/20050201/495.html]{.underline}](http://www.aafp.org/afp/20050201/495.html)

**Treatment of Panic Disorder (See Patient Education)**

[[http://www.aafp.org/afp/20050215/733.html]{.underline}](http://www.aafp.org/afp/20050215/733.html)

**Care of Cancer Survivors (See Patient Education)**

[[http://www.aafp.org/afp/20050215/699.html]{.underline}](http://www.aafp.org/afp/20050215/699.html)

**Features**

**American Family Physician\*\***

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

**Radio-Frequency Endometrial Ablation for Menorrhagia**

**Clinical Question:** Is radio-frequency endometrial ablation more
effective than balloon ablation for the treatment of menorrhagia?

**Bottom Line:** Amenorrhea is achieved more often with radio-frequency
endometrial ablation than with hot-water balloon ablation. Women tend to
be more satisfied with the radio-frequency technique one year after
therapy. A reassessment of the treated women after a longer follow-up
period is needed. (Level of Evidence: 1b-)

[[http://www.aafp.org/afp/20050201/tips/26.html]{.underline}](http://www.aafp.org/afp/20050201/tips/26.html)

**Esterified Estrogen and Venous Thrombotic Risk**

**Clinical Question:** Do different formulations of estrogen similarly
increase the risk of venous thrombosis?

**Bottom Line:** Oral therapy with conjugated equine estrogen is
associated with an increased risk of venous thrombosis in a
dose-dependent fashion during the time the woman takes it. Concomitant
use of medroxyprogesterone further increases the venous thrombosis risk.
Esterified estrogen does not appear to increase venous thrombosis risk.
Until more reliable data are available from prospective comparison
trials, it makes sense to strongly consider prescribing esterified
estrogen to control symptoms in perimenopausal and postmenopausal women.
(Level of Evidence: 3b)

[[http://www.aafp.org/afp/20050201/tips/27.html]{.underline}](http://www.aafp.org/afp/20050201/tips/27.html)

**Physical Therapy and Stress Urinary Incontinence**

**Clinical Question**: Can physical therapy cure stress urinary
incontinence in women with symptoms persisting longer than three months
postpartum?

###### **Bottom Line:** Eight weekly sessions of pelvic floor muscle physiotherapy, including electrical stimulation and biofeedback exercises, cured stress urinary incontinence in 70 percent of the treated women. None of the control patients who received massage only was cured. Instructions for a home exercise program alone, is usual care and would have been a better control intervention. (Level of Evidence: 1b) 

[[http://www.aafp.org/afp/20050101/tips/23.html]{.underline}](http://www.aafp.org/afp/20050101/tips/23.html)

**Lactobacillus Does Not Prevent Post-Antibiotic Vaginitis**

**Clinical Question:** Can lactobacillus preparations, given orally,
vaginally, or both, prevent post-antibiotic vaginal candidiasis?

**Bottom Line:** Lactobacillus, given orally, vaginally, or both, has no
effect on the development of culture-proven vaginal candidiasis.
Lactobacillus probiotics are effective, however, in decreasing
antibiotic-associated diarrhea

(Level of Evidence: 1b)

[[http://www.aafp.org/afp/20050115/tips/24.html]{.underline}](http://www.aafp.org/afp/20050115/tips/24.html)

###### **Cochrane for Clinicians- AFP** 

**Antidepressants and Smoking Cessation**

**Clinical Question**

Which antidepressants help patients stop smoking?

**Evidence-Based Answer**

Bupropion and nortriptyline increase the likelihood of smoking
cessation, but selective serotonin reuptake inhibitors (SSRIs) do not.

**Practice Pointers**

The U.S. Preventive Services Task Force^1^ and U.S. Department of Health
and Human Services^2^ recommend that physicians screen all adults for
tobacco use and recommend intervention for those who report using
tobacco products. There is good evidence that brief behavioral
counseling and pharmacotherapy increase rates of abstinence. More
intensive counseling has a dose-response relationship, with more minutes
of contact producing better results. Nicotine replacement and bupropion
have been approved by the U.S. Food and Drug Administration for use in
smoking cessation.
[[http://www.aafp.org/afp/20050101/cochrane.html]{.underline}](http://www.aafp.org/afp/20050101/cochrane.html)

**Spinal Manipulative Therapy for Low Back Pain**

**Clinical Scenario**

A 42-year-old woman presents with low back pain that started after she
had moved furniture a week earlier. She wants pain relief as quickly as
possible and asks if she should go to a chiropractor.

**Clinical Question**

Should we recommend spinal manipulation as a treatment for low back
pain?

**Evidence-Based Answer**

In the short term, manipulative therapy is as effective for acute or
chronic low back pain as other treatments such as analgesics, physical
therapy, exercises, back school, and routine care from a primary care
physician. Radiation of pain, type of manipulation, and use of multiple
modalities do not alter these results.
[[http://www.aafp.org/afp/20050201/cochrane.html]{.underline}](http://www.aafp.org/afp/20050201/cochrane.html)

**Efficacy of Antioxidants in GI Cancer Prevention**

**Clinical Question**

Does supplementation with antioxidant vitamins prevent gastrointestinal
(GI) cancer?

**Evidence-Based Answer**

There is no evidence that supplementation with beta carotene or vitamins
A, C, or E prevents GI cancer. Data for selenium is inconsistent and
based on poor-quality studies, and supplementation with this mineral
should not be recommended routinely. Most importantly, combinations of
antioxidant vitamins appear slightly to increase overall mortality
rates.

[[http://www.aafp.org/afp/20050201/cochrane.html]{.underline}](http://www.aafp.org/afp/20050201/cochrane.html)

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

**Coping With the Stress of Medical Professional Liability Litigation**

Obstetrician--gynecologists should recognize that being a defendant in a
medical professional liability lawsuit can be one of life\'s most
stressful experiences. Coping with the stress of medical professional
liability litigation is an ongoing, complex process in which physicians
often must struggle to regain a sense of professional mastery and
control of their practices. Open communication with family members will
assist in reducing emotional isolation and self-blame; however, legal
and clinical aspects of a case must be kept confidential. Peer support
and individual professional counseling can be of great benefit. Rapid
intervention facilitates healthier coping strategies and can restore a
sense of equilibrium and self-esteem during an unpredictable time.

**Non-ACOG members**

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15684197]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15684197)

**ACOG Members**

[[http://www.acog.org/publications/committee_opinions/co309.cfm]{.underline}](http://www.acog.org/publications/committee_opinions/co309.cfm)

**AHRQ**

**Computerized Order Entry Leads to Unwanted Testing**

**Web M + M - Clinical Ethics**

Mrs. G visited her obstetrician for first trimester routine prenatal
care. The obstetrician offered genetic testing for a variety of
conditions, including Tay-Sachs and Canavan\'s diseases, since both Mrs.
G and her husband, a healthy 35-year-old physician, were of Ashkenazi
Jewish descent. Mrs. G consented to be tested and told the obstetrician
that she would discuss with her husband that evening whether he wanted
to have the genetic tests. The obstetrician gave Mrs. G consent forms
and information to take home to her husband. The obstetrician also
entered laboratory test orders in the computerized order entry system
for the genetic screening panel for both Mrs. G, since she had consented
to be tested, and for Dr. G, assuming he would consent to be tested.
However, the obstetrician did not mention this to Mrs. G.

At home that evening, Dr. G reviewed the materials and told his wife
that he definitely did not want to be tested. Several weeks later, Dr. G
visited his primary care doctor for a check-up. The physician ordered
routine screening laboratory tests (fasting lipid profile, complete
blood count, and urinalysis) through the computerized order entry
system, and the next morning Dr. G presented to the laboratory for
testing. The laboratory and its computer system were the same as used by
Mrs. G\'s obstetrician.

Unbeknownst to Dr. G, the phlebotomist drew samples not only for the
routine testing ordered by his primary care doctor but also for the
genetic screening, because it was listed in the computer even though Dr.
G had not consented. In doing so, the phlebotomist overrode the
computerized alert that prompted him to be sure the patient had
consented; he assumed that the physician must have obtained consent
before ordering the tests. Ten days later, the obstetrician called Mrs.
G to give her \"the good news\" that all her screening tests were
normal. The obstetrician mentioned incidentally that her husband tested
positive as a carrier of Canavan\'s disease. This disclosure caused some
distress, but no physical harm. No increased level of care was needed.

Further discussion at
[[http://www.webmm.ahrq.gov/]{.underline}](http://www.webmm.ahrq.gov/)

**Women who have given birth only via cesarean are less likely than
those with vaginal deliveries to report stress incontinence**

[http://www.ahrq.gov/research/jan05/0105RA16.htm#head1]{.underline}

**Ask a Librarian: Diane Cooper, M.S.L.S. / NIH**

**Infant Mortality: Bad News, Good News**

The U.S. infant mortality rate is higher, according to the latest
analysis. That's the bad news. The U.S. mortality rate (IMR) rose from
6.8 to 7.0 per 1000 live births from 2001 to 2002. It was the first
increase in IMR in 40 years. The good news is, bucking that trend, the
IMR for American Indians improved, from 9.7 to 8.6. Other rates fro 2002
were: Asian/Pacific Islander 4.8; Hispanic 5.6; white 5.8; total 7.0;
black 13.8.

Analysts said the U.S. upturn was because the proportion of very low
birth-weight babies increased. They speculated 3 possibilities that
could have contributed to this change. 1.) There may have been a change
in reporting live or viable births among very low weight fetuses (IMR
does not include stillbirths); 2.) There may have been changes in the
risk profile of expectant women, although it was not due to an increase
in higher risk age groups; 3) improved medical management of pregnancy
may have brought more nonviable fetuses to live birth. National Vital
Statistics Reports 53/12, Jan 24, 2005
[[http://www.cdc.gov/nchs/data/nvsr/nvsr53/nvsr53_12.pdf]{.underline}](http://www.cdc.gov/nchs/data/nvsr/nvsr53/nvsr53_12.pdf)

[[cooperd@mail.nih.gov]{.underline}](mailto:cooperd@mail.nih.gov)

#####  

**Breastfeeding**

**American Academy of Pediatrics Revised policy on Breastfeeding**

Breastmilk and the Use of Human Milk cites substantial new research on
the importance of breastfeeding and sets forth principles to guide
pediatricians and other health professionals in assisting women and
children in the initiation and maintenance of breastfeeding. The policy
statement replaces the American Academy of Pediatrics\' 1997 policy
statement on breastfeeding. The revised statement includes information
on child, maternal, and community health benefits of breastfeeding;
contraindications to breastfeeding; recommendations on breastfeeding for
healthy term infants and high-risk infants; and the role of
pediatricians and other health professionals in protecting, promoting,
and supporting breastfeeding. The policy statement emphasizes the
central role of the pediatrician in coordinating breastfeeding
management and providing a medical home for the child. American Academy
of Pediatrics, Section on Breastfeeding. 2005.

Breastfeeding and the Use of Human Milk. Policy Statement. Pediatrics
115(2):496-506

[[http://pediatrics.aappublications.org/cgi/content/abstract/115/2/496]{.underline}](http://pediatrics.aappublications.org/cgi/content/abstract/115/2/496)

**CCC Corner Digest**

**A compact digest of last month's CCC Corner - Highlights include:**

Depo Provera and bone loss

Oral rehydration solution -- reverse transfer of technology

What maneuver is in best in shoulder dystocia?

Midwives serving in Indian Country

Marriage may be good for you

Consumer Reports evaluates condoms, and 16 other contraceptive methods

Bariatric surgery may be a viable treatment option in severe obesity

[[http://www.ihs.gov/MedicalPrograms/MCH/M/documents/0501_OL.pdf]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/0501_OL.pdf)

If you want a copy of the CCC Digest mailed to you each month, please
contact [[nmurphy@scf.cc]{.underline}](mailto:nmurphy@scf.cc)

**Domestic Violence**

**Intimate Partner Violence During Pregnancy APRIL 2005 MCH EPI GRAND
ROUNDS** PRESENTER: Kenneth D. Rosenberg, MD, MPH

WHEN: Wednesday, April 6, 2005 at 2:00-3:00 pm EDT

WEBCAST REQUIREMENTS: To join the webcast, you must register at least a
day ahead of time at
[[http://www.uic.edu/sph/cade/mchepi/]{.underline}](http://www.uic.edu/sph/cade/mchepi/)

**Primary Care Discussion Forum: Domestic Violence in AI/AN - Just
finished**

**Domestic Violence in Native Women -- Moderated by Terry Cullen**

**Summary**

[[http://www.ihs.gov/MedicalPrograms/MCH/M/documents/DVQuestionsTCcomments.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/DVQuestionsTCcomments.doc)

**Full Discussion**

[[http://www.ihs.gov/MedicalPrograms/MCH/M/documents/DVDisc1405.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/DVDisc1405.doc)

**Assaults during pregnancy: both immediate and long-term adverse
neonatal outcomes**

CONCLUSION: Women sustaining an assault during pregnancy experience both
immediate (uterine rupture, increased fetal and maternal mortality) and
long-term sequelae (prematurity and low birth weight infants), which
have significant negative effects on pregnancy outcome. LEVEL OF
EVIDENCE: III. El Kady et al Maternal and neonatal outcomes of assaults
during pregnancy. Obstet Gynecol. 2005 Feb;105(2):357-63.
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684165&dopt=Abstract]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684165&dopt=Abstract)

**Elder Care News**

**Caring for elders at home: what is the best bath strategy?**

This is a beautifully designed, randomized, controlled trial of bathing
techniques in 73 nursing home residents with dementia who had problems
with agitation during bathing. Two specific approaches to bathing, both
using techniques designed to make the bath a more comfortable process
and tailor it more specifically to the mood and needs of the elder, were
tested. Agitation and aggressive behaviors declined significantly in
both treatment groups but not in the control group.

**Bruce Finke:** *Most elders with dementia in Indian country are cared
for in the home, in most cases by family members. A terribly difficult
aspect of caring for elders with dementia is dealing with anger and
agitation and bathing is an activity that often triggers these
responses. Our care for elders with dementia must include ensuring that
family members and caregivers receive the specific education they need
to provide care in the best way possible. This study confirms that there
are specific, teachable techniques that can reduce agitated behavior
during bathing. We need to think about how we can provide this
information to the caregivers of our elders with dementia.*

[Sloane PD, Hoeffer B, Mitchell CM, McKenzie DA, Barrick AL, Rader J,
Stewart BJ, Talerico KA, Rasin JH, Zink RC, Koch
GG.](http://www.blackwell-synergy.com/links/toc/jgs/52/11) Effect of
person-centered showering and the towel bath on bathing-associated
aggression, agitation, and discomfort in nursing home residents with
dementia: a randomized, controlled trial. J Am Geriatr Soc. 2004
Nov;52(11):1795-804.
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15507054]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15507054)

**Cultural Diversity at the End of Life: Issues and Guidelines**

[[http://www.aafp.org/afp/20050201/515.html]{.underline}](http://www.aafp.org/afp/20050201/515.html)

**Editorial**

[[http://www.aafp.org/afp/20050201/editorials.html]{.underline}](http://www.aafp.org/afp/20050201/editorials.html)

**Management of Hypertension in Older Persons**

[[http://www.aafp.org/afp/20050201/469.html]{.underline}](http://www.aafp.org/afp/20050201/469.html)

**White House Conference on Aging**

October 23-26, 2005

Focus on policy issues that affect older Americans and the baby boom
generation (born between 1946 and 1964) WHCoA website,
[[www.whcoa.gov]{.underline}](http://www.whcoa.gov/)

**Family Planning**

**Hormonal Contraceptives and Weight Gain: Cochrane for Clinicians -
AFP**

**Clinical Question**

Do combination hormonal contraceptives cause weight gain?

**Evidence-Based Answer**

There is no causal relationship between combination contraceptives and
weight gain.

**Practice Pointers**

Many women and physicians believe that weight gain is associated with
combination hormonal contraceptives. The weight gain could be the result
of water retention, increased muscle mass, or increased fat deposition.
To test this perception, Gallo and colleagues performed a systematic
review of randomized controlled trials. They included studies of at
least three menstrual cycles\' duration that compared combination
contraceptives with placebo or other drugs, dosages, regimens, or study
lengths. They found three placebo-controlled trials, none of which found
a significant difference in weight gain between groups. The largest of
these studies, with 473 patients, found a difference of less than 1 lb
after six months. There was also no difference between groups in
discontinuation of the contraceptives because of weight gain.
Furthermore, most of the studies comparing two contraceptive regimens
did not show differences in weight gain.

When patients are reluctant to take combination contraceptives because
they fear weight gain, physicians can tell them that it is true that
women gain weight with the pill and the patch. However, they also gain
weight when they don\'t use these products. Physicians can direct them
to the excellent resources on healthy lifestyles that have been
developed by the National Institutes of Health.^1^ The \"Aim for a
Healthy Weight" program has an interactive Web site on diet and exercise
for patients
([[http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/]{.underline}](http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/)).

[[http://www.aafp.org/afp/20050101/cochrane.html]{.underline}](http://www.aafp.org/afp/20050101/cochrane.html)

**Availability and Use of Publicly Funded Family Planning Clinics: U.S.
Trends, 1994-2001**

The Indian Health Service was able to provide a complete listing of
clinics it funds and contraceptive clients served in 2001. Nationwide,
nearly 200 clinics were added through this listing, and although many of
these are new sites, some may have existed but been missed previously.
These added sites are concentrated in Western states, where most Indian
reservations are located.
[[http://www.guttmacher.org/pubs/journals/3620604.html]{.underline}](http://www.guttmacher.org/pubs/journals/3620604.html)

Contraceptive Needs and Services, 2001-2002
[[http://www.guttmacher.org/pubs/win/index.html]{.underline}](http://www.guttmacher.org/pubs/win/index.html)

**Frequently asked questions**

**Q. What is the Indian Health policy on use of chaperones?**

A. There is no official IHS policy yet, but we strive to honor our
patients' dignity and choice.

[[http://www.ihs.gov/MedicalPrograms/MCH/m/documents/Chaperone2605.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/m/documents/Chaperone2605.doc)

**Q. How does one manage possible exposure to hand foot and mouth
disease in pregnancy?**

**A.** With reassurance, unless the mother has a febrile illness in the
last week of pregnancy.

[http://www.ihs.gov/MedicalPrograms/MCH/M/MCHfaq.asp#handfootmouth]{.underline}

**Q. The 'quad' second trimester screening test is expensive Is it worth
it?**

**.**A. The 'quad' screen is more cost effective and patient friendly.

[[http://www.ihs.gov/MedicalPrograms/MCH/m/documents/QuadScr122304.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/m/documents/QuadScr122304.doc)

**Q. How can you predict if a placenta previa will persist based on US
at 15-24 weeks?**

A. If the placental edge is \> 1 cm over the os, or if the cord
insertion is over the os

[[http://www.ihs.gov/MedicalPrograms/MCH/m/documents/USPearl2705.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/m/documents/USPearl2705.doc)

**Hormone Replacement Update**

**Benefits and Risks of Estrogen in Postmenopausal Women**

CONCLUSIONS: The use of CEE increases the risk of stroke, decreases the
risk of hip fracture, and does not affect CHD incidence in
postmenopausal women with prior hysterectomy over an average of 6.8
years. A possible reduction in breast cancer risk requires further
investigation. The burden of incident disease events was equivalent in
the CEE and placebo groups, indicating no overall benefit. Thus, CEE
should not be recommended for chronic disease prevention in
postmenopausal women. Anderson et al. Effects of conjugated equine
estrogen in postmenopausal women with hysterectomy. The Women\'s Health
Initiative Randomized Controlled Trial. JAMA April 14, 2004;291:1701-12.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15082697]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15082697)

**Information Technology**

**Free CME from Harvard to 60 of our providers**

1.  1\. Harvard is only waiving CME tuition

    2\. Send the names to your CMO as well as a copy to me

    3\. We will work directly with Harvard about notification of
    individuals who wish to attend

[[http://www.pri-med.com/pmo/LiveProgramDetail.aspx?url=/pmo/10/HP234867]{.underline}](http://www.pri-med.com/pmo/LiveProgramDetail.aspx?url=/pmo/10/HP234867)

**International Health Update**

**The Institute for OneWorld Health \-- A Not-for-Profit Pharmaceutical
Company**

[The Institute for OneWorld Health \-- A Nonprofit Pharmaceutical
Company](http://www.oneworldhealth.org/) in San Francisco, California,
created to find, develop, and market effective and safe drugs for these
terrible diseases. Begun in 2000 by young pharmacologist Victoria Hale,
the institute employs some 3 dozen people, is advised by pharmacy guru
Jere Goyan, and enjoys many volunteers while receiving support primarily
from foundations. It recently reported early results from a clinical
trial in India finding that the cheap off-patent antibiotic, injectable
paromomycin, can cure a high percentage of patients with visceral
leishmaniasis.[[http://www.oneworldhealth.org]{.underline}](http://www.oneworldhealth.org/)

[[http://www.medscape.com/viewarticle/496086?src=mp]{.underline}](http://www.medscape.com/viewarticle/496086?src=mp)

**MCH Alert**

**Entire supplement on sleep in children: Cultural impacts**

Cultural Issues and Children\'s Sleep: International Perspectives, a
supplement to the January 2005 issue of Pediatrics, examines the
cultural variables that impact children\'s sleep. The articles represent
a broad range of cultures, age groups, and subtopics and include several
cross-cultural comparison studies, a longitudinal study conducted over a
10-year period, and a comprehensive review of the literature. The
articles explore a number of the most important cultural issues in the
pediatric sleep field including co-sleeping, adolescent sleep patterns,
and napping.

Owens JA (ed.). 2005. Cultural Issues and Children\'s Sleep:
International Perspectives. Pediatrics 115(1, Part 2):1-271.
[http://pediatrics.aappublications.org/content/vol115/issue1/#SUPPLS1]{.underline}

**Medscape\***

######### **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]{.underline}](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]{.underline}](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]{.underline}](http://boards.medscape.com/forums?14@@.ee6e57b)

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

[[http://www.medscape.com/cmecenterdirectory/Default]{.underline}](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.

**Midwives Corner: Marsha Tahquechi, CNM, GIMC**

If anyone wishes to contribute to the Midwives Corner, please contact
Marsha Tahquechi at GIMC
[[Marsha.Tahquechi@IHS.GOV]{.underline}](mailto:Marsha.Tahquechi@IHS.GOV)

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

**Cesarean Rate Highest Ever**

Preliminary data for 2003 indicated that 27.6% of all births in the
United States resulted from cesarean deliveries, an increase of 6% from
2002 and the highest percentage ever reported in the United States.
After declines during 1989-1996, the total cesarean rate and the primary
cesarean rate (i.e., percentage of cesareans among women with no
previous cesarean delivery; 19.1% in 2003) have increased each year.
[[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5402a5.htm]{.underline}](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5402a5.htm)

**Osteoporosis**

**"Uncertain Role" of Biochemical Markers Use in Osteoporosis Therapy**

Some folks have been using biochemical markers to follow patients on
antiresorptive therapy. One example is urinary cross linked
N-telopeptides (NTX). The first NTX measurement is just a baseline. The
second NTX has clinical value for the patient, e.g., measure either
urinary NTX or serum CTX and look for a 50 percent decline with therapy
as an index of adequate treatment.

Another approach use is to use markers in between DEXAs, perhaps as
'poor man's DEXA', e.g., get a baseline NTX, start therapy, get second
NTX, if one sees a good response, then skip the next DEXA as DEXAs are
only covered q 24 mo and many contract health case managers may refuse
to pay for the DEXA.

**Recommendation** --- Although the optimal approach is uncertain, we
recommend the second approach in which monitoring with markers is
performed. We measure either urinary NTX or serum CTX and look for a 50
percent decline with therapy as an index of adequate treatment.
Follow-up with a measurement of bone density in two to three years, to
make sure that the predictions about bone loss were correct, is advised.

[[http://www.uptodateonline.com/application/topic.asp?file=minmetab/17366&type=A&selectedTitle=3\~3]{.underline}](http://www.uptodateonline.com/application/topic.asp?file=minmetab/17366&type=A&selectedTitle=3~3)

**SUMMARY** --- Measurements of biochemical markers of bone turnover
reflect the rates of bone resorption and bone formation. The most
important clinical use for these tests is in monitoring patients taking
antiresorptive therapy for osteoporosis. Other uses include following
patients with Paget\'s disease, metastatic bone disease, and
inflammatory arthritis. Measurements of urinary NTX and SERUM CTX
excretion are the most specific and clinically useful markers for bone
resorption, while bone-specific alkaline phosphatase is the most
clinically useful marker of bone formation.

[[http://www.uptodateonline.com/application/topic.asp?file=minmetab/19988&type=A&selectedTitle=1\~3]{.underline}](http://www.uptodateonline.com/application/topic.asp?file=minmetab/19988&type=A&selectedTitle=1~3)

**Biochemical markers of bone turnover** --- Measurements of biochemical
markers of bone turnover can be used to complement measurements of BMD:

![](media/image1.jpeg){width="4.027777777777778e-2in"
height="3.263888888888889e-2in"} If the BMD is in the upper tertile, we
consider the woman at low risk for osteoporosis and drug therapy to
prevent bone loss is not needed.
![](media/image2.jpeg){width="4.027777777777778e-2in"
height="4.375e-2in"} If the BMD is in the lowest tertile, we consider
the woman at high risk for osteoporosis and we recommend preventive
therapy. ![](media/image1.jpeg){width="4.027777777777778e-2in"
height="3.263888888888889e-2in"} If the BMD is in the middle tertile, we
recommend measuring a marker of bone turnover such as the urinary
excretion of DPD or NTX; we treat women with a value above the upper
limit of normal for premenopausal women.

**Bruce Finke:**

Biochemical markers have what best could be termed an 'uncertain role'
at this time. With regard to using them to follow treatment, although
this makes sense and *should* work, there really isn't data indicating
that this strategy actually works. I'm willing to treat with
bisphosphonates based on BMD knowing that this reduces the risk of
fracture, and wait for more data to refine this approach.

Another question that comes up -- use in the young patient on long term
Depo Provera? It doesn't follow that one can extrapolate to using
biochemical markers to evaluate risk of future osteoporosis in a very
young population on Depo Provera. We would need more data to properly
evaluate.

**Other resource-biochemical markers**

**Screening for osteoporosis**

[[http://www.uptodateonline.com/application/topic.asp?file=minmetab/19499&type=A&selectedTitle=2\~3]{.underline}](http://www.uptodateonline.com/application/topic.asp?file=minmetab/19499&type=A&selectedTitle=2~3)

**Fracture Protection Lost Five Years After Stopping Hormone Replacement
Therapy**

CONCLUSION: Postmenopausal women who have discontinued HT within the
past 5 years have a risk for hip fracture that is at least as high as
that in women who have never used HT. LEVEL OF EVIDENCE: II-2

Yates J, et al Rapid loss of hip fracture protection after estrogen
cessation: evidence from the National Osteoporosis Risk Assessment.
Obstet Gynecol. 2004 Mar;103(3):440-6.
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14990403]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14990403)

**Impact of Intense Exercise on Early Osteopenia in Women**

CONCLUSION: General purpose exercise programs with special emphasis on
bone density can significantly improve strength and endurance and reduce
bone loss, back pain, and lipid levels in osteopenic women in their
critical early postmenopausal years

Kemmler W, et al. Benefits of 2 years of intense exercise on bone
density, physical fitness, and blood lipids in early postmenopausal
osteopenic women. Results of the Erlangen Fitness Osteoporosis
Prevention Study (EFOPS). Arch Intern Med May 24, 2004;164:1084-91.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15159265]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15159265)

**Patient Information**

**Painful Menstrual Periods**

[[http://www.aafp.org/afp/20050115/292ph.html]{.underline}](http://www.aafp.org/afp/20050115/292ph.html)

**Urinary Tract Infections**

[[http://www.aafp.org/afp/20050101/133ph.html]{.underline}](http://www.aafp.org/afp/20050101/133ph.html)

**Pelvic Floor Muscle Exercises**

[[http://www.aafp.org/afp/20050115/329ph.html]{.underline}](http://www.aafp.org/afp/20050115/329ph.html)

**Microscopic Hematuria**

[[http://www.aafp.org/afp/20050101/135ph.html]{.underline}](http://www.aafp.org/afp/20050101/135ph.html)

**Heart Palpitations**

[[http://www.aafp.org/afp/20050215/755ph.html]{.underline}](http://www.aafp.org/afp/20050215/755ph.html)

**Constipation**

[[http://www.aafp.org/afp/20050201/539ph.html]{.underline}](http://www.aafp.org/afp/20050201/539ph.html)

**Irritable Bowel Syndrome**

[[http://www.aafp.org/afp/20050201/547ph.html]{.underline}](http://www.aafp.org/afp/20050201/547ph.html)

**Inflammatory Bowel Disease**

[[http://www.aafp.org/afp/20050201/553ph.html]{.underline}](http://www.aafp.org/afp/20050201/553ph.html)

**Kidney Cysts**

[[http://www.aafp.org/afp/20050101/130ph.html]{.underline}](http://www.aafp.org/afp/20050101/130ph.html)

**Polycystic Kidney Disease**

[[http://www.aafp.org/afp/20050101/137ph.html]{.underline}](http://www.aafp.org/afp/20050101/137ph.html)

**Alcoholism-What Should I Know About It?**

[[http://www.aafp.org/afp/20050201/509ph.html]{.underline}](http://www.aafp.org/afp/20050201/509ph.html)

**Health Care After Cancer Treatment**

[[http://www.aafp.org/afp/20050215/713ph.html]{.underline}](http://www.aafp.org/afp/20050215/713ph.html)

**Panic Attacks**

[[http://www.aafp.org/afp/20050215/740ph.html]{.underline}](http://www.aafp.org/afp/20050215/740ph.html)

**Primary Care Discussion Forum**

**April 1, 2005: Methamphetamine use in Indian Country**

Moderator: Steve Holve

-How common is Methamphetamine use in your area?

-In your tribal area are there laws that make Methamphetamine production
and use a crime?

-Should all mothers be screened at delivery for Methamphetamine use or
only if medically indicated?

-What resources are available in your community if a pregnant mother is
found

to be using Methamphetamine?

-What resources are available for teenagers and adults who are
Methamphetamine

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

Subscribe to the Primary Care listserv

[[http://www.ihs.gov/generalweb/helpcenter/helpdesk/index.cfm?module=listserv&option=subscribe&newquery=1]{.underline}](http://www.ihs.gov/generalweb/helpcenter/helpdesk/index.cfm?module=listserv&option=subscribe&newquery=1)

Unsubscribe from the Primary Care listserv

[[http://www.ihs.gov/generalweb/helpcenter/helpdesk/index.cfm?module=listserv&option=unsubscribe&newquery=1]{.underline}](http://www.ihs.gov/generalweb/helpcenter/helpdesk/index.cfm?module=listserv&option=unsubscribe&newquery=1)

Questions on how to subscribe, contact
[[nmurphy@scf.cc]{.underline}](mailto:nmurphy@scf.cc) directly

**STD Corner - Laura** **Shelby, STD Director, IHS**

**Men have often been overlooked for routine chlamydia screening**

In this study conducted in 4 cities, 96% of males screened were
asymptomatic and had an overall percent positivity at 7%. At 7% percent
positivity, chlamydia is moderately high among men tested in nonclinical
and clinical settings. Schillinger, et al Prevalence of Chlamydia
trachomatis Infection Among Men Screened in 4 U.S. Cities. Sexually
Transmitted Diseases. 32(2):74-77, February 2005.
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15668611]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15668611)

**Other STD News**

**Expedited treatment of sex partners reduces the rates gonorrhea or
chlamydial infection**

CONCLUSIONS: Expedited treatment of sex partners reduces the rates of
persistent or recurrent gonorrhea or chlamydial infection Golden MR, et
al. Effect of expedited treatment of sex partners on recurrent or
persistent gonorrhea or chlamydial infection**.** N Engl J Med. 2005 Feb
17;352(7):676-85.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15716561&dopt=Abstract]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15716561&dopt=Abstract)

and

**Editorial: Toward Better Control of Sexually Transmitted Diseases**

Erbelding EJ, et al Toward better control of sexually transmitted
diseases.N Engl J Med. 2005 Feb 17;352(7):720-1.
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15716568&dopt=Abstract]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15716568&dopt=Abstract)

**Health Burden Due to Unsafe Sex High in U.S.**

As part of an analysis of the burden of disease and injury in the United
States, we identified and quantified the incidence of adverse health
events, deaths, and disability adjusted life years (DALY) attributed to
sexual behaviour. In 1998, about 20 million such events (7532/100 000
people) and 29 782 such deaths (1.3% of all US deaths) occurred,
contributing to 2 161 417 DALYs (6.2% of all US DALYs). The majority of
incident health events (62%) and DALYs (57%) related to sexual behaviour
were among females, and curable infections and their sequelae
contributed to over half of these. Viral infections and their sequelae
accounted for nearly all sexual behaviour related deaths-mostly
HIV/AIDS. Sexual behaviour attributed DALYs in the United States are
threefold higher than that in overall established market economies.

Ebrahim SH, et al Sexual behaviour: related adverse health burden in the
United States. Sex Transm Infect. 2005 Feb;81(1):38-40.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15681721]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15681721)

**HSV-2 Testing and Treatment of Pregnant Women Appears Worthwhile**

CONCLUSION: Compared with commonly accepted benchmarks for
cost-effectiveness (\<\$50,000/QALY), type-specific HSV-2 serologic
testing of pregnant women may be a cost-effective strategy. Baker D et
al Cost-effectiveness of herpes simplex virus type 2 serologic testing
and antiviral therapy in pregnancy. Am J Obstet Gynecol. 2004
Dec;191(6):2074-84.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15592294]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15592294)

**Barbara Stillwater, Alaska State Diabetes Program**

**Walk 2000 More Steps a Day and Never Gain Another Pound** 6000 steps a
day significantly reduces risk of death, and 8000-10,000 a day promotes
weight loss. If you add just 2000 more steps a day to your regular
activities, you may never gain another pound. So says research by Dr.
James O. Hill of the Center for Human Nutrition at the University of
Colorado Health Sciences Center. To lose weight, add in more steps.
Sedentary people in the USA generally move only 2000-3000 steps a day.
Previous studies have shown that moving 6000 steps a day significantly
reduces risk of death, and 8000-10,000 a day promotes weight loss. How
far is 2000 steps? It is about a mile. But the benefits for health and
for weight management don\'t depend on you walking a mile all at one
time, but simply adding in more steps throughout the day. By wearing a
pedometer all day, you are motivated to add in extra steps whenever you
can. There are many little trips that can add up to a mile or two a
day - parking further from the door of your destination, taking the
stairs rather than the elevator, pace around as you talk on the
telephone, take a marching-in-place minute once an hour. \"All in all,
it is entertaining to ponder that such a seemingly insignificant gadget
may be of practical importance in the war on obesity!\" said Catrine
Tudor-Locke, Ph.D., Department of Exercise and Wellness, Arizona State
University in the conclusion of a report by the President\'s Council of
Physical Fitness and Sports, June, 2002.
[[http://www.fitness.gov/home_pubs.htm]{.underline}](http://www.fitness.gov/home_pubs.htm)

**Fit And Fat Not Good Enough**

CONCLUSIONS: Both increased adiposity and reduced physical activity are
strong and independent predictors of death Hu FB, et al Adiposity as
compared with physical activity in predicting mortality among women. N
Engl J Med. 2004 Dec 23;351(26):2694-703.
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15616204]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15616204)

**15-Year Study Shows Link Between Fast Food, Obesity and Insulin
Resistance**

INTERPRETATION: Fast-food consumption has strong positive associations
with weight gain and insulin resistance, suggesting that fast food
increases the risk of obesity and type 2 diabetes

Pereira MA, et al Fast-food habits, weight gain, and insulin resistance
(the CARDIA study): 15-year prospective analysis. Lancet. 2005 Jan
1;365(9453):36-42.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15639678]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15639678)

**How Well Do Adults Follow Prescriptions for insulin?**

CONCLUSIONS: Adults prescribed a specific insulin regimen averaged using
77% of prescribed doses, demonstrating good intention to follow the
prescription. However, HbA1c higher than the recommended level suggested
that the rate of insulin use, the prescribed regimen, or both were
inadequate to achieve good glycemic control in patients with long-term
insulin use.

Cramer JA, Pugh MJ. The influence of insulin use on glycemic control:
How well do adults follow prescriptions for insulin? Diabetes Care. 2005
Jan;28(1):78-83.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15616237&dopt=Abstract]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15616237&dopt=Abstract)

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

**Use an 'Opt Out' HIV screening policy in pregnancy**

[[http://www.ihs.gov/MedicalPrograms/MCH/m/documents/HIVscreen21305.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/m/documents/HIVscreen21305.doc)

**Hormone replacement, difficulties in management**

[[http://www.ihs.gov/MedicalPrograms/MCH/m/documents/HRT21405.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/m/documents/HRT21405.doc)

**Prevention of preeclampsia**

[[http://www.ihs.gov/MedicalPrograms/MCH/m/documents/AspirPreec21405.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/m/documents/AspirPreec21405.doc)

**Best staffing ratios**

[[http://www.ihs.gov/MedicalPrograms/MCH/m/documents/Staffing21205.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/m/documents/Staffing21205.doc)

**Opportunities to provide Indian Health care**

[[http://www.ihs.gov/MedicalPrograms/MCH/m/documents/Recruit21305.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/m/documents/Recruit21305.doc)

There are several upcoming **Conferences**

[http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#top]{.underline}

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

[[http://www.ihs.gov/MedicalPrograms/MCH/M/CN13.cfm]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/CN13.cfm)

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

[[http://www.ihs.gov/MedicalPrograms/MCH/M/MCHpericrnr.asp]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHpericrnr.asp)

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

[http://www.ihs.gov/MedicalPrograms/MCH/W/WN00.asp#top]{.underline}

**Save the dates**

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

1.  • For providers caring for Native women and children

    • February 25 - 27, 2005

    • First announcement details
    [[http://www.ihs.gov/MedicalPrograms/MCH/M/documents/tldr20051stnotice.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/tldr20051stnotice.doc)

    • Telluride, CO
    [[http://www.ihs.gov/MedicalPrograms/MCH/M/ConfDnlds/Tellurideagenda10-2004.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/ConfDnlds/Tellurideagenda10-2004.doc)

    • Contact Alan Waxman
    [[awaxman@salud.unm.edu]{.underline}](mailto:awaxman@salud.unm.edu)

**NIH: Management of Menopause-Related Symptoms**

1.  • March 21-23, 2005

    • Bethesda, Maryland

    • Consensus: State-of-the-Science Conference

    •
    [[http://consensus.nih.gov/ta/025/menopausalsymptomsintro.html]{.underline}](http://consensus.nih.gov/ta/025/menopausalsymptomsintro.html)

**IHS Advanced Colposcopy course / Refresher Workshop**

1.  • March 30 - April 1, 2005 respectively

    • Albuquerque, New Mexico

    • Brochure
    [[http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Colpo05mailoutbrochure.pdf]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Colpo05mailoutbrochure.pdf)

    • Or contact [[Roberta Paisano]{.underline}](mailto:Roberta Paisano)
    [[Roberta.Paisano@na.ihs.gov]{.underline}](mailto:Roberta.Paisano@na.ihs.gov) (505)
    248-4431

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

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

[[http://www.aap.org/nach/InternationalMeeting.htm]{.underline}](http://www.aap.org/nach/InternationalMeeting.htm)

**3rd Western MCH Epidemiology**

1.  • May 12-13, 2005

    • Portland, OR

    •
    [[http://sphcm.washington.edu/mchepi2005/]{.underline}](http://sphcm.washington.edu/mchepi2005/)

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

1.  • May 7-11, 2005

    • San Francisco , California

    • 53rd Annual ACOG ACM
    [[http://www.acog.org/ACM2005/]{.underline}](http://www.acog.org/ACM2005/)

**Advances in Indian Health**

1.  • May 11-13, 2005

    • Albuquerque, NM

    • 2004 Brochure (2005 pending)

    •
    [[http://hsc.unm.edu/cme/2004%20Web%20Info/AIH2004/AIHIndex.shtml]{.underline}](http://hsc.unm.edu/cme/2004 Web Info/AIH2004/AIHIndex.shtml)

    • Contact
    [[CNorth@abq.ihs.gov]{.underline}](mailto:CNorth@abq.ihs.gov)

**Prevention of Cardiovascular Disease & Diabetes Among AI / AN**

1.  • May 16 - 19, 2005

    • Denver, CO

    • Co-sponsored by IHS, Joslin, ADA, NIH

    •
    [[http://professionaled.joslin.org/CourseListing/CourseDesc.asp?intCourseTypeId=4&intCourseID=1269&strFullInd=Y]{.underline}](http://professionaled.joslin.org/CourseListing/CourseDesc.asp?intCourseTypeId=4&intCourseID=1269&strFullInd=Y)

**2005 U.S. Public Health Conference/Global Health Summit**

1.  • June 5-9, 2005

    • Philadelphia, PA, Development of the Report on Global Health

    • 40^th^ Annual U.S. Public Health Professional Conference, June
    6-9, 2005

    • [www.coausphsconference.org]{.underline}

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

1.  • June 19 - 23, 2005

    • Denver, CO

    • Contact [Yvonne Malloy](mailto:YMalloy@acog.org)
    [[YMalloy@acog.org]{.underline}](mailto:YMalloy@acog.org)
    202-863-2580

    • Save the date info
    [[http://www.ihs.gov/MedicalPrograms/MCH/M/documents/pgcoursesavethedate.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/pgcoursesavethedate.doc)

    • 2005 Brochure

    1.  •
        [[http://www.ihs.gov/MedicalPrograms/MCH/M/Documents/Brochure2005EL.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/Documents/Brochure2005EL.doc)

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

    • NRP Class size limited. Sign up now
    [[http://www.ihs.gov/MedicalPrograms/MCH/M/documents/NeonatalResuscitationProvider2.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/NeonatalResuscitationProvider2.doc)

    1.  • Meeting Website
        [http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#June05]{.underline}

**National Summit on Preconception Care**

1.  • JUNE 21-22, 2005

    • Atlanta, Georgia

    • Catalyst for national recommendations for preconception care, CDC

    •
    [[http://www.signup4.net/Public/ap.aspx?EID=NATI14E]{.underline}](http://www.signup4.net/Public/ap.aspx?EID=NATI14E)

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

**The** January 2005 OB/GYN CCC Corner **is available at:**

[[http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0105.cfm]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0105.cfm)

**Volume 3, No. 1, January, 2005**

**Abstract of the Month: page 3**

**Limit use of Depo Provera to 2 consecutive years only: Black Box
Warning from the FDA**

**From your colleagues: page 4**

**Burt Attico:** Smoking During Pregnancy Tied to Gestational Diabetes
Risk

**Donna Brown**: Hand foot and mouth disease in pregnancy

**Terry Cullen:** IHS prenatal assessment form - ETOH, tobacco,
substances, DV, other issues

**George Gilson**: Which fetal heart rate / contraction patterns are
worrisome with misoprostol use**?**

**Steve Holve:** Oral Rehydration Solution: 5 articles -- January Indian
Child Health Notes

## **Chuck North:** Serving Native American Communities 

**Lori de Ravello:** National Summit on Preconception

**Judy Thierry**: Birth Simulator for Shoulder Dystocia - Rubin\'s
maneuver requires least traction

**Hot Topics:**

##### **Obstetrics: page 7** 

-Highest percentage ever reported in the United States: Cesarean
Delivery

-Alcohol Consumption Among Women Who Are Pregnant, or Who Might Become
Pregnant

-Normalizing blood pressure rapidly and reducing the need for
antihypertensive therapy

-Preterm premature rupture of membranes: Optimal gestational age for
delivery?

-Factor V Leiden polymorphism is associated with an increased risk of
preeclampsia

**Gynecology: page 8**

-Passive smoking increases the risk of cervical neoplasia

-Consumer Reports Magazine Rates Condoms, Reviews 16 Other Contraceptive
Methods

**Child Health: page 8**

-Social Norms and Friends' Influences on weight control behavior:
Adolescent girls

-Teenagers in the United States: Sexual Activity, Contraceptive Use, and
Childbearing

**Chronic Illness and Disease: page 8**

-Bariatric Surgery May Be a Viable Treatment Option for Severe Obesity:
2 articles

-The Recognition of Depression: The Primary Care Clinician\'s
Perspective

-High Folate Intake May Reduce Risk of Hypertension in Women

-Women With Diabetes Do Worse After Stenting

-Premature birth and later insulin resistance

**Features: page 9**

**American Family Physician**

\-[Imaging for Suspected
Appendicitis](http://lyris.aafp.org/t/132975/5913807/251197/0/)

**ACOG**

\- Intrauterine Device - ACOG Practice Bulletin NUMBER 59

-EC does not increase promiscuity or unprotected sex among women, nor
does it cause women to abandon their regular birth control methods

**AHRQ**

-Wrong Site \"Near Miss\" -- Web M+M -Surgery

**Ask a Librarian**

\- Great New Resource: MD Consult available: Many journals at your
fingertips

**Breastfeeding**

\- Free website for medications and breastfeeding that is useful and
credible

\- State Legislation on Breastfeeding

**Domestic Violence**

-Sexual assault is associated with significantly higher levels of PTSD

-Just finished..... Domestic Violence in Native Women -- Primary Care
Forum Summary

**Elder Care News**

-Co-incidence of Alzheimer's and cerebrovascular disease accelerates
cognitive decline

-Native Americans Social and Economic Development Strategies (SEDS)
Grants

-Palliative Care resource for hospitals and clinics

**Family Planning**

-Being overweight may increase the risk of becoming pregnant while using
OCs

-EC does not cause women to abandon their regular birth control methods

**Frequently asked questions**

-The 'quad' second trimester screening test is expensive. Is it worth
it?

-What are the best cut-offs to use while monitoring diabetes in
pregnancy therapy?

-How does birth interval affect the repeat cesarean vs vaginal delivery
decision?

-Are there alternatives to insulin / diet in diabetes and pregnancy?
Glyburide? Others?

-How many colposcopies in a year does a non-OB/GYN provider need to
perform?

**Hormone Replacement Update**

-Venlafaxine significantly decreases postmenopausal patient-perceived
hot flush score

**Information Technology**

\- Electronic Health Record: Overview, Implementation & Lessons
Learned - Courses

**International Health**

-Lifelong accumulated racial discrimination by African American: Preterm
delivery

#### **MCH Alert** 

-National Birth Defects Prevention Month

#### **Medscape** 

######### -Are Vaginal Symptoms Ever Normal? A Review of the Literature 

**Midwives Corner**

-Midwives Serving Indian Country

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

-Marriage may be good for you

-Explaining the 2001-02 Infant Mortality Increase: Linked Birth/Infant
Death Data Set

**Osteoporosis**

-Alendronate is safe and effective: Can carry treatment out ten years
without concern

\-[Effect of Vitamin D on falls: a
meta-analysis](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15113819)

**Patient Education**

-Maternal Child Health Patient Education: new web page envisioned

**Primary Care Discussion Forum**

-Surgery for obesity? February 2005

-Just finished..... Domestic Violence in Native Women -- Primary Care
Forum Summary

**What's new in Sexually Transmitted Diseases?**

-Preventive Health Care Seeking Among Adolescents: The Gonorrhea
Community Action Project

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

-The \'Polymeal\' Cuts Heart Disease by 76% - Recipe for Life **-**
Depression Increases Insulin Resistance, Diabetes in Middle-Aged Women

## -Dietary Guidelines for Americans 2005 

#### **What's new on the ITU MCH web pages page 17** 

###### **Save the Dates:** Upcoming events of interest **page 18** 

The past CCC Corners are archived at:

[http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN01.cfm#top]{.underline}

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]{.underline}](mailto:nmurphy@scf.cc)

or 907 729 3154 (with voicemail)

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

2/19/05